Patients with low back pain are often plagued with frustrations, confusion and distress. Depending on whom they consult (orthopedic, neurosurgeon, traditional medicine practitioners, physiotherapist and chiropractors), they may be told different things, ranging from muscle strain, bone degeneration to spinal pain.

Doctors have many ideas about what causes low back pain, but no single explanation applies to everyone.  No one back pain is the same as another person. The causes of low back pain can be very complex as there are many structures in the back that can cause pain.

  Sources of back pain:

• Prolapsed Disc/Slipped Disc (See Condition)
• Nerve Root compression/Spinal Cord compression (See Condition)
• Intervertebral Disc Inflammation (See Condition)
• Arthritis of Facet Joints in the spine (See Condition)
• Spinal Fractures
• Degeneration of Spine (See Condition)
• Abnormal slippage of spine (Spondylolisthesis)
• Myofascial Pain/Fibromyalgia (See Condition)

1. Intervertebral Disc.  It may be a disc herniation or a discal tear, resulting in protrusion of disc material into the spinal canal.  Treatments using interventional pain procedures include nucleoplasty, intradiscal radiofrequency lesioning.
2. Impingement of spinal nerve roots. This impingement may be due to protruding disc or enlarging facet joints, encroaching into the spinal canal, resulting in narrowing of the space (spinal stenosis) and nerve entrapment.  For patients who are afraid of surgery or not a candidate for open surgical decompression, we can offer adhesiolysis and ballooning of the spine.
3. Disc Inflammation and Degeneration.  The disc may be damaged due to excessive stress and load.  This can cause chronic axial back pain without any leg symptoms.  Prolonged sitting will  precipitate the pain.  
   
4. Facet Arthropathies/Spondylosis. Facetal pain can be secondary to acute inflammation or degeneration.  Additional physical stress may pose on the facet joints if it is compounded with scoliosis or kyphosis of the spine.  Radiofrequency ablation of the painful nerves can give relief to patients who do not want fusion of their spine.
   
5. Pathological conditions of the vertebral body. Compression fractures of the vertebral body can result in loss of height and additional stress on the surrounding facet joints. Vertebroplasty can be useful to increase the height of those compressed spinal bodies.   
   
6. Spinal degeneration such as scoliosis, spondyloslisthesis can result in significant structural problems such as curvature of spine – this can cause narrowing of the spinal canal internally or increased muscle tension and spasm externally.

  Combination of different conditions

Low back pain may be related to aging. As a result of wear and tear on the spine, ligaments, and disks, increased pressure applied axially (by excessive lifting of a load), a disk may begin to protrude or collapse and put pressure on the nerve root leading to a leg or foot, causing pain in those areas (sciatica).

The problem can be aggravated by associated conditions, such as narrowing of the canal or shifting of the vertebra (slippage of spine on top of one another).

  Low back pain is sometimes caused by:

• Excessive stress to the back, such as lifting something heavy
• Excessive weight gain, with poor surrounding abdominal muscles
• Minimal movement, such as bending or reaching for something
• Problems with tendons or ligaments in and around the spine
• Malpositioning of vertebrae

Occasionally, back pain happens with no cause. There may not be a trauma or any injury sustained by the patient. Nonetheless, the pain is real and needs to be treated. Otherwise the back pain can present slowly and progressively becomes chronic and disabling. Advance investigations with Xray may not pick up any abnormalities in the spine. Muscle sprain resulting in back pain can present this way, and may not show up in any investigations. These conditions while may be disabling, will need other less invasive treatment rather than surgical approaches.

The symptoms of low back pain presents in a variety of ways. Some only complain of pain in their backs while others have both leg and back pain.  Walking a distance can precipitate their painful area.  Some patients may have localized back pain when prolong sitting or sitting, while others have pain only when flexing or extending their back. Most people find that lying down will improve their pain and after their initial severe episode, many will be able to rest at night without severe pain. Most people experience more severe pain when they lift or carry something heavy. Some get relief from extending the back.

Leg pain also can be part of the problem. The pain is most common in the back or outer side of the thigh, and can go all the way to the foot. Pain that goes to the foot is called “sciatica” because it is pain that follows the course of the sciatic nerve. Sciatica is often made worse by coughing or sneezing or straining.

