Back Pain

Overview

Because about 90 percent of back pain episodes clear up within six weeks with little or no treatment, people suffering from back pain can safely try self-treatment as long as they are not experiencing severe pain or symptoms of a dangerous condition. In general, back pain due to muscle injury will abate completely in about six to eight weeks. Back pain lasting longer than this is usually due to spinal column changes and merits a visit to a physician.

People whose severe back pain lasts more than a few days, or whose mild to moderate back pain does not respond to self-treatment, should see their primary-care physician.

This section has more on

• Self-treatment
• Alternative therapies
• Prescription drugs
• Spinal manipulation
• Treatment for particular causes of back pain
• Are you a good candidate for spinal fusion?

Prolonged bed rest (more than four days), spinal traction, lumbar corsets (except as a preventive measure by people who often lift heavy objects), support belts, and back machines are not recommended. Though still used occasionally, transcutaneous electrical nerve stimulation (TENS), the application of low-energy electrical radiation to numb the nerves, is not advised.

Self-treatment

Back relaxation exercises--which involve gentle stretching to relax back muscles, lengthen the spine, and relieve compression of the vertebrae--are useful for alleviating stress and strain on the back. Ask your doctor for instructions or a referral to a physical therapist.

In addition, several steps can be taken at home to help ease a backache.

Lying down takes pressure off the spine and usually lessens the pain. Most experts advise limiting bed rest to one or two days. The inactivity associated with longer periods of bed rest may do more harm than good by weakening muscles and prolonging the time to recovery. It is better to get out of bed and move around as soon as you can do so with reasonable comfort, even if some pain persists.

Immediate application of ice can alleviate pain after a sudden back injury that causes localized pain. In addition to relieving pain, ice reduces internal bleeding and swelling by decreasing blood flow. An ice bag, commercial cold pack, or even a package of frozen vegetables should be used for 10 to 20 minutes every two waking hours for 48 hours.

It is best to wait for 48 hours after an acute back injury before applying heat. However, chronic back pain or a more widespread backache that starts sometime after a back injury may be eased by relaxing muscles with a hot bath or shower, heating pad, heat lamp, or hot, moist compresses.

Nonsteroidal anti-inflammatory drugs (NSAIDs)--such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), or ketoprofen (Orudis)--or the pain reliever acetaminophen (Tylenol) may help alleviate discomfort, reduce inflammation, or both.

Little evidence supports the use of traction or corsets, although temporary use of a corset with built-in supports may be helpful when recovering from surgery or for allowing essential activities despite continued symptoms. Whether back braces help in treating back pain is unclear, and seemingly contradictory findings continue to be published.

Alternative therapies

A comprehensive study of alternative therapy use found that almost 60 percent of people who consulted a medical doctor for back pain have also tried some sort of alternative therapy. When contemplating one of these options, it is important to remember that the treatments are considered alternative precisely because there is no scientific evidence proving that they work consistently. In addition, people should be cautious about undertaking any treatments that are expensive and require more than half a dozen visits.

Some of the alternative methods frequently tried for back pain are:

Acupuncture comes from the traditional Chinese medical theory that pain or disease occurs when the body's natural energies (chi) are out of balance. Stimulating these points through acupuncture needles is meant to correct the improper flow of chi--and relieve the disorder. Acupuncture may relieve pain by triggering nerves to send out natural, pain-blocking chemicals (endorphins) within the body. Pain relief, while common, is usually temporary. Although a panel convened by the National Institutes of Health found few well-designed studies of the technique, they concluded that there was enough evidence of its value for further research.

Acupressure, a special kind of massage, adheres to the same theory of energy channels in the body as acupuncture. Continuous pressure, exerted on a trigger sport for three to five minutes to stimulate the flow of healing energy, may temporarily divert the individual from the pain, but it usually returns.

Massage therapy should be performed by a trained, licensed massage therapist. In addition to relaxing muscles and easing tension in the back, it is thought that the motion of a massage may, for a little while, overpower pain signals going to the brain.

Relaxation therapy teaches people muscle relaxation and breathing techniques to help them deal with the stress of everyday life. Another relaxation technique is meditation, designed to calm the mind as well as the body. Reducing stress, of course, should prove beneficial for overall health as well.

Biofeedback employs electronic sensors to measure the body's automatic functions--such as muscle tension, breathing patterns, and pulse rate--while the individual practices different relaxation methods. Using data from the sensors, people can employ the appropriate relaxation techniques (eventually without the sensors) to consciously regulate their body functions and lower their level of stress.

Prescription drugs

Regardless of the cause of the pain, a doctor will probably recommend the self-treatment techniques described [back.treat.self]. In general, limiting both bed rest and pain medication for back pain has increasingly become the approach of choice among primary-care physicians--a preference supported by current research.

