Low Back Pain
Low back pain is an extremely common problem. Up to 80% of people experience at least one episode of back pain in their lifetime, with about one-quarter experiencing an episode of back pain in any given year (1). It is one of the most common reason for all physician visits in the United States (2). Although most people recover from episodes of low back pain fairly quickly, a small proportion develops back pain that doesn’t go away and leads to persistent inability to work or participate in normal activities. In subacute (between acute and chronic) low back pain, there is usually some improvement in symptoms, though less dramatic than seen in the first few weeks.
The back is very complicated and consists of a number of structures, including bones, muscles, nerves, discs, and other tissues. These structures all work together to support the body and allow us to stand, bend, and perform other movements. The bones of the back are called the vertebrae. Together, the vertebrae are connected to each other at joints (called the facet joints) to form the spinal column, which protects the spinal cord. The spinal cord is connected to the brain and is where the nerves needed for movement, sensation, and other functions originate.
There are four parts of the back: cervical (neck), thoracic (upper back), lumbar (lower back) and sacrum/coccyx (tailbone). There are five lumbar vertebrae, numbered from top (L1) to bottom (L5). The sacrum and coccyx are fused to form the tailbone and are below the fifth (lowest) lumbar vertebra. This write-up focuses on low back pain, or pain that occurs in the lumbar and sacral area of the back, which is the most common location for back pain.
Low back pain is categorized as acute (duration of symptoms less than 4 weeks) or chronic (duration of symptoms more than 3 months). This distinction is important because low back pain tends to stop improving on its own after 3 months (3). In between acute and chronic is subacute (4 weeks to 3 months) low back pain.
In between each pair of vertebrae is an intervertebral disc. This disc consists of a soft, gelatinous, inner material surrounded by a tough outer covering. The purpose of the intervertebral discs is to help cushion and protect the bones in the back. Each pair of vertebrae is also connected at joints (facet joints), one on each side. The nerves that come off the spinal cord pass through spaces between the vertebrae called intervertebral foramina. Although the spinal cord doesn’t reach all the way to the bottom of the spinal column, the nerves continue to come out through these openings all the way down to the sacrum. The bundle of nerves after the end of the spinal cord resembles a horse’s tail and is called the cauda equina.
“Non-specific” low back pain is used to describe back pain that can’t be attributed to a specific cause; it constitutes the vast majority of cases (more than 80%). It refers to low back pain without leg pain or weakness (which can be a sign of nerve root compression) or clinical or historical findings suggesting a serious underlying condition (such as cancer, infection, or cauda equina syndrome). Back pain is often called “non-specific” even when common degenerative conditions (such as degenerative disc disease, facet joint arthropathy, low-grade isthmic spondylolisthesis [when one vertebra slips forward on the adjacent vertebrae], herniated disc, or spinal stenosis [narrowing]) are seen on x-rays or MRI, because these findings don’t correlate well with the presence (or absence) of symptoms (4).
Sciatica refers to low back pain with radiating leg pain. This can happen when a nerve from the spinal cord is pinched as it comes through its intervertebral foramen. Usually, the leg pain is more severe than the back pain, and occurs on one side, traveling below the knee. Sciatica is the most common symptom of radiculopathy, or dysfunction (usually due to compression by a herniated disc) of a spinal nerve root. Other symptoms and signs of radiculopathy include numbness, weakness, and loss of reflexes in the ankles and knees.
Another condition that can occur with back pain is spinal stenosis, or narrowing around the spinal canal. When this narrowing is severe enough, it can cause symptoms due to compression of the spinal canal or cauda equina. Spinal stenosis is often associated with neurogenic claudication, which refers to leg pain that is usually worse on standing or walking, runs down the back of the buttocks, thigh, and legs, and can occur on both sides. Spinal stenosis is usually worse with standing or walking because this accentuates the narrowing of the spinal cord. It tends to improve with sitting or leaning forward.
This write-up focuses on evaluation and treatment of low back pain in adults. Although some of the principles are similar to those encountered when evaluating children and adolescents, those groups also have their own specific diagnoses and treatments to consider.
What causes low back pain?
