DSI Newsletter: Back Pain and Sciatica

DSI Newsletters, Issue 49:
Back Pain and Sciatica

WHAT ARE LOW BACK PAIN AND SCIATICA?
Most people will have at least one backache during their lives, and many will live with recurrent or prolonged back problems. While discomfort can affect any area of the back, pain most often afflicts the lower part, which supports most of the body's weight. Indeed, low back pain is among the most common reasons why Americans visit the doctor, and it is a leading cause of work-related disability. In many backaches that cause significant disability, the pain or numbness radiates down the leg or into the foot, a condition known as sciatica.

The Spine
The back is highly complex, and pain may result from damage or injury to any of various bones, nerves, muscles, ligaments, and other structures. Still, despite sophisticated techniques that provide detailed anatomical images of the spine and other tissues, the cause of most cases of back pain remain elusive.
Vertebrae. The spine is a column of small bones, or vertebrae, that support the entire upper body. The column is grouped into three sections of vertebrae:

The cervical (C) vertebrae are the seven spinal bones that support the neck.
The thoracic (T) vertebrae are the twelve spinal bones that connect to the rib cage.
The lumbar (L) vertebrae are the five lowest and largest bones of the spinal column. Most of the body's weight and stress falls on the lumbar vertebrae.

Below the lumbar region is the sacrum, a shield-shaped bony structure that connects with the pelvis at the sacroiliac joints.
At the end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or "tail bone."

Each vertebra is designated by using a letter and number, which allows the physician to determine where it is in the spine.

The letter reflects the spinal region where the vertebra is located: C=cervical (neck region), T=thoracic (chest, or middle back, region), and L=lumbar (lower back).
The number signifies the vertebra's place within that spinal region. The numbers start with 1 at the top of a region and count up as the vertebrae descend within the region. For example, C4 is the fourth bone down in the cervical region and T8 is the eighth thoracic vertebrae.

The Discs. Vertebrae in the spinal column are separated from each other by small cushions of cartilage known as intervertebral discs. The disc is 80% water and is structured follows:

Inside each disc is a jelly-like substance called the nucleus pulposus.
The nucleus pulposus is surrounded by a tough, fibrous ring called the annulus.

This structure plus its heavily fluid-content makes the disc both elastic and strong. The discs have no blood supply of their own, however, but need to rely on nearby blood vessels to keep them nourished.

Processes. Each vertebra in the spine has a number of bony projections, known as processes. The spinal and transverse processes attach to the muscles in the back and act like little levers, allowing the spine to twist or bend. The particular processes form the joints between the vertebrae themselves, meeting together and interlocking at the zygapophysial joints (more commonly known as facet or z joints).
Spinal Canal. Each vertebra and its processes surround and protect an arch-shaped central opening. These arches, aligned to run down the spine, form the spinal canal, which encloses the spinal cord.

Spinal Cord. The spinal cord is the central trunk of nerves that connects the brain with the rest of the body. Each nerve root passes from the spinal column to other parts of the body through small openings bounded on one side by the disc and the other by the facets. When the spinal cord reaches the lumbar region, it splits into four bundled strands of nerve roots called the cauda equina (meaning horsetail in Latin).

The Sciatic Nerve. The sciatic nerve is the one most likely to be affected in low back pain and has an extensive pathway:

It first branches from the nerve roots that descend off the lowest part of the spinal cord (in the lumbar and sacral areas). Each of the two branches of the sciatic nerve is about as wide as a thumb.
Each threads through the pelvis and deep into either side of the buttocks.
Each then passes down the hip and along the back of the thigh to the foot.

Low Back Pain
Low back pain is usually defined as either acute or chronic.

Acute low back pain lasts less than a month and is not caused by serious medical conditions. Most cases clear up in a few days without medical attention, although recurrence after a first attack is common.
Chronic low back pain persists beyond six months. It constitutes only 1% to 5% of all low back pain cases.

The source of low back pain can be from abnormalities in one or more of the many structures in the spine, including the following:

Injuries and small fractures in the spine.
Muscle spasm.
Rupture in the weakened disc. Pressure on a weakened disc may cause it to rupture so the nucleus pulposus protrudes out from the spinal column, a condition known as a herniated disc.
The facets (z-joints) can become misaligned or deteriorate.
The spinal canal itself can become narrowed, a disorder called spinal stenosis.
Scar tissue in the lower spine can trap nerves.
Tears in muscles and ligaments that support the back.

Sciatica
At some time, up to 40% of people experience pain, known as sciatica, which occurs when the sciatic nerve is trapped or inflamed.
Causes of Sciatica. A herniated disc pressing on the sciatic nerve is the most common cause of this problem, although spinal stenosis or other vertebral abnormalities that press on the sciatic nerve can also cause pain. [See What Causes the Pain in Low Back Pain or Sciatica?]
Symptoms of Sciatica. Symptoms of sciatica involve the following:

The sensation of sciatica is usually experienced along the course of the sciatic nerve, which travels from the lower back, through the buttock, into the calf, and sometimes even the foot.
The pain can vary widely, from a mild tingling, to a dull ache, to a burning sensation, to pain severe enough to cause immobility.
It most often occurs on one side. Some people experience sharp pain in one part of the leg or hip and numbness in other parts. The affected leg may feel weak.
The pain often starts slowly and typically worsens at night.
The pain increases after prolonged standing or sitting.
It is often aggravated by sneezing, coughing, or laughing.
Patients may also experience symptoms after bending backwards or walking more than 50 to 100 yards, particularly if it is caused by spinal stenosis.
The pain usually resolves within six weeks with mild activity, unless there are serious conditions underlying the problem, although these are very uncommon.

One study noted that certain symptoms during the acute, early phase of sciatica may predict a more prolonged recovery. They included the following:

Symptoms that persist longer than 30 days.
Pain that is aggravated by sitting.
Pain the becomes worse when coughing, sneezing, or straining.

WHAT CAUSES THE PAIN IN LOW BACK PAIN OR SCIATICA?
In about 85% of back pain cases, the origin of the pain is unknown and even imaging studies usually fail to determine the cause. Disc herniation and disc degeneration due to aging are the most common causes of low back pain. Other problems can also cause this pain, however.
Lumbar Degenerative Disc Disease
Over the years, the disc can degenerate and produce low-grade inflammation and irritation. This age-related condition is a major source of chronic low back pain.
Herniated Disc and the Inflammatory Response
A herniated disc, sometimes, but incorrectly, called a slipped disc, is widely held to be the most common cause of severe back pain and sciatica. A disc in the lumbar area becomes herniated when it ruptures or thins out and degenerates to the point that the nucleus pulposus (the gel within the disc) balloons outward. Experts have defined the degree of this disc event as follows:

A bulge (the gel has been pushed out slightly from the disc and is evenly distributed around the circumference).
Protrusion (the gel has pushed out slightly and asymmetrically in different places).
Extrusion (the gel balloons extensively into the area outside the vertebrae or breaks off from the disc).

