Animals. That's what we are. And like our Simian relatives, the apes, we
were meant to roam around, for the most part, on all fours. But once we
stopped swinging in trees and came down to the ground we assumed a peculiar
upright stance. This may bode well for standing room only at a major
sporting event, but not for a lifetime of walking, lifting, and pulling.
The spinal cord, a veritable extension of your brain, passes through a
series of tiny holes in each vertebra until it reaches your lower back
where tentacles of nerves carry messages to and from your limbs through yet
tinier openings in the lower spine. Consider for a moment that the cord is
the thickness of your thumb and the consistency of a scallop. It is easy to
understand how even a little trauma or irritation to the spine that
surrounds it can have painful and/or serious consequences.
The spinal column is like a stack of poker chips made of bone.
Between each vertebra lies a rubber-like disc with a thick gelatinous
center. These discs serve to both cushion the heavy load placed on the
spine by body weight and gravity, and to prevent bone from rubbing directly
on bone. Without disc cushions our bones would grind down to a powder. In
fact, in many people-especially as they get older-the cushions weaken, the
bones get closer together, and begin to crumble (Degenerative
Osteoarthritis). It is also reasonable to expect that the more weight
placed on the vertebral column, the greater the forces of gravity and the
greater the potential for degeneration. This is why the medical profession
places great emphasis on weight reduction for large patients with back
But I often have to remind my well-meaning colleagues that being
large can also paradoxically be beneficial since bones tend to remain
denser and stronger if they carry more weight. This is why women and some
men who are slight of build tend to suffer from Osteoporosis (osteo=bone,
porosis=porous) which may lead to crumbling of the spine and the
"hunched-over" posture one often sees in the elderly.
Back problems are second only to colds as a cause of absenteeism
and runner up to headaches as a cause of pain. But they are second to none
as the leading causes of work-related disability claims. Although back
conditions are the primary cause for visits to my colleague Orthopedic
Surgeons, many now refuse to see chronic back pain patients because of a
generally poor permanent solution with any medical or surgical intervention.
80% of low back pain is mechanical which simply means that it is
due to some stress or strain. This is a diagnosis which is commonly used
when no anatomic or other overt defect is identifiable. Other more
"tangible" causes of back pain include degeneration, tumors, inflammation,
People who notice the sensation of something pulling or giving way suddenly
in their back after heavy lifting, twisting, pushing or bending often
present with immediate onset of pain. This mechanical pain may be caused by
a sudden stretching of the long elastic "bands" that actually hold the
spine in place. People with back strain often have difficulty sitting still
or finding any comfortable position for at least the first few hours after
injury. It should also be noted that pain and stiffness may actually
increase several hours later, as those of you who have been in minor auto
accidents can attest to.
DEGENERATIVE DISC PROBLEMS
The disc cushions may get more brittle with time and the continued downward
pounding of weight, work and gravity. With the vertebrae and cushions
crumbling and weakening, the spaces between the bones narrows impinging on
the delicate nerves which exit between them. Pinching of these nerves not
only causes pain in the area but refers pain and even numbness and shooting
or tingling pains to the areas of the leg supplied by these long nerves.
Most people will notice an insidious progression of problems over several
years although an exacerbation can seem sudden.
Sciatica (named for the Sciatic nerve which supplies most of the
nervous function of the leg) is an often debilitating pain caused by disc
encroachment. Pain is often noted all the way to the back of the foot and
big toe. There might also be symptoms in the buttock, thigh, calf or ankle.
Upright posture, standing and extremes of bending may cause pain. Many
large people in their thirties and forties will notice this sort of
discomfort and get relief only when they sit. Often a person tends to tilt
to one side to avoid pressure on the nerve in question. Unfortunately, this
can cause strain on a variety of muscles, ligaments and even feet. A
vicious cycle of pain, spasm, and more pain ensues.
If the vertebrae were just stacked one atop another they could tumble and
collapse every time we bent over. Besides strong muscles and ligaments
supporting the column, there are actually articulating joints between each
pair of vertebrae to allow for flexibility of the trunk without total
collapse. Time, wear, and tear can eat away at these Facet joints (from the
French facette="face", referring to the small flat surface on a bone)
which, unfortunately, lie adjacent to the gaps were nerves exit the column.
