Back Pain

What Is Back Pain?

Back pain is one of the most common physical complaints among adults – and a chief cause of misery for many. At some point in their lives, most people will experience some sort of back discomfort.

Back pain describes pain or discomfort felt in the upper, middle, or lower back. The pain may extend to the hips and legs. The back consists of a complex arrangement of bone, ligaments, joints, muscles, and nerves, and pain can result from a problem with any of these components.

The most common type of back pain is low back pain. That’s because the lower portion of the back is under the most pressure when a person is sitting or lifting, and it can be easily damaged.

There are many causes of back pain.

  • The most common cause is a strain of the back, which is a small tear of the back muscles or ligaments. This usually results from a sudden or awkward movement, or from lifting a heavy object. But often, a person can’t remember a particular incident that brought on the pain.
  • Other common causes include poor muscle tone in the back, tension or spasm of the back muscles and problems with the joints that make up the back.

Nice To Know:

Some 50 years ago, back pain was seen in simple terms. Today, there is better understanding of the complex nature of the spinal structures, and the relationship of the brain and spinal cord. As a result, the causes of back problems are identified with much greater accuracy but in some cases may still be elusive.

Back pain can be classified as either:

  • Acute – Sudden pain that lasts for just a short while, usually a few days to a few weeks.
  • Chronic – Pain that lasts for more than three month, or pain that recurs.

Statistics show that with simple treatment, up to 90% of people with acute back pain improve within one month and up to 60% improve within a week. Even severe back pain due to a herniated disc often resolves within six weeks, as the protruding discs begins to shrink.

Fortunately, most cases of acute low back pain improve quickly – within a few days, or sometimes within a few weeks. And in less than 5% of people the pain persists and becomes chronic.

Nice To Know:

How common is low back pain?

Low back pain is common. At some point in their lives, most people will experience some form of back discomfort. Some researchers believe that back pain is a problem of civilization – primitive tribes lived by hunting and did not experience the type of back pain that comes from sitting in chairs, in today’s culture, from our very childhood at school. Other researchers believe that people began to experience back pain as soon as man began to walk in an upright manner. Despite today’s increasing medical technology and understanding, back pain continues to be an obvious and complex problem.

Who Is At Risk?

Certain people are at higher risk for back pain, including:

  • Those whose work includes heavy labor or long periods of sitting and standing.
  • Those who are “out of shape,” as they may have let the muscles in the abdomen and back become weak and easily fatigued, placing extra strain on the muscles and joints of the back.
  • Those who have jobs that subject their backs to a lot of vibration.
  • Those who do heavy lifting without having the proper education and training to lift correctly.
  • Those who smoke (smokers are more likely than nonsmokers to suffer from back pain).

Facts About Back Pain

  • In the U.S., back pain competes with the common cold as the leading reason why people see a physician.
  • Back pain is the number-one cause of disability in workers under age 45.
  • Aside from the physical distress, back pain carries steep economic costs – an estimated $20 to $50 billion annually in medical treatments and disability payments.
  • Most episodes of acute back pain go away within a month.
  • Despite today’s medical technology, many forms of treatment do not affect the course of most acute low back pain episodes.
  • Only 10% of those suffering from acute back pain require special diagnostic testing.


Understanding How The Back Works

The spine, which connects the skull to the pelvis, is also called the vertebral column. It consists of 24 segments of block-shaped bone called vertebrae and an additional 9 fused vertebrae that make up the lowest part of the spine, the sacrum and tailbone. Each vertebrae of the vertebral column has protruding bony areas for the attachment of muscles that are important for the spine to move. The spinal column protects the spinal cord and its emerging nerves that run down most of the length of the spine.

The vertebrae have two major functions:

  • To bear the weight of the body
  • To house the spinal cord or spinal nerve roots (cauda equina) within the spinal column

The spine is arranged in three natural curves:

  • The neck region or cervical spine, made up of 7 vertebrae – where the vertebrae curve forward.
  • The trunk region or thoracic spine, made up of 12 vertebrae – where the vertebral column curves backward, and to which the ribs attach
  • The low back region or lumbar spine, made up of 5 vertebrae – which curves forward in the same direction as the cervical spine.

When these curves are in their normal alignment, the body is in a balanced position. This distributes weight evenly throughout the vertebrae so one is in a less vulnerable position for strain and injury.

There are two major parts to each vertebra:

  • Vertebral body – The vertebral body is the front portion of the vertebrae. It is shaped like a cylinder and is greater in height than the back portion.
  • Vertebral arch – The vertebral arch is the back portion of the vertebrae. It is an irregularly shaped structure.

At the center of each vertebra is a hole, protected by the surrounding strong bone. Placed together, the central opening of each vertebra makes up the spinal canal through which the spinal cord, cauda equina, or spinal nerve roots pass. The spinal cord is the mass of nerve that connect the brain to the rest of the body.

Each vertebra has important bony projections called processes that provide sites for the attachment of ligaments and muscles that are important for the stability and movement of the spine.

  • The projections on either side of each vertebra are called transverse processes, and the ones at the back are called the spinous processes. The transverse processes are long and slender; the spinous processes are broad and thick.
  • The back portion of the vertebrae, behind the transverse processes, consists of an area of bone called the laminae.
  • On the back part of the vertebrae are two upper and two lower processes that form the joints connecting the back part of each vertebra. These are the facet joints. They are important for movement between each vertebra and for movements of the entire vertebral column as a unit.

The Discs Of The Back

Between each vertebra are spongy pads, like soft cushions, called discs – or more correctly, intervertebral discs. Each disc has a soft jelly-like center called the nucleus pulposus, which is surrounded by a fibrous outer envelope called the annulus fibrosis. Eighty percent of the disc is water, which is why it is so elastic. Together, a disc with the attached part of the vertebra above and below is considered an intervertebral joint. These joints allow the movement of the back.

Healthy discs are elastic and springy. They make up 20% to 25% of the total length of the vertebral column. Initially, the disc contains about 85% to 90% water, but this amount decreases to 65% with age, resulting in disc degeneration.

The Spinal Cord And The Lower Back

The nerves that come off the spinal cord are called nerve roots. These nerve roots pass through small openings on either side of the connecting vertebrae. Various nerve roots combine to form spinal nerves.

