Low Back Pain

Common causes of low back pain include

Injuries may occur during routine activities (for example, lifting, exercising, moving in an unexpected way) or result from trauma, such as a fall or car crash. Often no specific injured structures are identified with imaging tests, but doctors presume that some muscles and/or ligaments have been affected.

Osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more (degenerative arthritis) causes the cartilage between the facet joints to wear away and bone spurs (osteophytes) to form. This disorder is due in part to the wear and tear of years of use. People who repetitively stress one joint or a group of joints are more likely to develop osteoarthritis in that area. The disks between the vertebrae deteriorate, and the spaces between the vertebrae narrow, increasing the pressure on the facet joints, which become inflamed (arthritis) and form bone spurs in the openings for the nerve roots. With severe degeneration and loss of disc height the osteophytes in the opening can compress spinal nerve roots. All of these changes can cause low back pain as well as stiffness.

Vertebral compression (crush) fractures Compression Fractures of the Spine In a compression fracture of the spine, the drum-shaped part (body) of one or more back bones (vertebrae) collapses into itself and becomes squashed (compressed) into a wedge shape. Most compression... read more (fractures of spinal vertebrae) commonly develop when bone density decreases because of osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks (fractures) likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and... read more , which typically develops as people age. Vertebrae are particularly susceptible to the effects of osteoporosis. Vertebral compression fractures (which may cause sudden, severe back pain) can be accompanied by compression of spinal nerve roots (which may cause chronic back pain). However, most fractures due to osteoporosis occur in the upper and middle back and cause upper and middle rather than low back pain.

A ruptured or herniated disk Herniated Disk A herniated disk occurs when the tough covering of a disk in the spine tears or ruptures. The soft, jelly-like interior of the disk may then bulge out (herniate) through the covering. Aging... read more can cause low back pain. A disk has a tough outer layer and a soft, jelly-like interior. If a disk is repeatedly overloaded by the vertebrae above and below it (as when bending forward, particularly when lifting a heavy object), the outer layer may tear (rupture), causing pain. The interior of the disk can squeeze through the tear, so that part of the interior bulges out (herniates). This bulge can compress, irritate, and even damage the spinal nerve root next to it, causing more pain and symptoms that are felt in one or both legs. A ruptured or herniated disk in the low back that affects nerves commonly causes sciatica Sciatica Sciatica is pain along the sciatic nerves. These nerves run from the lower back, through the buttocks, and down the legs, ending just below the knee. A herniated disk, complications of osteoarthritis... read more . However, imaging studies such as magnetic resonance imaging (MRI) often show bulging disks in people who have no symptoms or problems.

Lumbar spinal stenosis Lumbar Spinal Stenosis Lumbar spinal stenosis is narrowing of the spinal canal in the lower back. The narrowing squeezes (compresses) the nerves that travel through the lower back into the legs. Osteoarthritis, injuries... read more is narrowing of the spinal canal, which runs through the center of the spine and contains the spinal cord and the bundle of nerves that extends downward from the bottom of the spinal cord in the lower back. It is a common cause of low back pain in older people. Spinal stenosis also develops in middle-aged people who were born with a narrow spinal canal. Spinal stenosis is caused by such disorders as osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more , spondylolisthesis Spondylolisthesis Spondylolisthesis is partial displacement of a bone in the lower back. Injuries or a degenerative condition can cause this disorder. Pain is felt in the low back and may travel down one or both... read more , ankylosing spondylitis Ankylosing Spondylitis Ankylosing spondylitis is a spondyloarthritis characterized by inflammation of the spine (spondylitis), large joints, and fingers and toes, resulting in stiffness and pain. Prolonged joint pain... read more , and Paget disease of bone Paget Disease of Bone Paget disease of bone is a chronic disorder of the skeleton in which areas of bone undergo abnormal turnover, resulting in areas of enlarged and softened bone. The breakdown and formation of... read more .

Spinal stenosis may cause sciatica Sciatica Sciatica is pain along the sciatic nerves. These nerves run from the lower back, through the buttocks, and down the legs, ending just below the knee. A herniated disk, complications of osteoarthritis... read more as well as low back pain.

