Chronic Low Back Pain

Learn About Chronic Low Back Pain

Nearly everyone at some point has pain in the lower back that is memorable for the degree of pain experienced or the extent of interference with routine activities. Fortunately, most occurrences of low back pain go away within a few days, but in some instances the condition takes much longer to resolve (chronic low back pain) and becomes a serious cause of disability and impairment. We spend at least $50 billion each year on low back pain, the most common cause of job-related disability and absenteeism. Most cases of low back pain generally last from a few days to a few weeks (acute low back pain). Chronic low back pain is often progressive and the cause can be difficult to determine.

The back is a structure of bones, muscles, and other tissues extending from the neck to the pelvis. The spinal column (or spine) supports the upper body’s weight, housing and protecting the spinal cord. Stacked on top of one another are the vertebrae — bones that form the spinal column, creating a channel that surrounds the spinal cord. Nerve roots enter and emerge from the spinal cord through spaces between the vertebrae, which are maintained by pads of cartilage called the intervertebral discs. These discs have a semi-solid center called the nucleus pulposus. Pain can occur due to sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward, most often due to movement of the contents of the nucleus pulposus within the disc. This rupture may put pressure on the nerves rooted to the spinal cord, resulting in back pain.

Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition. People with these symptoms should contact a doctor immediately to help prevent permanent damage.

Men and women are equally likely to develop chronic low back pain. It occurs most often between ages 30 and 50. A frequent cause of chronic low back pain is a bulging disc (also called protruding, herniated, or ruptured disc). The cartilage of the intervertebral discs can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, or lumbar, portion of the spinal column. Sciatica is one such condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that carries nerve fibers to and from the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve numbness and some loss of motor control over the leg.

A thorough medical history and physical exam can usually identify any dangerous conditions that may be associated with the chronic low back pain. Medications are often used to treat chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.

Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Anticonvulsants — drugs primarily used to treat seizures — may be useful in treating certain types of nerve pain and may also be prescribed with analgesics. Some antidepressants, particularly tricyclic antidepressants such as amitriptyline and desipramine, have been shown to relieve pain (independent of their effect on depression) and assist with sleep. Antidepressants alter levels of brain chemicals to elevate mood and dull pain signals. Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe chronic back pain. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and even increasing pain. Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks. However, chronic use of steroid injections may lead to increased functional impairment. In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves.

Many work-related injuries are caused or aggravated by stressors such as heavy lifting and awkward posture. The use of wide elastic belts that can be tightened to “pull in” lumbar and abdominal muscles to prevent low back pain remains controversial. Although there have been reports of injury reduction among workers using back belts, many companies that have back belt programs also have training and ergonomic awareness programs. The reported injury reduction may be related to a combination of these or other factors.

Mark J. Woyshville MD

Adapted from: Low Back Pain Fact Sheet - National Institute of Neurological Disorders and Stroke

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