| Back Pain and Back Disorders and Disability Benefits |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
If you suffer from disabling Back Pain and can no longer work a full time
work week, I would be happy to help you obtain your rightful Disability
Benefits. You may be eligible for Social Security Disability benefits, even if
you will eventually recover.
Start by filling out the FREE online Social Security Disability Claim
Evaluation Form (see Tab, on Left Hand Navigation), calling me at
201-317-0610 or emailing SsiHelp@ptd.net or sojlaw@ptd.net.
work week, I would be happy to help you obtain your rightful Disability
Benefits. You may be eligible for Social Security Disability benefits, even if
you will eventually recover.
Start by filling out the FREE online Social Security Disability Claim
Evaluation Form (see Tab, on Left Hand Navigation), calling me at
201-317-0610 or emailing SsiHelp@ptd.net or sojlaw@ptd.net.
| What is Back Pain from?? |
Low back pain is very common. It affects 4 of 5 people at some time
during their lives. It is the leading cause of disability for those aged 19 to
45 and is the second most common cause of missed work days (after the
common cold) for adults younger than 45. Low back pain becomes more
common as people age. It affects half of the people older than 60 at any
given time. Each year, the treatment of low back pain costs more than
$80 billion, and insurance claims for disability due to low back pain
exceed $8 billion. Thus, although low back pain rarely results from life-
threatening disorders, it is a significant health problem. However, the
number of back injuries in the workplace is decreasing, perhaps because
awareness of the problem has increased and preventive measures have
improved.
The spine (spinal column) consists of the back bones (vertebrae), which
are separated and cushioned by shock-absorbing disks made of
cartilage. The vertebrae are also covered by a thin layer of cartilage.
They are held in place by ligaments and muscles, which help stabilize the
spine. These muscles include the two iliopsoas muscles (which run along
both sides of the spine), the two erector spinae muscles (which run along
the length of the spine behind it), and the many short paraspinal muscles
(which run between the vertebrae). The abdominal muscles (which run
from the bottom of the rib cage to the pelvis) also help stabilize the spine.
Enclosed in the spine is the spinal cord (see Biology of the Nervous
System: Spinal Cord and Spinal Cord Disorders: Introduction). Along the
length of the spinal cord, the spinal nerves emerge through spaces
between the vertebrae to connect with nerves throughout the body. The
part of the spinal nerve nearest the spinal cord is called the spinal nerve
root. Because of their position, spinal nerve roots can be compressed
when the spine is injured, resulting in pain. The lower (lumbar) spine
consists of five vertebrae. It connects the chest to the pelvis and legs,
providing mobility—for turning, twisting, and bending. It also provides
strength—for standing, walking, and lifting. Thus, the lower back is
involved in almost all activities of daily living. Low back pain can limit many
activities and reduce the quality of life.
Low back pain is very common. It affects 4 of 5 people at some time
during their lives. It is the leading cause of disability for those aged 19 to
45 and is the second most common cause of missed work days (after the
common cold) for adults younger than 45. Low back pain becomes more
common as people age. It affects half of the people older than 60 at any
given time. Each year, the treatment of low back pain costs more than
$80 billion, and insurance claims for disability due to low back pain
exceed $8 billion. Thus, although low back pain rarely results from life-
threatening disorders, it is a significant health problem. However, the
number of back injuries in the workplace is decreasing, perhaps because
awareness of the problem has increased and preventive measures have
improved.
The spine (spinal column) consists of the back bones (vertebrae), which
are separated and cushioned by shock-absorbing disks made of
cartilage. The vertebrae are also covered by a thin layer of cartilage.
They are held in place by ligaments and muscles, which help stabilize the
spine. These muscles include the two iliopsoas muscles (which run along
both sides of the spine), the two erector spinae muscles (which run along
the length of the spine behind it), and the many short paraspinal muscles
(which run between the vertebrae). The abdominal muscles (which run
from the bottom of the rib cage to the pelvis) also help stabilize the spine.
Enclosed in the spine is the spinal cord (see Biology of the Nervous
System: Spinal Cord and Spinal Cord Disorders: Introduction). Along the
length of the spinal cord, the spinal nerves emerge through spaces
between the vertebrae to connect with nerves throughout the body. The
part of the spinal nerve nearest the spinal cord is called the spinal nerve
root. Because of their position, spinal nerve roots can be compressed
when the spine is injured, resulting in pain. The lower (lumbar) spine
consists of five vertebrae. It connects the chest to the pelvis and legs,
providing mobility—for turning, twisting, and bending. It also provides
strength—for standing, walking, and lifting. Thus, the lower back is
involved in almost all activities of daily living. Low back pain can limit many
activities and reduce the quality of life.