If over-the-counter medications do not relieve the pain or if they cause serious side effects, a doctor might prescribe an NSAID such as diflunisal (Dolobid) or meclofenamate (available in generic form). Other commonly prescribed drugs include celecoxib (Celebrex) and valdecoxib (Bextra), from the drug class called cyclooxygenase-2 inhibitors. These drugs are theorized to treat pain and inflammation as effectively as traditional NSAIDs but with fewer adverse gastrointestinal effects. Not all studies have shown cox-2 inhibitors to be safer for the stomach than other NSAIDs, however.

Studies have shown that muscle relaxants are an effective treatment for acute low back pain; the usefulness of muscle relaxants for chronic low back pain requires further study. Muscle relaxants appear to work by depressing the activity of nerves in the spinal cord and brain. A few studies suggest that a combination of a muscle relaxant and an NSAID may be more beneficial than a muscle relaxant alone. Despite the benefits of muscle relaxants, their use is controversial. For example, muscle relaxants frequently cause drowsiness. In addition, muscle relaxants are potentially addictive.

Potentially addicting drugs such as opiates (for example, morphine, codeine, or meperidine) should be used with great caution as a treatment for back pain and only after all else has failed. Controlled-release formulations of oxycodone and morphine (OxyContin and MS Contin, respectively) are often used by people who need opiates for more than a few days.

Spinal manipulation

Spinal manipulation can be a good choice for treatment of back pain lasting less than a month, provided there is no evidence of spinal nerve root disorders such as a herniated disk or spinal stenosis. If symptoms do not improve after four weeks, however, use of spinal manipulation should be re-evaluated.

Spinal manipulation, which involves "adjusting" the vertebrae to reduce pain caused by poor alignment, may be provided by a chiropractor, osteopath, physical therapist, or specially trained medical doctor. The healthcare professional must be sure that back pain is not due to bone or joint disorders, since manipulating a spine damaged by osteoporosis, for example, could result in further, more serious injury. X-rays of the area are usually taken before spinal manipulation to rule out vertebral fractures.

In properly screened patients, spinal manipulation by a trained professional appears to be safe.

Treatments for particular causes of back pain

Particular causes of back pain may have particular treatments. This section has more on:

• Treatment of a herniated disk
• Treatment of vertebral compression fractures
• Treatment of spinal stenosis
• Treatment of Paget's disease
• Treatment of spinal deformity
• Treatment of cancer

Treatment of a herniated disk

About 80 percent of people with classic symptoms of a herniated lumbar disk--sciatica and back spasm--respond within six weeks to bed rest and pain medication. Surgery may be required in cases of impaired bowel or bladder function, persisting or increasing sciatica despite bed rest, progressive leg weakness, and recurring episodes of incapacitating pain from sciatica.

This section includes information on:

• Surgery
• Chymopapain treatment

Surgery

Surgical treatment of a herniated disk, called diskectomy, is used only if six weeks of nonoperative treatment fail or if neurological deficits are present. The procedure involves relieving pressure on the pinched nerve by making an incision into the distended annulus fibrosus (the tough outer layers of the disk) and removing the protruding nucleus pulposus (the gellike center).

In some cases, a spinal fusion is also performed. Spinal fusion, which involves the use of bone grafts to fuse together two or more adjacent vertebrae, should be considered in cases where chronic back pain was present before the onset of acute disk herniation that is causing leg pain. Spinal fusion is not always reliable, and guidelines as to when it should be done are not as clear as those for diskectomy.

In 2004, the FDA approved the first artificial spinal disk, called the Charité, for use in single-level disk problems. Whether artificial disks will maintain long-term motion and prevent disk degeneration near the surgical site will take five to 10 years to know.

Another alternative to spinal fusion is intradiskal electrothermal therapy (IDET), a minimally invasive procedure in which the tiny nerves in the outer wall of the disk are destroyed with a heated wire. This procedure initially appeared promising, but more recent reports have been disappointing.

Microdiskectomy, percutaneous arthroscopic diskectomy, and laser diskectomy are less invasive surgical alternatives to traditional surgery, which requires a larger incision. Microdiskectomy is performed under magnification through a 1-to 1 ½-inch opening. It appears to have a success rate similar to that of open diskectomy. Percutaneous arthroscopic diskectomy involves inserting a probe into the spine to scoop out the disk. Laser diskectomy uses a laser to burn out the disk. Laser diskectomy has been the subject of considerable debate. Outcomes have varied from improvement no greater than not having surgery to success similar to that of standard surgery.

Chymopapain

A controversial alternative to surgery is injecting chymopapain into a herniated disk. Chymopapain, an enzyme obtained from the papaya plant, breaks down the noncollagen components of the nucleus pulposus. The procedure was introduced in the mid-1960s, and the FDA approved its use in 1983.