Spondylolisthesis Spondylolisthesis Spondylolisthesis is partial displacement of a bone in the lower back. Injuries or a degenerative condition can cause this disorder. Pain is felt in the low back and may travel down one or both... read more is partial displacement of a vertebra in the lower back. One type usually occurs during adolescence or young adulthood (often in athletes) caused by an injury that fractures a part of the vertebra. If both sides of the vertebra are involved, the vertebra can then slip forward over the one below it. Spondylolisthesis can also occur in older adults but mainly as the result of a degenerative condition. People who develop spondylolisthesis as adults are at risk of developing lumbar spinal stenosis.

Fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more is a common cause of pain that affects many parts of the body, sometimes including the low back. This disorder causes chronic widespread (diffuse) pain in muscles and other soft tissues in areas outside the lower back. Fibromyalgia is also characterized by poor sleep and fatigue.

Less common causes of low back pain include

In people with low back pain, certain symptoms and characteristics are cause for concern. They include

People should see a doctor immediately if they have fever or any of the warning signs that suggest nerve damage, an abdominal aortic aneurysm Abdominal Aortic Aneurysms Abdominal aortic aneurysms are bulges (dilations) in the wall of the aorta in the part that passes through the abdomen (abdominal aorta). Abdominal aortic aneurysms typically slowly expand and... read more , a digestive disorder, or a urinary tract disorder. People with most other warning signs should see a doctor within a day. If pain is not severe and people have no warning signs other than pain for more than 6 weeks, their need to see a doctor is not as urgent.

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see table ).

Doctors ask questions about the pain:

Certain characteristics of the pain can give clues to possible causes:

The physical examination is focused on the spine and on evaluation of the nerves to the groin and legs to look for signs of nerve root compression. Signs of nerve root compression depend on which nerve roots are involved and include weakness of one of the muscle groups in a leg, abnormal reflexes (tested by tapping the tendons below the knee and behind the ankle), decreased sensation in an area of the leg, and, very rarely, retention of urine Urinary Retention Urinary retention is inability to urinate or incomplete emptying of the bladder. People who have incomplete emptying of the bladder may have urinary frequency or urinary incontinence. If the... read more and incontinence of urine Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine. Incontinence can occur in both men and women at any age, but it is more common among women and older people, affecting about 30% of older women... read more or stool (fecal incontinence Fecal Incontinence Fecal incontinence is the loss of control over bowel movements. Fecal incontinence can occur briefly during bouts of diarrhea or when hard stool becomes lodged in the rectum ( fecal impaction)... read more ).

Doctors may ask the person to move in certain ways to determine the type of pain. Doctors typically ask the person to bend forward and backward. They may have the person lie flat and then lift their leg without bending the knee to see if it brings on pain, which would suggest a herniated disc. Doctors may also check a person's abdomen for tenderness or a mass and the pulses, particularly in people over 55, who may have an aortic aneurysm Abdominal Aortic Aneurysms Abdominal aortic aneurysms are bulges (dilations) in the wall of the aorta in the part that passes through the abdomen (abdominal aorta). Abdominal aortic aneurysms typically slowly expand and... read more . They may examine the prostate in men by doing a digital rectal examination and the internal reproductive organs in women by doing a pelvic examination.

With information about the pain, the person’s medical history, and results of a physical examination, doctors may be able to determine the possible cause.

Usually, no tests are needed because most back pain results from osteoarthritis, strains and sprains, or other minor musculoskeletal disorders and resolves within 6 weeks. Imaging tests are often needed if

People who did not respond to initial treatment or those whose symptoms have worsened or changed may also undergo testing.