There are five pairs of lumbar (lower back) spinal nerves. The nerve roots that arise from the end of the spinal cord and continue down the spinal canal through the lower part of the spine looks like a “horse’s tail” and are collectively named the cauda equina.

The Ligaments Of The Back

There are a series of ligaments that are important to the stability of the vertebral column. Important to the lumbar spine (lower back) are seven types of ligaments:

  • Anterior longitudinal ligaments and posterior longitudinal ligaments are associated with each joint between the vertebrae. The anterior longitudinal ligament runs along the front and outer surfaces of the vertebral bodies. The posterior longitudinal ligaments run within the vertebral canal along the back surface of the vertebral bodies.
  • The ligamentum flavum is located on the back surface of the canal where the spinal cord or caude equina runs.
  • The interspinous ligament runs from the base of one spinous process (the projections at the back of each vertebra) to another.
  • Intertransverse ligaments and supraspinous ligaments run along the tips of the spinous processes.
  • Joint-related structures called capsular ligaments also play an important role in stabilization and movement.

The Muscles Of The Lower Back

The muscles and tendons of the spine have been described as being a supporting system for the spine, much like a tent supported by guide ropes.

  • A group of back muscles called the erector spinae are an example of these muscles, which form on each side of the spine and consist of three columns. These muscles move the lower back, help straighten the back, provide resistance when a person is bending forward at the waist, and help a person return to the erect position.
  • The multifidus is another important muscle of the lumbar region. This muscle is thick and prominent in the lumbar spine and becomes smaller at its attachments high up the spine. It is an effective lever arm that allows the lumbar spine to bend backward.
  • The interspinales muscles, located on either side of the interspinous ligament, also are active in the backward bending of the lumbar spine.
  • The intertransversarii muscles attach to the transverse processes. These muscles are not only active in backward bending, but also in bending from side to side.
  • The intersegmental muscles are a series of muscles near the bottom of the spine that connect one intervertebral segment to another.
  • The abdominal muscles, located at the front and side of the abdomen, are very important in supporting and protecting the abdominal internal organs. They also play an important role in protecting movement of the vertebral column in backward bending, forward bending, and side bending.

What Causes Back Pain?

Common Causes Of Back Pain

The most common causes of lower back pain are sprains and strains.


Despite their size and strength, muscles of the lumbar spine can rip or tear. This is called a muscle “strain.”

A strain is the result of a heavy load or sudden force applied to the muscles before they are ready for activity. The muscle essentially rips, along with the blood vessels within the muscle tissue. This may cause bleeding into the injured area.

It can take up to two to three hours before sufficient bleeding or irritation sets in to produce significant pain. This can help explain why many people often can tolerate finishing the task at hand, only to suffer from intense pain later.

This tear in the muscle tissue is followed by symptoms such as:

  • Pain
  • Swelling
  • Muscle spasms


Sprains refer to an overstretching of one or more of the ligaments of the back. The ligaments can be stretched beyond their natural integrity and in some cases can completely tear.

It is common to have both ligament sprains and muscle strains occurring together. This is especially the case in severe falls and motor vehicle accidents.

Nice To Know:

Acute and intense low back pain often results from unspecific sprains and strains. Acute low back pain from lumbar strains and sprains can be accompanied by sciatica, a term used to describe pain extending down into the buttock and leg from the irritation of a larger nerve exiting the lumbar spine called the sciatic nerve.

Other Conditions Causing Back Pain

Other conditions that can cause back pain include:

  • Disc Injury
  • Spinal Stenosis
  • Osteoarthritis of the Spine
  • Spondylolisthesis
  • Ankylosing Spondylitis
  • Osteoporosis and Fractures of the Lumbar Spine
  • Pregnancy
  • Fibromyalgia

Disc Injury

herniated disc, also called a “slipped disc,” is a disc that bulges out from its position between two vertebrae. There are four types of disc herniation:

  • Disc bulge or protrusion results when the disc bulges out from between two vertebrae without rupturing its surrounding envelope, the annulus fibrosis.
  • Disc prolapse results when the inner jelly-like central part of the disc ( the nucleus pulposis), seeps into the outermost fibers of the surrounding envelope, the annulus fibrosis.
  • Disc extrusion results when a tear occurs in the surrounding envelope of the disc, and the inner jelly-like central part of the disc leaks out of the disc.
  • Sequestrateddisc is the term used when disc fragments are separated from the disc, coming to lie well outside the disc space in the spinal canal.

A herniated disc has the potential to cause compression against a nerve, producing what is called radicular pain. Radicular pain is also called sciatica. This pain is caused by compression of the nerves as they exit the spinal column. The pain may be felt radiating into the buttock or down the leg, and may be accompanied by a sensation of numbness or tingling in the leg.

Spinal Stenosis

Stenosis means a constriction or narrowing. Spinal stenosis refers to narrowing of the spinal canal, a condition usually affecting people over age 50.

It results mostly from degenerative changes, or osteoarthritis, in the spine, particularly from bony formations called osteophytes, which form around the joints of the spine. These bony overgrowths, together with thickening of the ligaments inside the spinal canal, narrow the available space in the spinal canal for the spinal cord and its nerves, and may place pressure on these structures.

The condition may cause back pain and pain in the thigh or leg, that often is made worse with long periods of standing or walking, particularly downhill, as well as weakness in the legs.

When symptoms are severe and persistent, and do not respond to conservative therapy, surgical treatment may be necessary to take pressure off affected nerves.

Osteoarthritis Of The Spine

Osteoarthritis refers to joint damage that results from “wear and tear.” The cartilage (the tissue that lines the joints) between the vertebrae may become increasingly damaged. This may affect a single joint or any number of the joints of the spine. These changes to the joints are also known as degenerative changes.

The main features of osteoarthritis of the spine are the development of bony outgrowths, called spurs, along the junction of vertebral bodies and discs. This is believed to be a natural result of stresses applied to the spine throughout life. Other features are narrowing of the joint due to the loss of cartilage between the affected vertebrae, and sometimes small areas of erosion of the bone beneath the joint.