There is some debate, however, about how pain develops from a herniated disc and how frequently it causes low back pain. Many people have discs that bulge or protrude and do not suffer back pain. Extrusion (which is less common than the other two conditions) is highly associated with back pain, since the gel is likely to extend out far enough to press against the nerve root, most often the sciatic nerve. Extrusion is very uncommon, however, and sciatic and low-back pain is very common suggesting that there are other, more prominent causes of this pain.
Ordinarily, at the time of any injury, the immune system triggers key factors that are designed to promote healing. Evidence is now pointing to an abnormal and persistent immune response in the cells of the nucleus pulposus that may be responsible for nerve injury and pain in the lower back. In such cases, the nucleus pulposus in the herniated disc overproduces certain factors known as cytokines-notably tumor necrosis factor (TNF) — that, in high levels, cause inflammation and cell damage. Evidence now suggests that such cytokines cause a biochemical reaction in the regions surrounding the bulging or protruded nucleus pulposus, which results in pain.
Abnormalities in the Annular Ring. Research has also focused on tears in the annular ring — the fibrous band that surrounds and protects the disc. The annular ring contains a dense nerve network and high levels of peptides that heighten perception of pain. Tears in the annular ring are a frequent finding in patients with degenerative disc disease. Some cases of chronic low back pain may be caused by inward growth of nerve fibers into the annular ring, which triggers pain within the intervertebral disc.
Muscle and Ligament Injuries
Other than age-related degenerative disc disorders, injuries in the muscles and ligaments supporting the back are the major causes of low back pain. Of note, is the iliac crest pain syndrome (iliolumbar syndrome), in which there are tears in the ligaments that help support the pelvic bone.
Spinal Stenosis
Spinal stenosis is the narrowing of the spinal canal. This typically develops as a person ages and the discs become drier and start to shrink. At some point in this process, any disruption, such as a minor injury that results in disc inflammation, can cause impingement on the nerve root and trigger pain. Pain from spinal stenosis can occur in both legs or can present as sciatica. Spinal stenosis occurs mostly in the elderly with degenerative osteoarthritis, but it can sometimes be caused by other problems, including infection and birth defects.
Spondylosis and Spondylolisthesis
Spondylosis is a condition in which the fourth or fifth lumbar vertebrae degenerate or develop small fractures. This condition affects 4% to 6% of the general population, and the rates may be higher in certain populations. As it progresses, the spine can become unstable and lead to spondylolisthesis, in which one vertebra slips forward over the other and causes sciatica. The condition occurs mostly older individuals with women having a higher risk than men. It is also a common cause of back pain from stress fractures in young athletes and can also be due to inherited problems, injury, or bone disease.

Piriformis Syndrome
Some experts believe that one cause of sciatica pain is the entrapment of the sciatic nerve deep in the buttock by the piriformis muscle. This condition, called piriformis syndrome, usually develops after an injury. In rare cases leg swelling, deep-vein blood clots, or both may occur. Some experts believe there is no real evidence that this condition, known as piriformis syndrome, causes any sciatic pain. Nevertheless, tests have been developed that are fairly accurate in identifying the muscle as the source of trouble in some patients with sciatica. Ankylosing Spondylitis
Ankylosing spondylitis is a chronic inflammation of the spine that may gradually result in a fusion of vertebrae. Symptoms include a slow development of back discomfort, with pain lasting for more than three months. The back is usually stiff in the morning; pain improves with exercise. In severe cases, the patient must continually stoop over. It can be quite mild, however, and it rarely affects a person's ability to work. It occurs mostly in young Caucasians in their mid-twenties. The disease is more common in men, but about 30% of the cases are in women. Researchers believe that in most cases it is hereditary. About 20% of people with inflammatory bowel disease and about 20% of people with psoriasis develop a form of ankylosing spondylitis. There are few effective treatments for this potentially disabling disease, although etanercept (Enbrel) and infliximab (Remicade), anti-inflammatory agents known as TNF-blockers, are proving to be beneficial.
Miscellaneous Abnormalities
Any abnormality in joints, vertebrae, or nerve roots can cause back pain:

The facet (z-joints) joints can wear down. In such cases, pain occurs on arching the back or when walking.
In some cases a segment (consisting of two vertebra and their common joint and disc) becomes unstable when its parts wear down.
Injury to nerve roots, notably deep root ganglia (nerve cells in the spine whose fibers extend from skin to muscle tissue), may be important in some cases. Some patients may have scar tissue that traps the nerve roots in the lower spine and causes sciatica.

WHAT CONDITIONS MAKE PEOPLE SUSCEPTIBLE TO LOW BACK PAIN?
Putting Stress on the Back
In most known cases, pain begins with an injury, after lifting a heavy object, or after making an abrupt movement. Not all people experience back pain after such events, however. A number of conditions may make people more or less susceptible to low back pain. In 85% of back pain cases, the causes are unknown.
Aging Process
Intervertebral discs begin deteriorating and growing thinner by age 30. One-third of adults over 20 show evidence of herniated discs (although only 3% of these discs cause symptoms). As people continue to age and the discs lose moisture and shrink, the risk for spinal stenosis increases. The incidence of low back pain and sciatica increases in women at the time of menopause as they lose bone density. In older adults, osteoporosis and osteoarthritis are also common. However, the risk for low back pain does not mount steadily with ever-increasing age, which suggests that at a certain point, the conditions causing low back pain plateau.
Genetic Factors
Inherited Spinal Structure Abnormalities. Many people have a genetic susceptibility to low back pain, usually from inheriting spinal structural abnormalities.
Inherited Weakened Discs. Studies are finding that specific mutations of the COL9A gene may play a role in about 10% of sciatica cases. The gene is normally involved in producing collagen, the protein building block in all structural tissue in the body. When defective, it may cause the disc to be less able to resist compressive forces. One 2001 study found the defective gene was present in twice as many patients with disc problems as in patients without back pain.
Central Nervous System Abnormalities and Changes in Pain Perception
Some evidence suggests that after episodes of back pain, some people may experience changes in the brain that produces an exaggerated response in nerve cells and other factors. Such activity causes a persistent perception of pain even though the actual injury has healed.
Psychological and Social Factors
Although disc abnormalities are certainly a cause of low back pain, many people with disc rupture or tears do not experience back pain. And some people without disc abnormalities complain of back pain. Psychological factors are known to play a strong influential role in three phases of low back pain:

Onset of pain. Some evidence suggests preexisting depression and the inability to cope may be more likely to predict the onset of pain than physical abnormalities in some people who have abnormal discs. For example, a British study reported that people who showed emotional distress at age 23 were nearly twice as likely to suffer from back pain ten years later.

The perception of pain. Social and psychological factors play a role in the severity of a person's perception of back pain. For example, one study compared truck drivers and bus drivers. Nearly all the truck drivers liked their work. Half of them reported low back pain but only 24% lost time at work. Bus drivers, on the other hand, reported much lower job satisfaction than truck drivers, and these workers with back pain had a significantly higher absentee rate than truck drivers in spite of less stress on their backs. Similarly, another study found that pilots, who generally reported "loving" their jobs," reported far fewer back problems than their flight crews. And yet another study reported that low rank, low social support, and high stress in soldiers was associated with a higher risk for disabling back pain.

