Handout on Health: Back Pain

This booklet is for people who have back pain, as well as family members, friends, and others
who want to find out more about it. The booklet describes causes, diagnosis, and treatments, and
research efforts to learn more about back pain, many of which are supported by the National
Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of
the U.S. Department of Health and Human Services National Institutes of Health (NIH). If you
have further questions after reading this booklet, you may wish to discuss them with your doctor.

What Is Back Pain?

Back pain is an all-too-familiar problem that can range from a dull, constant ache to a sudden,
sharp pain that leaves you incapacitated. It can come on suddenlyfrom an accident, a fall, or
lifting something heavyor it can develop slowly, perhaps as the result of age-related changes
to the spine. Regardless of how back pain happens or how it feels, you know it when you have it.
And chances are, if you dont have back pain now, you will eventually.

How Common Is Back Pain?

What Are the Risk Factors for Back Pain?
What Are the Causes of Back Pain?
Can Back Pain Be Prevented?
When Should I See a Doctor for Pain?
Which Type of Doctor Should I See?
How Is Back Pain Diagnosed?
What Is the Difference Between Acute and Chronic Pain?
How Is Back Pain Treated?
What Kind of Research Is Being Done?
For More Information
Keywords
Acknowledgments

Illustrations

Side View of Spine

Normal Vertebra (Cross-Section)

How Common Is Back Pain?

In a 3-month period, about one-fourth of U.S. adults experience at least 1 day of back pain. It is
one of our societys most common medical problems.

What Are the Risk Factors for Back Pain?

Although anyone can have back pain, a number of factors increase your risk. They include:
Age: The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain
becomes more common with age.

Fitness level: Back pain is more common among people who are not physically fit. Weak back
and abdominal muscles may not properly support the spine.
Weekend warriorspeople who go out and exercise a lot after being inactive all weekare
more likely to suffer painful back injuries than people who make moderate physical activity a
daily habit. Studies show that low-impact aerobic exercise is good for the disks that cushion the
vertebrae, the individual bones that make up the spine.

Diet: A diet high in calories and fat, combined with an inactive lifestyle, can lead to obesity,
which can put stress on the back.

Heredity: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that
affects the spine, have a genetic component.

Race: Race can be a factor in back problems. African American women, for example, are two to
three times more likely than white women to develop spondylolisthesis, a condition in which a
vertebra of the lower spinealso called the lumbar spineslips out of place.

The presence of other diseases: Many diseases can cause or contribute to back pain. These
include various forms of arthritis, such as osteoarthritis and rheumatoid arthritis, and cancers
elsewhere in the body that may spread to the spine.

Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling,
particularly when this involves twisting or vibrating the spine, can lead to injury and back pain.
An inactive job or a desk job may also lead to or contribute to pain, especially if you have poor
posture or sit all day in an uncomfortable chair.

Cigarette smoking: Although smoking may not directly cause back pain, it increases your risk of
developing low back pain and low back pain with sciatica. (Sciatica is back pain that radiates to
the hip and/or leg due to pressure on a nerve.) For example, smoking may lead to pain by
blocking your bodys ability to deliver nutrients to the disks of the lower back. Or repeated
coughing due to heavy smoking may cause back pain. It is also possible that smokers are just less
physically fit or less healthy than nonsmokers, which increases the likelihood that they will
develop back pain. Smoking also increases the risk of osteoporosis, a condition that causes weak,
porous bones, which can lead to painful fractures of the vertebrae. Furthermore, smoking can
slow healing, prolonging pain for people who have had back injuries, back surgery, or broken
bones.

What Are the Causes of Back Pain?

It is important to understand that back pain is a symptom of a medical condition, not a diagnosis
itself. Medical problems that can cause back pain include the following:

Mechanical problems: A mechanical problem is a problem with the way your spine moves or
the way you feel when you move your spine in certain ways. Perhaps the most common
mechanical cause of back pain is a condition called intervertebral disk degeneration, which
simply means that the disks located between the vertebrae of the spine are breaking down with
age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the
back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and
ruptured disks, which are also called herniated disks.

Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain.
Sprains are tears in the ligaments that support the spine, and they can occur from twisting or
lifting improperly. Fractured vertebrae are often the result of osteoporosis. Less commonly, back
pain may be caused by more severe injuries that result from accidents or falls.

Acquired conditions and diseases: Many medical problems can cause or contribute to back pain.
They include scoliosis, a curvature of the spine that does not usually cause pain until middle age;
spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and
ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure
on the spinal cord and nerves. Although osteoporosis itself is not painful, it can lead to painful
fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or
infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and
fibromyalgia, a condition of widespread muscle pain and fatigue.

Infections and tumors: Although they are not common causes of back pain, infections can cause
pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the
disks that cushion the vertebrae, which is called diskitis. Tumors also are relatively rare causes of
back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a
result of cancer that has spread from elsewhere in the body.

Although the causes of back pain are usually physical, emotional stress can play a role in how
severe pain is and how long it lasts. Stress can affect the body in many ways, including causing
back muscles to become tense and painful.
Can Back Pain Be Prevented?

One of the best things you can do to prevent back pain is to exercise regularly and keep your
back muscles strong. Four specific types of exercises are described in How Is Back Pain
Treated?. All may help you avoid injury and pain. Exercises that increase balance and strength
can decrease your risk of falling and injuring your back or breaking bones. Exercises such as tai
chi and yogaor any weight-bearing exercise that challenges your balanceare good ones to
try.

Eating a healthy diet also is important. For one thing, eating to maintain a healthy weightor to
lose weight, if you are overweighthelps you avoid putting unnecessary and injury-causing
stress and strain on your back. To keep your spine strong, as with all bones, you need to get
enough calcium and vitamin D every day. These nutrients help prevent osteoporosis, which is
responsible for a lot of the bone fractures that lead to back pain. Calcium is found in dairy
products; green, leafy vegetables; and fortified products, like orange juice. Your skin makes
vitamin D when you are in the sun. If you are not outside much, you can obtain vitamin D from
your diet: nearly all milk and some other foods are fortified with this nutrient. Most adults dont
get enough calcium and vitamin D, so talk to your doctor about how much you need per day, and
consider taking a nutritional supplement or a multivitamin.

Practicing good posture, supporting your back properly, and avoiding heavy lifting when you can
may all help you prevent injury. If you do lift something heavy, keep your back straight. Dont
bend over the item; instead, lift it by putting the stress on your legs and hips.

When Should I See a Doctor for Pain?

In most cases, it is not necessary to see a doctor for back pain because pain usually goes away
with or without treatment. However, a trip to the doctor is probably a good idea if you have
numbness or tingling, if your pain is severe and doesnt improve with medication and rest, or if
you have pain after a fall or an injury. It is also important to see your doctor if you have pain
along with any of the following problems: trouble urinating; weakness, pain, or numbness in
your legs; fever; or unintentional weight loss. Such symptoms could signal a serious problem
that requires treatment soon.

Which Type of Doctor Should I See?

Many different types of doctors treat back pain, from family physicians to doctors who specialize
in disorders of the nerves and musculoskeletal system. In most cases, it is best to see your
primary care doctor first. In many cases, he or she can treat the problem. In other cases, your
doctor may refer you to an appropriate specialist.

How Is Back Pain Diagnosed?

Diagnosing the cause of back pain requires a medical history and a physical exam. If necessary,
your doctor may also order medical tests, which may include x rays.
During the medical history, your doctor will ask questions about the nature of your pain and
about any health problems you and close family members have or have had. Questions might
include the following:

Have you fallen or injured your back recently?

Does your back feel betteror hurt worsewhen you lie down?
Are there any activities or positions that ease or aggravate pain?
Is your pain worse or better at a certain time of day?
Do you or any family members have arthritis or other diseases that might affect the spine?
Have you had back surgery or back pain before?
Do you have pain, numbness, or tingling down one or both legs?

