Lower Back Pain Treatment and Management

What is lower back pain?

Lower back pain is one of the most frequent musculoskeletal complaints. Pain may arise from damage or irritation to any of the structures of the lower back including the:

• Vertebrae
• Facet joints
• Discs between the vertebrae
• Vertebral ligaments
• Muscles of the lower back
• Spinal cord
• Peripheral nerves

It can also stem from damage to the internal organs of the pelvis and abdomen, such as the spleen, kidney, pancreas, and liver.

Typically, the symptoms are acute and resolve within a few weeks, depending on the cause of your pain. However, if the pain returns and is persistent for three months or longer, your acute back pain may have evolved into chronic back pain.

Lower back pain anatomy

Understanding the anatomy and physiological function of the lower back is key to figuring out the cause of your lower back pain. There are three main structures that support the body in the back and also contribute to pain.

1. Bony structures

The bony spine is positioned so that all 33 individual vertebrae (bones of the spine) interconnect with other spine bones above and below.

This provides a flexible yet stable support structure to protect the spinal cord.

2. Intervertebral discs

Separating adjacent vertebrae are intervertebral discs that act as cushions that minimize the impact that the spinal column receives.

Since the discs are soft and provide support, they have a tendency over time and with misuse to herniate (bulge) backwards through the outer ligaments and cause irritation to the adjacent nerves. Bulging disc disease is one of the most common causes of chronic lower back pain and accounts for approximately 10% of all low back pain complaints. Disc disease may occur from herniation that results from trauma or heavy lifting.

More commonly, though, chronic low back pain is caused by degenerative disc disease. Degenerative disc disease is due to thinning and degeneration of the discs. It can lead to:

• Spinal stenosis
• Nerve impingement
• Worsening facet arthritis
• Peripheral nerve irritation

3. Spinal ligaments and muscles

Ligaments attach to each vertebra and provide strength and mobility to the spine as well as the many groups of muscles that are responsible for the spine’s movement. Nerve roots attach to the spinal cord and exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities.

These muscles and ligaments have a tendency to become strained and irritated during strenuous lifting or excessive exercise and can cause local nerve irritation. Myofascial (muscle and connective tissue) and ligament injuries may account for the majority of low back pain cases.

What causes lower back pain?

Common lower back pain causes include:

• Herniated discs
• Spinal stenosis
• Strained muscles and injuries
• Arthritis
• Fibromyalgia
• Vertebral body fractures
• Osteoporosis

Less common causes include infections, ankylosing spondylitis, and metastatic cancer. Note that risk factors for metastatic cancer are more common in those over 50, with pain not relieved by lying down, symptoms that are worse at night, and pain for longer than one month.

Causes can be acute or chronic. Let’s look at acute pain causes, chronic causes, and specific causes of pain for each of the back’s structures.

Referred lower back pain

Organs in the abdomen and pelvis can also cause pain in the back. This is known as “referred pain” and is most often caused by the kidney, pancreas, spleen, and liver.

This type of pain occurs due to the following changes in the organs:

• Obstruction
• Inflammation
• Infection
• Decreased blood supply
• Enlargement
• Cancer

Nerves at the same level of the lower back activate when these conditions occur, causing pain in the lower back. Even though the pain originates in the organs, you’ll feel it in your back.

Acute lower back pain causes

Acute pain usually comes on abruptly and occurs during a specific activity. An acute pain episode typically occurs due to:

• Overuse by excessive exercise
• Lifting heavy objects
• Motor vehicle accidents
• Falls
• Any trauma involving the lower back

Vertebral body fractures, ruptured discs, and spinal cord compressions are also acute injuries related to chronic conditions such as osteoporosis, cancer, or spinal stenosis.

Acute pain due to ligament and muscle injury generally responds to mild activity (e.g., stretching and low-impact exercise) and the use of non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen). Talk to your doctor about your acute back pain. They’ll evaluate the cause of your pain, ruling out serious issues like kidney stones, kidney infection, and acute pancreatitis.