Chronic pain. Depression and a tendency to develop physical complaints in response to stress also increase the likelihood that acute back pain will become a chronic condition. The way a patient perceives and copes with pain at the beginning of an acute attack may actually condition the patient to either recover or develop a chronic condition. Those who over-respond to pain and fear for their long-term outlook tend to feel out of control and become discouraged, increasing their risk for long-term problems.

Studies also suggest that patients who reported prolong emotional distress have less favorable outcomes after back surgeries. It should be strongly noted that the presence of psychological factors in no way diminishes the reality of the pain and its disabling effects. Recognizing it as a strong player in many cases of low back pain, however, can help determine the full range of treatment options.

Pregnancy
Pregnant women are prone to back pain due to a shifting of abdominal organs, the forward redistribution of body weight, and the loosening of ligaments in the pelvic area as the body prepares for delivery. Tall women are at higher risk than short women. Although some earlier research had suggested that the use of epidurals for pain relief during labor could lead to chronic back pain, studies in 2002 reported no increased risk.
Infections and Other Medical Conditions
Infections. A number of common and uncommon infections are a cause of back pain. Chronic uterine or pelvic infections can cause low back pain in women. Osteomyelitis is infection in the spine, a rare cause of back pain. Other infections that cause back pain include Lyme disease, septic arthritis, bacterial endocarditis, Reiter's syndrome, mycobacterial and fungal arthritis, and viral arthritis. Chlamydia pneumonia, an atypical organism that is a common cause of mild pneumonia in young adults, is now believed to cause widespread inflammation in the body's tissue, including blood vessels, and may be responsible for a number of chronic conditions, including heart disease. Some evidence further suggests it may cause inflammation in arteries of the lower spine and contribute to spinal stenosis.
Common Medical Conditions. Many other medical conditions are associated with back pain.

Osteoporosis is a disease of the skeleton in which the amount of calcium present in the bones slowly decreases to the point where the bones become fragile and prone to fracture. It usually does not cause pain unless the vertebrae collapse suddenly, in which case the pain is often severe. Studies indicate, however, that the incidence of low back pain and sciatica increase around the time of menopause, and very tiny fractures in the vertebrae caused by osteoporosis may be an undetected cause of back pain in many elderly women. [For more information, see Well-Connected Report #18: Osteoporosis.]

Osteoarthritis occurs in joints where cartilage is damaged and then destroyed, usually as a result of aging. In reaction to this destruction, the bones associated with the joints develop abnormalities. When osteoarthritis affects the spine, it may damage the cartilage in the discs, the moving joints of the spine, or both. The nerves may become pinched, causing pain and in advanced cases, numbness and muscle weakness. The patient may also experience muscle spasms and diminished mobility. [For more information, see Well-Connected Report #35 Osteoarthritis.]

Inflammatory disorders, such as Crohn's disease and rheumatoid arthritis, can produce inflammation in the spine (sacroiliitis), although the spine is less commonly affected than other locations.

Other conditions that can directly cause pain include fibromyalgia, Paget's disease, or Parkinson's disease, abscesses, blood clots, and cancer.

Others medical conditions cause referred back pain, which occurs in conjunction with problems in organs unrelated to the spine (although usually located near it). Such conditions include ulcers, kidney disease (including kidney stones), ovarian cysts, and pancreatitis.

It should be noted, however, that a number of medical conditions, such as lung and heart problems and chronic headaches, commonly occur with low back pain, but a causal relationship is uncertain.
Muscular Abnormalities
Some research is suggesting that some people have motor control abnormalities in the deep muscles near the spine. Such lack of control causes instability in the spine that can lead to pain.
Medications
Medications may trigger back pain. For example, anticoagulants can cause bleeding or an internal bruise. Long-term steroid use can cause infection or compression fractures.
Conditions That Cause Back Pain in Children
Persistent low back pain in children is more likely to have a serious cause that requires treatment than back pain in adults. According to one small study, one third of children being treated at a hospital for back pain were found to have serious underlying problems. Among the conditions that cause back pain in children are the following:

Stress fractures (spondylolytis) in the spine, is a common cause of back pain in young athletes. (Sometimes a fracture may not show up for a week or two after an injury.) It can cause spondylolisthesis, in which the spine becomes unstable and the vertebrae slip over each.

Hyperlordosis is an inborn exaggerated inward curve in the lumbar area. (Scoliosis, an abnormal curvature of the spine in children, does not usually cause back pain.)

Injuries.

Benign tumors (e.g., osteoblastoma or neurofibroma).

Cancers, including leukemia.

Juvenile chronic arthropathy is an inherited form of arthritis. It can cause pain in the sacrum and hip joints of children and young people. It used to be grouped under juvenile rheumatoid arthritis, but is now defined as a separate problem.

WHAT ARE THE LIFESTYLE TRIGGERS FOR LOW BACK PAIN AND HOW CAN IT BE PREVENTED?
Between 60% and 90% of the population experience back pain at one time or another during their lifetimes. Every year, nearly 15% of American adults visit their doctors because of low back pain episodes. Men and women are equally at risk. Low back pain is second only to upper respiratory infections (such as colds and flus) as the reason for seeing a doctor. In its costs to the country, it is second only to cancer and heart disease.
High-Risk Occupations
In one study, 16 out of 100 warehouse workers reported back injuries in one year, and in two major food service organizations 30% of all injuries involved the back. A major study of work-related injuries reported that, in 1994, there were nearly 330,000 cases of back injury due to overexertion in handling objects.
Jobs that involve lifting and forceful movements, bending and twisting into awkward positions, and whole-body vibration (usually caused by long-distance truck driving) place workers at particular risk for low back pain. The longer a person is on such jobs, the higher the risk. Some workers wear back support belts, but evidence strongly suggests that they are useful only for people who are currently suffering from low back pain. They offer little added support for the back and do not prevent back injuries. In fact, in one study workers who wore the belt for prevention reported more back pain than the workers who didn't wear them.
A number of companies are developing programs to protect against back injuries. Although studies are mixed on the effects of company interventions, one analysis suggested that they do have a positive effect. Employers and workers should make every effort to create a safe working environment. Office workers should have chairs, desks, and equipment that support the back or help maintain good posture.
Too Little or Improper Exercise
Sedentary Lifestyle. People who do not exercise regularly face an increased risk for low back pain, especially during times when they suddenly embark on stressful unaccustomed activity, such as shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, sedentary living is probably a primary nonmedical culprit contributing to this condition. Lack of exercise leads to the following conditions that may threaten the back:

Muscle inflexibility (can restrict the back's ability to move, rotate, and bend).

Weak stomach muscles (can increase the strain on the back and can cause an abnormal tilt of the pelvis).

Weak back muscles (may increase the load on the spine and the risk for disc compression).

Obesity, associated with sedentary lifestyle (may put more weight on the spine and increase pressure on the vertebrae and discs). Studies report only a weak association between obesity and low back pain, however.

[See Box Specific Exercises for Low Back Strength under What Is the Role of Exercise and Movement in People with Low Back Pain?]

Improper or Intense Exercise. On the other side of the coin, improper or excessive exercise is also an important risk factor for back pain.