Causes
Low back pain has many causes, although often no specific cause can be
identified. One of the most common causes is muscle and ligament strains
and sprains. Strains and sprains may result from lifting, exercising, or
moving in an unexpected way (such as when falling or when in a car
accident). When due to exercise, injury to the lower back is sometimes
called weight lifter's back (lumbar strain). Weight lifter's back may be
caused not only by snatching a heavy weight from the ground in weight
lifting but also by pushing against an opposing lineman in football,
suddenly turning to dribble after a rebound in basketball, swinging a bat
in baseball, or swinging a club in golf. The lower back is more likely to be
injured when a person's physical conditioning is poor and the supporting
muscles of the back are weak. Having poor posture, lifting improperly,
being overweight, and being tired also contribute. Osteoarthritis
(degenerative arthritis) causes the cartilage that covers and protects the
vertebrae to deteriorate. This disorder is thought to be due, at least in
part, to the wear and tear of years of use. The disks between the
vertebrae deteriorate, narrowing the spaces there and compressing
spinal nerve roots. Irregular projections of bone (spurs) may develop on
the vertebrae and also compress spinal nerve roots. All of these changes
can cause low back pain as well as stiffness. In osteoporosis, bone
density decreases, making the bones more likely to fracture. The
vertebrae are particularly susceptible to the effects of osteoporosis, often
resulting in crush (compression) fractures (which may cause sudden,
severe back pain) and 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 Herniated Disk
The tough covering of a disk in the spine can tear (rupture), causing pain.
The soft, jelly-like interior may bulge out (herniate) through the covering,
causing more pain. Pain occurs because the bulge puts pressure on the
spinal nerve root next to it. Sometimes the nerve is damaged. More than
80% of herniated disks occur in the lower back. They are most common
among people aged 30 to 50 years. Between these ages, the covering
weakens. The interior, which is under high pressure, may squeeze
through a tear or a weakened spot in the covering and bulge out. After
age 50, the interior of the disk begins to harden, making a herniation less
likely. A disk may herniate because of a sudden, traumatic injury or
repeated minor injuries. Being overweight or lifting heavy objects,
particularly lifting improperly, increases the risk. Where the pain occurs
depends on which disk is herniated and which spinal nerve root is
affected. The pain is felt along the pathway of the nerve compressed by
the herniated disk. For example, a herniated disk commonly causes
sciatica. The pain varies from slight to debilitating, and movement
intensifies the pain. Numbness and muscle weakness may also occur. If
the pressure on the nerve root is great, the legs may be paralyzed. If the
cauda equina (the bundle of nerves extending from the bottom of the
cord) is affected, control of bladder and bowels can be lost. If these
serious symptoms develop, medical attention is required immediately.
After about 2 weeks, many people recover without any treatment.
Applying cold (such as ice packs) or heat (such as a heating pad) or
using over-the-counter analgesics may help relieve the pain. Sometimes
surgery to remove part or all the disk and part of a vertebra is necessary.
In 10 to 20% of people who undergo surgery for sciatica due to a
herniated disk, another disk ruptures. A ruptured or herniated disk can
cause low back pain. A disk has a tough covering and a soft, jelly-like
interior. If a disk is suddenly squeezed by the vertebrae above and below
it (as when lifting a heavy object), the covering may tear (rupture),
causing pain. The interior of the disk can squeeze through the tear in the
covering, 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. A ruptured or herniated disk also commonly causes
sciatica.
What Is Sciatica?
The two sciatic nerves are the largest and longest nerves in the body.
Each is almost as large as a finger. On each side of the body, the sciatic
nerve runs from the lower spine, behind the hip joint, down the buttock
and back of the knee. There the sciatic nerve divides into several
branches and continues to the foot. When the sciatic nerve is pinched,
inflamed, or damaged, pain—sciatica—may radiate along the length of
the sciatic nerve to the foot. Sciatica occurs in about 5% of people who
have back pain. In some people, no cause can be detected. In others, the
cause may be a herniated disk, irregular projections of bone due to
osteoarthritis, or swelling due to a sprained ligament. Rarely, spinal
stenosis, Paget's disease, nerve damage due to diabetes (diabetic
neuropathy), a tumor, or a blood clot causes sciatica. Some people seem
to be prone to sciatica. Sciatica usually affects only one side. It may
cause a pins-and-needles sensation, a nagging ache, or a shooting pain.
Numbness may be felt in the leg or foot. Walking, running, climbing stairs,
and straightening the leg worsens the pain, which is relieved by bending
the back or sitting. Often, the pain goes away on its own. Resting,
sleeping on a firm mattress, taking over-the-counter nonsteroidal anti-
inflammatory drugs (NSAIDs), and applying heat and cold may be
sufficient treatment. For many people, sleeping on their side with the
knees bent and a pillow between the knees provides relief. Stretching the
hamstring muscles gently after warming up may help.
In older people, a common cause of low back pain is spinal stenosis
(narrowing of the spinal canal, the passageway that runs through the
center of the spine and contains the spinal cord). Spinal stenosis also
develops in middle-aged people who were born with a narrow spinal
canal. It is caused by such disorders as osteoarthritis and Paget's
disease. Spinal stenosis may cause sciatica as well as low back pain. In
ankylosing spondylitis, the spine and large joints are inflamed, resulting in
stiffness and back pain. This disorder is more common among men,
usually starting between the ages of 20 and 40. Sometimes low back pain
is referred pain (see What Is Referred Pain?), which originates in another
part of the body, such as the kidneys, bladder, uterus, or prostate, but is
felt in the lower back. For example, premenstrual syndrome or a bladder
infection can cause low back pain. Other less common causes of low back
pain include shingles; cancer that has spread to the spine from organs
such as the breast, lung, prostate, or kidney; bone cancer (multiple
myeloma); fibromyalgia; and birth defects such as scoliosis. Stress may
contribute to low back pain, but how it does so is unclear. Heavy physical
labor, obesity, smoking, and lack of exercise also contribute to low back
pain.
