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Overview
Neck and back pain, especially pain
in the lower back, is one of the most common
health problems in adults. Fortunately, most back
and neck pain is temporary, resulting from
short-term stress on the muscles or ligaments that
support the spine rather than from a serious
injury or medical condition such as nerve damage
or kidney disease.
Anatomy
The back is an intricate structure of bones,
ligaments, muscles, nerves, and tendons. The
backbone, or spine, is made up of 31 bony segments
called vertebrae:
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8 cervical (neck) vertebrae
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12 thoracic (middle back)
vertebrae
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5 lumbar (lower back) vertebrae
-
5 sacral (lowest area of the
back) vertebrae
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1 coccygeal (coccyx, or tailbone)
vertebra (made up of several fused segments)
The vertebrae are arranged in a
long vertical column and held together by
ligaments, which are attached to muscles by
tendons. Between each vertebra lies a gel-like
cushion called an intervertebral disc, consisting
of semifluid matter (called nucleus pulposus) that
is surrounded by a capsule of elastic fibers
(called annulus fibrosus).
The spinal cord is an
extension of the brain that runs through a long,
hollow canal in the column of vertebrae. The
meninges , cerebrospinal fluid, fat, and a network
of veins and arteries surround, nourish, and
protect the spinal cord.
Thirty-one pairs of nerve roots
emerge from the spinal cord through spaces in each
vertebra. The spinal cord and peripheral nerves
perform essential sensory and motor activities of
the body. The peripheral nervous system conveys
sensory information from the body to the brain and
conveys motor signals from the brain to the body.
Incidence and Prevalence
In the United States, back pain is reported to
occur at least once in 85% of adults below the age
of 50. Nearly all of them will have at least one
recurrence. It is the second most common
illness-related reason given for a missed workday
and the most common cause of disability.
Work-related back injury is the number one
occupational hazard.
Risk Factors
Aging
produces wear and tear on the spine that may
result in conditions (e.g., disc degeneration,
spinal stenosis) that produce neck and back pain.
Having a previous back injury puts one at
risk for another injury.
Physically demanding occupations
that require repetitive bending and lifting have a
high incidence of back injury (e.g., construction
worker, caregiver). Jobs that require long hours
of standing without a break (e.g., hairdresser) or
sitting in a chair (e.g., keyboard operator) that
does not support the back well put a person at
risk for neck and lower back injury.
Being sedentary (i.e., not
exercising regularly or engaging in physical
recreation) and being overweight, which
increases stress on the lower back, are risk
factors.
Poor posture,
such as slouching in a chair, driving hunched
over, standing incorrectly, and using poor body
mechanics when lifting and carrying heavy loads
are risk factors. Sleeping on a soft or sagging
mattress also can lead to back pain.
Sports
that involve twisting the back, like golf, can
result in back injury or worsen existing lower
back pain.
Joint and/or bone disease
(e.g., osteoporosis, arthritis) and infectious
disease (e.g., spinal meningitis) can lead to
degeneration, inflammation, and compression.
Risk
Factor:
Risk Factors
Aging
produces wear and tear on the spine that may
result in conditions (e.g., disc degeneration,
spinal stenosis) that produce neck and back pain.
Having a previous back injury puts one at
risk for another injury.
Physically demanding
occupations that require repetitive bending
and lifting have a high incidence of back injury
(e.g., construction worker, caregiver). Jobs that
require long hours of standing without a break
(e.g., hairdresser) or sitting in a chair (e.g.,
keyboard operator) that does not support the back
well put a person at risk for neck and lower back
injury.
Being sedentary (i.e.,
not exercising regularly or engaging in physical
recreation) and being overweight, which
increases stress on the lower back, are risk
factors.
Poor posture,
such as slouching in a chair, driving hunched
over, standing incorrectly, and using poor body
mechanics when lifting and carrying heavy loads
are risk factors. Sleeping on a soft or sagging
mattress also can lead to back pain.
Sports
that involve twisting the back, like golf, can
result in back injury or worsen existing lower
back pain.