The effect of high-impact exercise on the back is not entirely clear. Some research suggests that over time, it may increase the risk for degenerative disc disease. A survey of people who played tennis, however, found no increased risk for low back pain or sciatica.

Between 30% and 70% of cyclists experience low back pain. (One 1999 study reported that 70% of cyclists reported improvement simply by adjusting the angle of the bicycle seat.)

Improper exercise instruction and inattention to mechanics can be sources of sudden trouble. As examples, a single jerky golf swing or incorrect use of exercise equipment (especially free weights, nautilus, and rowing machines) can cause serious back injuries.

Tips for Daily Movement and Inactivity
The way a person moves, stands, or sleeps during the day plays a major role in back pain:

Maintaining good posture is very important. This means keeping the ears, shoulders, and hips in a straight line with the head up and stomach pulled in. It is best not to stand for long periods of time. If it is necessary, walk as much as possible and wear shoes without heels, preferably with cushioned soles. Using a low stool, alternate resting each foot on it.

Sitting puts the most pressure on the back. Chairs should either have straight backs or low-back support. If possible, chairs should swivel to avoid twisting at the waist, have arm rests, and adjustable backs. While sitting, the knees should be a little higher than the hip, so a low stool or hassock is useful to put the feet on. A small pillow or rolled towel behind the lower back helps relieve pressure while either sitting or driving.

Riding and particularly driving for long periods in a vehicle increases stress. Move the seat as far forward as possible to avoid bending forward. The back of the seat should be reclined not more than 30° and, if possible, the seat bottom should be tilted slightly up in front. For long rides, one should stop and walk around about every hour and avoid lifting or carrying objects immediately after the ride.

Be sure to have a firm mattress. If the mattress is too soft, a 1/4-inch plywood board can be put between the mattress and box spring. On the other hand, some people have experienced morning backache from a mattress that is too hard. The back is the best guide.

Tips for Lifting and Bending
Anyone who engages in heavy lifting should take precautions when lifting and bending:

If an object is too heavy or awkward, get help.

Spread your feet apart to give a wide base of support.

Stand as close as possible to the object being lifted.

Bend at the knees--not at the waist. As you move up and down, tighten stomach muscles and tuck buttocks in so that the pelvis is rolled under and the spine remains in a natural "S" curve. (Even when not lifting an object, always try to use this posture when stooping down.)

Hold objects close to the body to reduce the load on the back.

Lift using the leg muscles, not those in the back.

Stand up without bending forward from the waist.

Never twist from the waist while bending or lifting any heavy object. If you need to move an object to one side, point your toes in that direction and pivot toward it.

If an object can be moved without lifting, pull it, don't push.
Quit Smoking
Smokers are at higher risk for back problems, perhaps because smoking decreases blood circulation. The association may also be due to an unhealthy lifestyle in general. A British study found that young adults who were long-term smokers were nearly twice as likely to develop low back pain than nonsmokers. [See Well-Connected Report #41 Smoking.]
Risk Factors for Back Pain in Children and Adolescents
The likelihood of experiencing back pain increases as children age, and pain is more common among girls than boys, according to some studies. A common cause of temporary back pain is carrying backpacks that are too heavy for children (more than 20% of their body weight, or even less for very young children). Emotional or behavioral problems may also contribute to back pain (often along with stomachaches and headaches) in children.
HOW SERIOUS IS LOW BACK PAIN OR SCIATICA?
Outlook for Uncomplicated Low Back Pain
Most people with acute low back pain are back at work within a month and fully recover within a few months. According to one study, about a third of patients with uncomplicated low back pain significantly improved after a week and two thirds recovered by seven weeks. However, studies now suggest that up to three quarters of patients suffer at least one recurrence of back pain over the course of a year. In another study, after four years, less than half were symptom-free. Some physicians are approaching the problem as they would any chronic illness, one that is not necessarily curable and that needs a consistent on-going approach.
Specific conditions can determine the rate of improvement:

In the majority of patients with herniated discs, the condition improves (although the actual physical improvement may be slower than the reduction in pain). Researchers attempted to identify factors most likely to predict an elevated risk for recurrent pain and found that only depression was a significant factor in the majority of those who had not recovered.

Spinal stenosis stabilizes in about 70% of cases and worsens in 15%. Only about 15% of these patients improve.
Effects on Work
Studies have found that when people stay home because of back injury, only 65% are back at work within a week and nearly 14% are still absent at one month. And, if someone is on disability for more than six months, the person has only a 50% chance of returning to work.
Low back pain accounts for significant losses in work days and dollars. In 1990, it cost the US $23 billion in direct medical costs and possibly as much as $85 billion in total costs (such as lost productivity). Chronic back pain has become one of the most expensive causes of disability among workers under the age of 45. One study found that although severe back pain comprised only 10% of workers compensation cases it accounted for 86% of compensation costs.
Cauda Equina Syndrome
Cauda equina syndrome is the impingement of the cauda equina (the four strands of nerves leading through the lowest part of the spine) and can have severe complications in the bowel or bladder. It is an emergency condition. It is usually caused by massive extrusion of the disc material. Cauda equina syndrome can cause permanent incontinence if not promptly treated with surgery. Symptoms of the syndrome include the following:

Dull back pain.

Weakness or numbness in the buttocks, in the area between the legs, or in the inner thigh, backs of legs, or feet. May cause difficulty in standing or stumbling.

An inability to control urination and defecation.

Pain accompanied by fever (can indicate an infection).

Warning Signs for Serious Underlying Problems
Certain warning signs should alert a patient to see a physician immediately for low back pain. Any very severe back pain warrants attention, particularly if any of the following conditions are present:

Being over 50.

Recent injury.

Severe pain.

Pain awakens the person at night.

Pain accompanied by fever (possible infection).

Pain increased by lying down.

Pain unrelated to movement.

Pain lasts for a month, and is accompanied by unexplained fever or weight loss. (Possible indication of a tumor particularly in people with a history of cancer).

History or chronic use of corticosteroids.

Intravenous drug use.

History of urinary tract infection.

In children, any severe neck or back pain or pain that persists for more than three days.

HOW IS LOW BACK PAIN OR SCIATICA DIAGNOSED?
Because nearly all cases of low back pain clear up in a short time and are not due to serious problems, a medical history and a brief physical examination are almost always sufficient.
Still, with very severe or chronic back pain, it is important that any serious medical causes as well as cauda equina syndrome and progressive nerve damage be ruled out first. If the physician suspects a serious underlying cause, the approach to determining the origin of back pain involves answering three questions:

Is some general medical disorder present that could be causing the pain?

Are there social or emotional factors that might be intensifying the pain?

Are the nerves in the spine involved in the pain (such as in sciatica)?

Such questions can usually be answered with a medical history and physical examination.
Medical History
A medical and family history should include heart problems, cancer, arthritis, and any other serious conditions. The patient should report the following:

Previous episodes of back pain.

Any history of injuries or accidents involving the neck, back, or hips.

Any indications of a serious underlying disease (e.g., history of cancer, unexplained weight loss, chronic infection).