Low back pain can be due to many things. However, in most patients it is not possible to assign a precise cause for back pain. Although degenerative disc disease, arthritis and other abnormalities in the back are common on x-rays and other imaging studies, lots of people without back pain also have these findings (5). Other patients have severe pain but normal x-rays. In addition, getting x-rays or more detailed imaging studies like magnetic resonance imaging (MRI) usually doesn’t help guide treatment or improve pain or ability to function (6). Serious conditions causing back pain are rare in people who don’t have other risk factors or clinical signs (7).
Low back pain without abnormalities on x-rays
Sprains and strains can occur in the muscles and ligaments of the back, just like in other parts of the body, and are a common reason for low back pain. Fibromyalgia and myofascial pain syndrome, which are characterized by presence of localized tender points in the muscles and soft tissues, are also common and can cause pain in the area of the back. X-rays and other imaging studies won’t pick up any of these conditions. Similarly, these conditions can be the cause of back pain even when other abnormalities are seen on x-rays.
Degenerative disc disease
Degenerative disc disease is one of the most common things found when x-rays or other imaging studies of the back are performed. As people get older, the intervertebral discs start to wear down. This can lead to tears in the discs, drying out of the disc with shrinking and hardening, or weakening of the outer membrane leading to bulging of the disc. These changes can also lead to the formation of bone spurs. This condition is referred to as degenerative disc disease.
However, it is somewhat misleading to refer to this condition as a “disease” because these changes occur with normal aging and frequently aren’t associated with any symptoms (5). In fact, more than half of patients over the age of fifty have degenerative discs, even when they don’t have any back pain at all. Many people and healthcare providers blame back pain on degenerated discs, but there is only a loose correlation between degenerative disc disease seen on x-rays or other imaging studies and pain or other symptoms.
Facet joint arthropathy
Facet joint arthropathy is also a common finding. It refers to arthritis in the joints connecting each pair of vertebrae. The arthritis leads to bone spurs and may cause pain. However, like degenerative disc disease, facet joint arthropathy is frequently present in people who have no back pain at all. Just because facet joint arthritis is present doesn’t mean it is necessarily causing the back symptoms. In some cases, facet joint arthropathy can lead to instability of the spine (degenerative spondylolisthesis) or cause sciatica when bone spurs compress nerve roots.
Herniated disc
Herniated disc occurs when the outer lining of the intervertebral disc becomes so worn down or torn that the inner gelatinous material is no longer contained. It is different than a bulging disc, which refers to a disc that bulges out, but the inner gelatinous material is still contained. Bulging discs usually don’t cause any symptoms. Herniated discs, on the other hand, are more likely to cause leg pain or weakness because they occupy more space and can compress an adjacent nerve root. However, herniated discs are often seen in people without any symptoms at all. Herniated discs tend to get reabsorbed by the body, so it isn’t always necessary to treat them with surgery or other invasive procedures even when they cause symptoms from compressing a nerve (8).
Degenerative spondylolisthesis
Spondylolisthesis refers to slippage of one vertebra relative to another. It occurs when the structures that normally hold the vertebrae in place become weakened or disrupted. Degenerative spondylolisthesis refers to slippage that occurs because of facet joint arthropathy and the formation of bone spurs. There are other types of spondylolisthesis, but degenerative spondylolisthesis is the most common, particularly in older persons.
Degenerative spondylolisthesis can cause symptoms when the slippage results in pressure on the nerves (resulting in sciatica) or narrowing around the spinal cord (spinal stenosis). However, like the other conditions described here, degenerative spondylolisthesis can be present but not cause any symptoms at all.
Lumbar spinal stenosis
Spinal stenosis occurs when there is narrowing of the vertebral canal, resulting in pressure on the spinal cord. It is more common in older people, and is usually a result of bone spurs and inflammation from degenerated disc disease or degenerative spondylolisthesis. Spinal stenosis often causes leg pain, though it may also be asymptomatic even when it looks fairly severe on imaging studies. Because narrowing of the vertebral canal is accentuated when the back is in a relatively more extended position, leg pain associated with spinal stenosis often gets worse when people go from a sitting to a standing position (neurogenic claudication).