Joint and/or bone disease
(e.g., osteoporosis, arthritis) and infectious
disease (e.g., spinal meningitis) can lead to
degeneration, inflammation, and compression.
Causes
Many conditions can cause back and
neck pain, ranging from injury to infection to
simply twisting the wrong way. An injury sustained
in an automobile or other type of accident can
damage muscles, joints, ligaments, and vertebrae.
Overuse or underuse of the back
is by far the most common cause of back pain that
manifests as tightening or spasm of the muscles
that connect to the spine. Inflammation and
swelling often occur in the joints and ligaments,
especially in the cervical and lumbar regions, as
people age.
A herniated disc occurs when
the nuclear pulposus, the inner material of the
disc, pushes through a tear in the annulus
fibrosus, causing nerve root compression.
The cervical and lumbar regions of
the spine have the most mobility and the discs
there are more likely to wear down or be injured.
Ninety percent of disc herniations occur in the
lower two lumbar vertebrae.
Over time, repeated daily stress
coupled with minor injury can contribute to
intervertebral disc degeneration. The annulus
fibrosus, the capsule of elastic fibers that
surrounds the disc, may develop small tears and
form scar tissue.
As more scar tissue forms, the
nucleus pulposus, the semifluid inner portion of
the disc, begins to dry up. Over time, the disc
collapses and significantly narrows the space
between vertebrae, causing spinal stenosis.
Spinal stenosis,
narrowing of the spine, can cause spinal cord
irritation and injury. Conditions that cause
spinal stenosis include infection, tumors, trauma,
herniated disc, arthritis, thickening of
ligaments, growth of bone spurs, and disc
degeneration. Spinal stenosis most commonly occurs
in older individuals as a result of vertebral
degeneration.
A pinched nerve, or
radiculopathy, occurs when something rubs or
presses against a nerve, creating irritation or
inflammation. Radiculopathy can result from a
herniated disc, bone spur, tumor growing into the
nerves, and vertebral fracture, and many other
conditions.
Sciatica
is a certain type of radiculopathy that involves
inflammation of the sciatic nerve. Pain is
experienced along the large sciatic nerve, from
the lower back down through the buttocks and along
the back of the leg.
A spinal tumor that
originates in the spine (primary tumor) or spreads
to the spine from another part of the body (metastatic
tumor) can compress the spine or nerve roots and
cause significant pain.
An infection that develops
in the vertebrae (e.g., vertebral osteomyelitis),
the discs, the meninges (e.g., spinal meningitis),
or the cerebrospinal fluid can compress the spinal
cord and result in serious neurological
deterioration, if it is not diagnosed and treated
immediately.
Facet joints
allow movement of the spine. These consist of two
knobs, or facets, that meet between each vertebra
to form a joint. As facet joints degenerate, they
may not align correctly, and the cartilage and
fluid that lubricates the joints may deteriorate.
Bone then rubs against bone, which can be very
painful.
Bone and joint diseases
(e.g, osteoporosis, ankylosing spondylitis,
osteoarthritis) can cause degeneration,
inflammation, and spinal nerve compression.
Pain can radiate to the back from
other areas of the body (i.e., referred pain)
affected by disease or injury, such as bleeding
from the aorta, the large artery that carries
blood out of the heart; pancreatic disease;
pneumonia; kidney diseases; bladder disorders; and
uterine abnormalities.
Symptoms
Pain can be constant or
intermittent. Intensity can vary from a dull ache
to searing agony. The onset may be sudden, with or
without apparent reason, or gradual.
Most back pain resolves in a few
days or weeks with or without treatment. However,
some people have chronic pain that lasts months or
years.
Severe pain
lasting more than a few days without improvement
may require medical attention. Anyone having
difficulty passing urine; numbness in the back or
genital area; numbness, pins and needles, or
weakness in the legs; shooting pain down the leg;
or unsteadiness when standing should see a
physician immediately.
Localized pain
is often described as aching, tight, stiff, sore,
burning, throbbing, or pulling. The pain may
worsen while bending, sitting, walking, or
standing too long in one position. It may also be
more prevalent at different times of the day, such
as when a person wakes up in the morning.
