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Lumbar (low-back)
Understanding Low Back Problems

Why do I have low back pain?

Unfortunately, low back pain is a common part of the human condition. Most people will experience low back pain at some time in their life. The lumbar spine is the scaffolding connecting our body to the pelvis and legs allowing us to be upright and the freedom of movement. It is because of this ability to be upright and move about that we develop pain in our backs. Many individuals will experience back pain without any injury or illness. Just living life places stress on the structures in the back creating internal changes to the discs, bone, ligaments, cartilage, tendons, and muscle. This can cause pain. Of course, other injuries can and do occur beyond simple wear and tear of daily living. These injuries can present special problems in the back.

What are some specific conditions in the low back?

  • Lumbar disc herniation occurs when a weak spot in the covering of the disc develops allowing a piece of rubbery disc to escape. This can pinch, or compress, a nerve generally causing pain down one leg. This generally causes pain down one leg, but if the fragment is large enough, pain may be present in both legs. Low back pain often precedes leg pain if a tear in the covering occurs suddenly prior to the disc herniating, or escaping, from its natural position.
  • Lumbar stenosis is narrowing of the bony canal that the nerves run through down the spine. This is usually caused by degeneration with age and enlargement of the joints and bony elements as we age. Just as the knuckles on our hands enlarge with age, so do other joints in the body, including the low back. This crowds the nerves as they travel down the spinal canal and exit small openings called foramen. The foramen or the main canal can be narrowed or "stenotic" and cause pain in one or both legs.
  • Lumbar disc degeneration is a wearing of the discs in the lumbar spine. This occurs as we age and the discs desiccate (dry out), collapse, and weaken. The inside of the disc can become fragmented and the covering (annulus) can tear and weaken. Although this may cause low back pain, it is often a very controversial diagnosis as it is seen on many MRI studies and has been seen in at least 50% or more of individuals with no low back complaints who are studied with MRI. Determining if a degenerated disc is causing pain is very difficult and not very accurate.
  • Lumbar fractures are generally traumatic. This is simply a "broken bone" in the back. There is a congenital "fracture" called a pars defect which can lead to slippage of one vertebrae on another, a condition known as spondylolisthesis (spondy - spine and listhesis - slip). This is a congenital condition of the bones in the spine which do not completely come together during development. Other traumatic fractures usually have a known cause as the injury will trigger immediate pain.
  • Lumbar tumors also cause low back pain. Nocturnal, or night time low back pain, is a common feature of metastatic tumors to the spine (cancer elsewhere in the body with spread to the spine). Tumors can be malignant, such as metastatic tumors or primary tumors of bone, or benign such as neurofibromas, meningiomas, or ependymomas. Tumors in the bony elements of the spine usually cause pain and tumors of the nerves or supporting elements of the nerves usually cause pain in one or both legs. When tumors are large enough, they may cause nerve dysfunction and weakness, numbness, or bowel/bladder dysfunction can occur.
  • Other lumbar conditions such as infections, tethered spinal cord, congenital variations, pelvic lesions, or renal conditions must also be kept in mind when evaluating the source of low back pain or leg pain.

What are the structures of the back?

There are five vertebrae that are the structural building blocks of the lumbar spine. Between each vertebra is a lumbar disc. The disc and vertebrae are on the front of the spine, and bony extensions extend back and surround the spinal canal enclosing the nerves. The spinal cord does not extend beyond L2 (the second lumbar vertebra) in a normal spine. If it does it is said to be "tethered", which is another source of pain and dysfunction. The nerves and tip of the spinal cord (conus medullaris) are enclosed in a tough membrane called the dura mater (tough mother in latin). They are surrounded and float in spinal fluid, a salty water solution.

Why do I have low back pain?

In determining the cause of back pain, important clues are obtained from a good patient history. The location, intensity, duration, nature, and radiation of the pain are important. Any past injuries or conditions may be important.  Aggravating and/or relieving positions or motions are also helpful. Physical examination is also very helpful in determining the source and cause of the pain. Neurologic dysfunction found on examination can be extremely helpful in finding the cause of the problem.

Testing with imaging such as MRi, CT scans, and x-rays are very useful, and the type of test needed is determined by the suspected problem. All three tests do not generally need to be done. One or more may be needed depending on the history and physical examination.

Ancillary tests such as nerve studies (EMG, NCV, SSEP) are not generally very specific, but may be useful if a nerve problem is suspected in the leg or pelvis. These tests are usually ordered for very specific questions. Blood tests are not generally needed unless a specific question is raised such as possibility of infection.

How is back pain treated? 

The treatment of back pain is generally cautious observation and time with the aid of anti-inflammatories or other medications, therapy or home exercises, modification of activities (usually temporary) and some rest. Most back pain is not serious and does not indicate a more serious problem. If the pain persists or has unique features (leg pain, excessive weight loss, fever, etc.) more immediate evaluation and work-up is indicated.

 

 

 
     
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