Uncommon causes of back pain
In rare cases, back pain can be due to a serious problem outside of the back, such as an aortic aneurysm, gallstones, or blood infection. There are usually other symptoms that point to these conditions when they are present. In other rare instances, back pain can be due to a serious problem in the back, such as a tumor, infection, or bone fracture. Another serious condition is cauda equina syndrome, which occurs when the bottom part of the spinal cord is compressed, usually by a large herniated disc. This results in back pain, numbness in the saddle area (inner thighs), and bowel and bladder problems (such as inability to urinate). Other conditions that can cause low back pain include vertebral compression fractures (collapse of a bone in the spine) and ankylosing spondylitis, an inflammatory condition usually diagnosed in younger adults. One of the main goals when assessing people with back pain is to determine whether any of these conditions are likely to be the cause of symptoms, as they are each treated differently.
What are risk factors for low back pain?
There are a number of risk factors for low back pain. They include smoking, obesity or sedentary lifestyle, previous history of back pain, physically difficult work, work stressors, improper lifting or work ergonomics, and presence of depression or anxiety (9, 10). It makes sense to try to deal with these issues through exercise, smoking cessation, proper lifting techniques, ergonomics, and appropriate counseling or treatment in order to reduce the likelihood of developing low back pain. Although there isn’t strong evidence that these methods are effective for preventing low back pain episodes, they may be helpful for the back and are likely to improve general health and well-being.
What is the prognosis of low back pain?
The course of acute low back pain is generally quite favorable, with the vast majority of patients experiencing substantial improvement in pain and return to normal activities and work within the first four weeks (3). This is true for low back pain either with or without sciatica. Continued but slower improvement is usually seen through the first three months after an episode of low back pain begins. About 90% of patients with acute low back pain stop consulting their doctor for it within three months.
Although acute low back pain episodes usually resolve fairly quickly, recurrences of low back pain are common. In addition, a small proportion of patients develop back pain that lasts longer than three months. In some patients, chronic low back pain can be disabling and prevent return to work and normal activities. Risk factors for chronic disabling back pain include presence of depression, fear that movements or activities will make back pain worse, job dissatisfaction, stress at home or work, higher disability levels, presence of disputed compensation claims, and presence of somatization (3, 11). There is a lot of research looking into ways to identify patients who are at higher risk for developing chronic disabling back pain and ways to prevent it, possibly by targeting therapies at specific risk factors.
How should low back pain be evaluated?
Guidelines for evaluation of low back pain recommend that healthcare providers carefully evaluate for risk factors or clinical signs suggesting a serious condition and perform a focused neurologic examination, looking for signs of weakness or other neurologic dysfunction (12). Diagnostic testing such as x-rays or MRIs are not recommended in the majority of patients, particularly for acute low back pain.
History and physical examination
A healthcare provider will ask when the back pain started, if there was an identifiable cause (heavy lifting or fall), what helps or worsens the pain, and if there is pain or any weakness/numbness in the legs or feet. It is also important to inquire about risk factors or clinical signs that a serious conditions might be present, such as previous history of cancer, weight loss, or night sweats (for cancer); fevers, history of intravenous drug use (for infection); history of osteoporosis or chronic corticosteroid use (for vertebral compression fracture); and trouble urinating or numbness in the saddle (inner thigh) area (for cauda equina syndrome) (13). In younger patients, morning stiffness can be a sign of ankylosing spondylitis.
The healthcare provider will ask about stress at work or home, depression, anxiety, severity of pain, ability to work or perform normal functions, and what you are doing to cope with the low back pain. This can help in the evaluation of factors that might be contributing to the low back pain.
The physical examination generally focuses on evaluating the appearance of the back and posture; range of motion of the back; strength, sensation, and reflexes in the legs, feet, and ankle; and ability to walk and to get up from a sitting position. When someone reports back pain radiating into the leg, a straight leg raise test, which involves lying on the back and lifting the leg to see if it reproduces the leg pain can help determine if a nerve is being pinched. The healthcare provider will usually palpate the back to evaluate tender spots, though this hasn’t been shown to be a reliable predictor for the source of back pain. Other items may be performed on the physical examination if there are signs or symptoms of a specific or serious underlying condition.