Nice To Know:

Degenerative changes in the disc are probably related to aging. Any trauma in addition to these changes may speed up the process of degeneration. For example, an injury that causes a fracture to the vertebrae near the disc can make the disc more likely to degenerate in the future.


Spondylolisthesis is a condition in which one vertebra slips forward on the one beneath it. It may result from a number of causes, including trauma to the spine or osteoarthritis (wear and tear) of the spine, or it may have been acquired from birth.

The amount the vertebra has slipped forward on the one beneath it may be minimal or very significant.

  • There may be no symptoms or there may be back pain and the back may feel stiff.
  • If the slip has caused pressure on a nerve root, pain may be felt in the buttocks or thigh.
  • With a major slip, an increase in the bend of the lower back can be noticed (called increased lordosis).

Treatment depends on the severity of the condition and the symptoms. This may range from simple exercises and physical therapy to spinal fusion (hyperlink glossary) to stabilize the spine.

Ankylosing Spondylitis

Ankylosing spondylitis is a type of arthritis that primarily affects the spine. “Ankylosing,” in Greek, means, “causing stiffness and immobility of a joint,” and “spondylitis” means inflammation of one or more vertebrae.

Ankylosing spondylitis causes inflammation of the ligaments and tendons that connect the vertebrae and ultimately results in fusion of the spine. This occurs because the inflammation causes some damage to the bone, and the body heals this damage by growing new bone, which replaces the elastic soft tissue at the back of the spine. This can result in stiffness and pain. In some cases, as the fusion progresses, the spine curves forward, causing a person to stoop.

Ankylosing spondylitis occurs sometimes in people with psoriasis and inflammatory bowel disease.

Stiffness and pain usually begins in the pelvis and at the base of the spine, and progresses upward through the back and to the neck. The back is generally stiff in the morning and improves during the day. Early diagnosis and treatment can control the pain and stiffness.

For more detailed information about Ankylosing Spondylitis, GO TO Ankylosing Spondylitis.

For more information about psoriasis, GO TO Psoriasis.

For more information about inflammatory bowel disease, GO TO Ulcerative Colitis.

Osteoporosis And Fractures Of The Lumbar Spine

Osteoporosis is a condition in which bone density and bone strength decreases, making a person more susceptible to fractures. It is a major cause of bone fractures in postmenopausal women and older persons in general.

Because the signs of osteoporosis are subtle and can be easily missed, many people do not know they have osteoporosis until a bone actually breaks. In many cases it is the vertebrae that fracture, causing back pain or deformity. The hip and wrist are also common sites of fractures resulting from osteoporosis.

After menopause, osteoporosis is much more common in women. Bone loss in the spine results in reduced bone strength, and this can easily lead to fractures of the spine.

For more detailed information about osteoporosis, go to Osteoporosis.


A woman’s body undergoes significant hormonal and physical changes during the nine months of pregnancy. For most women, this can lead to back pain as an unavoidable side effect during this time.

Early in pregnancy, certain hormonal changes result in increased joint laxity. As a result, the spine, abdominal and back muscles, and posture of the low back change and become more relaxed.

Poor posture and poor muscle tone prior to pregnancy can affect how the back adjusts. The lumbar (lower back) curve begins to increase slightly as the pelvis tilts backward. This posture begins to influence the weakened and now fatigued lower back muscles. A woman may experience mildly painful spasms, which can be the first sign of a persistent backache in early pregnancy.

As the pregnancy progresses:

  • The abdomen protrudes.
  • Both gravity and hormonal changes continue to relax the muscles of the low back and abdomen.
  • The increased lumbar curve places stress on the lower back muscles and lumbar spine.
  • The chance of back pain rises significantly with activity.
  • Without treatment, the frequency of muscle spasms and pain may increase.

Back pain during pregnancy can usually be managed with:

  • Using better posture
  • Learning about body mechanics (proper sitting, bending, lifting, etc.)
  • Using an external brace or support
  • Following a proper exercise plan

Sciatica during pregnancy can also develop from the increased size of the baby itself. The growing fetus can place pressure directly on the nerves of the lumbar area, causing direct pressure and pain. Sciatica almost always goes away after delivery.


Fibromyalgia may cause chronic back pain and is believed to be a result of inflammation of the body’s connective tissue. The condition is characterized by widespread muscle pain, fatigue, and multiple tender points on the body.

Fibromyalgia is more common than most people realize. In many sufferers, pain is present most of the time and may last for years. The severity of the pain goes up and down, and the location of the back pain as well as the generalized pain can vary.

Low back pain resulting from a diagnosis of fibromyalgia is real, but can also be subjective. Many people with this condition find that emotional stress makes the pain worse. Fatigue is also a common aspect of this condition. Chronic pain, along with anxiety about the problem and how to get well, can be fatiguing by itself. In addition, the inflammatory process within the body produces chemicals that are known to cause fatigue.

Nice To Know:

In 1990, the America College of Rheumatology developed criteria that health care practitioners can use to diagnose fibromyalgia. According to the criteria, a person is considered to have fibromyalgia if she or he has widespread pain in combination with tenderness in at least 11 of the 18 tender spot (trigger point) sites.


How Are Different Types Of Back Pain Diagnosed?

The cause of the back pain is most often diagnosed through a history and a physical exam. Only 10% of those suffering from acute back pain will require any special diagnostic testing.

In selected cases, clinical tests can help determine the cause and source of back pain. Because most symptoms of acute back pain resolve within four to six weeks, it is important to note that most, if not all, of these tests are not performed unless pain persists for more than four to six weeks.

History and Physical Examination

A physical examination by your physician will address how and when the back pain occurred. The doctor will ask about any earlier back injuries and will ask about your health history. Questions may include:

  • What events, actions, or positions started the pain?
  • Where does it hurt?
  • How long does the pain last?
  • Which activities increase the pain?

All aspects of a person’s history are important, because different conditions may be related to a person’s age and medical background.

The physical exam will also involve a detailed physical examination with particular emphasis on examination of the back. This involves:

  • Testing the range of motion of the spine
  • Determining the area of the tenderness
  • Assessing the strength of the lower limb muscles
  • Testing the power, tone, sensation and reflexes in the legs

“Straight leg-raising test’ is very helpful in determining if sciatica is present. If raising a straightened leg off a couch or examining table is painful, it is likely that the sciatic nerve is irritated.

