Evaluating low back pain in patients can be extremely difficult. Thankfully, 90% of acute back pain resolves within three months no matter what the treatment. However, if appropriate pain management treatment is instituted pain relief can potentially be achieved sooner rather than later.
Statistics show that over 30% of the time, medical providers can not give an accurate low back pain diagnosis with regards to the pain generator. Even in this day and age of such modern technology as MRI and CT scans and EMG testing, low back pain still remains a conundrum in many cases.
The main categories of pain generation include fracture, infection, tumor, trauma, arthritis, soft tissue, or neuropathic.
1) Fracture or Trauma – Vertebral Compression Fractures are seen as a result of an axial load on the spinal column. The number one cause is osteoporosis, number two is a traumatic event like a car accident or fall from a height. These fractures are typically seen on plain x-rays, and also very easy to see on an MRI. Traumatic injuries also can result in soft tissue sprains / strains with damaged ligaments, tendons, or spinal musculature.
2) Infection – There are two areas of infection around the spine. One is the vertebra itself, which is called vertebral osteomyelitis. Another is infection in the intervertebral disc, which is called discitis. Infections occur post-surgical, post-procedure, and also in immunocompromised patients such as diabetics.
3) Tumor – There are various tumors that affect the spine and cause low back pain. Most commonly, the spine has a tumor from metastasis of a tumor elsewhere, such as the breast or lung. There are some tumors that occur primarily in the spine, such as multiple myeloma.
4) Arthritis – Just as degenerative arthritis occurs in the knee and hip, it also occurs in the spinal column. The joints of the spine are called facet joints, and they are about the size of a thumbnail. The facet joints are located on each side of each level of the spine. For instance the L3-L4 facet joint is the one located between the third lumbar and fourth lumbar vertebra. When arthritis occurs in facet joints, it is called facet syndrome or simply facet arthritis.
5) Soft tissue – The soft tissue areas of the spine include the following: Intervertebral disc, spinal ligaments, and also the para-spinal musculature with its tendons. Patients involved in a trauma can experience spinal ligament injury with resultant pain. Para-spinal musculature strain is extremely common. Often times the para-spinal mucles will react to other injuries such as fractures, ligament sprains, etc by going into spasm. This is called muscle guarding. Pain from the intervertebral disc itself is a result of disc injury. This can be chronic, called degenerative disc disease, or more acute. The outer part of the intervertebral disc contains pain fibers. This area of the disc is called the annulus and an annular tear can cause significant pain in the low back.
6) Neuropathic – This refers to pain emanating from an intervertebral disc herniation that is impinging on a nerve root. The pinched nerve sparks up inflammation and causes pain to radiate down the leg, called sciatica.
Evaluating a patient with low back pain takes determination and thoroughness with a specific algorhithm. If done correctly, it will give patients the best chance of success by leading to an appropriate treatment regimen.