The frequency, duration, and nature of the pain (e.g., whether it is dull, piercing, throbbing, or burning).

The timing of back pain (whether it occurs at night or during the day).

Events surrounding the onset and whether the pain was triggered by an event, such as lifting a heavy object. (Often, the patient cannot describe an event that produced the pain.)

Any condition that worsens the pain (for example, coughing, exercise, straining during bowel movements, walking).

Any situation that relieves the pain (lying down, exercise).

Problems with urination or defecation (symptom of cauda equina syndrome).

Other relevant symptoms (e.g., morning stiffness, weakness or numbness in the legs).

Physical Examination
The main objectives of a physical examination are to attempt to locate the specific location of the pain source and to determine limits of movement:

Patients are asked to sit, stand, and walk in different ways (flat-footed, on the toes, and on their heels).

In some cases they are asked to walk on a treadmill to test for weakness in toe or heel walking (which may indicate stenosis).

Patients will be requested to bend forward, backward, and sideways and to twist.

Patients will be asked to lift their leg straight up while lying down. The physician will also move the patient's legs in different positions and bend and straighten the knees. (Pain caused by sciatica can be intensified by lifting the affected leg straight in the air. It is usually sharp, localized, and accompanied by numbness or tingling. Pain caused by inflammation is duller and more generalized and not affected by lifting a straight leg.)

The physician may measure the circumference of the calves and thighs to look for muscle deterioration.

To test nerve function and reflexes, physicians will tap the knees and ankles with a rubber hammer. The physician may also touch parts of the body lightly with a pin, cotton swab, or feather to test for numbness and nerve sensitivity.
Imaging Techniques
Because most patients with back pain are on the mend or completely recovered within six weeks, imaging techniques such as x-rays or scans are rarely recommended in the first month unless a tumor, fracture, infection, cauda equina syndrome, or progressive neurologic disease is suspected.
Symptoms that may indicate the need for imaging studies include the following:

Pain that lasts more than a month.

Very severe or progressive pain, numbness.

Muscle weakness.

A previous accident or injury that might have affected the back.

A history of cancer or other indications of an underlying disease, such as fever or unexplained weight loss.

Pain that occurs in older patients (over 65 years of age).

If these conditions exist, usually an x-ray is used first. If results are inconclusive, either computed tomography (CT) or magnetic resonance imaging (MRI) may be performed. (Ultrasound is not useful.)
X-Rays Although many patients with acute and uncomplicated low back pain believe that plain x-rays of the spinal column are important in a diagnosis, they are not very helpful in most patients except for reducing anxiety. If pain persists after six to eight weeks, then x-rays are usually warranted. In such cases, x-rays may reveal signs of injury, infection, tumors, stenosis, or changes in the vertebrae that may be causing inflammation or compression on the nerve. Types of x-rays for the spine include the following:

A discography is an x-ray of the disc. It requires injections into discs suspected of being the source of pain and discs nearby. It can be painful and is generally only used for patients who are undergoing back surgery to identify the location of the injured disc.

An x-ray myelogram is an x-ray of the spine that requires a spinal injection of a special dye and the need to lie still for several hours to avoid a very painful headache. It has value only for select patients with pain on moving and standing. It has largely been replaced by CT and MRI scans.

Magnetic Resonance Imaging (MRI). Magnetic resonance imaging (MRI) is not painful and can provide very well-defined images of soft tissue and bone. MRIs are able to detect annular tears or disc fragments and can detect non-spinal causes of back pain, including infection and cancer. MRIs are no more effective than x-rays in identifying bone problems, however, and they are more expensive. Furthermore, evidence suggests that relying on MRI images of disc abnormalities to determine treatment has resulted in many unnecessary surgeries. At least 40% of all adults have bulging or protruding vertebral discs, and most have no back pain. The degree of disc abnormalities revealed by MRIs, therefore, have very little to do with the severity of the pain or the need for surgery. Disc abnormalities in people who have back pain may simply be a coincidence rather than an indication for treatment.

Advanced imaging techniques should be used only when underlying infection, cancer, or nerve involvement are suspected.
Bone Scintigraphy and SPECT Imaging. In rare cases, doctors may use bone scintigraphy to determine abnormalities in the bones. In this technique, a small amount of radioactive material is injected into a vein, circulates through the body, and is taken up by the bones. The bones can then be visualized using x-rays or, in specialty cases, nuclear scanning techniques such as a single photon emission computed tomography (SPECT). Bone scintigraphy may be useful for early detection when bone abnormalities are suspected from such conditions as spinal fracture, cancer that has spread to the bone, or osteoarthritis.
Electrodiagnostic Tests Electrodiagnostic tests that analyze the electric waveforms of nerves and muscles may be useful for detecting nerve abnormalities that may be causing back pain and identifying possible injuries. They are also useful to determine if any abnormal structural findings on an MRI or other imaging test have real significance as a cause of the back pain. It should be noted that any nerve injuries that affect these tests may not be present for two to four weeks after symptoms begin.
Nerve conduction studies and electromyography are the electrodiagnostic tests most commonly performed.

Nerve Conduction Studies. To perform nerve conduction studies, surface electrodes are attached to the skin. Small electric shocks are then applied to measure the speed of nerve conduction.

Electromyography. To perform electromyography, a fine, sterile, wire electrode is inserted briefly into a muscle and the electrical activity is displayed on a viewing screen. Electromyography can be quite painful, and some experts question, in fact, whether it adds any valuable diagnostic information. They suggest it be limited to unusual cases or when other tests indicate that the condition is aggressive and may increase the risk for rapid, significant injury.
Other Tests
Blood and urine samples may be used to test for infections, arthritis, or other conditions. Injecting a drug that blocks pain into the nerves in the back helps locate the level in the spine where problems occur. A procedure called a facet block is also useful in locating areas of specific damage. Provocative discometry is a test that uses an injection of saline solution into the suspected disc to reproduce the pain, which is then followed by injection of an anesthetic to dull the pain.
WHAT ARE THE TREATMENTS FOR UNCOMPLICATED ACUTE LOW BACK PAIN OR SCIATICA?
General Approach for Uncomplicated Acute Low Back Pain or Sciatica
For treating short-term acute low back pain, the best results derive from the least aggressive treatments. The general approach is the following:

Patients with no indication of any serious underlying cause should stay as active as possible within the limits of the back pain. (Bed rest is not recommended.) Some studies suggest that a third of patients with uncomplicated low back pain are significantly improved after a week with no other treatment than normal activity and two thirds have recovered by seven weeks.

Physical therapy or spinal manipulations may be helpful if pain continues for more than two to three weeks.

The patients should seek a specialist if pain continues for more than a month (or less than this if there are indications of an underlying disorder, nerve damage, or injury).

Back pain attributed to medical conditions, such as arthritis, osteoporosis, or pregnancy, either resolves when the condition does or is treated as part of the overall therapeutic plan.