During the physical exam, your doctor may:

watch you stand and walk

check your reflexes to look for slowed or heightened reflexes, either of which might suggest
nerve problems
check for fibromyalgia by examining your back for tender points, which are points on the body
that are painful when pressure is applied to them
check for muscle strength and sensation
check for signs of nerve root irritation.

Often a doctor can find the cause of your pain with a physical and medical history alone.
However, depending on what the history and exam show, your doctor may order medical tests to
help find the cause.

Following are some tests your doctor may order:

X rays: Traditional x rays use low levels of radiation to project a picture onto a piece of film
(some newer x rays use electronic imaging techniques). They are often used to view the bones
and bony structures in the body. Your doctor may order an x ray if he or she suspects that you
have a fracture or osteoarthritis or that your spine is not aligned properly.

Magnetic resonance imaging (MRI): MRI uses a strong magnetic force instead of radiation to
create an image. Unlike an x ray, which shows only bony structures, an MRI scan produces clear
pictures of soft tissues, too, such as ligaments, tendons, and blood vessels. Your doctor may
order an MRI scan if he or she suspects a problem such as an infection, tumor, inflammation, or
pressure on a nerve. An MRI scan, in most instances, is not necessary during the early phases of
low back pain unless your doctor identifies certain red flags in your history and physical exam.
An MRI scan is needed if the pain persists for longer than 3 to 6 weeks or if your doctor feels
there may be a need for surgical consultation. Because most low back pain goes away on its own,
getting an MRI scan too early may sometimes create confusion for the patient and the doctor.

Computed tomography (CT) scan: A CT scan allows your doctor to see spinal structures that
cannot be seen on traditional x rays. A computer creates a three-dimensional image from a series
of two-dimensional pictures that it takes of your back. Your doctor may order a CT scan to look
for problems including herniated disks, tumors, or spinal stenosis.
Blood tests: Although blood tests are not used generally in diagnosing the cause of back pain,
your doctor may order them in some cases. Blood tests that might be used include the following:

Complete blood count (CBC), which could point to problems such as infection or inflammation
Erythrocyte sedimentation rate (also called sed rate), a measure of inflammation that may
suggest infection. The presence of inflammation may also suggest some forms of arthritis or, in
rare cases, a tumor.
C-reactive protein (CRP), another blood test that is used to measure inflammation, may indicate
an infection or some forms of arthritis.
HLA-B27, a test to identify a genetic marker in the blood that is more common in people with
ankylosing spondylitis (a form of arthritis that affects the spine and sacroiliac joints) or reactive
arthritis (a form of arthritis that occurs following infection in another part of the body, usually
the genitourinary tract).

It is important to understand that medical tests alone may not diagnose the cause of back pain.
Often, MRI scans of the spine show some type of abnormality, even in people without
symptoms. Similarly, even some healthy pain-free people can have elevated sed rates.

Only with a medical history and examand sometimes medical testscan a doctor diagnose the
cause of back pain. Many times, the precise cause of back pain is never known. In these cases, it
may be comforting to know that most back pain gets better whether or not you find out what is
causing it.

What Is the Difference Between Acute and Chronic Pain?

Pain that hits you suddenlyafter falling from a ladder, being tackled on the football field, or
lifting a load that is too heavy, for exampleis acute pain. Acute pain comes on quickly and
often leaves just as quickly. To be classified as acute, pain should last no longer than 6 weeks.
Acute pain is the most common type of back pain.

Chronic pain, on the other hand, may come on either quickly or slowly, and it lingers a long
time. In general, pain that lasts longer than 3 months is considered chronic. Chronic pain is much
less common than acute pain.

How Is Back Pain Treated?

Treatment for back pain generally depends on what kind of pain you experience: acute or
chronic.

Acute Back Pain

Acute back pain usually gets better on its own and without treatment, although you may want to
try acetaminophen, aspirin, or ibuprofen to help ease the pain. Perhaps the best advice is to go
about your usual activities as much as you can with the assurance that the problem will clear up.
Getting up and moving around can help ease stiffness, relieve pain, and have you back doing
your regular activities sooner. Exercises or surgery are not usually advisable for acute back
pain.