Symptoms and Types of Low Back Pain
Low back pain may be intermittent or constant; superficial or deep; or dull
and aching, throbbing, or sharp and stabbing, depending on the cause
and type of pain. There are several types of low back pain. Local pain
occurs in a specific area of the lower back. It is usually due to sprains and
strains. Sudden pain may be felt when the injury occurs. Local pain can
often be relieved by changes in position or by light activity followed by
stretching. Intense physical activity or inactivity tends to make it worse.
Local pain may be constant and aching or, at times, can be intermittent
and sharp. The lower back may be sore when touched. Muscle spasms
may develop because the body moves in unusual ways as it tries to avoid
the movements that trigger pain.
Usually, local pain resolves gradually over days to weeks. Pain due to
compression of a spinal nerve root may be due to such disorders as a
herniated disk, osteoarthritis, osteoporosis, spinal stenosis, or Paget's
disease. The pain often occurs within minutes or hours of lifting a very
heavy weight, but it may occur spontaneously. This type of pain tends to
be a dull ache with a sharp, intense radiating pain sometimes
superimposed on it. The pain can radiate to different parts of the body,
depending on which nerve root is affected. Commonly, the pain extends
from the lower back into the buttock and down the leg on the affected
side, causing sciatica. Coughing, sneezing, straining, or bending over
while keeping the legs straight can evoke the sharp, radiating pain. If a
herniated disk is the cause, the pain is worsened by walking a distance. If
spinal stenosis is the cause, the pain is typically increased by
straightening the back (for example, when walking) and is relieved by
bending the spine forward (for example, when leaning forward). If a
compression fracture is the cause, the pain usually starts suddenly, stays
in a particular area of the back, and worsens when a person stands or
walks. The area near the fracture may be tender. Usually, the pain and
tenderness disappear gradually after a few weeks or months.
If pressure on the nerve root is great, the pain may be accompanied by
muscle weakness in the leg, a pins-and-needles sensation, or even loss
of sensation and of bladder and bowel control. Referred pain (which
originates in other organs (see What Is Referred Pain?) tends to be deep,
aching, constant, and relatively widespread (diffuse). Typically, movement
does not affect it, and it worsens at night. For example, kidney infections
can cause low back pain that is felt to the side rather than the center of
the back.
Diagnosis
The symptoms, history, and results of a physical examination may
suggest the cause of low back pain. As part of the physical examination, a
doctor may ask the person to move in certain ways to determine the type
of pain. For example, a doctor may ask the person to lie flat, then lift the
leg without bending the knee. Usually, no other procedures are needed if
the cause is a strain or sprain. If another cause is suspected, other
procedures are often needed. X-rays of the lower back can help detect a
herniated disk, degenerative changes due to osteoarthritis, compression
fractures due to osteoporosis, and scoliosis. However, magnetic
resonance imaging (MRI) or computed tomography (CT) provides clearer
images and can confirm or exclude the diagnosis of a herniated disk,
spinal stenosis, or cancer. Rarely, when results of MRI are unclear,
myelography (see Diagnosis of Brain, Spinal Cord, and Nerve Disorders:
Myelography) with CT is required. Occasionally, electromyography (see
Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Electromyography)
is performed to confirm the location of nerve damage. Prevention
The most effective way to prevent low back pain is to exercise regularly
(see Exercise and Fitness: Introduction). Two types of exercises—aerobic
exercise and specific muscle-strengthening and stretching exercises—are
helpful. Aerobic exercise, such as swimming and walking, improves
general fitness, decreases obesity, and generally strengthens muscles.
Specific exercises to strengthen and stretch the muscles in the abdomen,
buttocks, and back can help stabilize the spine and decrease strain on
the disks that cushion the spine and the ligaments that hold it in place.
Muscle-strengthening exercises include pelvic tilts and abdominal curls.
Stretching exercises include the sitting leg stretch, knee-to-chest stretch,
and hip and quadriceps stretch. Stretching exercises can increase back
pain in some people and therefore should be performed carefully. As a
general rule, any exercise that causes or increases back pain should be
stopped. Exercises should be repeated until the muscles feel mildly but
not completely fatigued. Breathing during each exercise is important.
When lifting weights, wearing a weight-lifting belt may help prevent back
injury. People who have back pain should consult a doctor before
beginning to exercise.
Exercises to Prevent Low Back Pain
Pelvic Tilts
Lie on the back with the knees bent, the heels on the floor, and the weight
on the heels. Press the small of the back against the floor, contract the
buttocks (raising them about half an inch from the floor), and contract the
abdominal muscles. Hold this position for a count of 10. Repeat 20 times.
Abdominal Curls
Lie on the back with the knees bent and feet on the floor. Place the hands
across the chest. Contract the abdominal muscles, slowly raising the
shoulders 10 inches from the floor while keeping the head back (the chin
should not touch the chest). Then release the abdominal muscles, slowly
lowering the shoulders. Do 3 sets of 10.
Knee-to-Chest Stretch
Lie on the back with the knees bent and both heels on the floor. While
keeping the knees bent, place both hands behind one knee and bring it
to the chest. Hold for a count of 10. Slowly lower that leg and repeat with
the other leg. Do this exercise 10 times.
Sitting Leg Stretch
Sit on the floor with the knees straight but slightly flexed (not locked) and
the legs as far apart as possible. Place both hands on the same knee.