Imaging tests
Because most people with acute low back pain with or without sciatica improve rapidly, there is usually no need to get x-rays or more advanced imaging studies (such as MRI or computed tomography [CT]) (5). Studies have shown that routinely getting x-rays doesn’t help people get better faster, exposes people to unnecessary radiation, and could lead to unnecessary procedures down the road. Situations when imaging of the back is warranted are when there are risk factors for a serious underlying condition such as cancer, infection, or cauda equina syndrome, or when there is severe or progressive weakness (12). X-rays can be helpful if there are risk factors for ankylosing spondylitis (such as younger age with morning stiffness and decreased spinal mobility) or compression fracture (such as corticosteroid use or history of osteoporosis).
In people with persistent (longer than 4 to 6 weeks), disabling back pain with radiculopathy or neurogenic claudication, an MRI or CT can be helpful to determine whether there is a herniated disc or spinal stenosis. MRI or CT is more helpful than a plain x-ray in these cases because it provides better detail and visualization of the discs, spinal cord, and nerve roots. An MRI or CT will be most helpful if surgery or other invasive procedures are being considered. In people without signs of radiculopathy or neurogenic claudication or who aren’t interested in surgery or other invasive procedures, it isn’t clear that imaging tests need to routinely be obtained, as long as there are no progressive neurologic symptoms or signs of a serious underlying condition. One study found that routinely getting MRI or CT for chronic low back pain had only a small effect on improving patient symptoms (pain and ability to function) and did not help guide therapies or change diagnoses (6, 14).
Other diagnostic tests
Other tests may be considered in patients with persistent low back pain. Some lab tests can help determine the presence of infection or cancer. Nerve conduction tests can evaluate how well the nerves are functioning, and can be helpful when the MRI or CT is equivocal or borderline for showing nerve root compression, or when it is not clear if nerve root compression seen on imaging studies matches up with symptoms.
Several tests involving injections into various parts of the back are sometimes used in patients with persistent low back pain. These include provocative discography, facet joint blocks, medial branch (the nerve innervating the facet joint) block, sacroiliac joint block, and selective nerve root block. In theory, the results of these tests could help guide therapies by identifying the specific source of low back pain. However, the accuracy of these tests for diagnosing different sources of pain is unknown, and no studies have shown that using these tests helps guide subsequent therapies or improves patient outcomes compared to making treatment decisions based on history, physical examination, and non-invasive imaging studies .
How should low back pain be treated?
Self-care
Many people with acute low back pain will improve over the first few weeks even if they don’t do anything for it. However, they can do several things on their own to help cope with symptoms and possible speed their recovery. These are some things that everyone can do to help the back without necessarily seeing a healthcare provider.
* Remain active: Remaining active is one of the best things to help with recovery. In the past, healthcare providers used to tell patients to rest in bed. This has been shown to be the wrong advice (15). In fact, people who remain active and stick with their usual activities improve more and return to work faster than people told to rest in bed. Although many people are afraid that they will hurt their back further by remaining active, that is not the case. Regularl activities probably help relieve muscle spasm and keep the back muscles strong. Although high-impact activities should be avoided, it is fine to continue regular day-to-day activities and light exercises like walking. If certain activities make the back hurt too much, they should be stopped and other activities or rest tried for a short period of time.
* Home exercise programs: Once back symptoms have started improving, a home exercise program can help strengthen and improve the flexibility of the back. These include low-impact activities such as walking, bicycling, swimming, and low-impact aerobics. Activities that involve twisting, bending, or are high impact could make the back pain worse, and should be avoided until the back is significantly better. Although it isn’t known which specific back exercises are best, it’s reasonable to try several different stretching and strengthening exercises and stick with the ones that seem to help the most. For people with frequent back pain episodes, doing back exercises regularly may help prevent future episodes.
* Heat: Using a heating pad can help with low back pain during the first few weeks (16). It isn’t known if a cold pack is helpful.
* Mattresses: Some people believe that it is helpful to sleep on a hard board or use a hard mattress to improve back pain. However, one study found that a firm mattress was associated with less improvement than using a medium-firm mattress (17). In general, if the mattress is comfortable for everyday use there is probably no need to change the mattress or where you sleep because of an episode of back pain.
