Year after year, back pain easily maintains a top spot as one of the most common reasons for an emergency department (ED) visit. Patients frequently come to us for both pain relief, as well as a diagnosis to explain why their body and spine are suddenly revolting against them. The treatment of lower back pain, admittedly, is often a multi-step process, and therefore the lack of a quick resolution in the ED can be understandably frustrating. We want to take the time to explain the most common causes of back pain, the recommended treatment, and the ways you can help support the return to the days when the biggest pain in your butt is your toddler’s meltdown in the middle of the grocery store after your babysitter just canceled last minute.
While back pain is a very common symptom, the causes are varied and complex from patient to patient. It can result from obvious and direct injury (even adults fall on their butt from time to time), repeated stress and tension (I am talking to you, my CrossFit bros with the heavy dumbbells), or can seemingly develop spontaneously as if a spiny monster with a personal vendetta sneaked into your body in the middle of the night (it’s okay if you want to blame your boss or ex, they probably sent him). Let’s first review some of the most common reasons that patients experience lower back pain:
- Degenerative Disk Disease – Similar to our other bones and joints in our bodies, the vertebrae in our spine can start to wear down and lose their natural, lubricated relationship with the bones around them. This typically causes pain in the middle of the back and is worse with standing up straight or leaning back.
- Spinal Stenosis – This is also a condition that grows more common as we age, and occurs when the natural degenerative changes of the vertebrae leading to narrowing of the central canal in the spine (where the spinal cord is located). Similar to degenerative disc disease, this pain often worsens with walking or leaning back, and improves when with leaning forward.
- Herniated Disc – Think of discs as cartilage pancakes that sit between each vertebra, providing cushioning and shock protection for our lower back. With repeated flexion and extension events (often seen in athletes or those who perform heavy manual labor for work), this disc can protrude out like jelly in a PB&J sandwich. This often leads to pain radiating down the legs (see ‘sciatica’ below), as well as pain with bending or sitting.
- Fractures – There are many different types of fractures of the vertebrae, and some can occur with very little to no trauma (especially in older patients with osteoporosis). A discussion of all the different types of fracture is outside the scope of this article, but know that they are common, often do not require bracing or surgery, and the main complication is . . . you guessed it . . . pain.
- Muscle spasm – Tightening, tension, and spasming of the lumbar muscles is a common cause of back pain, and we are all guilty of holding unnecessary tension in our back muscles on a daily basis. This can be the primary and only problem or can accompany some of the above conditions and add an extra special source of pain to a pre-existing injury (yes, that vindictive spiny monster is at work again). Muscle pain can range in character, from an unrelenting ache or burn, to a sharp stabbing pain that feels like a knife in your back when you do something as innocent as blowing your nose or reaching for a handful of potato chips (or, err, vegetables). Spasms tend to have a domino effect, with the spasm of one muscle triggering the discomfort and tension in surrounding muscles.
- Sciatica – The medical term for this common condition is a ‘radiculopathy’, from the Latin word for ‘root.’ It results from the compression of the nerve root as it is exiting the spinal canal, from a herniated disc or degenerative bone disease as discussed earlier. It causes that unpleasant sharp pain that radiates from your lower back or buttocks, down your leg, and sometimes all the way to the foot. It can sometimes lead to a tingling sensation in the foot and toes as well. Ridiculous, we know.
The above conditions can occur in isolation, but also can co-exist in the delicate ecosystem of muscle and bone that is your lower back, thus contributing to multiple sources of discomfort (a more pleasant way to think of your lower back, than a painful web of disrupted anatomy, right?). The diagnosis of a patient’s cause for back pain is most reliably made from their description of the pain, and some simple physical exam maneuvers. The patient often asks if imaging should be performed for diagnosis (such as an Xray or MRI), but this is often not necessary, and furthermore, not recommended by spine specialists as a useful or necessary part of the ED evaluation. While there are rare circumstances when radiographic images will be obtained (a bad traumatic injury where a fracture is suspected, or a constellation of neurologic symptoms that could represent serious spinal cord injury, for example), these cases are rare. Do not be dismayed if you do not take a field trip to the radiology suite during your ED stay – this is to save you from unnecessary tests, radiation, time.
Perhaps the most important discussion topic in this article is pain relief. As doctors, we want to alleviate pain just as much as the patient wants to be pain-free. The reality is that recovery and healing take time. Given the prevalence of back pain, there is no shortage of clinical research and investigations into the most effective way to treat it. No matter the cause of a patient’s back pain, the treatment is often the same: decrease the inflammation in the musculoskeletal tissues that are leading to the exacerbation of the pain, followed by physical rehabilitation to stretch and strengthen the back. In the ED, we are most involved in the anti-inflammatory step. This can be as simple as an appropriate combination of over-the-counter medications (such as ibuprofen, naproxen, and acetaminophen), but when the pain is bad enough for an ED visit, we often prescribe a short course of steroids given their strong anti-inflammatory properties. This is sometimes combined with prescription muscle relaxants if there is a component of muscle spasm with the pain. Patients sometimes ask about prescription opiates (such as oxycodone or hydrocodone), given these medications have a reputation for being ‘stronger’ remedies (and believe us, we know your back pain deserves something strong). All our current evidence suggests this is not an effective treatment for most back pain, and there is evidence to show it can ultimately worsen the patient’s condition and recovery, and thus they are only prescribed in rare cases ( for example, when there are acute fractures of the spine).
In conjunction with the appropriately selected pain medication for each patient, there are some basic care instructions that can be started at home, even before physical therapy, to help with pain relief:
- Try to avoid bed rest and increased sedentary lifestyle, as this tends to ultimately worsen the pain. Gentle activity and movement, and continuing your daily life activities, is very important to keep your back healthy. The patient should avoid movements that seem to sharply exacerbate the pain (sorry Dad, doing the dishes does not pass as one of those activities).
- While there is no evidence to suggest hot or cold helps with the pain, some patients do find this provides some relief, and there is nothing dangerous about temperature therapy. A warm shower or heating pad may also allow for more comfortable stretching and movement, which is encouraged.
- Avoid any heavy lifting or direct attempts to strengthen the back muscle in the setting of an acute pain exacerbation (again, I’m looking at you, CrossFitters). Give your body an appropriate break from strenuous activities.
- Perhaps the most important piece of advice we can give (and the hardest to follow) is to not get discouraged. While many conditions that cause back pain are chronic conditions, the pain is not (with the right treatment, of course). Be gentle and patient with your body, and be sure to keep your regular appointments with your doctors, specialists, and physical therapists. With time and the right approach, you will get better.