Immediate Treatment of Acute Low Back Pain of Unknown Cause
Experts now recommend that people with acute low back pain attempt to resume normal activities as soon as possible. They should be conducted without strain or stretching. Simply letting pain be the guide is the best approach for achieving movement. In general, normal activity should be resumed in a gradual fashion as soon as the patient feels ready, reserving therapeutic exercises until after the acute pain has resolved.
Specific Tips for Relieving Pain. At the onset of acute low back pain when the cause is unknown, the following tips may be helpful:

Bed rest is no longer recommended and may delay recovery. Patients should remain active, but should let the pain guide his or her behavior and should probably stop normal physical activities for the first couple of days in order to calm symptoms.

Over-the-counter pain relievers, usually the nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil and others) often provide significant benefits. Muscle relaxants may be helpful in some patients, although their benefits are uncertain. Once started, medications should be taken on a regular schedule in order to maintain consistent effectiveness. [For details on these agents, see What Are the Noninvasive Treatments for Low Back Pain?]

Application of heat (104 degrees for eight hours a day) can be very helpful. In one study it was more effective than ibuprofen (Advil and other brands) or acetaminophen (Tylenol and other brands) for nonspecific low back pain. Many people find that alternating ice packs and heating pads is helpful in relieving the pain. Some people recommend changing from hot to cold every three minutes and repeating this sequence three times. (Some experts believe ice packs should be applied first.) This regimen should be performed two or three times during the day. (Heat or cold treatments do not have much effect on sciatica.)

Supportive back belts, braces, or corsets may help some people temporarily, but they can reduce muscle tone over time and should be used only briefly.

Healthy sleep plays a vital role in recovery. It is often difficult to get a good night's sleep when suffering from back pain, particularly because the pain can intensify at night. Take a warm bath before bedtime, and practice relaxation techniques. It may be necessary to take medication to help manage nighttime pain or treat sleeplessness. To help promote sleep, avoid caffeine in the afternoon and evening. Lying curled up in a fetal position with a pillow between the knees or lying on the back with a pillow under the knees may help.

Massage therapy may be helpful for many people with both acute and chronic low back pain. In fact, three well-conducted studies demonstrate some benefit and suggest it may reduce the costs of care. However, it is usually not covered by insurance.

Spinal manipulation may be helpful, although it is not clear if it is any more helpful than physical therapy or general care. Some experts recommend delaying this treatment until pain has persisted for three weeks, if possible, since the back pain will most likely have resolved on its own by then. [For details on these agents, see What Are the Noninvasive Treatments for Low Back Pain?]

Treatments That Provide No Benefits
Patients should be aware of and avoid certain approaches that are not helpful and, in some cases, may be harmful for acute low back pain:

Bed rest. Bed rest for low back pain, including most cases of sciatica, is no more effective and may even be worse than simply continuing normal activities to the degree possible. Long-term bed rest results in loss of muscle tone and bone strength, increases susceptibility to blood clots, and causes depression and lethargy.

Exercise in the acute phases of low back pain. Intense exercise and physical activity should be avoided during acute back pain, particularly heavy lifting and trunk twisting. (Specific exercises can be important during recovery, however, as well as for patients with chronic low back pain.)

Acupuncture. Acupuncture has not proven to have any value for acute low back pain in most patients, but may provide some help for patients with chronic low back pain.

Magnet therapy. Permanent bipolar magnets have gained some popularity as a non-invasive method of relieving pain. To date no studies support such claims and one 2000 study reported no effect in alleviating low back pain. It should be noted that magnets can deactivate heart devices and must be kept at least six inches away from pacemakers or implantable cardioverter defibrillators.

WHAT IS THE GENERAL APPROACH TO SEVERE CHRONIC LOW BACK PAIN?
General Guidelines on Treating Chronic Low Back Pain
Evidence strongly suggests that only intensive treatment using a combination of physical and psychological rehabilitation programs can reduce pain and improve function in patients with chronic low back pain. Even with the best treatments, many patients with chronic back pain do not experience complete pain relief and need to develop methods for improving daily life in the face of some persistent pain.
Noninvasive Therapies. In general, early treatments for severe low back pain or for episodes of chronic low back pain are similar to those of acute uncomplicated low back pain, including avoiding bed rest. The following are the most common noninvasive treatments for chronic back pain of unknown causes:

Pain Relievers. Patients often take pain relievers, particularly NSAIDs, although they can have severe effects on the gastrointestinal tract over time. The newer agents, COX-2 inhibitors or coxibs, may have fewer effects on the GI tract, but their long-term safety is unknown. Some physicians have recommended long-term opioids for patients with severe chronic pain, but studies suggest they do not improve activity levels and can have significant side effects. [See the section What Are the Noninvasive Treatments for Low Back Pain?]

Corticosteroid injections may be helpful for some patients.

Exercise and Physical Therapy. Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although it is often very difficult to sustain. [See the section What Is the Role of Exercise and Physical in Low Back Pain?]

Antidepressants. In some patients antidepressants may be helpful, particularly those known as tricyclics.

Cognitive-Behavioral Therapy. This form of psychological therapy helps change behavior and attitudes toward pain, and may be helpful for dealing with pain.

Alternative Therapies. Some alternative therapies, particularly transcutaneous electrical nerve stimulation (TENS) and massage may relieve pain in certain cases. Other mind-body techniques such as relaxation and meditation may be helpful by reducing stress.

Other promising approaches, such as Botox injections and lidocaine patches, are also being investigated.
Surgery and Invasive Procedures. In severe cases, more invasive procedures may be needed. The most common reasons for surgery for low back pain are sciatica and spinal stenosis. Evidence of a herniated disc and nerve compression, however, is not an automatic indication for surgery. It is advised only for selected patients.
Back surgery rates are more than 40% higher in the US than in any other country. Some experts believe that less than 1% of back pain patients need aggressive medical or surgical treatments. Nevertheless, when it is appropriate, surgery can provide great relief. There are many approaches and procedures that are available or being investigated, including many minimally invasive operations. However, there are still few well-conducted studies to determine differences among them or if, indeed, some are better than no surgery at all. There are so many noninvasive options currently available that patients should investigative all possibilities before choosing surgery.
It is extremely important that the patient be sure that the surgeon has had significant experience with any procedure to be performed. [See What Are the Surgical and Invasive Treatments for Severe Low Back Pain (Herniated Disc or Spinal Stenosis)?]