* Lumbar supports (back supports, corsets, or braces): Though many people use them, it is not known if back supports help in the recovery from a low back pain episode, though they might prevent future episodes of back pain (18).
When to seek help
Many people with low back pain will improve with self-care therapies. However, in some cases it is important to see a healthcare provider. Some situations when people should seek medical advice include:
· Back pain with new or progressive weakness in the leg or foot.
· Presence of fevers, weight loss, or night sweats (can be due to cancer or an infection in the back).
· Presence of risk factors for vertebral compression fracture (such as corticosteroid use or history of osteoporosis).
· Back pain that doesn’t go away, even with rest or with sleep (can be due to cancer).
· Bowel or bladder problems (e.g., difficulty urinating or holding urine), which can be a sign of cauda equina syndrome.
· Very severe back pain that isn’t manageable despite self-care.
· Failure of back pain to improve after 3 or 4 weeks of self-care.
· People who have an impaired immune system, a previous history of cancer, or who use intravenous drugs.
Medications
Medications can be helpful for controlling the symptoms of low back pain. In fact, pain medications are one of the few therapies shown to be helpful for acute low back pain. However, all medications, even over-the-counter drugs, are associated with risks as well as benefits. If self-care options are helping or there is a preference for non-medication therapies, there is no need to use medications. If medications are used, the general principle is to choose medications that are least likely to cause problems but control pain enough to improve ability to work and perform daily activities (19). It is not realistic to expect any medication will take the back pain completely away.
* Pain medications: Over-the-counter medications such as aspirin, acetaminophen (Tylenol), and ibuprofen (Motrin) or naproxen (Aleve) are mild pain relievers and usually safe when used at recommended over-the-counter doses for a short period of time. They are considered first line medication options for most people with low back pain. However, people with a history of bleeding, heart problems, kidney problems, or liver problems should talk to their healthcare provider before taking even an over-the-counter medication. Stronger medications include prescription-strength non-steroidal anti-inflammatory drugs (such as ibuprofen and naproxen) and opioids. Opioids are considered the strongest type of pain medication. However, they are associated with a number of serious side effects including constipation, nausea, sleepiness, and can lead to addiction or abuse. They are reserved for people with severe pain and require closer monitoring by healthcare providers.
* Skeletal muscle relaxants: A number of skeletal muscle skeletal muscle relaxants are available. They can help with pain and improve function, but are probably no better than simple pain relievers like acetaminophen or ibuprofen and frequently cause drowsiness. Muscle relaxants are generally a second line medication option, and may be most helpful when used before bedtime for a short period of time. Benzodiazepines (such as valium) have also been used as muscle relaxants, though they aren’t approved by the U.S. Food and Drug Administration for this purpose. They also cause drowsiness and can cause addiction when used for extended periods.
* Gabapentin: Gabapentin is an antiseizure medication used for treatment of neuropathic (nerve-related) pain due to diabetes or shingles. It may be helpful in people with radiculopathy or spinal stenosis, but there are so far only a few small studies showing relatively small benefits.
* Antidepressants: Certain antidepressants (tricyclic antidepressants such as amitriptyline, nortriptyline, and desipramine; venlafaxine; and duloxetine) are thought to have effects on chronic pain. However, there is conflicting evidence on how effective they are for chronic low back pain. In general, antidepressants are not considered a first-line option for treatment of low back pain because they are all associated with side effects and benefits appear to be small. However, depression and anxiety are very common in people with low back pain, and should be treated appropriately.
* Other medications: Taking corticosteroids (either by mouth or by intramuscular or intravenous injections) is not effective for low back pain. Botulinum toxin injections may be helpful for short-term pain relief, but there are few good studies and long-term follow-up data are lacking. Botulinum toxin is also very expensive.
Nonpharmacologic therapies
A number of nonpharmacologic therapies are used for low back pain. They can be used as alternatives to medications for people with chronic low back pain, or can be used in conjunction with medications. In general, there are several nonpharmacologic therapies that appear to be similarly effective (20). They are all associated with moderate benefits that are similar to medications. Patient preferences are important when choosing nonpharmacologic therapies, as people who believe that a specific therapy is more likely to be effective than others tend to do better with that therapy. The therapies also vary widely in cost and other factors (such as number of visits required and discomfort while receiving therapy).