While chymopapain injection may be effective at relieving pain in about 70 percent of patients, this procedure has been viewed with suspicion by many orthopedic surgeons and neurosurgeons (although it is used with greater frequency in Japan and Europe). The most serious adverse effects are anaphylaxis (severe respiratory symptoms and circulatory collapse triggered by an allergic reaction) and neurological complications.

Treatment of vertebral compression fractures

Treatment of vertebral compression fractures includes bed rest, pain medication, and osteoporosis treatment to reduce the risk of future fractures. In some cases, surgical procedures such as percutaneous vertebroplasty, kyphoplasty, or spinal fusion are performed.

Treatment of spinal stenosis

Conservative treatment is appropriate if symptoms are mild or if the person is not a good candidate for surgery--for example, an older adult with another serious illness. Conservative management of spinal stenosis includes pain relievers such as acetaminophen (Tylenol) or NSAIDs, weight loss, and, especially, exercises to increase flexibility. Some success has been reported with the use of caudal epidural blocks--injections of analgesics (pain relievers) and a steroid directly into the base of the spine.

If these measures fail to control symptoms, surgery is considered. Surgery is necessary when severe neurological deficits or impaired bowel or bladder function develops.

Decompression surgery for central stenosis enlarges the spinal canal to relieve pressure on the spinal cord. Results are usually excellent if the disease is limited to one or two vertebrae.

Older adults with spinal stenosis may have other health conditions, such as heart disease or arthritis, that increase the risk of surgical complications. However, these conditions need not always preclude surgical treatment.

Treatment of Paget's disease

No treatment is needed for many people with Paget's disease because they have no symptoms. The most clear-cut reasons for using drugs to treat Paget's disease are bone pain, bone fractures (such as vertebral fractures), and compression of nerves in the spine or elsewhere. Injectable calcitonin, four oral bisphosphonate drugs, and one intravenous bisphosphonate drug are approved by the FDA for treatment of Paget's disease.

People with Paget's disease should also take 1,000 to 1,500 mg of calcium and 400 IU of vitamin D each day. People with signs and symptoms of spinal stenosis secondary to Paget's disease may require surgery if medication is ineffective in reducing the stenosis.

Treatment of spinal deformity

Most spinal deformities in adults, including those over age 50, can be helped with flexibility exercises, posture maintenance, general fitness, and back-stretching exercises. Mild anti-inflammatory medication and, occasionally, a rigid brace may help, although many older people cannot tolerate braces.

Not until the late 1960s did surgery for spinal deformities in adults become more routine, and only in the past 15 years has it been used more frequently in people over age 50. Surgery for spinal deformity is indicated in an adult if the deformity is severe; if it will continue to progress in later adult life; if it is accompanied by associated neurological problems; or if pain is unresponsive to other measures.

Treatment of cancer

Although myeloma and metastatic cancer cannot be cured, palliative treatment of back pain is often possible. Palliative treatment refers to treatment aimed at relieving pain and limiting disease complications rather than curing the disease. Palliative treatment of back pain may include chemotherapy, radiation directed at the site of tumor invasion, and, at times, surgery. In cases of metastatic cancer of the spine, surgery may be highly effective for pain relief and preservation or restoration of nerve function. Bisphosphonate drugs are also used to reduce pain in metastatic cancer. People with metastatic prostate cancer may benefit from hormone treatments.

Are you a good candidate for spinal fusion?

The use of spinal-fusion surgery has increased drastically in recent years, from 150,000 procedures in 1993 to 300,000 in 2001. Although many long-established uses exist for spinal fusion--for the treatment of severe scoliosis, spinal tuberculosis, and vertebral fractures--doctors are increasingly using it to treat back pain resulting from degenerative changes in the spine, disk disorders such as herniated disks, and spinal stenosis. However, there is no convincing evidence that spinal fusion works for most patients with back pain from these conditions.

If your doctor recommends spinal fusion for treatment of degenerative changes, a herniated disk, or spinal stenosis, how do you know if you're actually a good candidate? First, you should have severe disability from your back pain--for example, being unable to perform activities of daily living (such as dressing or bathing yourself) or to do your job. Second, you already should have tried conservative care--such as self-treatment, pain relievers, and exercise--at least for six months without success. Third, the back problem should be localized, that is, confined to a small area (one to two levels) of the spine, with no associated deformity.

In addition, potential candidates for spinal fusion should have no significant psychosocial problems. Research has consistently shown that people with back pain who have problems such as depression, large debts, an unhappy marriage, or jobs that involve repetitive manual labor do not experience improvement in pain after a fusion. Their pain tends to be magnified because of their psychological issues, and fixing the physical problem has little benefit. These patients should instead seek psychological counseling.

Although studies have not clearly shown that spinal fusion is effective for spinal degenerative changes, herniated disks, or spinal stenosis, some people with these conditions report pain relief from the procedure. To reduce your odds of undergoing a surgical procedure that will provide no benefit, get a second opinion before yielding to the knife.