For about 60% of back pain, the acute episode of back pain can be very severe for a few days or a week and then will often improve. By 2 weeks to 4 weeks, most people get better.  The cause of this type of pain is usually injury to the muscles or ligaments.  The rest of 40% of patients can have disabling pain flare without getting better including disabling effects interfering standing, sitting and walking, resulting in hospitalization and medicalisation.  These patients usually have a spine disorder, involving nerves, discs and facet joints.  The length of time between episodes of pain flare varies greatly from person to person, as does the length of each episode, the intensity of each episode, and how well each individual copes with the pain.

See your doctor to diagnose low back pain. Tell him your complete medical history. It is important to identify the site of primary pain (maximum local pain site) as well as secondary pain (diffuse, non discrete pain).  The physical examination may yield neurological signs with motor and sensory deficit. The doctor checks for:

• Evidence of nerve problems. The doctor evaluates strength, sensation and reflexes. He or she may ask you to move your spine to see how limited the motion is.
• Poor blood circulation. Although not related to the spine, poor blood circulation can lead to back pain.  Tell the doctor what activities aggravates or improves your symptoms.
• Injury to the spine and the integral supporting elements
• Muscle spasm affecting posture and alignment of spine.  Tell the doctor what motions or positions hurt and what helps relieve the pain.

  Types of lower back pain that indicate a surgical emergency

These symptoms indicate a serious medical condition requiring urgent medical attention and possibly surgery:

• Sudden bowel and/or bladder incontinence  
  
• Progressive weakness in the legs
  
• Severe, continuous abdominal and low back pain (possible leaking blood vessel)
  
• Back pain with fever and chills
• History of cancer with recent weight loss, or those have just suffered a severe trauma should also seek immediate medical attention.

Treatments for low back pain are:

1. Nonsurgical Treatment
   1. Rest
      A few days of rest can often calm the pain down as well. Prolonged bed rest (more than 2 days to 3 days) is no longer generally recommended for people with low back pain.
   2. Braces
      Although there is minimal scientific evidence of their effectiveness in treating low back pain, back braces are commonly used. Most common is a corset type brace that can be wrapped around the back and abdomen. People who use corset type braces sometimes report feeling better supported and more comfortable.  Short term use has its benefits but chronic use has more disadvantages than advantages. 
   3. Local Muscle Injections
      The most commonly used injections are local anesthetic, hypertonic glucose and/or steroids. They are usually given either in the area that is believed to be the source of the pain, such as into a muscle or ligament.  Once the muscle is deactivated, and inflammation is removed, the painful area is allowed to heal and recover. 
      
   4. Exercise and Stretching
      Exercising to restore motion and strength to a painful lumbar spine can be very helpful in relieving pain. Although there is controversy as to which are the most effective spine exercises, it is generally agreed that exercise should be both aerobic (aimed at improving heart and lung function) and stretches specific to the spine. Aerobic exercises include walking, jogging, swimming, and bicycling.  In principle, exercises being engaged should be both strengthening and stretching.
   5. Proper Posture and Lifting Technique
      Improperly bending over to lift can cause a large increase in strain on the low back. Proper lifting keeps the back straight while you bend with the knees.
2. Surgical Treatment Options

Open Surgical Options:

1. Laminectomy Decompression.Open surgery - A segment of the bone of the spine is cut off to allow space for the nerves to be freed. 
2. Instrumental Fusion of spine. Screws and plates are fused with the spine to cause a rigid structure, preventing mobility, hence no movement - no pain.

Interventional Pain Procedures (Minimally Invasive):

1. Needle Laser Decompression. Through a needle, a laser wand is inserted into the spine to decompress the intervertebral disc.  (See Nucleoplasty Dekcompressor)
2. Needle Ballooning Decompression. Through a needle, a balloon catheter is inserted into the spine to decompress the narrowed area of the spine.  This is liken to ballooning of a narrowed blood vessel.  (See Neuroplasty)

Low back pain caused by lifting can be prevented by using proper lifting techniques and by exercising regularly to improve muscle strength and overall physical condition.

The normal effects of aging that result in loss of bone mass and decreased strength and elasticity of muscles and ligaments can't be avoided. However, the effects can be slowed by:

• Exercising regularly to keep the muscles of the back strong and flexible
• Using the correct lifting and moving techniques
• Maintaining a proper body weight; being overweight puts a strain on the back muscles
• Avoiding smoking
• Maintaining a proper posture when standing and sitting; don't slouch