X-rays of the lower back show only the bones. They can help detect degenerative changes due to osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more , vertebral compression fractures Compression Fractures of the Spine In a compression fracture of the spine, the drum-shaped part (body) of one or more back bones (vertebrae) collapses into itself and becomes squashed (compressed) into a wedge shape. Most compression... read more , spondylolisthesis Spondylolisthesis Spondylolisthesis is partial displacement of a bone in the lower back. Injuries or a degenerative condition can cause this disorder. Pain is felt in the low back and may travel down one or both... read more , and ankylosing spondylitis Ankylosing Spondylitis Ankylosing spondylitis is a spondyloarthritis characterized by inflammation of the spine (spondylitis), large joints, and fingers and toes, resulting in stiffness and pain. Prolonged joint pain... read more . However, magnetic resonance imaging Magnetic Resonance Imaging (MRI) In magnetic resonance imaging (MRI), a strong magnetic field and very high frequency radio waves are used to produce highly detailed images. MRI does not use x-rays and is usually very safe... read more (MRI) or computed tomography Computed Tomography (CT) In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more (CT) provides clearer images of bones and, particularly MRI, can show soft tissues (including disks and some nerves). MRI or CT is usually necessary when doctors are checking for disorders that cause subtle changes in bone and disorders of soft tissue. For example, MRI or CT can confirm or exclude the diagnosis of a herniated disk Diagnosis A herniated disk occurs when the tough covering of a disk in the spine tears or ruptures. The soft, jelly-like interior of the disk may then bulge out (herniate) through the covering. Aging... read more , spinal stenosis, cancer, and usually infection. These tests can also indicate whether nerves are being compressed.

If compression of the spinal cord is suspected, MRI is done immediately. Rarely, when results of MRI are unclear, myelography Myelography Diagnostic procedures may be needed to confirm a diagnosis suggested by the medical history and neurologic examination. Imaging tests commonly used to diagnose nervous system (neurologic) disorders... read more with CT is required. Rarely, if cancer or infection is suspected, removal of tissue (biopsy) is necessary. Occasionally, electromyography and nerve conduction studies Electromyography and Nerve Conduction Studies Diagnostic procedures may be needed to confirm a diagnosis suggested by the medical history and neurologic examination. Imaging tests commonly used to diagnose nervous system (neurologic) disorders... read more are done to confirm the presence, location, and sometimes duration and severity of nerve root compression.

Measures include

For low back pain that has recently developed, treatment begins with avoiding activities that stress the spine and cause pain—such as lifting heavy objects and bending. Bed rest does not hasten the resolution of the pain, and most experts recommend continued light activity. Bed rest, if required to relieve severe pain, should last no more than 1 or 2 days. Longer bed rest weakens the core muscles and increases stiffness, thus worsening back pain and prolonging recovery. Spinal corsets and traction Traction Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more are not helpful. Traction may delay recovery.

Acetaminophen is usually recommended for pain relief unless inflammation is present. Over-the-counter or prescription nonsteroidal anti-inflammatory drugs Nonsteroidal Anti-Inflammatory Drugs Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more (NSAIDs) can relieve pain and reduce inflammation. If acetaminophen or NSAIDs do not provide sufficient pain relief, opioid analgesics are occasionally prescribed but, if so, should be used only for a short duration because long-term use of opioid analgesics can actually increase sensitivity to pain, cause side effects, and risk the development of a substance use disorder Substance Use Disorders Substance use disorders generally involve behavior patterns in which people continue to use a substance (for example, a recreational drug) despite having problems caused by its use. The substances... read more .

Muscle relaxants, such as carisoprodol, cyclobenzaprine, diazepam, metaxalone, or methocarbamol, are sometimes given to relieve muscle spasms, but their usefulness is controversial. These drugs are not recommended for older people, who are more likely to have side effects such as drowsiness and confusion. Doctors try not to prescribe muscle relaxants unless people have visible and palpable muscle spasms. If prescribed, muscle relaxants should be used for no more than 72 hours, except in some people with disorders in which pain originates in the brain or spinal cord (central pain syndrome). For example, cyclobenzaprine may improve quality of sleep and reduce pain in people with fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more . Doctors sometimes tell people to take them only at bedtime.

Application of heat Heat therapy Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more or cold Cold therapy (cryotherapy) Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more may help (see Treatment of Pain and Inflammation Treatment of Pain and Inflammation Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more ). Cold is usually preferred to heat during the first 2 days after an injury. Ice and cold packs should not be applied directly to the skin. An ice pack should be enclosed (for example, in plastic) and placed over a towel or cloth. The ice is removed after 20 minutes, then reapplied for 20 minutes over a period of 60 to 90 minutes. This process can be repeated several times during the first 24 hours. Heat, using a heating pad, can be applied for the same periods of time. Because the skin on the back may be insensitive to heat, heating pads must be used cautiously to prevent burns. People should not use a heating pad at bedtime to avoid the risk of falling asleep with the pad still on their back.