Nice To Know:

Not all causes of low back pain are due to problems in the spine. Other causes include:

  • Kidney and urinary tract infections
  • Kidney stones
  • Peptic ulcers
  • Disorders of the pancreas
  • Problems with the hip

For more information about kidney stones, go to Kidney Stones

Special Tests

It is no longer routine to order x-rays and other sophisticated imaging tests for people who first develop low back pain. These tests have not been found to be helpful in most instances – and most people with back pain tend to improve within a fairly short time. Thus, these tests are now usually reserved for those people still suffering back pain after four to six weeks.

However, if the history and physical examination suggest a serious cause for the back pain, tests may be ordered immediately. Such circumstances include:

  • People who experience sudden back pain from an injury (especially if they have fallen), in order to rule out a fracture
  • People who experience back pain at night, in order to rule out a tumor
  • People who have signs of an infection in their back; these signs may include fever and night sweats in addition to pain
  • People who have cancer that may have spread to the back
  • People who experience back pain and incontinence
  • Children with back pain
  • Progressive weakness of the legs

These tests include:

  • X-rays
  • Bone scan
  • MRI scan
  • CT scan
  • Myelography (rarely used)
  • Electromyelography
  • Discography

Bone Scans

Bone scans are a method of studying bone structure or function by injecting into the bloodstream a medication that can be detected by a special scanning camera. Bone scans are appropriate for people with acute low back pain when there is the possibility of a spinal tumor, infection, or specific types of fractures.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is used to see internal structures of the body – including bone, discs, and nerves – without the use of x-rays. Magnetic radio frequency energy is used to transmit signals from the body into a computer.

The computer produces exceptionally clear images of the soft tissues and the bones. MRI is especially useful in detecting problems with the soft tissues – for example, problems with the discs in the spine.

An MRI will normally not be ordered unless the pain has persisted for four to six weeks, or neurological changes have been noted like a loss of the ankle reflex. An MRI can detect other problems in the back in addition to those originating in the spine.

Nice To Know:

Between 40% and 60% of people who have no back pain will show disc bulges on an MRI. Therefore, disc bulges on an MRI do not always signify a problem with the disc. A bulging disc usually only causes pain when it actually presses directly on a spinal nerve

For more detailed information about MRI, go to  MRI Scan

CT Scan

CT scans of the spine are sophisticated x-rays in which a computer is used to produce a detailed images of the spine. These images help diagnose specific back problems, including spinal nerve compression. The test is particularly valuable in the diagnosis of spinal stenosis.

For more detailed information about CT Scan, go to CT Scan


A myelogram is a special x-ray of the spine in which dye is injected into the spinal canal. The individual then lies on a table, which tilts in various directions, and spot x-rays are taken. This test helps the physician examine nerve structures that may be compressed within the spinal canal or as the nerve root exits the spinal canal. This test is often followed by a CT scan.

The myelogram is an invasive technique and carries an increased risk for complications. Because of this, this procedure is rarely used and has been replaced by MRI and CT scans.


Electromyography (EMG) and nerve conduction studies may be useful for people whose back pain radiates down the leg and has lasted more than three to four weeks. Very thin needles are placed into the muscle in order to test the nerves and study the response time of the muscle. This testing is a powerful tool for assessing nerve involvement.

Nerve conduction tests are not normally performed until pain and neurological signs prove to be continuous, or muscles appear to be weak.


A procedure called discography involves an x-ray of the spine after a dye is injected into a disc space thought to be the source of the pain. Discography is an invasive procedure. However, some physicians find it useful in pinpointing a particular disc space as the source of pain, and will suggest this test for individuals who are planning to have back surgery. It is not commonly used any longer.

What Are The Symptoms Of Back Pain?

The type and severity of the back pain will depend on the condition that’s causing the pain. However, various causes of back pain may produce similar symptoms.

Low back pain may come on suddenly or gradually.

  • When low back pain is intense or “acute,” it usually lasts a brief period such as a few days to several weeks.
  • Low back pain lasting longer than three months is termed “chronic.”
  • Low back pain may or may not radiate down into the leg.

Pain from injury to the muscles or ligaments of the back is usually confined to the back, and depending on the cause may or may not be aggravated by bending the back.

Pain from pressure on the sciatic nerve due to a herniated disc, or any condition that compresses the nerve, may be felt as:

  • Mild pain in the hip or part of the leg, or tingling in these regions
  • A sharp pain down part of the leg, with numbness in certain parts of the leg.
  • Pain that gets worse with sneezing or coughing.
  • Pain that is usually located on one side, but may radiate down both legs if the disc is pressing on the nerve roots to both legs.
  • The pain may be worsened by sitting or standing for long periods

These symptoms may accompany back pain – or they may be felt without any accompanying back pain at all. These symptoms are commonly called “sciatica” – pain radiating into the hip or down the leg – due to the pressure on the nerve roots that make up the sciatic nerve, the great nerve of the leg.

With spinal stenosis (the condition in which the spinal canal is narrowed and the area in the spine where the nerves pass through may be tight), the pain is often felt in both legs as well, particularly when walking. It is sometimes improved when bending forward.

Nice To Know:

Compression in the lower parts of the spinal canal (the cauda equina) by a disc can be serious. Emergency surgery may be required to decompress the nerves. Symptoms may include:

  • Mild low back pain
  • A feeling of numbness in the buttocks or thighs
  • An inability to control urine or stools


How Serious Is Back Pain?

The seriousness of back pain depends on the cause. Tumor, infection, and fractures are serious problems but are rare. Cauda equina syndrome, in which the nerves in the lower part of the spinal canal are compressed for any reason (such as by a herniated disc) or because of spinal stenosis may result in permanent incontinence (inability to control urination) if the compression is not immediately relieved by surgery. In general, when first seeing a patient with back pain, physicians consider that the cause of the pain may be serious if:

  • It wakes a person from sleep.
  • It occurs in children (although many cases of back pain in children prove not to be serious).
  • It occurs along with an inability to control urine or stools.
  • It is accompanied by unexplained fever or weight loss
  • It occurs in someone with a history of cancer

But back pain may have long-term, adverse effects on the quality of one’s life. While most causes of back pain are certainly not life threatening, chronic back pain can be life-altering. For many individuals who suffer from chronic back pain, the condition can certainly affect their lifestyle.