Specific Approaches for Patients with Herniated Discs
Nonsurgical Procedures. In patients with herniated discs, nonsurgical methods should be used for at least a month before considering surgery. Nonsurgical procedures include spinal manipulation, massage therapy, and physical therapy. (Patients should wait at least two to three weeks before using spinal manipulation, since early effectiveness and safety are not yet clear.)
Surgery. According to a 2001 review of studies, about 10% of patients experience pain after six weeks that is severe enough to warrant consideration of discectomy, the standard procedure for herniated discs. For many of these patients, surgery may bring significant relief. In one 2001 study, for example, 70% of patients with moderate to severe sciatica who had had surgery reported improvement. And the improvement was superior to that from nonsurgical treatments for about four years in most patients. After that, and by ten years, however, it is not clear if surgery maintains its advantage over nonsurgical approaches.
Specific Approaches for Patients with Spinal Stenosis
Preventing Falls. Falling is a risk for patients with spinal stenosis. They should avoid alcohol and sedatives. Leg strengthening exercises (walking, cycling) may be helpful, with brief resting if pain occurs.
Nonsurgical Treatments. The use of common pain relievers, such as NSAIDs, physical therapy, and steroid or other spinal injections may be helpful for some patients.
Surgery. If pain is persistent, patients may require surgery, most often a procedure called decompressive laminectomy. Some patients may require spinal fusion as well. Studies suggest that surgery reduces back pain in many patients, at least for a few years. By four years after surgery, however, 30% of patients have severe pain again and 10% have had another operation. It should be noted that surgery does not always improve outcome and in some cases can even make it worse. Surgery can be an extremely effective approach, however, for certain patients with severe back pain that does not respond to conservative measures.
Specific Approaches for Patients with Piriformis Syndrome
Nonsurgical Treatments. The general approach for patients with piriformis are corticosteroid injections and physical therapy. Botox injections are show promise.
Surgery. In carefully selected patients who do not respond to physical therapy and injections, some studies report dramatic pain relief with a procedure that releases the piriformis muscle.
WHAT ARE THE NONINVASIVE TREATMENTS FOR LOW BACK PAIN?
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). These agents block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Evidence suggests that short term use brings effective relief in patients with acute back pain. Their benefits for chronic back pain are less certain.
There are dozens of NSAIDs. The most common are the following:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).

Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), indomethacin (Indocin).

Topical NSAIDs delivered in gels, creams, or patches are proving to reduce arthritic pain and pose less of a risk for gastrointestinal complications associated with oral NSAIDs. Topical forms that contain diclofenac (Pennsaid, Oxa Sat) are now available outside the US. Others showing promise contain the NSAIDs eltenac, ibuprofen, or ketoprofen. One interesting agent combines and NSAID with fish oil compounds, which have anti-inflammatory effects.

Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:

Ulcers and gastrointestinal bleeding. This is the major danger with long-term use of NSAIDs. (Indomethacin poses a higher risk than many others for this adverse effect.) [See Box NSAID-Induced Ulcers and Gastrointestinal Bleeding.]

Increased blood pressure. Most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). (Sulindac has the smallest effect and aspirin as no risk.) People with hypertension, severe vascular disease, kidney, or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDs.

May delay the emptying of the stomach, which could interfere with the actions of other drugs. The elderly are at special risk.

Dizziness.

Tinnitus (ringing in the ear).

Headache.

Skin rash.

Depression has also been noted.

Confusion or bizarre sensation (in some higher-potency NSAIDs, notably indomethacin).

Possible higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception).

Kidney abnormalities have been reported in people taking NSAIDs, which resolve when the drugs are withdrawn. Any sudden weight gain or swelling should be reported to a physician. Anyone with kidney disease should avoid these drugs.

There is a small risk for liver abnormalities.

Note on interactions: Of great concern is research suggesting taking NSAIDs with aspirin might reduce the benefits of aspirin or other heart protective drugs. Diabetics taking oral hypoglycemics may need to adjust the dosage if they also need to take NSAIDs because of possible harmful interactions between the drugs.
NSAID-Induced Ulcers and Gastrointestinal Bleeding
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers and the rate of NSAID-caused ulcers is increasing. Ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to bleed than those caused by the bacteria H. pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Because there are usually no gastrointestinal symptoms from NSAIDs until bleeding begins, physicians cannot predict which patients taking these drugs will develop bleeding. Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis).

Preventing Ulcers or Rebleeding Induced by NSAIDS. If NSAID-induced ulcers or bleeding are identified, the first steps are the following:

Test for H. pylori and if infected take antibiotic treatments.

Try switching to alternative pain relievers. The first choice at this time are coxibs, usually celecoxib (Celebrex). It should be noted, however, that although they have a lower risk for ulcers and bleeding than standard NSAIDs, they are not entirely safe for the GI tract.

People who still need to take NSAIDs may try the following:

Use the lowest NSAID dose possible.

Try adding a proton-pump inhibitors (PPIs). Studies suggest they lower the risk for NSAID-induced ulcers but cannot completely prevent them. Brands include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprozole (Protonix).

Try misoprostol or Arthrotec. If other agents are inappropriate, misoprostol protects against the major intestinal toxicity of NSAIDs. It was the first drug approved for preventing NSAID-induced ulcers. It is equally or even more effective than some of the PPIs, but it does not heal existing ulcers and has more side effects than PPIs. Patients tend to stop using it. Arthrotec is a combination of an ulcer protective agent called misoprostol and the NSAID diclofenac. One study found that patients taking Arthrotec had 65% to 80% fewer ulcers than those who took NSAIDs alone.

One small study on animals suggested that taking L-arginine (an amino acid found in health stores) may help protect against damage from NSAIDs. As with all alternative agents, this product is not government regulated and more research is needed to confirm its benefits.

A 2002 study compared the coxib Celebrex with an NSAID (diclofenac) plus Prilosec in patients who had NSAID-induced bleeding. Unfortunately, there were no significant differences in rebleeding rates, which were high (about 5% within six months). Pain relief was about equal. More research is needed to determine whether other combinations may prove to be better options for these patients.
COX-2 Inhibitors (Coxibs)
Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors, or coxibs. They inhibit an inflammation-promoting enzyme called COX-2. Others, such as etoricoxib, are under investigation. Meloxicam (Mobicox) is a related drug known as a preferential COX-2 inhibitor.
Evidence is increasing that the coxibs are significantly less harmful to the gastrointestinal (GI) tract than common NSAIDs, but they still pose some risk. In an important 2003 study, Celebrex had a significantly better safety record in the GI tract than NSAIDs and had lower rates of ulcers even in patients who needed to also take aspirin prevent heart attacks. Another 2003 study also suggested that rofecoxib was safer for the GI tract than NSAIDs. Some early evidence also suggests that, like NSAIDs, they may be partially protective against colon cancer and possibly even Alzheimer's disease.
In spite of their potential promise, some researchers believe that inhibiting COX-2 may have some negative side effects over the long term. The effects of these drugs on the heart particularly require clarification. The following are possible adverse effects or complications:

They still pose a risk for gastrointestinal bleeding, although it is lower than with standard NSAIDs.

Some studies have reported a higher incidence of heart attacks in patients taking Vioxx compared to those taking standard NSAIDs. There were limitations to these studies, however, and 2003 study of 67,000 elderly patients found no higher risk compared to patients taking other NSAIDs or none of these drugs. Some (but not all evidence) suggests that the COX-2 inhibitors may increase the risk for blood clots. On the other hand, some studies have suggested that the anti-inflammatory effects, at least in Celebrex and meloxicam (Movicox), may have beneficial effects on blood vessels that would be heart protective.

Celebrex or Vioxx can increase in blood pressure, with Vioxx having the greater effect.

A few cases of neurologic side effects (hallucinations) have been observed with higher doses of Celebrex or Vioxx.

Coxibs may have some adverse effects on kidney function, particularly in elderly people, which is similar to the effects of standard NSAIDs. Liver abnormalities, which are side effects of many drugs, have also been reported with coxibs and need further follow-up.

They may have negative effects on pregnancy and fertility.

