White Coat Underground

Low back pain—the scourge of Homo sapiens

It started a few weeks ago—a dull ache in my lower back, more on the right, worse with sitting for prolonged periods of time. I did my usual stretches, although not as much as I should have. The pain waxed and waned, until a few days ago, when the pain escalated suddenly, preventing me from standing up straight, and making even a trip to the bathroom an unwelcome adventure. Two nights ago, I lay in bed awake, pillows wedged at strategic points, hoping to find some comfort, any comfort.

And then all hell broke loose. My back spasms loosened up a bit last night, so I got a few essential things done—and felt sudden burning pain shooting down my right leg, accompanied by numbness, tingling, and weakness. I writhed on the floor in pain, with even more drama than usual. Around 1:00 a.m., Mrs. Pal said, “Hey, I hear there’s a pain clinic open now…it’s over in the guest room.” I rifled through the medicine cabinet and tried various tablets searching for relief.

I ended up laying on the floor of the guest room, legs on a pillow, sleeping fitfully. I was so desperate that I actually saw my doctor.

What is this low back pain stuff anyway?

First of all, it’s common. When people come to see their primary care physician for other-than regularly scheduled visits, low back pain is one of the most common complaints (ranking anywhere between first and fifth, depending on the survey). This is a common problem. The good news is that most of the time it gets better spontaneously. The bad news is that while it’s healing, there is significant lost work, and significant suffering.

There are many causes for low back pain, but quite often the cause isn’t so important. It’s useful to divide low back pain into two broad categories: benign causes, and not-so-benign causes. As physicians, we look for “red flags” that point toward the not-so-benign causes, which probably make up less than 5% of all back pain.

In evaluating the patient with low back pain, three questions form a useful framework:

    Is there evidence of systemic disease?
    Is there evidence of neurologic compromise?
    Is there social or psychological distress that may contribute to chronic, disabling pain?

The first two help detect back pain caused by other underlying systemic disease. The last is a prognostic question. People who answer “yes” to the third question are at risk of prolonged back problems and possibly substance abuse if the underlying psychosocial problems are not addressed.

Some of the conditions discovered by the first two questions include infections of the spine, cancers affecting the spine, and other serious neuroanatomical spine problems.

But, as I said, most back problems not due to other serious diseases respond very well to conservative therapy, regardless of the cause.

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The picture above is one example. See where the red bit is pushing on the yellow bit? That’s probably somewhat like what’s happening in my back at this very minute. An intervertebral disk is prolapsed, pushing against a nerve root, causing pain, tingling, numbness, and weakness in my leg. It’s possible that surgery could be of some use, but even fairly dramatic injuries such as this one usually heal up with time (and pain control and physical therapy). In fact, imaging is rarely needed (but, at least in the U.S., often obtained).

The evidence would suggest that since I don’t have weight loss, fever, incontinence, or other concerning symptoms, I should take some pain medication, go to physical therapy, and try not to do anything stupid.

I’ve definitely got the first two covered.

Comments

  1. #1 eddie
    January 29, 2009

    I have had similar symptoms in the last year. Got so bad at one point that I could hardly dress myself in the morning.

    I was refusing to take pain killers as I didn’t like the idea of something narcotic that simply hid the symptoms, but when I saw my doctor, he said to take ibuprofen as it has an anti-inflammatory action that is actual treatment of the condition. He prescribed a short course of super-strength anti-inflammatories to start.

    He explained that the pain that starts in the lower back and goes on down the leg is due to inflammation of the sciatic nerve, most probably at the point it passes the hip bone, as opposed to the slipped disk idea you illustrate above. Not saying your pain is in exactly the same area as mine.

    The irony of sciatica from the evolutionary perspective your title alludes to, is that the nerve wouldn’t have such difficulty passing the hip if we didn’t walk upright.

  2. #2 Chas
    January 29, 2009

    I’ve had central lower back pain come and go the last few years since I turned 50ish. After a little research determined it wasn’t due to a systemic or neurologic cause I figured it had to be stress related. Heat works great to relieve symptoms and the worst case lasts only a couple of days. Exercise (hiking, walking, light occasional calisthenics) and stress reduction has minimized my occurrences. Hope you feel better soon.

  3. #3 leigh
    January 29, 2009

    it’s the not doing anything stupid that usually has the steepest learning curve.

    my husband was pretty much incapacitated after rupturing two adjacent lumbar discs and during associated diagnostic and intervention attempts. it came down to quitting the very physically demanding career (!) and pretty much not lifting anything heavy ever again. he still screws up the latter sometimes.

    yeah. um. got NSAIDs?

  4. #4 chezjake
    January 29, 2009

    I’d recommend that you seriously consider at least the temporary use of a heated waterbed. Being able to sleep (and sleep well) on a warm surface that conforms to your body, whether sleeping on your back or side, helps greatly in achieving the relaxation that is necessary for real healing. It helped me greatly when I had a repetitive stress injury from repeated lifting and moving of not-too-heavy objects (the efforts of packing all the books, journals, etc. from a decent sized medical library, and then unpacking and re-shelving them in a new facility).

  5. #5 Russell
    January 29, 2009

    People don’t walk enough.

  6. #6 KristinMH
    January 29, 2009

    Geez, Pal, don’t mess around with those “pain” “medications”. Don’t you know a chiropractor can snap your back into submission in no time and keep it there as long as you pay him $75 per week for life?