Slowly slide both hands toward the ankle. Stop if pain is felt and go no
farther than a position that can be held comfortably for 10 seconds.
Slowly return to a sitting position. Repeat with the other leg. Do this
exercise 10 times for each leg.
Hip and Quadriceps Stretch
Stand with one foot on the floor and the knee of the other leg bent at
about a 90° angle. Grasp the front of the ankle of the bent leg with the
hand on the same side. (The other hand may be placed on the back of a
chair or on the wall for balance.) Keeping the knees together, press the
foot against the hand and away from the body. Hold for a count of 10.
Repeat with the other leg. Do this exercise 10 times.
Exercise can also help people maintain bone density and a desirable
weight. Thus, exercise may reduce the risk of developing two conditions
that can lead to low back pain—osteoporosis and obesity. Maintaining
good posture when standing and sitting reduces stress on the back;
slouching should be avoided. Chair seats can be adjusted to a height that
allows the feet to be flat on the floor, with the knees bent up slightly and
the lower back flat against the back of the chair. If a chair does not
support the lower back, a pillow can be used behind the lower back.
Sitting with the feet on the floor rather than with the legs crossed is
advised. People should avoid standing or sitting for long periods. If
prolonged standing or sitting is unavoidable, changing positions
frequently may reduce stress on the back. Sleeping in a comfortable
position on a firm mattress is recommended. Pillows under the waist and
head can be used for support by people who sleep on their side, and a
pillow under the knees can be used by those who sleep on their back.
Pillows under the head should not force the neck to bend too much.
Learning to lift properly helps prevent back injury. The knees should be
bent enough that the arms are level with the object to be lifted. The legs,
not the back, should be used to lift. Lifting an object over the head
increases the risk of back injury. Using a steady footstool makes such
lifting unnecessary. Heavy objects should be carried close to the body.
Stopping smoking is also recommended. Treatment 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 for a few days may relieve pain. However, it does not
hasten the resolution of the pain, and most experts recommend continued
activity. Bed rest, if required, should last no more than 1 or 2 days. If a
specific disorder is causing low back pain, treating that disorder—for
example, giving antibiotics to treat a bladder infection—may relieve the
low back pain. Over-the-counter or prescription nonsteroidal anti-
inflammatory drugs (NSAIDs) (see Over-the-Counter Drugs: Analgesics
and Anti-Inflammatory Drugs and Pain: Nonsteroidal Anti-Inflammatory
Drugs) can be taken to relieve pain and reduce inflammation. Muscle
relaxants, such as methocarbamol , carisoprodol , cyclobenzaprine, or
diazepam, may be given to relieve muscle spasms, although many experts
question their usefulness. These drugs are not recommended for older
people, who are more likely to experience side effects. Application of heat
or cold and massage may help (see Rehabilitation: Pain and
Inflammation). Usually, traction is not useful. Some reports suggest that
acupuncture and chiropractic manipulation hasten the resolution of pain,
but others suggest little or no benefit. During recovery, a back brace or
corset is sometimes recommended for a short period or for use during
back-stressing activities. However, these support garments can be
uncomfortable and, if worn for a long time, may weaken the back muscles
by doing their work for them. After the pain has subsided, light activity, as
recommended by a doctor or physical therapist, can speed healing and
recovery. Specific exercises to strengthen and stretch the back are
usually recommended to help prevent low back pain from becoming
chronic or recurring.
Other preventive measures (maintaining good posture, using a firm
mattress with appropriately placed pillows, lifting properly, and stopping
smoking) should be continued or started. In response to these measures,
most episodes of back pain resolve in 1 to 2 weeks. Regardless of
treatment, 80 to 90% of such episodes resolve within 6 weeks. If low back
pain is chronic, additional measures are needed. Aerobic exercise may
help, and weight reduction, if necessary, is advised.
If the pain is severe, NSAIDs may not provide sufficient pain relief, and
opioid analgesics (see Pain: Opioid Analgesics) may be required. If these
analgesics are ineffective, some experts recommend that a corticosteroid,
such as dexamethasone or methylprednisolone, plus a local anesthetic,
such as lidocaine, be periodically injected around the spinal canal—as an
epidural injection. However, these injections are effective usually only for
several days to weeks. Transcutaneous electrical nerve stimulation
(TENS) is sometimes recommended (see Pain: Nondrug Pain
Treatments). A device that produces a gentle tingling sensation by
generating a low oscillating current is used. A therapist applies the device
to the painful area several times a day for 20 minutes to several hours at
a time, depending on the severity of the pain. People are sometimes
taught to use the device themselves. If a disorder is causing severe and
constant pain or serious symptoms, surgery may be necessary. If spinal
nerve root compression due to a herniated disk is causing symptoms
such as relentless sciatica, weakness, loss of sensation, or loss of
bladder and bowel control, surgical removal of the disk (diskectomy) and
part of the vertebra (laminectomy) may be necessary. A general
anesthetic is usually required. The hospital stay after surgical removal of
a disk is usually 1 or 2 days. Often, microsurgical techniques, with a small
incision, can be used. A local anesthetic is used, and hospitalization is not
required. However, when the incision is small, the surgeon may not be
able to see and therefore may not remove all fragments of the herniated
disk. After either procedure, most people can resume all of their activities
after a few weeks. More than 90% of people recover fully. For severe
spinal stenosis, surgery to widen the spinal canal by removing a larger
part of the vertebra may be performed. 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
the people have a good or full recovery. For most of the rest, symptoms
are prevented from worsening. When the spine is unstable because of
degeneration due to osteoarthritis, vertebrae may be fused together.