* Spinal manipulation: Spinal manipulation is a technique used by physical therapists, chiropractors, osteopathic physicians, and others. It involves moving the joints in the spinal column beyond the normal range of voluntary movement. Spinal manipulation of the lower back appears to be safe and effective for treatment of low back pain, but has mainly been studied for chronic low back pain (21). The optimal course of therapy is not known, though most clinical trials evaluated spinal manipulation 2-4 times a week for several weeks.
* Acupuncture: Acupuncture involves inserting needles into specific points on the body, as determined by traditional Chinese beliefs regarding the flow of the body’s energy. Acupuncture may be effective for chronic low back pain, though some studies have shown that inserting needles into non-acupuncture points is just as effective as “real” acupuncture (22, 23). This has caused some people to question whether effects of acupuncture are real, or due to a placebo effect.
* Exercise: A formal exercise program supervised by a physical therapist can be helpful for people with back pain that has lasted longer than four to six weeks (24). In addition to effects on back pain, exercise also benefits overall health and well-being. The physical therapist may directly supervise exercise sessions, or teach the exercise program to use at home. These exercises can involve stretching, flexion and extension exercises, strengthening, aerobic activity, general overall fitness, or some combination of these components. It is not clear what the best exercise program is, though many different types of exercise programs are probably beneficial. Some physical therapists will tailor the exercise program based on patient symptoms and physical examination findings.
* Psychological interventions: Because chronic low back pain is associated with depression, anxiety, and problems coping with pain, it isn’t surprising that psychological interventions have been shown to be effective (25). A variety of psychological interventions are available for chronic low back pain, including cognitive/behavioral counseling, biofeedback, and progressive relaxation. The best evidence is for cognitive/behavioral counseling, followed by progressive relaxation.
* Massage and yoga: Massage and yoga have both been shown to be effective for treatment of chronic low back pain and are probably quite safe, though there are only a few studies of each therapy.
* Traction: Traction involves the use of weights to pull on the spinal column into alignment or relieve pressure on compressed nerves. Evidence on whether traction is effective for low back pain is quite mixed, with a number of studies showing no clear benefit (26).
* Other interventions: Other interventions include ultrasound, interferential therapy, short-wave diathermy, transcutaneous electrical nerve stimulation, and low-level laser therapy. In general, these therapies all involve the superficial application of different types of energy to the back. Many of these therapies are provided by physical therapists. None of these interventions are clearly effective for improving low back pain symptoms (20), though they also don’t appear to be harmful.
* Interdisciplinary therapy: Interdisciplinary or multidisciplinary therapy usual refers to a coordinated program involving an exercise/rehabilitation program, psychological therapies along with other therapies. The most effective interdisciplinary therapy programs are quite intense and require several multi-hour sessions per week. Intensive interdisciplinary therapy are more effective than other standard therapies for chronic low back pain (27). The main problems with interdisciplinary therapy are that it is quite expensive, not available in all settings, and requires a large time commitment. It is probably most useful to consider interdisciplinary therapy when back pain is persistent, hasn’t responded to several standard therapies, and there is strong motivation to participate in such a program.
Injections
Injections into the muscles, other soft tissues, or deeper into the back are available for treatment of low back pain. However, evidence on effectiveness of different injection therapies is generally quite limited. They are also invasive. Because of these factors, injections should only be considered in people with persistent and disabling back pain despite non-invasive therapies.
* Trigger point or local injections: Injections with a local anesthetic into the superficial muscles or soft tissues are sometimes given at tender points. Although these may be helpful in people with myofascial pain syndrome or fibromyalgia, it is not clear if these injections are helpful for other types of low back pain (28).
* Epidural corticosteroid injections: Injections of corticosteroids into the epidural space (the space around the spinal cord) could help relieve low back pain by decreasing inflammation and swelling (29). Some studies show that epidural steroid injections are helpful in patients with sciatica due to a herniated disc, but benefits are short-lived. They may be most helpful in people with symptomatic herniated discs who aren’t good candidates for surgery or who don’t want surgery. There is no evidence that epidural corticosteroid injections are helpful for low back pain without sciatica or for symptomatic spinal stenosis.