Chronic Back Pain

Treatment for chronic back pain falls into two basic categories: the kind that requires an
operation and the kind that does not. In the vast majority of cases, back pain does not require
surgery. Doctors will nearly always try nonsurgical treatments before recommending surgery. In
a very small percentage of caseswhen back pain is caused by a tumor, an infection, or a nerve
root problem called cauda equina syndrome, for exampleprompt surgery is necessary to ease
the pain and prevent further problems.

Following are some of the more commonly used treatments for chronic back pain.

Nonsurgical Treatments

Hot or cold: Hot or cold packsor sometimes a combination of the twocan be soothing to
chronically sore, stiff backs. Heat dilates the blood vessels, both improving the supply of oxygen
that the blood takes to the back and reducing muscle spasms. Heat also alters the sensation of
pain. Cold may reduce inflammation by decreasing the size of blood vessels and the flow of
blood to the area. Although cold may feel painful against the skin, it numbs deep pain. Applying
heat or cold may relieve pain, but it does not cure the cause of chronic back pain.

Exercise: Although exercise is usually not advisable for acute back pain, proper exercise can
help ease chronic pain and perhaps reduce the risk of it returning. The following four types of
exercise are important to general physical fitness and may be helpful for certain specific causes
of back pain:

Flexion: The purposes of flexion exercises, which are exercises in which you bend forward, are
to (1) widen the spaces between the vertebrae, thereby reducing pressure on the nerves; (2)
stretch muscles of the back and hips; and (3) strengthen abdominal and buttock muscles. Many
doctors think that strengthening the muscles of the abdomen will reduce the load on the spine.
One word of caution: If your back pain is caused by a herniated disk, check with your doctor
before performing flexion exercises because they may increase pressure within the disk, making
the problem worse.

Extension: With extension exercises, you bend backward. They may minimize radiating pain,
which is pain you can feel in other parts of the body besides where it originates. Examples of
extension exercises are leg lifting and raising the trunk, each exercise performed while lying
prone. The theory behind these exercises is that they open up the spinal canal in places and
develop muscles that support the spine.

Stretching: The goal of stretching exercises, as their name suggests, is to stretch and improve
the extension of muscles and other soft tissues of the back. This can reduce back stiffness and
improve range of motion.
Aerobic: Aerobic exercise is the type that gets your heart pumping faster and keeps your heart
rate elevated for a while. For fitness, it is important to get at least 30 minutes of aerobic (also
called cardiovascular) exercise three times a week. Aerobic exercises work the large muscles of
the body and include brisk walking, jogging, and swimming. For back problems, you should
avoid exercise that requires twisting or vigorous forward flexion, such as aerobic dancing and
rowing, because these actions may raise pressure in the disks and actually do more harm than
good. In addition, avoid high-impact activities if you have disk disease. If back pain or your
fitness level make it impossible to exercise 30 minutes at a time, try three 10-minute sessions to
start with and work up to your goal. But first, speak with your doctor or physical therapist about
the safest aerobic exercise for you.

Medications: A wide range of medications are used to treat chronic back pain. Some are
available over the counter. Others require a doctors prescription. The following are the main
types of medications used for back pain.

Analgesics: Analgesic medications are those designed specifically to relieve pain. They include
over-thecounter acetaminophen (Tylenol1) and aspirin, as well as prescription narcotics, such as
oxycodone with acetaminophen (Percocet) or hydrocodone with acetaminophen (Vicodin).
Aspirin and acetaminophen are the most commonly used analgesics; narcotics should only be
used for a short time for severe pain or pain after surgery. People with muscular back pain or
arthritis pain that is not relieved by medications may find topical analgesics helpful. These
creams, ointments, and salves are rubbed directly onto the skin over the site of pain. They use
one or more of a variety of ingredients to ease pain.
1
Brand names included in this booklet are provided as examples only, and their inclusion does
not mean that these products are endorsed by the National Institutes of Health or any other
Government agency. Also, if a particular brand name is not mentioned, this does not mean or
imply that the product is unsatisfactory.

NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that relieve pain and
inflammation, both of which may play a role in some cases of back pain. NSAIDs include the
nonprescription products ibuprofen (Motrin, Advil), ketoprofen (Actron, Orudis KT), and
naproxen sodium (Aleve). More than a dozen others, including a subclass of NSAIDs called
COX-2 inhibitors, are available only with a prescription.

All NSAIDs work similarly by blocking substances called prostaglandins that contribute to
inflammation and pain. However, each NSAID is a different chemical, and each has a slightly
different effect on the body.2
2
Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function.
The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from
mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs
because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your
health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are
associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of
the stomach or intestine. People age 65 and older and those with any history of ulcers or
gastrointestinal bleeding should use NSAIDs with caution.

Side effects of all NSAIDs can include stomach upset and stomach ulcers, heartburn, diarrhea,
and fluid retention; however, COX-2 inhibitors are designed to cause fewer stomach ulcers. For
unknown reasons, some people seem to respond better to one NSAID than another. Its important
to work with your doctor to choose the one thats safest and most effective for you.

Other medications: Muscle relaxants and certain antidepressants have also been prescribed for
chronic back pain, but their usefulness is questionable. If the cause of back pain is an
inflammatory form of arthritis, medications used to treat that specific form of arthritis may be
helpful against the pain.

Traction: Traction involves using pulleys and weights to stretch the back. The rationale behind
traction is to pull the vertebrae apart to allow a bulging disk to slip back into place. Some people
experience pain relief while in traction, but that relief is usually temporary. Once traction is
released, the stretch is not sustained and back pain is likely to return. There is no scientific
evidence that traction provides any long-term benefits for people with back pain.

Corsets and braces: Corsets and braces include a number of devices, such as elastic bands and
stiff supports with metal stays, that are designed to limit the motion of the lumbar spine, provide
abdominal support, and correct posture. Although these may be appropriate after certain kinds of
surgery, there is little, if any, evidence that corsets and braces help treat chronic low back pain.
In fact, by keeping you from using your back muscles, they may actually cause more problems
than they solve by causing lower back muscles to weaken from lack of use.

Behavioral modification: Developing a healthy attitude and learning to move your body
properly while you do daily activities, particularly those involving heavy lifting, pushing, or
pulling, are sometimes part of the treatment plan for people with back pain. Other behavior
changes that might help pain include adopting healthy habits, such as exercise, relaxation, and
regular sleep, and dropping bad habits, such as smoking and eating poorly.

Injections: When medications and other nonsurgical treatments fail to relieve chronic back pain,
doctors may recommend injections for pain relief. Following are some of the most commonly
used injections, although some are of questionable value:

Nerve root blocks: If a nerve is inflamed or compressed as it passes from the spinal column
between the vertebrae, an injection called a nerve root block may be used to help ease the
resulting back and leg pain. The injection contains a steroid medication or anesthetic and is
administered to the affected part of the nerve. Whether the procedure helps or not depends on
finding and injecting precisely the right nerve.

Facet joint injections: The facet joints are those where the vertebrae connect to one another,
keeping the spine aligned. Although arthritis in the facet joints themselves is rarely the source of
back pain, the injection of anesthetics or steroid medications into facet joints is sometimes tried
as a way to relieve pain. The effectiveness of these injections is questionable. One study suggests
that this treatment is overused and ineffective.

Trigger point injections: In this procedure, an anesthetic is injected into specific areas in the
back that are painful when the doctor applies pressure to them. Some doctors add a steroid
medication to the injection. Although the injections are commonly used, researchers have found
that injecting anesthetics or steroids into trigger points provides no more relief than dry
needling (inserting a needle and not injecting a medication).

Complementary and alternative treatments: When back pain becomes chronic or when
medications and other conventional therapies do not relieve it, many people try complementary
and alternative treatments. Although such therapies wont cure diseases or repair the injuries that
cause pain, some people find them useful for managing or relieving pain. Following are some of
the most commonly used complementary therapies.