Current Treatments For Back Pain

Nearly nine out of ten people with back pain will recover without treatment within the first month. Treatment depends on the condition that is causing the pain. Some of the conventional treatments that have long been used to treat back pain – including traction, corsets, and electrical stimulation – are now accepted to be generally unhelpful for many sufferers, though some do obtain benefit.

Nonsurgical treatments for back pain include:

  • Heat and Cold
  • Exercise (and Pilates)
  • Physical Therapy
  • Spinal Manipulatio
  • Epidural Steroid Injections
  • Medication

Heat And Cold

When a back injury occurs, the use of heat or cold applied to the back may be helpful.

  • Use cold within the first 48 hours after the back symptoms start. Apply a cold pack (or a bag of ice) to the painful area for five to ten minutes at a time. This can control excessive inflammation and provide pain relief.
  • Use heat if symptoms last longer than 48 hours. A heating pad or hot shower or bath can helps relieve muscle tension and pain. Be careful to avoid burns with a heating pad; don’t use it while sleeping.


Exercise is the most important component for the treatment of chronic low back pain. Experts suggest resting the back in the very early stages, but usually not for more than two days, and then beginning an exercise plan as soon as the pain permits, once the worst is over. Appropriate exercises aim to strengthen the back muscles.

Pilates is exceptional for overall strengthening of the core. If you suffer back pain from almost any cause consider joining a Pilates group.

Nice To Know:

What About Bed Rest?

Spending more than a day or two in bed is not recommended. Too much bed rest cause the bones to lose calcium, weakens muscles, and is likely to make your back problem worse.

To strengthen your back after injury – and to help prevent future backaches – try aerobic exercise. Research has shown that low-stress aerobic exercise is an effective form of treatment for back pain.

  • Aerobic exercise releases the body’s own natural painkillers, called endorphins.
  • Exercise speeds up back rehabilitation and has been shown to help reduce the risk of future back injuries.
  • In addition, the more fit a person is, the more discomfort he or she can tolerate.

It is important to start any exercise program slowly and to gradually build up the speed and length of time of the exercise. At first, symptoms may worsen as one increases activity. Usually this is nothing to worry about, but if pain becomes severe, contact your physician.

Activities that can be performed without putting much stress on the lower back include:

  • Walking short distances
  • Using a stationary bicycle
  • Water aerobics or swimming

Physical Therapy

Physical therapy offers a wide range of treatments for back problems. Physical therapy treatments have four main goals:

  • Relieve pain
  • Accelerate natural healing processes
  • Increase strength and flexibility of back muscles and ligaments
  • Help prevent future episodes of back pain

Types of treatment used by the physical therapist will depend on the nature of the condition being treated. Some treatments have not been proven scientifically but can still be helpful in certain individuals. These treatments include:

  • Flexibility and strengthening exercise programs. These types of programs are important to keep the low back muscles flexible and strong. They are among the main safeguards to prevent future back injuries. It is important to begin slowly and progress as tolerated, using pain as your guide. The old adage “no pain, no gain” is not the rule of thumb for the recovery of back pain.
  • Heat. Heat usually is applied when there is a small area of tissue damage and inflammation. Electrical currents can be used to relieve pain and also to stimulate circulation in the deeper tissues.
  • Hydrotherapy. Hydrotherapy involves the use of water to treat physical disorders and may include baths, spas, pools, or shower sprays.
  • Electrical nerve stimulation. This includes transcutaneous electrical nerve stimulation (TENS), in which electrodes are placed on the back to gently stimulate nerves and help alleviate pain. TENS appears to be helpful for some people with spinal stenosis, but has not otherwise been found to be generally helpful. An alternative version delivers the electrical stimulation through acupuncture needles. Treatment generally consists of 45-minute treatment periods three times a day. Most people hardly feel the electrical sensation.
  • Tissue mobilization and massage techniques. Massage and a variety of soft tissue mobilization techniques are being used more often by therapists who specialize in manual therapy. These techniques may be helpful to increase circulation to the area, release muscle spasms, and stretch back tissues.
  • Traction. Traction or spinal stretching equipment has been used to help decrease pressure on the nerve roots and provide a stretch to tight muscles of the back. Some experts, however, question the effectiveness of this technique. While once used commonly, traction has now generally fallen out of favor.
  • Back education. This involves teaching proper posture and lifting techniques as part of a total back care program. This information helps people to adapt and adopt the right attitudes toward the body and its functional use.

Spinal Manipulation

This involves manual treatment to apply force to the back to adjust the spine. The aim is to “manipulate” the back, or “realign the spine” in order to restore the range of motion of the back.

Spinal manipulation can be helpful for some people in the first month of low back symptoms. It is unlikely to help those with a disc prolapse and may be unsafe for people who have had:

  • Previous back surgery
  • Back injury from disease affecting the back
  • Malformation of the back

Only a professional with experience in manipulation should do this. This includes chiropractors, osteopaths, and therapists.

With the patient lying on his or her side, the practitioner places one hand on the shoulder and the other on the hip, and applies pressure in opposite directions, thus twisting or rotating the spine. A cracking sound is often heard.

Before having a spinal manipulation, it is important to have a proper medical assessment to be sure there is no serious condition that may be causing the back pain. Manipulations are not generally dangerous, but in people with osteoarthritis, the bony spurs may rarely cause serious complications if the twisting maneuver brings the spurs into contact with and damages the spinal cord or nerves.

Epidural Steroid Injections

Epidural steroid injections involve injecting medication directly into the spine, as a way to reduce swelling and relieve pain. These injections do not work well for everyone with back pain, but they can be helpful for some people in whom other therapies have not been effective but who wish to avoid surgery.


Medicines for back pain can be purchased over-the-counter (OTC) or are prescribed by a physician. Their purpose is to relieve pain and reduce inflammation.