* Chemonucleolysis: Chemonucleolysis involves the injection of an enzyme into a herniated disc in order to shrink the disc and relieve pressure on a compressed nerve root. It appears to be effective for short-term pain relief, but is no longer widely available in the United States, in part due to concerns about allergic reactions.
* Prolotherapy: Prolotherapy involves the injection of irritant chemicals into the soft tissues of the back, with the theory that the chemicals will subsequently decrease pain by causing scarring. It is not effective for low back pain (30).
* Other injections: A variety of other injections in patients with non-radiating low back pain and degenerative findings on x-rays or other imaging studies have been studied. In general, all of these techniques involve an injection deep into the back that targets a specific part of the back that is thought to be causing the pain. However, evidence on all of these techniques is limited and inconsistent, with some studies showing no benefit (31, 32). The injection methods include:
o For presumed facet joint pain: Facet joint corticosteroid injection (injection of corticosteroid into the facet joint), therapeutic medial branch block (injection of corticosteroid and local anesthetic into the area of the medial branch nerve of the facet joint), radiofrequency denervation (use of radiofrequency waves to destroy nerves surrounding the facet joint)
o For presumed discogenic back pain: Intradiscal corticosteroid injection (injection of corticosteroid directly into a degenerated disc), intradiscal electrothermal therapy (use of electrothermal energy in the degenerated disc), and percutaneous intradiscal radiofrequency thermocoagulation (use of radiofrequency waves in the degenerated disc)
o For presumed sacroiliac joint pain: Sacroiliac joint corticosteroid injection (injection of corticosteroid into or around the sacroiliac joint)
Surgery
Few patients suffering from low back pain require surgery. Surgery is often necessary if there is evidence of cauda equina syndrome, another serious problem such as a tumor or infection, or severe or progressive weakness due to spinal stenosis or compression of a nerve root. In other situations, deciding whether to undergo surgery requires a careful consideration of potential risks and benefits.
* Surgery for non-radiating low back pain thought to be related to degenerative disc disease: The most common surgery for non-radiating low back pain thought to be related to degenerative disc disease is fusion, a surgical procedure that unites (fuses) two vertebral together. This is thought to decrease pain by restricting motion at the presumed source of spinal pain (the degenerated intervertebral disc) after removing the disc. A variety of spinal fusion techniques are practiced. All involve placement of a bone graft between the vertebrae, which leads to fusion once the graft heals. In addition, fusion is often performed with the use of instrumentation (plates, screws, or metal cages) that serves as an internal splint while the bone graft heals.
European studies have shown that fusion surgery is no better than an intensive rehabilitation program with a cognitive/behavioral component, even in highly selected patients (33, 34). However, such programs are not widely available in the U.S. and are quite expensive. One study found fusion surgery better than standard (non-intensive) non-surgical therapies, though benefits were only moderate, even in highly selected patients (patients without other significant medical or psychologic issues). In fact, fewer than half of patients who undergo fusion surgery experience optimal outcomes (defined as minimum or no pain, discontinuation of pain medications, and return to work). Despite high additional costs, there is no evidence that using instrumentation improves patient outcomes from fusion surgery compared to not using instrumentation, though fusion rates are improved.
Vertebral disc replacement is a recently introduced alternative to fusion. A theoretical advantage of total disc replacement over fusion is that a prosthetic disc could help preserve normal range of motion and mechanics of the spine. This might reduce long-term degenerative changes in adjacent vertebral segments, which has been observed following fusions. Prosthetic discs approved by the U.S. Food and Drug Administration as of December 2007 are the Charite and the ProDisc-L artificial discs. Studies have shown that vertebral disc replacement is equivalent or similar in effectiveness to fusion surgery (35, 36). However, long-term safety and continued effectiveness of the artificial disc are not yet known.