However, fusion decreases mobility and may put additional stress on the
rest of the spine.
Excerpted from Merck Manual Online.
during their lives. It is the leading cause of disability for those aged 19 to
45 and is the second most common cause of missed work days (after the
common cold) for adults younger than 45. Low back pain becomes more
common as people age. It affects half of the people older than 60 at any
given time. Each year, the treatment of low back pain costs more than
$80 billion, and insurance claims for disability due to low back pain
exceed $8 billion. Thus, although low back pain rarely results from life-
threatening disorders, it is a significant health problem. However, the
number of back injuries in the workplace is decreasing, perhaps because
awareness of the problem has increased and preventive measures have
improved.
The spine (spinal column) consists of the back bones (vertebrae), which
are separated and cushioned by shock-absorbing disks made of
cartilage. The vertebrae are also covered by a thin layer of cartilage.
They are held in place by ligaments and muscles, which help stabilize the
spine. These muscles include the two iliopsoas muscles (which run along
both sides of the spine), the two erector spinae muscles (which run along
the length of the spine behind it), and the many short paraspinal muscles
(which run between the vertebrae). The abdominal muscles (which run
from the bottom of the rib cage to the pelvis) also help stabilize the spine.
Enclosed in the spine is the spinal cord (see Biology of the Nervous
System: Spinal Cord and Spinal Cord Disorders: Introduction). Along the
length of the spinal cord, the spinal nerves emerge through spaces
between the vertebrae to connect with nerves throughout the body. The
part of the spinal nerve nearest the spinal cord is called the spinal nerve
root. Because of their position, spinal nerve roots can be compressed
when the spine is injured, resulting in pain. The lower (lumbar) spine
consists of five vertebrae. It connects the chest to the pelvis and legs,
providing mobility—for turning, twisting, and bending. It also provides
strength—for standing, walking, and lifting. Thus, the lower back is
involved in almost all activities of daily living. Low back pain can limit many
activities and reduce the quality of life.
Low back pain is very common. It affects 4 of 5 people at some time
during their lives. It is the leading cause of disability for those aged 19 to
45 and is the second most common cause of missed work days (after the
common cold) for adults younger than 45. Low back pain becomes more
common as people age. It affects half of the people older than 60 at any
given time. Each year, the treatment of low back pain costs more than
$80 billion, and insurance claims for disability due to low back pain
exceed $8 billion. Thus, although low back pain rarely results from life-
threatening disorders, it is a significant health problem. However, the
number of back injuries in the workplace is decreasing, perhaps because
awareness of the problem has increased and preventive measures have
improved.
The spine (spinal column) consists of the back bones (vertebrae), which
are separated and cushioned by shock-absorbing disks made of
cartilage. The vertebrae are also covered by a thin layer of cartilage.
They are held in place by ligaments and muscles, which help stabilize the
spine. These muscles include the two iliopsoas muscles (which run along
both sides of the spine), the two erector spinae muscles (which run along
the length of the spine behind it), and the many short paraspinal muscles
(which run between the vertebrae). The abdominal muscles (which run
from the bottom of the rib cage to the pelvis) also help stabilize the spine.
Enclosed in the spine is the spinal cord (see Biology of the Nervous
System: Spinal Cord and Spinal Cord Disorders: Introduction). Along the
length of the spinal cord, the spinal nerves emerge through spaces
between the vertebrae to connect with nerves throughout the body. The
part of the spinal nerve nearest the spinal cord is called the spinal nerve
root. Because of their position, spinal nerve roots can be compressed
when the spine is injured, resulting in pain. The lower (lumbar) spine
consists of five vertebrae. It connects the chest to the pelvis and legs,
providing mobility—for turning, twisting, and bending. It also provides
strength—for standing, walking, and lifting. Thus, the lower back is
involved in almost all activities of daily living. Low back pain can limit many
activities and reduce the quality of life.
Causes
Low back pain has many causes, although often no specific cause can be
identified. One of the most common causes is muscle and ligament strains
and sprains. Strains and sprains may result from lifting, exercising, or
moving in an unexpected way (such as when falling or when in a car
accident). When due to exercise, injury to the lower back is sometimes
called weight lifter's back (lumbar strain). Weight lifter's back may be
caused not only by snatching a heavy weight from the ground in weight
lifting but also by pushing against an opposing lineman in football,
suddenly turning to dribble after a rebound in basketball, swinging a bat
in baseball, or swinging a club in golf. The lower back is more likely to be
injured when a person's physical conditioning is poor and the supporting
muscles of the back are weak. Having poor posture, lifting improperly,
being overweight, and being tired also contribute. Osteoarthritis
(degenerative arthritis) causes the cartilage that covers and protects the
vertebrae to deteriorate. This disorder is thought to be due, at least in
part, to the wear and tear of years of use. The disks between the
vertebrae deteriorate, narrowing the spaces there and compressing
spinal nerve roots. Irregular projections of bone (spurs) may develop on
the vertebrae and also compress spinal nerve roots. All of these changes
can cause low back pain as well as stiffness. In osteoporosis, bone
density decreases, making the bones more likely to fracture. The
vertebrae are particularly susceptible to the effects of osteoporosis, often
resulting in crush (compression) fractures (which may cause sudden,
severe back pain) and 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 Herniated Disk
The tough covering of a disk in the spine can tear (rupture), causing pain.