Pinched nerves
produce numbness or tingling, warm or cold
sensations, and burning or stabbing pain that
begins in the back and radiates down the leg
(e.g., sciatica) or arm. Activities such as
coughing, sneezing, or walking may increase
pressure on the pinched nerve and aggravate the
pain.
Compressed nerves
causes numbness and weakness in the muscle
associated with the nerve. The muscle may atrophy
if the compression is not relieved. An infection
affecting the spinal cord or nerves may produce
fever and lethargy as well as symptoms of
compression.
Symptoms
Pain can be constant or
intermittent. Intensity can vary from a dull ache
to searing agony. The onset may be sudden, with or
without apparent reason, or gradual.
Most back pain resolves in a few
days or weeks with or without treatment. However,
some people have chronic pain that lasts months or
years.
Severe pain
lasting more than a few days without improvement
may require medical attention. Anyone having
difficulty passing urine; numbness in the back or
genital area; numbness, pins and needles, or
weakness in the legs; shooting pain down the leg;
or unsteadiness when standing should see a
physician immediately.
Localized pain
is often described as aching, tight, stiff, sore,
burning, throbbing, or pulling. The pain may
worsen while bending, sitting, walking, or
standing too long in one position. It may also be
more prevalent at different times of the day, such
as when a person wakes up in the morning.
Pinched nerves
produce numbness or tingling, warm or cold
sensations, and burning or stabbing pain that
begins in the back and radiates down the leg
(e.g., sciatica) or arm. Activities such as
coughing, sneezing, or walking may increase
pressure on the pinched nerve and aggravate the
pain.
Compressed nerves
causes numbness and weakness in the muscle
associated with the nerve. The muscle may atrophy
if the compression is not relieved. An infection
affecting the spinal cord or nerves may produce
fever and lethargy as well as symptoms of
compression.
Diagnosis
Most cases fall into the loose
classification of “simple back pain.” Medical care
usually is not required, the condition is
self-limiting, and symptoms can be treated with
home remedies.
Diagnosing the underlying cause of
neck and back pain can be difficult. A medical
history is taken and complete physical
and neurological examinations are
performed.
Laboratory Tests
X-rays show the alignment of the cervical,
thoracic, and lumbar spine; and may reveal
degenerative joint disease, fracture, or tumor.
MRI
(magnetic resonance imaging) provides clear images
of disc deterioration, pathologies of the spinal
cord, spinal stenosis, herniated discs, spinal
tumors, and abnormalities in nerves and ligaments.
Contrast dye may be injected to highlight
problematic areas.
CT scan
(computerized tomography) is an x-ray that
utilizes computer technology and can be enhanced
with contrast dye. It is used to show
abnormalities in bones and soft tissue. CT scan
can be used for patients unable to tolerate MRI.
Myelography
is used to examine the spinal canal and cord.
Contrast dye is injected into the cerebrospinal
fluid to outline the spinal cord and nerve roots,
thus allowing abnormal disc conditions or bone
spurs to be visualized with x-ray or CT scan.
EMG
(electromyogram) uses tiny electrodes inserted
into muscle tissue to test for abnormal electrical
signals, which may indicate that a nerve root is
pinched or irritated at the spine.
Spinal tap
involves drawing and analyzing a sample of
cerebrospinal fluid for elevated pressure,
infection, bleeding, or tumor.
Bone scan
locates problems (e.g., fracture, osteoporosis) in
the vertebrae. A radioactive tracer is injected
into the patient and after several hours, x-ray
will reveal bone undergoing rapid changes where
large amounts of tracer accumulates.
Treatment
Most cases of back and neck pain
are treated conservatively. If pain persists or
worsens, or if other symptoms develop, a more
aggressive approach is taken.
Home Remedies
Applying ice immediately during the 48
hours after straining a muscle can reduce pain.
Ice slows inflammation and swelling, numbs soft
tissue, and slows nerve impulses in the injured
area. After spasms and acute pain subside, heat
can be applied to loosen tight muscles.
Two or three days of bed rest
followed by a gradual return to normal activity is
sometimes recommended.