OTC pain relievers include acetaminophen (Tylenol) and aspirin.

  • Acetaminophen generally is considered safe, although it may pose risks to the kidneys or to the liver in some individuals with liver disease.
  • Aspirin is a popular medicine because of its ability to relieve pain as well as inflammation (swelling, redness). However, aspirin is not suitable for people who have had a stomach ulcer or aspirin allergy. Children should never take aspirin because of the risk for a rare but serious condition called Reye’s syndrome.

OTC nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain as well as inflammation. There are a wide variety of NSAIDs to choose from, including:

  • Diclofenac (Cataflam, Voltaren)
  • Diflunisal (Dolobid)
  • Etodolac (Lodine)
  • Flurbiprofen (Ansaid)
  • Ibuprofen (Advil, Motrin)
  • Indomethacin (Indocin)
  • Ketoprofen (Actron)
  • Meclofenamate (Meclomen)
  • Nabumetone (Relafen)
  • Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
  • Orudis, Oruvail
  • Oxaprozin (Daypro)
  • Phenylbutazone
  • Piroxicam (Feldene)
  • Salsalate (Disalcid)
  • Sulindac (Clinoril)
  • Tolmetin (Tolectin)

Unfortunately, NSAIDs have been characterized as having a “double-edged sword,” since gastrointestinal (GI) complaints – which range from stomach upset to ulceration and bleeding – are common side effects of these medicines.

  • Such complaints sometimes can be controlled by taking the NSAID with food or by using antacids between meals.
  • However, if GI problems are more than mild or are long-lasting, the physician may prescribe an NSAID that causes fewer GI side effects (for example, salsalate).
  • NSAIDs also can cause kidney damage, worsen blood pressure (with salt and fluid retention), and contribute to bleeding by affecting the platelets (clotting elements in the blood).

NSAID partners may be prescribed by a physician to lessen the side effects of NSAIDs. These include:

  • Antacids
  • Misoprostol (Cytotec)
  • Ranitidine (Zantac)
  • Omeprazole (Prilosec)

COX-2 inhibitors are new medications that reduce pain without causing the ulcer disease and at least partially preventing the GI complaints associated with NSAIDs. These medicines, which are available by prescription only, include:

  • Celecoxib (Celebrex)
  • Rofecoxib (Vioxx)

Nice To Know:

Researchers have discovered two cyclooxygenase (“COX”) enzymes within the body:

  • the COX-1 enzyme releases prostaglandins (fatty acid molecules) that help to form a protective coating within the digestive tract, and
  • the COX-2 enzyme releases prostaglandins responsible for pain and inflammation.

Current NSAIDs inhibit both enzymes. Since inhibition of COX-1 leaves the stomach lining vulnerable, NSAIDs may promote side effects such as stomach ulcers and bleeding. By contrast, inhibition of COX-2, while providing pain relief, is less like to cause stomach ulcers or bleeding.

COX-2 inhibitors – a new class of medications – have been developed to manage the pain and inflammation of arthritis without the negative side effects of NSAIDs. Of three products initially approved for use in the United States, only celecoxib (Celebrex®) is currently available by prescription. In 2004, Merck & Co, Inc.voluntarily recalled rofecoxib (Vioxx®) after studies showed it was associated with increased risk of heart attack, stroke, and other cardiovascular events compared to placebo. Another drug, valdecoxib (Bextra®) was withdrawn from the U.S. market by its manufacturer, Pfizer, in 2005. Valdecoxib was withdrawn after it was linked to stroke, heart attack, and serious skin reactions.   Long-term studies of these medications are needed to fully understand their impact upon arthritis patients.

Muscle relaxants sometimes are prescribed for back pain if muscle spasms contribute to a person’s discomfort. These include:

  • Cyclobenzaprine (Flexeril)
  • Carisoprodol (Soma)
  • Methocarbamol (Robaxin)

Nice To Know:

Many medicines prescribed for low back pain can make people feel drowsy, especially muscle relaxants. These medicines should not be taken if you need to drive or operate heavy equipment. It is important to discuss with your physician all the benefits and risks of any medicine prescribed. If side effects (such as nausea, vomiting, rash, dizziness) develop, you should discuss other options with your healthcare provider.


Surgery For Back Pain

Surgery is an absolute last resort for the treatment of back pain (unless it is required for a surgical emergency).

Your physician may suggest that you consider surgery if you continue to experience considerable pain despite nonsurgical treatment and if the cause of your back pain is due to something that can be surgically corrected.

  • Surgery is an option in the case of a proven herniated disc that is causing the pain. Treating a herniated disc involves decompressing the nerve in the back that is causing the pain.
  • Traumatic conditions such as fractures of the spine and dislocations may require surgery.
  • Painful spondylolisthesis where one vertebra slips forward on the one beneath it, may also be a reason for surgery.
  • Neurologic deficits caused by nerve compression or instability may require surgery.

Nice To Know:

Fewer than 1 in 100 people ever require surgery for back pain. The determining factor should be whether the pain is significantly affecting a person’s day-to-day living and enjoyment of life, and whether if left alone, the condition can deteriorate to become more serious.

Most experts agree that in the past, too much surgery was done for back problems, and many people were not helped by it. Some were made worse. The key, physicians now realize, is the proper selection of the individuals who would benefit most from surgery.

Types of back surgery include:

  • Surgery for Disc Problems
  • Surgery to Stabilize the Spine
  • Surgery to Create More Space in the Spine

Surgery For Disc Problems

To determine who would benefit from back surgery to decompress a nerve due to pressure from a herniated disc, the following criteria are usually accepted by most physicians. The individual must:

  • Have a disc pressing on a nerve root, as shown by an MRI or CT scan
  • Have consistent pain despite conservative treatments, including a prescribed exercise program
  • Have severe pain radiating into the buttock or leg, (sciatica ) that does not decrease with conservative treatment such as physical therapy and medication, after 4 to 6 weeks of conservative treatment
  • Have neurological warning signs, like loss of an ankle reflex or the loss of urinary control (which is a surgical emergency)

There are several options for relieving pressure on a compressed nerve root:

  • Discectomy. Discectomy is one of the most common back operations. It involves removing the protruding disc, either a portion of it or all of it, that is placing pressure on the nerve root. This operation has a very high rate of success. In the classic discectomy, the surgeon makes a small incision over the disc to be operated upon, and removes only the disc material that is pressing on a nerve.
  • Microdiscectomy. Microdiscectomy is similar to discectomy except that it is done with the use of magnification such as an operating microscope and requires a smaller incision. The surgeon removes the disc, freeing the compressed nerve. Microdiscectomy often requires shorter hospital stays.
  • Percutaneous disc removal. This procedure involves removing the problem disc fragment through an endoscope – a small tube inserted through a tiny opening in the skin of the back. A miniature video camera is attached to the tube. Using specially designed surgical instruments on the end of the tube, a surgeon can cut away parts of the disc and remove them by suction through the tube. This leaves structures important to stability practically unaffected.