In some cases of acute back pain, an emergency room, pain specialist, or spine surgeon are required, along with proper imaging for immediate evaluation. If you experience any of the following, get immediate medical help:

• Acute vertebral compression fractures
• Acute disc herniation
• Fever or chills
• Weakness or paralysis
• Loss of bowel or bladder control
• Spinal cord compression

If you have back pain that worsens and includes loss of bowel or bladder control or paralysis in the legs, this could indicate a serious health emergency that requires immediate treatment.

Chronic lower back pain causes

Chronic pain is defined as pain that lasts longer than three months, or beyond the expected duration. Typically, symptoms start gradually but will persist for an extended period of time. With chronic lower back pain, a person may experience pain in their back as well sciatic pain that extends across their hips and down the legs.

There are many causes of chronic lower back pain. They may include:

• Arthritis
• Sacroiliac joint disease
• Spinal stenosis (narrowing of the spinal canal)
• Fibromyalgia
• Degenerative disc disease
• Disc protrusion
• Herniated disc
• Disc extrusion
• Facet joint osteoarthritis
• Nerve root irritation or compression
• Central sensitization
• Biomechanical factors
• Poor posture
• Psychological and emotional factors
• Vertebral body fractures
• Osteoporosis
• Spondylolisthesis
• Ankylosing spondylitis
• Neoplasms
• Infections

Bony structures 

Bony structures in the spine are susceptible to more than just vertebral body fractures. They can also be affected by:

• Facet joint osteoarthritis
• Spinal stenosis (narrowing of the spinal canal)
• Osteoporosis
• Spondylolisthesis
• Neoplasms (Primary vs. metastatic lesions)
• Infections

Intervertebral disc

The intervertebral discs in your spine are susceptible to degradation and injury over time that can cause chronic pain. Some conditions that affect all aspects of intervertebral discs include:

• Degenerative disc disease
• Disc protrusion
• Herniated disc
• Disc extrusion
• Facet joint osteoarthritis
• Spinal stenosis (narrowing of the spinal canal)
• Nerve root irritation or compression (sciatica)
• Disc infection

Spinal ligaments and muscles 

Stress, strain, and injury to the ligaments and muscles can cause chronic back pain. Common sources of this type of pain include:

• Myofascial pain syndrome
• Muscular strain
• Torn muscle
• Ligamentous strain
• Ligamentous tear

Getting a back pain diagnosis and why it’s important

Getting a proper diagnosis is the first step in treating your pain.

Diagnosing lower back pain can be challenging, but the physicians at Arizona Pain are up to it, with experience and specialized training in pain management for complex conditions.

To get a diagnosis, your physician will perform a physical exam, looking for tenderness over certain areas of your spine as well as assessing any limitation in your range of motion. They may also order radiological imaging such as X-rays, CT scans, MRIs, or bone scans depending on their clinical suspicion and your medical history.

Regardless of the cause of your pain, central sensitization is a common complication associated with chronic pain of all kinds. This condition involves both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain.

Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually with enough time, normal inputs from the PNS can begin to produce abnormal responses.

A very light touch of the skin could activate neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce a harmless sensation now produces significant pain. It’s because of this that it’s important to get a diagnosis as soon as possible, so you can avoid further complications.

What lower back pain treatments could help me?

Contrary to what many people might think, bed rest is not the best treatment for most causes of pain. While an acute injury may need a day or two of limited activity, most physicians agree that staying active and looking for the least invasive pain treatment approach is the best place to start.

For lower back pain management in Phoenix and the surrounding areas, Arizona Pain utilizes the following treatments, ordered from non-invasive treatments to surgical interventions.

Nutrition and exercise

Nutrition and healthy eating are powerful treatments to combat nutritional deficits that may be affecting your pain levels. Anti-inflammatory foods and a balanced diet of grains, vegetables, and lean protein helps your body heal.