SPONDYLOLYSIS AND SPONDYLOLISTHESIS
Spondylo(Greek=vertebra/spine)-Lysis(Greek=dissolution), a gradual
degeneration of the column usually as it joins with the pelvis, cannot just
be blamed on continuous stress of obesity. In fact, many thin adolescent
female athletes and young male football linemen suffer from this problem.
It is possible that in some people minor fractures of the ring surrounding
the delicate spinal cord and nerves in this area can eventually lead to a
degenerative crumbling arthritis and minor slippage of the vertebra on top
of each other.
If the slippage is more pronounced the defect is called
Spondylolisthesis (from the Greek olisthanein= "to slip") in which case
minor discomfort can become more constant. Often it begins with occasional
pain and spasm in the back mostly due to stress on the muscles and tendons
in the area which are trying to hold the joints in place.
In order to better understand the process of Spondylolisthesis try
standing sideways in front of a mirror and look behind you at the area
involved. It's in the "small" of the back, the fist-size valley in the
center, just before the buttocks begin. Now imagine that valley suddenly
enlarging and your abdomen lunging forward. Of course the process does not
happen this quickly, however, if the forward slippage of one vertebra over
another causes actual narrowing of the space that holds the spinal cord or
nerves, or even if arthritis develops in the area after repeated spasm and
bone degeneration, the pain will become relatively constant. Pain is
usually worse when standing or walking and there is almost immediate relief
when sitting or lying down. One may notice relief by leaning forward
slightly in a sitting position.
Analogously, infections that might originate in the lungs, kidneys or any
other bodily system, can spread to the spine. Osteomyelitis (from the Greek
myeIo meaning marrow and itis=inflammation/infection) is often introduced
locally from skin contagion especially near joints. Pain, redness, swelling
and fever art often clues to infection of the spine. Of course, one of the
most serious complications is spread of the infection to the spinal fluid
which bates the brain causing Meningitis (from the Greek meningo referring
to the membranes surrounding the brain).
SPONDYLOSIS AND SPONDYLITIS
Spondylosis (the suffix osis usually is a generic term meaning "condition"
or "disease") is a non specific term describing the eventual crusty look
and bending of the spine as seen on x-rays in older folks. Years of wear,
tear, and arthritis take their toll. Older men are often seen limping in
pain with this condition.
There are even problems with the back that may have a genetic or
inherited component. Ankylosing (greek-"bent" or "crooked") Spondylitis
(referring to inflammation of the spine) is a condition in which the spinal
joints actually fuse as one ages. Young men are most often affected but in
their early years, as the problem begins, they may only notice morning back
stiffness. As the bones begin to fuse, all movements of the spine are
difficult including taking a deep breath.
A variety of tumors have a tendency to grow in the bone marrow of the
spine. Benign tumors such as Hemangiomas( Heme= blood) associated with
"strawberry-like" birth marks on the skin of the back can actually
infiltrate underneath the surface to the bone and spinal cord producing
Sometimes cancers of the bone, bone marrow, or blood start in the
spinal area. This is understandable since essentially all blood products
are manufactured in bone marrow.
Quite often cancer that originates in cryptic sites in the lungs
(or virtually any other part of the body) makes its first appearance as
back pain. This is because secondary tumors spread to the spine where
pressure on the spinal cord or nerves cause patients to seek help.
BACK PAIN PROM OTHER SOURCES
Considering that nerves travel great distances in the body and that,
embryologically, they often originate from areas a great distance from
where they end up, the source of pain can often be confusing.
Abdominal and kidney problems are notorious for presenting as back
ache. Kidney stones run a course from the kidney down a narrow tube in the
back to the pelvis and ultimately out of the urethra. Most people assume at
first that they must have "done something" to their backs.
When the major artery leading away from the heart-the aorta-is
threatening to burst as a result of hardening of the arteries and/or high
blood pressure, patients often feel a severe pain in the back.
A wide variety of abdominal and pelvic problems from constipation
to serious bleeding can present as back ache.
Even with all the new technologies at our disposal, nothing replaces a
thorough history and physical examination by a health care professional. Do
not hesitate to describe anything new and unusual, no matter what part of
the body you think it is coming from.
The diagnostician should examine you both lying and standing. You
will be asked to touch your toes, stretch backward and slide your hand down
both thighs. These maneuvers assess back motion. A good clinician will be
feeling your back for evidence of spasm.