Manipulation: Spinal manipulation refers to procedures in which professionals use their hands
to mobilize, adjust, massage, or stimulate the spine or surrounding tissues. This type of therapy is
often performed by osteopathic doctors and chiropractors. It tends to be most effective in people
with uncomplicated pain and when used with other therapies. Spinal manipulation is not
appropriate if you have a medical problem such as osteoporosis, spinal cord compression, or
inflammatory arthritis (such as rheumatoid arthritis), or if you are taking blood-thinning
medications such as warfarin (Coumadin) or heparin (Calciparine, Liquaemin).

Transcutaneous electrical nerve stimulation (TENS): TENS involves wearing a small box
over the painful area that directs mild electrical impulses to nerves there. The theory is that
stimulating the nervous system can modify the perception of pain. Early studies of TENS
suggested it could elevate the levels of endorphins, the bodys natural pain-numbing chemicals,
in the spinal fluid. But subsequent studies of its effectiveness against pain have produced mixed
results.

Acupuncture: This ancient Chinese practice has been gaining increasing acceptance and
popularity in the United States. Acupuncture is based on the theory that a life force called Qi
(pronounced chee) flows through the body along certain channels, which if blocked can cause
illness. According to the theory, the insertion of thin needles at precise locations along these
channels by practitioners can unblock the flow of Qi, relieving pain and restoring health.

Although few Western-trained doctors would agree with the concept of blocked Qi, some believe
that inserting and then stimulating needles (by twisting or passing a low-voltage electrical
current through them) may foster the production of the bodys natural pain-numbing chemicals,
such as endorphins, serotonin, and acetylcholine.

Acupressure: As with acupuncture, the theory behind acupressure is that it unblocks the flow of
Qi. The difference between acupuncture and acupressure is that no needles are used in
acupressure. Instead, a therapist applies pressure to points along the channels with his or her
hands, elbows, or even feet. (In some cases, patients are taught to do their own acupressure.)
Acupressure has not been well studied for back pain.
Rolfing: A type of massage, rolfing involves using strong pressure on deep tissues in the back to
relieve tightness of the fascia, a sheath of tissue that covers the muscles, that can cause or
contribute to back pain. The theory behind rolfing is that releasing muscles and tissues from the
fascia enables the back to align itself properly. So far, the usefulness of rolfing for back pain has
not been scientifically proven.

Surgical Treatments

Depending on the diagnosis, surgery may either be the first treatment of choicealthough this is
rareor it is reserved for chronic back pain for which other treatments have failed. If you are in
constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function
at your job, or to perform daily activities, you may be a candidate for surgery.

In general, two groups of people may require surgery to treat their spinal problems. People in the
first group have chronic low back pain and sciatica, and they are often diagnosed with a
herniated disk, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement.
People in the second group are those with only predominant low back pain (without leg pain).
These are people with diskogenic low back pain (degenerative disk disease), in which disks wear
with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica
than in those with predominant low back pain.

Some of the diagnoses that may need surgery include:

Herniated disks: In this potentially painful problem, the hard outer coating of the disks, which
are the circular pieces of connective tissue that cushion the bones of the spine, are damaged,
allowing the disks jelly-like center to leak, irritating nearby nerves. This causes severe sciatica
and nerve pain down the leg. A herniated disk is sometimes called a ruptured disk.

Spinal stenosis: Spinal stenosis is the narrowing of the spinal canal, through which the spinal
cord and spinal nerves run. It is often caused by the overgrowth of bone caused by osteoarthritis
of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but
also to numbness in the legs and the loss of bladder or bowel control. Patients may have
difficulty walking any distance and may have severe pain in their legs along with numbness and
tingling.

Spondylolisthesis: In this condition, a vertebra of the lumbar spine slips out of place. As the
spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can
become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause
not only low back pain but also severe sciatica leg pain.

Vertebral fractures: These fractures are caused by trauma to the vertebrae of the spine or by
crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back
pain, but it may also put pressure on the nerves, creating leg pain.
Diskogenic low back pain (degenerative disk disease): Most peoples disks degenerate over a
lifetime, but in some, this aging process can become chronically painful, severely interfering
with their quality of life.