Medication
Acetaminophen and ibuprofen are most commonly
recommended for pain relief. Package directions or
the advice of a physician should be followed.
To relieve acute back pain,
anti-inflammatory drugs (e.g., Celebrex®),
non-narcotic pain relievers (e.g., Tramadol®),
muscle relaxants (e.g., Flexeril®), and narcotic
pain relievers may be prescribed.
An oral steroid (e.g., prednisone)
is sometimes prescribed for acute episodes of low
back pain. Patients are started on a high dose
that is gradually reduced over 5 or 6 days.
Serious side effects associated with
steroid use include bone loss, impaired wound
healing, and headache. Chronic back pain caused by
nerve root damage is sometimes treated with
tricyclic antidepressants, such as
amitriptyline (Elavil®) and nortriptyline (Pamelor®),
for numbness, burning, aching, throbbing, or
stabbing pain that shoot down the limbs. Side
effects include drowsiness, dry mouth, and
constipation.
Antiepileptic drugs, such as
gabapentin (Neurontin®), may alleviate pain caused
by nerve degeneration and persistent leg pain
after surgery. Their pain relieving action is not
well understood. Side effects include
drowsiness, dizziness, fatigue, and impaired motor
coordination.
Injections
Steroid injections can significantly decrease
inflammation and pain caused by spinal stenosis,
disc herniation, and degenerative disc disease. A
steroid is injected directly into the dura
(membrane that surrounds the nerve roots).
Selective nerve root block (SNRB) uses a steroid
with anesthetic.
Physical Therapy
The goals of physical therapy are to decrease
pain, increase function, restore normal movement,
and prevent recurrences.
Massage therapy
increases circulation to the affected area. There
are several techniques and devices used in massage
therapy.
Electrotherapy
involves sending gentle electric currents through
the skin to stimulate muscular contraction,
increase muscle strength, and increase the flow of
neurochemicals to the area. In ultrasound
sound waves penetrate the skin and cause soft
tissues to vibrate, creating deep gentle heat that
increases blood flow, relieves pain and
inflammation, and reduces muscle spasms.
Exercise
Exercise can correct current back problems, help
prevent new ones, and relieve back pain,
particularly after an injury. Proper exercise
strengthens back muscles that support the spine
and strengthens the abdomen, arms, and legs,
reducing strain on the back. Exercise also
strengthens bones and reduces the risk for falls
and injuries.
It is essential to speak with a
doctor or physical therapist before starting an
exercise regimen to ensure that it is appropriate.
Adjustment
Chiropractors and osteopaths manipulate the spine,
called an adjustment, to relieve pain
arising from musculoskeletal conditions such as
facet joint injuries, osteoarthritis, and
whiplash.
Acupuncture
An acupuncturist inserts hair-thin needles under
the skin, which remain in place for 15 to 30
minutes. The needles cause little or no pain. Pain
relief may result from the release of endorphins,
the body’s intrinsic painkillers. Generally,
several sessions are needed.
Surgery
Surgery may be indicated for progressive or severe
neurological dysfunction-such as muscle weakness,
spinal cord compression, or bowel, bladder, or
sexual dysfunction-and for cases of intractable
pain.
Discectomy
is the removal of herniated disc material that is
compressing nerves. Laminectomy, or removal of the
lamina, relieves compression on the spinal cord.
Spinal instability is corrected by using a bone
graft to fuse adjacent vertebrae.
Implanted pumps
deliver a constant rate of pain-relieving
medication to the spinal area. Surgically
implanted spinal cord stimulators modulate
the pain response, so the patient experiences less
pain.
Prevention
There is much that a person can do
to maintain a healthy back. Preventative measures
are especially important if back pain has already
been experienced:
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Learn proper body mechanics,
particularly if an occupation involves
repetitive bending, lifting, and twisting.
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Exercise regularly to keep back
muscles strong and flexible.
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Maintain good posture.
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Avoid standing or sitting in one
place for long periods of time.
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Maintain weight within an ideal
range for body size.
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Eat a healthy diet.
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