    This procedure is performed on an outpatient basis (without an overnight hospital stay), and recovery is generally faster and less painful. It is less expensive and does not require general anesthesia.

    However, the procedure does have drawbacks. Because the nerve root and the area outside the disc space cannot be fully visualized by the surgeon, loose disc fragments may be missed. The surgeon cannot be certain that the fragments that are removed were actually what was causing the problem.

  • Laser disc decompression. Laser disc decompression involves an approach similar to percutaneous disc removal. However, laser energy is used to remove the disc tissue. The laser energy is introduced through a needle to destroy a small amount of nucleus pulpous, thereby reducing the pressure on the nerve.

    Laser disc decompression is a relatively noninvasive procedure that takes place in an outpatient setting, and it is performed under local anesthesia with a short treatment time of approximately 30 minutes. However, results using this technique at this stage have not been impressive.

  • ChemonucleolysisChemonucleolysis is an alternative to surgical removal of the disc. Chymopapain, which is prepared from the papaya plant, is injected into the disc space to reduce the size of herniated discs. The resulting decrease in the size of the disc releases pressure on the nerve root. The injected disc tends to redevelop itself with normal tissue. Because of serious side effects, this procedure is not as common as it was once was in the U.S., but some physicians still do perform it.

Surgery To Stabilize The Spine

Spinal fusion is a process in which two vertebrae are goined together. Bone grafts are placed between or alongside the vertebrae, to join the bones together. Metal plates and screws are often used to attach the bones to be joined as an internal brace.

Fusion occurs when the adjacent bones growing together to form a single bone. A single level may be fused, (for example, the vertebrae across one disc space) or multiple levels, depending on the condition.

This approach can return normal alignment and strength between the vertebrae in individuals whose intervertebral structures are unstable because of a fracture or other condition such as spondylolisthesis.

A new fusion technique employs a small hollow metal cage that is packed with bone graft and placed in the disc space.

Surgery To Create More Space In The Spine

Laminectomy is a surgical procedure that involves removing the laminae parts of the vertebrae. These are the areas of bone in the back of the vertebrae.

When the lamina is removed, more space is created in the spinal canal. This decompresses (that is, takes the pressure off) the nerves or spinal cord. This procedure is especially helpful for people with spinal stenosis, in which the narrowed spinal canal lacks adequate space for the spinal cord or nerves, causing pain in the back and buttocks and weakness in the legs.

Laminotomy refers simply to the creation of a small window in the lamina, rather than removing the lamina, in order for the surgeon to reach the disc or spinal canal. This is commonly done when performing a discectomy (removing a disc).

Should I Have Back Surgery?

In certain cases, surgery can significantly help back pain sufferers. For many, it can completely abolish the pain; for others, it can greatly reducing the level of pain suffered daily. But surgery is always a last resort, offered when conservative treatments have failed (unless there is an emergency indication for surgery).

Back surgery has suffered an unhappy reputation over the years. Yet there are large numbers of people throughout the world whose back pain has been abolished or greatly relieved through surgery. However, there are many people whose back pain was not at all improved after surgery, and sometimes even made worse.

Why do some surgeons have such good results with their patients who have had back surgery and others often not quite as good results? The answer is simply  “correct patient selection” –  if surgery is undertaken for the correct reason in the appropriate patient, good results can generally be expected.

So how does a doctor decide that a particular patient’s back pain is likely to respond well to surgery? Here are the guidelines that guide an experienced back surgeon to make a decision whether or not to offer back surgery to someone with back pain. Every one of these conditions should apply:

  • You have a back condition that can be helped by surgery, based on detailed specialized imaging tests. Most causes of back pain are not good reasons for surgery.
  • The pain is definitely caused by the abnormality shown on the imaging tests. For example, most disc bulges seen on MRI do not cause symptoms and are usually coincidental to the back pain.
  • Your symptoms have not been helped by conservative therapies including medication and physical therapy. For example, despite six weeks of intensive treatment for a proven herniated disc, the severe pain continues.
  • The back pain significantly affects your day-to-day living. You are unable to do your daily chores or work due to the back pain.
  • You have a positive outlook about what’s involved with surgery.
  • You have chosen a skilled, experienced back surgeon.

If all these conditions are strictly adhered to, the outcome of the back surgery is very likely to be successful. But when these conditions are not strictly met, the outcome is unlikely to be successful, and the complication rate of the surgery increases.

What Is The Long-Term Outlook?

About 90 percent of people with acute low back problems will recover in one month. Sprains and strains of muscle and ligaments usually respond well to conservative treatment without any significant long-lasting effects. Mild pain does not justify surgery, and there’s little concern of irreversible changes occurring in the nerve.

However, it is not uncommon for a person to experience more than one episode of back pain. Whether the pain will recur depends in large part on the initial cause. It’s difficult to predict which people will have repeated episodes of back pain.

Nice To Know:

It is important to return to work and other daily activities as quickly as possible after experiencing back pain.

  • More than half of people with back pain return to work in a week.
  • About 90% of people with back pain return to work within three months.
  • But in people who remain on disability for longer than a year, about 75% will not return to work again. This puts them at risk for becoming significantly depressed.

The best way to prevent low back pain is to stay fit. You should continue with an exercise plan, even after your back seems better. Exercise has many other health benefits as well.