Following are some of the most commonly performed back surgeries:

For herniated disks:

Laminectomy/diskectomy: In this operation, part of the lamina, a portion of the bone on the back
of the vertebrae, is removed, as well as a portion of a ligament. The herniated disk is then
removed through the incision, which may extend two or more inches.

Microdiskectomy: As with traditional diskectomy, this procedure involves removing a herniated

disk or damaged portion of a disk through an incision in the back. The difference is that the
incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disk
through the incision. The smaller incision may reduce pain and the disruption of tissues, and it
reduces the size of the surgical scar. It appears to take about the same amount of time to
recuperate from a microdiskectomy as from a traditional diskectomy.

Laser surgery: Technological advances in recent decades have led to the use of lasers for
operating on patients with herniated disks accompanied by lower back and leg pain. During this
procedure, the surgeon inserts a needle in the disk that delivers a few bursts of laser energy to
vaporize the tissue in the disk. This reduces its size and relieves pressure on the nerves. Although
many patients return to daily activities within 3 to 5 days after laser surgery, pain relief may not
be apparent until several weeks or even months after the surgery. The usefulness of laser
diskectomy is still being debated.

For spinal stenosis:

Laminectomy: When narrowing of the spine compresses the nerve roots, causing pain or
affecting sensation, doctors sometimes open up the spinal column with a procedure called a
laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the
spine and removes the lamina and any bone spurs, which are overgrowths of bone that may have
formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that
requires a short hospital stay and physical therapy afterwards to help regain strength and
mobility.

For spondylolisthesis:

Spinal fusion: When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical
treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal
fusion, two or more vertebrae are joined together using bone grafts, screws, and rods to stop
slippage of the affected vertebrae. Bone used for grafting comes from another area of the body,
usually the hip or pelvis. In some cases, donor bone is used.
Although the surgery is generally successful, either type of graft has its drawbacks. Using your
own bone means surgery at a second site on your body. With donor bone, there is a slight risk of
disease transmission or tissue rejection, which happens when your immune system attacks the
donor tissue. In recent years, a new development has eliminated those risks for some people
undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate
bone generation, eliminating the need for grafts. The proteins are placed in the affected area of
the spine, often in collagen putty or sponges.

Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.

For vertebral osteoporotic fractures:

Vertebroplasty: When back pain is caused by a compression fracture of a vertebra caused by

osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and
inject a cement-like mixture called polymethylacrylate into the fractured vertebra to relieve pain
and stabilize the spine.3 The procedure is generally performed on an outpatient basis under a
mild anesthetic.
3
Used only if standard care, rest, corsets and braces, and analgesics fail.

Kyphoplasty: Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the
spine following fractures caused by osteoporosis. Kyphoplasty is a twostep process. In the first
step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the
second step, he or she injects polymethylacrylate to repair the fractured vertebra. The procedure
is done under anesthesia, and in some cases it is performed on an outpatient basis.

For diskogenic low back pain (degenerative disk disease):

Intradiskal electrothermal therapy (IDET): One of the newest and least invasive therapies for
low back pain involves inserting a heating wire through a small incision in the back and into a
disk. An electrical current is then passed through the wire to strengthen the collagen fibers that
hold the disk together. The procedure is done on an outpatient basis, often under local anesthesia.
The usefulness of IDET is debatable.

Spinal fusion: When the degenerated disk is painful, the surgeon may recommend removing it
and fusing the disk to help with the pain. This fusion can be done through the abdomen, a
procedure known as anterior lumbar interbody fusion, or through the back, called posterior
fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is
successful in about 60 to 70 percent of cases. Fusion for low back pain or any spinal surgeries
should only be done as a last resort, and the patient should be fully informed of risks.

Disk replacement: When a disk is herniated, one alternative to a diskectomy, in which the disk is
simply removed, is removing the disk and replacing it with a synthetic disk. Replacing the
damaged one with an artificial one restores disk height and movement between the vertebrae.
Artificial disks come in several designs. Although doctors in Europe had performed disk
replacement for more than a decade, the procedure had been experimental in the United States
until the Food and Drug Administration approved the Charit artificial disk for use in 2004.