The soft, jelly-like interior may bulge out (herniate) through the covering,
causing more pain. Pain occurs because the bulge puts pressure on the
spinal nerve root next to it. Sometimes the nerve is damaged. More than
80% of herniated disks occur in the lower back. They are most common
among people aged 30 to 50 years. Between these ages, the covering
weakens. The interior, which is under high pressure, may squeeze
through a tear or a weakened spot in the covering and bulge out. After
age 50, the interior of the disk begins to harden, making a herniation less
likely. A disk may herniate because of a sudden, traumatic injury or
repeated minor injuries. Being overweight or lifting heavy objects,
particularly lifting improperly, increases the risk. Where the pain occurs
depends on which disk is herniated and which spinal nerve root is
affected. The pain is felt along the pathway of the nerve compressed by
the herniated disk. For example, a herniated disk commonly causes
sciatica. The pain varies from slight to debilitating, and movement
intensifies the pain. Numbness and muscle weakness may also occur. If
the pressure on the nerve root is great, the legs may be paralyzed. If the
cauda equina (the bundle of nerves extending from the bottom of the
cord) is affected, control of bladder and bowels can be lost. If these
serious symptoms develop, medical attention is required immediately.
After about 2 weeks, many people recover without any treatment.
Applying cold (such as ice packs) or heat (such as a heating pad) or
using over-the-counter analgesics may help relieve the pain. Sometimes
surgery to remove part or all the disk and part of a vertebra is necessary.
In 10 to 20% of people who undergo surgery for sciatica due to a
herniated disk, another disk ruptures. A ruptured or herniated disk can
cause low back pain. A disk has a tough covering and a soft, jelly-like
interior. If a disk is suddenly squeezed by the vertebrae above and below
it (as when lifting a heavy object), the covering may tear (rupture),
causing pain. The interior of the disk can squeeze through the tear in the
covering, 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. A ruptured or herniated disk also commonly causes
sciatica.
What Is Sciatica?
The two sciatic nerves are the largest and longest nerves in the body.
Each is almost as large as a finger. On each side of the body, the sciatic
nerve runs from the lower spine, behind the hip joint, down the buttock
and back of the knee. There the sciatic nerve divides into several
branches and continues to the foot. When the sciatic nerve is pinched,
inflamed, or damaged, pain—sciatica—may radiate along the length of
the sciatic nerve to the foot. Sciatica occurs in about 5% of people who
have back pain. In some people, no cause can be detected. In others, the
cause may be a herniated disk, irregular projections of bone due to
osteoarthritis, or swelling due to a sprained ligament. Rarely, spinal
stenosis, Paget's disease, nerve damage due to diabetes (diabetic
neuropathy), a tumor, or a blood clot causes sciatica. Some people seem
to be prone to sciatica. Sciatica usually affects only one side. It may
cause a pins-and-needles sensation, a nagging ache, or a shooting pain.
Numbness may be felt in the leg or foot. Walking, running, climbing stairs,
and straightening the leg worsens the pain, which is relieved by bending
the back or sitting. Often, the pain goes away on its own. Resting,
sleeping on a firm mattress, taking over-the-counter nonsteroidal anti-
inflammatory drugs (NSAIDs), and applying heat and cold may be
sufficient treatment. For many people, sleeping on their side with the
knees bent and a pillow between the knees provides relief. Stretching the
hamstring muscles gently after warming up may help.
In older people, a common cause of low back pain is spinal stenosis
(narrowing of the spinal canal, the passageway that runs through the
center of the spine and contains the spinal cord). Spinal stenosis also
develops in middle-aged people who were born with a narrow spinal
canal. It is caused by such disorders as osteoarthritis and Paget's
disease. Spinal stenosis may cause sciatica as well as low back pain. In
ankylosing spondylitis, the spine and large joints are inflamed, resulting in
stiffness and back pain. This disorder is more common among men,
usually starting between the ages of 20 and 40. Sometimes low back pain
is referred pain (see What Is Referred Pain?), which originates in another
part of the body, such as the kidneys, bladder, uterus, or prostate, but is
felt in the lower back. For example, premenstrual syndrome or a bladder
infection can cause low back pain. Other less common causes of low back
pain include shingles; cancer that has spread to the spine from organs
such as the breast, lung, prostate, or kidney; bone cancer (multiple
myeloma); fibromyalgia; and birth defects such as scoliosis. Stress may
contribute to low back pain, but how it does so is unclear. Heavy physical
labor, obesity, smoking, and lack of exercise also contribute to low back
pain.
Symptoms and Types of Low Back Pain
Low back pain may be intermittent or constant; superficial or deep; or dull
and aching, throbbing, or sharp and stabbing, depending on the cause
and type of pain. There are several types of low back pain. Local pain
occurs in a specific area of the lower back. It is usually due to sprains and
strains. Sudden pain may be felt when the injury occurs. Local pain can
often be relieved by changes in position or by light activity followed by
stretching. Intense physical activity or inactivity tends to make it worse.
Local pain may be constant and aching or, at times, can be intermittent
and sharp. The lower back may be sore when touched. Muscle spasms
may develop because the body moves in unusual ways as it tries to avoid
the movements that trigger pain.