How To Information:

Back Tips

Here are some simple things you can do to help prevent low back pain:

  • Lift with objects held close to your body.
  • Avoid lifting while twisting or bending forward and reaching.
  • Wear comfortable, low-heeled shoes.
  • Keep work surfaces at a comfortable height.
  • Use a chair with a good lower back support that reclines slightly.
  • If sitting for long periods is unavoidable, try resting your feet on the floor or on a low stool, whichever is more comfortable.
  • If standing for long periods of time is unavoidable, try resting one foot on a low stool.
  • If driving for long distances is unavoidable, try using a pillow or rolled-up towel behind the small of your back. Also, be sure to stop frequently (every one to two hours) and walk around for a few minutes.
  • If you are having trouble sleeping, try sleeping on your back with a pillow under your knees, or sleep on one side with your knees bent and a pillow between your knees.


Frequently Asked Questions

Here are some frequently asked questions related to back pain.

Q: What is a slipped disc?

A: This is actually a mislabeling that refers to a herniated disc. In a herniated disc, the nucleus pulposus perforates the annulus fibrosis – but the entire disc does not “slip” out of place.

Q: Back pain wakes me up at night. Are there any correct positions to sleep at night that will benefit my back?

A: Try to avoid sleeping on your stomach. However, if you find yourself in this position often, try placing a pillow under your stomach to maintain support of the lumbar spine. A pillow between the legs can be a good support when lying on your side. A pillow under the knees is often helpful when lying on your back.

Q: Do elastic back supports help prevent back pain?

A: There is probably as much controversy about back supports as there are back supports. Thin neoprene supports may help abdominal muscles support the lumbar spine. If you feel as if it helps you be more conscientious about proper lifting mechanics, then the support may be worthwhile. More rigid braces are helpful when there is a need to restrict lumbar motion, as may be the case in compression fractures and significant strains or sprains. Keep in mind, however, that no back support is intended to replace a good back-strengthening program.

Putting It All Together

Here is a summary of the important facts and information related to back pain.

  • Back pain is common and is one of the leading reasons why people see a physician in the U.S.
  • Back pain carries steep economic costs annually in medical treatments and disability payments.
  • Rarely do people develop significant problems with the bones or joints in their back.
  • Unspecific sprains and strains account for much of acute and intense low back pain.
  • Sciatica is a term used to describe pain extending down into the buttock and leg from the irritation of a larger nerve that exits the lumbar spine.
  • Clinical diagnostic tests used to determine the cause of back pain include x-rays, magnetic resonance imaging, CT scans, myelography, and electromyography.
  • Common treatments used by health care professionals include heat, hydrotherapy, electrical stimulation, mobilization, massage techniques, traction, education, and flexibility and strengthening exercise programs.
  • In order for an individual to be a candidate for back surgery, most physicians feel the individual must have severe sciatica, imaging tests that indicate a disc is pressing a nerve root, and muscle weakness in the leg.
  • The best way to prevent low back pain is keep the back muscles flexible and strong with a good exercise program.

Glossary: Back Pain

Here are definitions of medical terms related to back pain.

Annulus fibrosis: Cartilage-like material formed in a series of rings surrounding the nucleus pulposus (soft center) of a disc.

Cauda equina: A region at the lower end of the spinal column in which nerve roots branch out in a fashion that resembles a horse’s tail.

Cervical: The neck region where the vertebrae (bones of the spine) curve forward.

Chemonucleolysis: A surgical procedure in which an enzyme is injected to dissolve a portion of the intervertebral disc.

CT scan: A sophisticated x-ray using a computer to produce a detailed cross-sectional three-dimensional picture of the bone and discs.

Discectomy: Surgical removal of part or the entire herniated intervertebral disc.

Electrical nerve stimulation: A type of physical therapy treatment that utilizes various frequencies and wave forms of electrical current, which have therapeutic effects on the nervous and musculoskeletal systems.

Electromyography (EMG): Procedure that tests nerves and muscles providing information to help determine if surgery may be required.

Herniated disc: A disc that is displaced from its position between two vertebrae, with injury to the annular ligament.

Ligament: Strong, dense structures made of connective tissue that stabilize a joint, connecting bone to bone across the joint.

Low back pain: Pain at the base of the spine that can be caused by several factors.

Lumbar: The low back region that curves forward in the same direction as the cervical spine.

Magnetic resonance imaging (MRI): Magnetic radio frequency energy used to see internal structures of the body, including bone, discs, and nerves without the use of x-rays.

Nucleus pulposus: Soft center of an intervertebral disc, made up of gel-like substance.

Osteophyte: A small, abnormal bony outgrowth.

Prolapsed disc: A disc that bulges out from its position between two vertebrae.

Ruptured disc: A disc with a torn annulus (the tough outer covering of a disc).

Sciatic nerve: The nerve that serves the legs and originates from several levels of the lower back.

Sciatica: An inflammation of the sciatic nerve usually marked by tenderness along the course of the nerve through the buttocks, thigh, and leg.

Spinal cord: The column of nerve tissue that runs from the brain to the lower back.

Spinal fusion: A process in which the disc and cartilage is removed from between the vertebrae, and bone grafts (often harvested from the pelvis) are placed between or alongside the vertebrae to join the bones together.

Stenosis: Narrowing of a portion of the spinal canal, usually because of bony overgrowth.

Tendons: White glistening fiber bands of tissue that attach muscle to bone.

Thoracic: The trunk region where the vertebral column curves in a rearward fashion.

Vertebrae: The 24 block-shaped bones that make up the vertebral column.

Vertebral column: Flexible structure that forms the “backbone” of the skeleton, arranged a straight line from the base of the skull to the tailbone; also called spine.

Additional Sources Of Information

Here are some reliable sources that can provide more information on back pain.

Academy of Orthopaedic Surgeons 
Phone: 847-823-7186
Phone: 800-346-2267

Physical Therapy Association 
Phone: 800/999-APTA (2782)

American Chronic Pain Association 
Phone: (916) 632-0922
Fax: (916) 632-3208

American Pain Society 
Phone: 847/375-4715
Fax: 847-375-6315 

Academy of Pain Management 
Phone: (209) 533-9744

California Orthopedic Institute 
Phone: (818) 901-6600 

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