Exercise can improve your pain by increasing flexibility and range of motion. Another benefit to exercise is the release of hormones called endorphins, your body’s natural pain relievers.

Braces

Back braces may be all you need to get some support while you heal from an acute injury.

Combined with proper nutrition and gentle exercise, back braces keep you active to help you regain your flexibility and range of motion.

Biofeedback

This is a treatment that teaches a patient to become aware of processes that are normally thought to be involuntary inside of the body (such as blood pressure, temperature, and heart rate control).

This method enables you to gain some conscious control of these processes, which can influence and improve your levels of pain. A better awareness of one’s body teaches one to effectively relax, thereby reducing pain.

Physical therapy

Physical therapy and occupational therapy can decrease or prevent functional limitations.

Especially for pain caused by misuse or misalignment, physical therapy can teach you how to use your body more safely and effectively to prevent further or future injury.

Massage

Gentle massage of your tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with it.

Massage can also help you relax, decreasing stress and tension.

Chiropractic manipulations

Targeted adjustments, especially combined with other treatments, may significantly reduce low back pain.

Manipulations open up blocked channels in the spine for proper nerve transmission and less pain.

Acupuncture

Small needles are inserted into specific points on the body during acupuncture.

These needles cause your body to release endorphins (more natural pain relievers). Acupuncture can also help you relax, decreasing stress, tension, and muscular spasm.

Pharmacotherapy

NSAIDs (ibuprofen-like drugs), acetaminophen (such as Tylenol), muscle relaxants, and membrane-stabilizing medications are often effective in treating low back pain. Opioids are not indicated for treating chronic back pain.

Epidural steroid injections

Epidural steroid injections can help with some common pain syndromes (e.g., degenerative disc disease).

This method involves injecting a steroid into the epidural space of the spinal cord where the irritated nerve roots are located. The medicine then spreads to other parts of the spine, reducing inflammation and irritation. You can learn more in the following video.

Trigger point injections

Trigger point injections can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and steroid into a “trigger point,” the apparent root of the pain.

Medial branch blocks and denervation

Medial branch blocks (MBBs) are a minimally invasive non-surgical treatment that is used for arthritis-related neck and back pain.

The injections work by reducing the inflammation and irritation in whichever facet joints of the spine are causing pain.

Lysis of adhesions

Also known as the Racz procedure, lysis of adhesions can help remove excessive scar tissue in the epidural space when conservative treatments for lower back pain have failed.

A study performed in 2005 found that lysis of adhesions resulted in significant pain relief for patients with chronic pain with few, if any, adverse effects. This procedure can be helpful for patients with vertebral body compression fractures, post-laminectomy syndrome, radiculopathy, and disc disease.

Infusion techniques

These techniques involve inserting a small catheter through a needle into the epidural space or directly next to affected nerves.

Local anesthetic and other medicines are given through the catheter for extended time periods. When the nerves are blocked continuously with an infusion, pain relief can be dramatic and long-lasting.

Transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation, or TENS unit therapy, is a technique that relieves pain by applying mild electric current to the skin at the site of the pain.

The electric impulses interfere with normal pain sensations and replace pain signals with a slight tingling sensation.

Spinal cord stimulation (SCS)

Spinal cord stimulation uses an implanted electrical device to decrease the perception of pain by confusing the spinal cord and pain processing centers in the brain.

Initially, a trial is done to see if this device will help you long-term. In the initial trial, your pain physician places a small electrical lead in the epidural space through a needle. Painful signals are replaced by tingling electrical signals. If you have success in your trial, you may decide to have a permanent SCS device implanted. You can learn more in the following video.

Peripheral nerve stimulation

This method involves tiny electrodes being placed close to the affected nerves. The electrodes release a small electrical current that inhibits pain transmission and may provide pain relief.