Massage Massage Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more may provide some temporary relief of low back pain. Some studies suggest that acupuncture may have similar benefits, but others suggest little or no benefit. Spinal manipulation, done by chiropractors or some other doctors (such as osteopathic doctors), may also provide relief when combined with an exercise program. However, spinal manipulation may increase the risk of further injury and should be avoided in people who have inflammatory arthritis, neck problems that cause instability of neck vertebrae, or a herniated disk Herniated Disk A herniated disk occurs when the tough covering of a disk in the spine tears or ruptures. The soft, jelly-like interior of the disk may then bulge out (herniate) through the covering. Aging... read more .

After the pain has subsided, light activity, as recommended by a doctor or physical therapist Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more , can speed healing and recovery. In some cases, a course of treatment with a physical therapist can help. Specific exercises to strengthen and stretch the back and to strengthen core muscles are usually recommended to help prevent low back pain from becoming chronic or recurring.

Sleeping in a comfortable position on a medium mattress is recommended. People who sleep on their back can place a pillow under their knees. People who sleep on their side should use a pillow to support their head in a neutral position (not tilted down toward the bed or up toward the ceiling). They should place another pillow between their knees with their hips and knees bent slightly if that relieves their back pain. People can continue to sleep on their stomach if they are comfortable doing so.

Other preventive measures Prevention Low back pain and neck pain are among the most common reasons for health care visits. The pain usually results from problems with the musculoskeletal system—most notably the spine, including... read more (maintaining good posture, lifting correctly) should be continued or started. In response to these measures, most episodes of back pain resolve in several days to 2 weeks. Regardless of treatment, 80 to 90% of such episodes resolve within 6 weeks.

Additional measures are needed for chronic low back pain. Aerobic exercise may help, and weight reduction, if necessary, is advised. If analgesics are ineffective, other treatments can be considered.

Transcutaneous electrical nerve stimulation Nondrug Pain Treatments Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more (TENS) may be used. The TENS device produces a gentle tingling sensation by generating a low oscillating current. This current can block transmission of some pain sensation from the spinal cord to the brain. The current can be applied to the painful area several times a day for 20 minutes to several hours at a time, depending on the severity of the pain.

Sometimes a corticosteroid (such as dexamethasone or methylprednisolone) plus a local anesthetic (such as lidocaine) can be periodically injected into facet joints in the spine or the epidural space—between the spine and the outer layer of tissue covering the spinal cord. The epidural injections may be more effective for sciatica caused by a herniated disk than for lumbar spinal stenosis. However, it is not clear that they produce a long-term benefit. They are usually effective only for several days to weeks. Their main use is to relieve pain enough that an exercise program, which can provide long-term pain relief, can be started.

If a herniated disk is causing relentless or chronic sciatica, weakness, loss of sensation, or loss of bladder and bowel control, surgical removal of the bulging part of the disk (diskectomy) and sometimes part of the vertebra (laminectomy) may be necessary.

For severe spinal stenosis, a large part of the back of the vertebra (the lamina) may be surgically removed to widen the spinal canal (lumbar laminectomy). A general anesthetic is usually required. The hospital stay is usually 4 or 5 days. People may need 3 to 4 months before they can resume all of their activities. About two thirds of people have a good or full recovery. For most of the rest, such surgery may prevent pain and keep other symptoms from worsening.

When the spine is unstable (as may result from a severe herniated disk, spondylolisthesis, or after laminectomy for spinal stenosis), surgery can be done to fuse vertebrae together (called lumbar spinal fusion). However, fusion decreases mobility and may put additional stress on the rest of the spine and cause further problems.

Vertebral compression fractures Treatment In a compression fracture of the spine, the drum-shaped part (body) of one or more back bones (vertebrae) collapses into itself and becomes squashed (compressed) into a wedge shape. Most compression... read more are quite common among women over 50 years of age. They can be treated conservatively with nonsurgical options such as braces, pain relievers, and possibly calcitonin nasal spray, which does not help bone healing but may decrease pain.

If pain is not adequately controlled, two surgical options are available:

However, recent studies have shown that, in the long term, these surgical procedures are no more effective than nonsurgical options.