Leg and foot pulses, sensation ("tickling" and "needle poking") and
motion tests are very important in assessing for nerve damage. One does not
even have to suffer from arthritis, disc or bone damage-simple muscle spasm
can squeeze the nerves causing pain and tingling
Often, with mechanical stress pain, no special tests are required. X-rays
of the back may reveal degenerative crumbling, fusion and/or narrowing of
disc spaces of the spine. Even if the bones look normal individually, the
spine may assume a stiff upright position from spasm. Normally the spine
assumes a gentle curve. Muscle spasm and pain are the body's splinting
system; a way of assuring that as little movement as possible takes place
that might create more damage.
Computerized Tomography (CAT) Scans are simply a rapid sequence of
x-rays pieced together by computer to give somewhat of a clearer view of
tough-to-get-at spots in the spine.
Magnetic Resonance Imaging (MRI) Scans take advantage of minute
differences in electrical activity of various tissues in the body and can
be especially useful in creating "virtual reality" three dimensional
pictures of many problems with the spine.
Electromyography measures the conduction of nerves in muscles and
may be useful in detecting nerve and muscle damage in weakened areas.
Myelography involves injecting dye into the spinal fluid which
outlines all the related structures on x-ray. Trapped nerves or impingement
points in the spinal canal can be accurately pin-pointed this way.
WHAT CAN BE DONE
Most back problems are treated in the same fashion. If there is pain,
stiffness and spasm, one does what the body is telling it to do. Initial
rest in a comfortable position for a day or two is fine.
In the past, patients were almost universally advised to lie for
extensive periods in a firm bed. We now know that early mobility is usually
best. This is because movement increases blood flow which, in turn, speeds
Heat over the affected areas also increases blood flow and provides
soothing relief. A hot tub is ideal because it also decreases the stresses
of gravity on the involved structures. A warm water bottle (notice I did
not say hot water bottle) is effective but avoid use of electric heating
pads. All too often people fall asleep with these devices on and we
commonly treat people for serious burns.
Hot or cold liniments are helpful. Many contain forms of Aspirin
which can be absorbed thought the skin. There are several products made
from hot peppers (Capsaicin) that when applied to the skin produce a
burning sensation. It is believed that local pain sensors art deactivated
temporarily giving relief.
Anti-inflammatory analgesic agents have been a mainstay of therapy
since Aspirin was introduced over a century ago (and likely in its
primitive form centuries earlier).
The colloquial term NSAIDs, which stands for Non-Steroidal
Anti-inflammatory Drugs, applies to a wide variety of modern agents that
decrease pain associated with inflammation of joints and muscles. The major
problem with most of these drugs including Salicylates (such as Aspirin) is
that they also tend to break down the buffer system that protects the
stomach. Ulcers and gastrointestinal bleeding are a serious and common
complication, although there are new drug combinations that hold the
promise of preventing such damage.
Acetaminophen, Opiates (such as Codeine) and Muscle Relaxants don't
necessarily cause bleeding and do offer some relief. Even these agents,
however, are not without there own potentially serious side effects,
especially when used long term.
There is increasing support scientifically for "alternative" treatments
including Massage Therapy, Acupuncture, Hypnosis, Psychotherapy,
Antidepressants, Meditation, etc., for certain conditions. One must be open
to a variety of culturally specific practices, many of which are time
honored. Spinal Manipulation should only be attempted by a suitably trained
and licensed health care professional and only in selected situations.
Malignancies, congenital disorders, and crippling back problems obviously
require special procedures.
Removal of degenerating discs and opening tight bony spaces were
once commonplace procedures. Injecting herniated disc cushions with a kind
of meat tenderizer is still occasionally practiced.
Although there are certain circumstances where surgery is an
option, the end result is often disappointing. Nature and time still seem
to have the upper hand in degenerative back and spine disorders.
Although cures for back pain are often not possible, physiotherapy,
controlled exercise programs, ultrasound, TENS (Electrode nerve
desensitization) and, of course, properly controlled and supervised
exercise programs often make back ailments less debilitating.
Most importantly, let me reiterate in closing the most obvious
caveat of all: Seek professional help and get as many opinions as you can
before embarking on any treatment for your aching back. ß