Percutaneous discectomy

To complete a percutaneous discectomy, your doctor inserts a needle through the skin into the affected disc.

Disc material is suctioned out of the bulging disc to relieve pressure within the disc.

Disc denervation

Needles are placed along the vertebral bodies in close proximity to the discs and electrical stimulation is initiated.

When the appropriate nerves are located, they are anesthetized and destroyed using electricity. This disc denervation essentially deactivates the nerves.

Kyphoplasty and vertebroplasty

These are both minimally invasive procedures that can treat osteoporotic fractures.

The method stabilizes crushed vertebrae by injecting an acrylic cement into the vertebra. Vertebroplasty is effective in relieving pain, most likely because of the added support and stability it provides the spine.

Intrathecal pump implants

Implanted pain pumps are also available and can be extremely helpful by providing long-term pain control for back pain.

With this procedure, pumps are implanted next to the spine, with medicine released to the targeted area. Patients will have a trial period before they get a more permanent implant.

Peripheral nerve blocks and ablation

Nerves away from the spinal cord are called peripheral nerves. These nerves can often be sources of pain and can be blocked with local anesthetic.

If pain relief is successful, ablation uses heat to destroy the nerve more completely for long-term relief. You can learn more about ablation in the following video.

Back surgery

Surgical procedures are typically done when all conservative treatments are unsuccessful in reducing pain or when the spinal cord or exiting nerves are severely damaged or compressed. Serious compressions are characterized by bladder or bowel incontinence, lower extremity weakness, spasticity, or loss of sensation.

Invasive surgical procedures include:

• Laminectomy
• Spinal fusion
• Spinal instrumentation

Long-term, these surgeries may not provide complete pain relief. In addition, surgical options for low back pain do have a significant risk of complications, including bleeding, nerve damage, epidural scarring, and prolonged recovery times.

Again, surgical procedures are typically done when conservative management by pain specialists have been exhausted, life-threatening complications have arisen, or neurological symptoms like weakness, bowel or bladder changes, or loss of sensation have occurred. The evidence does not support routine surgical fusion or surgery alone for the treatment of chronic lower back pain.

References

• Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. PMID: 15507794. Spine. 2004 Nov 1;29(21):2350-6.
• Surgical management of neck and low back pain. PMID: 17445741 Neurol Clin. 2007 May;25(2):507-22. Clinical Trials: 2007;10;425-440.
• Evaluation of Lumbar Facet Joint Nerve Blocks in the Management of Chronic Low Back Pain: Preliminary Report of a Randomized, Double-Blind Controlled Trial: Clinical Trial NCT00355914 Laxmaiah Manchikanti, MD, Kavita N. Manchikanti, BA, Rajeev Manchukonda, BDS, Kimberly A. Cash, RT, Kim S. Damron, RN, Vidyasagar Pampati, MSc, and Carla D. McManus, RN, BSN
• Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials. PMID: 17119962 Int Orthop. 2006 Nov 21
• Physiotherapist-Directed Exercise, Advice, or Both for Subacute Low Back Pain: A Randomized Trial Liset H.M. Pengel, Kathryn M. Refshauge, Christopher G. Maher, Michael K. Nicholas, Robert D. Herbert, and Peter McNair Abstract for study: http://www.annals.org/cgi/content/abstract/146/11/787
• “Meta-Analysis: Acupuncture for Low Back Pain.” 19 April 2005 issue of Annals of Internal Medicine (volume 142, pages 651-663). E. Manheimer, A. White, B. Berman, K. Forys, and E. Ernst Summary of study: http://www.annals.org/cgi/content/summary/142/8/651
• A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain [/fusion_builder_column][ISRCTN 16558617] Laxmaiah Manchikanti1 BMC Anesthesiology 2005, 5:10 doi:10.1186/1471-2253-5-10
• Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. J Orthop Sci. 2007 May;12(3):274-80. Epub 2007 May 31 PMID: 17530380.