Usually, local pain resolves gradually over days to weeks. Pain due to
compression of a spinal nerve root may be due to such disorders as a
herniated disk, osteoarthritis, osteoporosis, spinal stenosis, or Paget's
disease. The pain often occurs within minutes or hours of lifting a very
heavy weight, but it may occur spontaneously. This type of pain tends to
be a dull ache with a sharp, intense radiating pain sometimes
superimposed on it. The pain can radiate to different parts of the body,
depending on which nerve root is affected. Commonly, the pain extends
from the lower back into the buttock and down the leg on the affected
side, causing sciatica. Coughing, sneezing, straining, or bending over
while keeping the legs straight can evoke the sharp, radiating pain. If a
herniated disk is the cause, the pain is worsened by walking a distance. If
spinal stenosis is the cause, the pain is typically increased by
straightening the back (for example, when walking) and is relieved by
bending the spine forward (for example, when leaning forward). If a
compression fracture is the cause, the pain usually starts suddenly, stays
in a particular area of the back, and worsens when a person stands or
walks. The area near the fracture may be tender. Usually, the pain and
tenderness disappear gradually after a few weeks or months.
If pressure on the nerve root is great, the pain may be accompanied by
muscle weakness in the leg, a pins-and-needles sensation, or even loss
of sensation and of bladder and bowel control. Referred pain (which
originates in other organs (see What Is Referred Pain?) tends to be deep,
aching, constant, and relatively widespread (diffuse). Typically, movement
does not affect it, and it worsens at night. For example, kidney infections
can cause low back pain that is felt to the side rather than the center of
the back.
Diagnosis
The symptoms, history, and results of a physical examination may
suggest the cause of low back pain. As part of the physical examination, a
doctor may ask the person to move in certain ways to determine the type
of pain. For example, a doctor may ask the person to lie flat, then lift the
leg without bending the knee. Usually, no other procedures are needed if
the cause is a strain or sprain. If another cause is suspected, other
procedures are often needed. X-rays of the lower back can help detect a
herniated disk, degenerative changes due to osteoarthritis, compression
fractures due to osteoporosis, and scoliosis. However, magnetic
resonance imaging (MRI) or computed tomography (CT) provides clearer
images and can confirm or exclude the diagnosis of a herniated disk,
spinal stenosis, or cancer. Rarely, when results of MRI are unclear,
myelography (see Diagnosis of Brain, Spinal Cord, and Nerve Disorders:
Myelography) with CT is required. Occasionally, electromyography (see
Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Electromyography)
is performed to confirm the location of nerve damage. Prevention
The most effective way to prevent low back pain is to exercise regularly
(see Exercise and Fitness: Introduction). Two types of exercises—aerobic
exercise and specific muscle-strengthening and stretching exercises—are
helpful. Aerobic exercise, such as swimming and walking, improves
general fitness, decreases obesity, and generally strengthens muscles.
Specific exercises to strengthen and stretch the muscles in the abdomen,
buttocks, and back can help stabilize the spine and decrease strain on
the disks that cushion the spine and the ligaments that hold it in place.
Muscle-strengthening exercises include pelvic tilts and abdominal curls.
Stretching exercises include the sitting leg stretch, knee-to-chest stretch,
and hip and quadriceps stretch. Stretching exercises can increase back
pain in some people and therefore should be performed carefully. As a
general rule, any exercise that causes or increases back pain should be
stopped. Exercises should be repeated until the muscles feel mildly but
not completely fatigued. Breathing during each exercise is important.
When lifting weights, wearing a weight-lifting belt may help prevent back
injury. People who have back pain should consult a doctor before
beginning to exercise.
Exercises to Prevent Low Back Pain
Pelvic Tilts
Lie on the back with the knees bent, the heels on the floor, and the weight
on the heels. Press the small of the back against the floor, contract the
buttocks (raising them about half an inch from the floor), and contract the
abdominal muscles. Hold this position for a count of 10. Repeat 20 times.
Abdominal Curls
Lie on the back with the knees bent and feet on the floor. Place the hands
across the chest. Contract the abdominal muscles, slowly raising the
shoulders 10 inches from the floor while keeping the head back (the chin
should not touch the chest). Then release the abdominal muscles, slowly
lowering the shoulders. Do 3 sets of 10.
Knee-to-Chest Stretch
Lie on the back with the knees bent and both heels on the floor. While
keeping the knees bent, place both hands behind one knee and bring it
to the chest. Hold for a count of 10. Slowly lower that leg and repeat with
the other leg. Do this exercise 10 times.
Sitting Leg Stretch
Sit on the floor with the knees straight but slightly flexed (not locked) and
the legs as far apart as possible. Place both hands on the same knee.
Slowly slide both hands toward the ankle. Stop if pain is felt and go no
farther than a position that can be held comfortably for 10 seconds.
Slowly return to a sitting position. Repeat with the other leg. Do this
exercise 10 times for each leg.
Hip and Quadriceps Stretch
Stand with one foot on the floor and the knee of the other leg bent at
about a 90° angle. Grasp the front of the ankle of the bent leg with the
hand on the same side. (The other hand may be placed on the back of a
chair or on the wall for balance.) Keeping the knees together, press the
foot against the hand and away from the body. Hold for a count of 10.
Repeat with the other leg. Do this exercise 10 times.