In general, surgery for non-radiating low back pain thought to be due to a degenerated disc should only be considered when symptoms are persistent and disabling and several non-surgical therapies have been unsuccessful. Patients should understand that even though fusion surgery is associated with moderately better outcomes compared to standard non-surgical therapies, surgery does not “cure” low back pain in the majority of cases, and intensive interdisciplinary therapy if available may provide a similar outcome. The role of artificial disc replacement is evolving at this time and should become clearer as long-term data on artificial disc replacement becomes available. At this time, there is no clear advantage for artificial disc replacement over fusion surgery and uncertainty about long-term safety and benefits.
* Surgery for herniated lumbar disc with radiculopathy: The purpose of surgery for herniated lumbar disc with radiculopathy is to relieve pressure on affected nerve roots by removing part of (or the entire) disc. The most common surgical procedures for herniated disc with radiculopathy are open discectomy (removal of the disc through a standard surgical incision and direct visualization) and microdiscectomy (removal of the disc through a small incision and an operating microscope for visualization). Both surgeries are moderately more effective than continued non-surgical therapy for persistent radiculopathy due to a herniated disc for the first year or two (37, 38). However, by two years there is little difference in outcomes between people who had surgery and those that didn’t have surgery. People who don’t undergo surgery also experience improvements in symptoms (though not as rapidly as those who undergo surgery) and don’t appear to be at increased risk for serious, progressive, or permanent neurologic problems. Surgery may be most appropriate for patients at low risk for surgical complications who would like to experience quicker improvement in symptoms or return to work.
A variety of other “minimally invasive” techniques are also available for removing a herniated lumbar disc. These include discectomy with endoscopic guidance, surgery with the aid of lasers to vaporize parts of the disc, automated percutaneous discectomy (using a pneumatically driven, suction-cutting probe), and nucleoplasty (using a catheter emitting low-frequency radio waves to vaporize and heat parts of the nucleus). However, none of these methods have been well evaluated in clinical trials.
* Surgery for spinal stenosis with persistent neurogenic claudication: The most common surgery for spinal stenosis is decompressive laminectomy, or removal of parts of the bone surrounding the spinal cord (the vertebral laminae) in order to create more space and reduce pressure on the spinal cord, cauda equina, or nerve roots. Laminectomy can be performed with or without fusion or discectomy. Decompressive surgery is moderately more effective than continued non-surgical therapy in patients with persistent symptoms due to spinal stenosis with or without degenerative spondylolisthesis (33, 39). However, at long-term (eight to ten year) follow-up, patients with symptomatic spinal stenosis who had undergone surgery appear to fare similarly compared to patients who did not undergo surgery. A large multicenter trial sponsored by the U.S. federal government on surgery for spinal stenosis without degenerative spondylolisthesis is expected to be published in 2008 and should provide more information about benefits and risks of surgery.
Two trials found placement of an interspinous spacer (a device placed between the interspinous processes in order to reduce narrowing of the spine when standing by restricting back extension) better than no surgery in people with spinal stenosis symptoms relieved with flexion (40, 41). However, there are no data comparing the interspinous spacer to standard decompressive laminectomy or on long-term safety and benefits.
Other interventions
* Spinal cord stimulator: Spinal cord stimulation involves the placement of electrodes in the epidural space (the space around the spinal cord) adjacent to the area of the spine thought to be the source of pain. An electric current is then applied that is presumed to decrease pain through effects on the nerves. Spinal cord stimulators appear to be effective in patients who have persistent sciatica following surgery, but no compressed nerve roots on imaging studies (42, 43). However, it is associated with frequent complications including electrode or lead problems, infections, battery problems, and cerebrospinal fluid leak problems.
Where to get more information
Evidence-based guidelines developed through a joint partnership between the American College of Physicians and American Pain Society were published in Annals of Internal Medicine in October 2007 and are available via open access. Information is also available from the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
The American Physical Therapy Association has a brochure providing information on taking care of the back. The National Library of Medicine also has an on-line tutorial on exercises for the back.
The Cochrane Collaboration Back Review Group has conducted a number of systematic reviews on various treatments for low back pain. These systematic reviews attempt to review all the evidence for a particular intervention using systematic methods to reduce bias and error. The reviews are regularly updated and are not supported by industry funding.
Source of figures
Figures are from: Back Pain. National Institute of Arthritis and Musculoskeletal and Skin Diseases, U.S. Department of Health and Human Services (not copyrighted).
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