What Kind of Research Is Being Done?

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) supports
research to better understand and treat back pain.

One major focus of research in recent years has been on the relative efficacy and cost
effectiveness of surgical versus nonsurgical treatment of conditions associated with low back and
leg pain. A 5-year multicenter study called the Spine Patient Outcomes Research Trial (SPORT)
compared the most commonly used standard surgical and nonsurgical treatments for patients
with the three most common diagnoses for which spine surgery is performed: intervertebral disk
herniation, spinal stenosis, and degenerative spondylisthesis. Key findings included the
following:

Decompressive laminectomy: A surgical procedure called decompressive laminectomy, which

involves removing bone and soft tissue to relieve pressure on the nerves, is more effective than
nonsurgical treatments for degenerative spondylolisthesis, which can result in spinal stenosis.
Two years after enrollment in the SPORT trial, patients with degenerative spondylolisthesis and
spinal stenosis who received nonsurgical treatments such as physical therapy, steroid injections,
and analgesic medications, reported modest improvement in their condition. However, patients
who had the surgery reported significantly reduced pain and improved function. Furthermore, for
the surgery group, relief from symptoms came quickly; some reported significant relief as early
as 6 weeks after the procedure.

Lumbar diskectomy: The most common surgical procedure for back or leg pain, lumbar
diskectomy, offers significant benefits over nonsurgical treatment for herniated disksat least
short term. In one arm of the SPORT trial, 743 patients received surgery and 191 received the
usual nonoperative care. The benefits of surgery were seen as early as 6 weeks and were
maintained at least 2 years. Consistent with the earlier findings, however, the patients who
received nonoperative treatments also improved.

Other research from the SPORT study looked at the factors that go into patients decisions
whether to pursue surgery for herniated disks. It found that compared with patients who chose
nonsurgical treatments, patients who preferred surgery:

were more definite about their preference than those preferring nonoperative treatment
experienced longer periods away from work, either because of disability or because of
unemployment
reported higher levels of pain, worse physical and mental functioning, and more disability
related to back pain. They were also more likely to be taking narcotic pain medications.
expected more benefit from having surgery and had a low anticipation of risk from the
operation.
Because a patients expectations for a therapy are closely linked to his or her response to and
ultimate satisfaction with care, this research has important implications for tools to assist people
in making informed choices about herniated disk surgery.

NIAMS-supported researchers also reviewed the scientific literature concerning low back pain
and examined the costs, both direct (medications, hospitalization, outpatient visits) and indirect
(lost wages, decreased productivity, care-giving expenses), of the problem and the
socioeconomic factors that play in it. Some key findings of that research were:

Socioeconomic factors (including job dissatisfaction, physically strenuous work, psychologically

stressful work, low educational attainment, and Workers Compensation Insurance) are
important risk factors for the onset of back pain and disability in general, as are smoking,
obesity, older age, and issues such as anxiety and depression.
Socioeconomic factors are not major risk factors for the development of radiographically
apparent disk degeneration (that is, disk degeneration that can be seen on x rays).
The direct costs of low-back pain vary considerably by provider specialty, patient race, and
nationality.
Five percent of Americans miss at least 1 day of work annually because of low-back pain.
More than 80 percent of workers who report an episode of low-back pain return to work within
1 month, more than 90 percent return by 3 months, and 5 percent never return. By the time a
worker has been out of work for 6 months, the likelihood of ever returning to work drops to 50
percent. And by the time a worker has been out of work for 1 year, the likelihood of ever
returning to work drops to 25 percent.

The researchers say these data indicate that there is little rationale for aggressively treating
injured workers in the first week or two of the episode; however, there is compelling rationale
for intervening in the subacute periodbetween 2 to 4 weeks and 6 monthsbecause of the
increasing likelihood that those who remain out of work have a diminishing probability of ever
returning.

NIAMS-supported research is ongoing. Goals of current research are to:

understand the mechanisms of back pain

identify ways to prevent back pain
improve surgical and nonsurgical treatments for back pain
prevent disability in people who suffer from back pain.