    He can also make sure your spinal column is in constant communication with the deity of your choice. Or something.

  7. #7 KristinMH
    January 29, 2009

    I forgot to add: get well soon.

  8. #8 Ryan
    January 30, 2009

    Do more yoga.

  9. #9 Doug Alder
    January 30, 2009

    If it’s sciatica I can highly recommend a particular stretch a physiotherapist taught me for it. It’s one that starts relieving my symptoms very quickly. If it has a name I don’t know it so I’m going to0 have to describe it.

    Lie parallel to a wall with your wall side hip touching or very close to the wall. Bring your knees up towards your chest and at the same time swivel on your butt so that you can raise your legs up on to the wall – the goal is to have your butt less than a hands width from the wall with both legs going straight up. With full blown sciatica it will be almost impossible to straighten the affected leg right away but get it as straight as you can then start flexing your feet back towards your chest, hold 10 -20 seconds relax, then flex the opposite way. This is going to be painful but it works. Do as many reps as you can stand to do, do this several times a day until symptoms go away then do it once a day for maintenance – it will help prevent re-occurrences.

    Good luck and I hope you recover soon. 20 years of bartending destroyed my lower back so I know what you;re going through.

  10. #10 Noadi
    January 30, 2009

    Take care of yourself, you do not want to end up in the position my dad did. The position was on a stretcher being loaded into an ambulance because his back was spasming and in so much pain he couldn’t even sit up. Several shots of muscle relaxants and some morphine got him capable of going home but he was out of work a week recovering. Rest up, do what the physical therapist tells you, and please work on the not doing anything stupid.

  11. #11 Jason F.
    January 30, 2009

    Ryan recommends “Do more yoga”.

    While I certainly agree that yoga can lessen the frequency of back problems, it by no means is a cure-all.

    I’ve been doing yoga regularly for 10 years, and this past winter–after doing a very nice 1-hour yoga routine–I hurt my lower back, similar to what you’re describing. How? I was hiking with my dog and stepped over a log and…..crunch….I heard a funny sound and felt a little twinge. By the next morning, I had massive spasms and could only lay on my side with pillows between my legs.

    I didn’t have the leg pains and numbness you describe, but it hurt like hell. My big mistake was not taking anti-inflammatory meds for the first three days. Muscle relaxers and Tylenol didn’t alleviate the problem and just covered it up.

    It’s been about 4 months now and just this week I’m getting back into yoga. After a couple of weeks, I hope to return to the gym.

    So yeah…yoga helps, but sometimes apparently, it just doesn’t matter what you do.

  12. #12 cre8tivewmn
    January 30, 2009

    My sympathies. I have a lot of neck and back problems (due to the systemic disease you referred to) and I know that flare-ups are no fun. As you mentioned, sometimes pain killers are all you can do to keep functioning and give your body time to fix itself.

    I’m hoping for a complete and speedy recovery for you.

  13. #13 Comrade PhysioProf
    January 31, 2009

    I used to do a lot of stretching as part of my exercise routine, and did have some lower back issues. I completely eliminated stretching, and haven’t had any problems since. And yes, I was following all the stretching instructions like doing it only after warming up with aerobic exercise, etc.

    I have two blogging requests: Would you consider reviewing the evidence (1) concerning efficacy of stretching at preventing injury and (2) concerning the outcome of surgery for low-back pain versus doing nothing?

  14. #14 The Perky Skeptic
    January 31, 2009

    I do stretching exercises for my legs– they seem to help my knees not feel the stress of running. I, too, would be interested in a review of pain and stretching vs. not stretching. (It’s not going to make me stop stretching either way– I like being more limber at age 40 than I was at age 6, lol!)

  15. #15 Northern Blot
    February 1, 2009

    Can I second Comrade Physioprof’s request for a review of the evidence concerning back surgery versus the more conservative options. I have just got back from spending 36 hrs in an emergency room with my spouse, watching the physicians stuff him full of dilaudid so that he could actually walk again. After 3 years of these flare ups due to a herniated disk he is considering surgery and from what I’ve heard from doctors the outcome is pretty mixed.

  16. #16 Docmatt
    February 1, 2009

    Personal and professional experience (Emergency Medicine physician): VAST majority of acute musculoskeletal back pain lasts six weeks, whether muscle tear with spasms, or disk herniation, or sciatica. Severe pain may be 1-2 weeks, then very gradual resolution. Chiropractic visits 2-3 times weekly for 4-6 weeks vs. physical therapy 1-2 times weekly vs. education alone have the same ultimate outcome. Prescription and over-the-counter medicines may reduce discomfort slightly during this time, but do nothing to shorten the course of discomfort. Ice packs vs. heating pads? Do whichever feels best; nobody really knows the answer.

    Red flags include fever, midline spinal tenderness, neurologic deficits in the legs, bowel or bladder dysfunction, abdominal pain, age greater than 50 years need careful consideration. Spine manipulations, “adjustments”, etc. are useless. Once the acute episode has resolved, core strengthening, yoga, other stretching might reduce recurrences, but nobody knows for sure. My biggest warning for patients: if you bend down and twist to the side to pick something up, be certain to return your trunk to the midline before straightening.