Exercise can also help people maintain bone density and a desirable
weight. Thus, exercise may reduce the risk of developing two conditions
that can lead to low back pain—osteoporosis and obesity. Maintaining
good posture when standing and sitting reduces stress on the back;
slouching should be avoided. Chair seats can be adjusted to a height that
allows the feet to be flat on the floor, with the knees bent up slightly and
the lower back flat against the back of the chair. If a chair does not
support the lower back, a pillow can be used behind the lower back.
Sitting with the feet on the floor rather than with the legs crossed is
advised. People should avoid standing or sitting for long periods. If
prolonged standing or sitting is unavoidable, changing positions
frequently may reduce stress on the back. Sleeping in a comfortable
position on a firm mattress is recommended. Pillows under the waist and
head can be used for support by people who sleep on their side, and a
pillow under the knees can be used by those who sleep on their back.
Pillows under the head should not force the neck to bend too much.
Learning to lift properly helps prevent back injury. The knees should be
bent enough that the arms are level with the object to be lifted. The legs,
not the back, should be used to lift. Lifting an object over the head
increases the risk of back injury. Using a steady footstool makes such
lifting unnecessary. Heavy objects should be carried close to the body.
Stopping smoking is also recommended. Treatment 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 for a few days may relieve pain. However, it does not
hasten the resolution of the pain, and most experts recommend continued
activity. Bed rest, if required, should last no more than 1 or 2 days. If a
specific disorder is causing low back pain, treating that disorder—for
example, giving antibiotics to treat a bladder infection—may relieve the
low back pain. Over-the-counter or prescription nonsteroidal anti-
inflammatory drugs (NSAIDs) (see Over-the-Counter Drugs: Analgesics
and Anti-Inflammatory Drugs and Pain: Nonsteroidal Anti-Inflammatory
Drugs) can be taken to relieve pain and reduce inflammation. Muscle
relaxants, such as methocarbamol , carisoprodol , cyclobenzaprine, or
diazepam, may be given to relieve muscle spasms, although many experts
question their usefulness. These drugs are not recommended for older
people, who are more likely to experience side effects. Application of heat
or cold and massage may help (see Rehabilitation: Pain and
Inflammation). Usually, traction is not useful. Some reports suggest that
acupuncture and chiropractic manipulation hasten the resolution of pain,
but others suggest little or no benefit. During recovery, a back brace or
corset is sometimes recommended for a short period or for use during
back-stressing activities. However, these support garments can be
uncomfortable and, if worn for a long time, may weaken the back muscles
by doing their work for them. After the pain has subsided, light activity, as
recommended by a doctor or physical therapist, can speed healing and
recovery. Specific exercises to strengthen and stretch the back are
usually recommended to help prevent low back pain from becoming
chronic or recurring.
Other preventive measures (maintaining good posture, using a firm
mattress with appropriately placed pillows, lifting properly, and stopping
smoking) should be continued or started. In response to these measures,
most episodes of back pain resolve in 1 to 2 weeks. Regardless of
treatment, 80 to 90% of such episodes resolve within 6 weeks. If low back
pain is chronic, additional measures are needed. Aerobic exercise may
help, and weight reduction, if necessary, is advised.
If the pain is severe, NSAIDs may not provide sufficient pain relief, and
opioid analgesics (see Pain: Opioid Analgesics) may be required. If these
analgesics are ineffective, some experts recommend that a corticosteroid,
such as dexamethasone or methylprednisolone, plus a local anesthetic,
such as lidocaine, be periodically injected around the spinal canal—as an
epidural injection. However, these injections are effective usually only for
several days to weeks. Transcutaneous electrical nerve stimulation
(TENS) is sometimes recommended (see Pain: Nondrug Pain
Treatments). A device that produces a gentle tingling sensation by
generating a low oscillating current is used. A therapist applies the device
to the painful area several times a day for 20 minutes to several hours at
a time, depending on the severity of the pain. People are sometimes
taught to use the device themselves. If a disorder is causing severe and
constant pain or serious symptoms, surgery may be necessary. If spinal
nerve root compression due to a herniated disk is causing symptoms
such as relentless sciatica, weakness, loss of sensation, or loss of
bladder and bowel control, surgical removal of the disk (diskectomy) and
part of the vertebra (laminectomy) may be necessary. A general
anesthetic is usually required. The hospital stay after surgical removal of
a disk is usually 1 or 2 days. Often, microsurgical techniques, with a small
incision, can be used. A local anesthetic is used, and hospitalization is not
required. However, when the incision is small, the surgeon may not be
able to see and therefore may not remove all fragments of the herniated
disk. After either procedure, most people can resume all of their activities
after a few weeks. More than 90% of people recover fully. For severe
spinal stenosis, surgery to widen the spinal canal by removing a larger
part of the vertebra may be performed. 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
the people have a good or full recovery. For most of the rest, symptoms
are prevented from worsening. When the spine is unstable because of
degeneration due to osteoarthritis, vertebrae may be fused together.
However, fusion decreases mobility and may put additional stress on the
rest of the spine.
Excerpted from Merck Manual Online.
| MySsiCase.com |
| Brought to you by the Social Security Disability Law Office of Stephanie O. Joy, Esq. Helping clients, one-on-one, in all 50 U.S. States Ph: 201-317-0610 Email: SsiHelp@ptd.net Fax: 570-424-2384 |