Some severe allergic reactions have been reported in patients taking valdecoxib (Bextra). People allergic to sulfa drugs may be at particular risk. Anyone who develops a rash after taking these agents should stop taking them immediately.

Patients who are sensitive to aspirin should discuss coxibs with their physician. Some may be safer for these individuals than others.

Coxibs can interfere with other drugs taken concurrently. Patients taking anticoagulant drugs such as warfarin may experience a higher risk for bleeding with the use of these agents. The use of coxibs can interfere with many other drugs taken concurrently, including lithium, methotrexate, and many others taken for heart disease, high blood pressure, or epilepsy. Patients should discuss all other medications with their physician. Patients should discuss all other medications with their physician.
COX-2 inhibitors are also significantly more expensive than traditional NSAID, costing about $80 per month, compared to about $15 for an NSAID like naproxen. Although they pose a lower risk for ulcers than NSAIDs, this risk is small for most NSAID users, so choosing coxibs may be justified only in patients with evidence of GI bleeding. More research is needed.
Tramadol
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these agents.
Opioid Pain Relievers
Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of pain.
There are two types of narcotics:

Opiates, which are derived from natural opium (e.g., morphine and codeine).<.li>
Opioids, which are synthetic drugs. They include oxycodone (Percodan, Percocet, Roxicodone, Oxycontin), hydrocodone (Vicodin), and oxymorphone (Numorphan). A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids. A small, patient-controlled device (SynchroMed) that is implanted under the skin in the abdomen and delivers pulses of opioids to the spinal canal is also undergoing testing.

Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.
Antidepressants
A 2002 review of studies concluded that antidepressants may lessen pain severity in some patients, although they had little effect on daily functioning. Some experts suggest that treating people for depression who have both low back pain and depression may be even more beneficial and cost-effective than back treatments. Certain antidepressants, called tricyclics, can even be effective painkillers in non-depressed people with chronic back pain. They include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomill). It should be noted that tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.

Muscle Relaxants
A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) are sometimes used for patients with acute low back pain. Evidence as reported in a major 2003 review supported their effectiveness in relieving non-specific low back pain, but experts in the study warned that these drugs should be used cautiously, since their effects occur in the brain, not the muscles. They also added that more comparison studies are needed to determine if they are more effective then common pain relievers. For example, a 2003 study of patients in the emergency room reported no additional pain relief when Flexeril was added to ibuprofen. Patients also experienced a number of central nervous system side effects. Drowsiness and other side effects are common. Some of these drugs, such as Soma, can be addictive and do little more than produce sleep. Of further concern, in some people the tensed back muscles may be protecting the damaged disc or vertebrae, in which case muscle relaxants could be harmful.
Investigative Agents
Tumor-Necrosis Factor (TNF) Modifiers. TNF modifiers interfere with specific components of tumor-necrosis factor, a powerful immune factor that is important in the inflammatory process and may play role in nerve dysfunction and pain that occurs in sciatica. In one early study, one of these agents, infliximab (Remicade), was associated with significant improvement in sciatica. More research is warranted.
Lidocaine Patch. Lidocaine, a local anesthetic, is available in patch form (Lidoderm) and has been used specifically for herpes zoster pain. Early studies are suggesting that it may provide significant relief for people who suffer from low back pain with very few adverse effects, even with continuous use of four patches a day. If further studies support its benefits, the patch could prove to be an important treatment.
NO-NSAIDs. NO-NSAIDs are drugs that combine NSAIDs and nitric oxide (NO), a substance that enhances blood flow to the stomach and increases levels of protective mucus and bicarbonate. These agents show particular promise in providing pain relief and reducing the risk for GI problems and warrant additional investigation.

Herbal Remedies
There have been claims for a number of herbal and so-called natural remedies for relief of back pain. Most herbal remedies that are effective contain active ingredients, just as standard medications do, that relieve pain, relax muscles, or increase circulation. In such cases, they are also likely to have similar side effects. For example, in one trial, the herbal pain reliever white willow bark (Assaliz) was as effective as the COX-2 drug rofecoxib (Vioxx). Willow bark contains the active ingredient found in aspirin and so, theoretically, may have the same adverse effects as NSAIDs. A German study on pain management reported that herbal products containing black current leaf or oils, evening primrose, and borage may be useful and safe for pain due to inflammation. According to another German study, harpagophytum (a South African herb commonly called devil's claw or grapple plant) may be useful for back pain.
Because there are no government regulations of these products, neither the effectiveness nor safety of herbal products can be guaranteed.
Warnings on Alternative and So-Called Natural Remedies
Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.
There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most reported problems occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals. This website is building a database of natural remedy brands that it tests and rates. Not all are yet available.
The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to drugs and untested substances, such as herbal remedies and vitamins (call 800-332-1088).
Mind-Body Techniques
According to a 2001 review of studies, only intensive programs that include both psychological and physical rehabilitation therapies were successful in reducing chronic low back pain and improving function. A number of effective approaches to low back pain — called collectively mind-body techniques — employ psychological, behavioral, or physical methods to promote relaxation and reduce stress. Although many may be helpful, evidence is lacking on the specific approaches that would be most successful and which patients would most likely benefit.
Stress Reduction. Stress reducing techniques, including relaxation methods and meditation, may be helpful. One study, for example, reported that meditation was beneficial in reducing pain and improving mood among chronic pain sufferers who had not responded to traditional care. Another found that after three weeks, patients who were in pain after back surgery had less discomfort and slept better after practicing relaxation imagery techniques while listening to music for 25 minutes a day.
Cognitive-Behavioral Therapy. Studies report that a course of cognitive-behavioral therapy helps reduce chronic back pain or at least enhances the patient's ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves and their approach to pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative and, to a degree, a manageable experience among many positive ones. In one study, therapists also taught relaxation techniques and methods to improve posture. The sessions were two and a half hours each week for 12 weeks. More research is needed.
Patient Education and Support Groups. A 2002 study reported that patients with chronic low back pain who participated in an expert-moderated e-mail support and discussion group had less pain and disability after 12 months. An Australian massive public-health campaign that educated patients and doctors about the importance of staying active and dispelled fears about long-term impairment from back pain dramatically reduced disability and worker compensation claims.
Massage Therapy
A number of well-conducted studies have supported that benefits of massage therapy for patients with chronic or acute back pain, especially when it is combined with exercise and patient education. In fact, one analysis in 2003 suggested it may reduce the costs of care. However, it is usually not covered by insurance.
Spinal Manipulation
Spinal Manipulation for Uncomplicated Acute Low Back Pain. Spinal manipulation may be useful for acute back pain that persists beyond two to three weeks. There are a number of variations, but one example of a spinal manipulation technique is the following:

The patient first lies on his or her side.

The practitioner grasps the exposed shoulder and either the hip or knee and then presses the upper and lower portions of the body in opposite directions, so that the torso rotates.

The shifting vertebrae make a cracking or popping sound, indicating that they have exceeded the normal range of motion.

Often this results in a greater sense of ease and mobility. (The effect, however, may be temporary.)

Controversy exists over whether on-going manipulations after a first visit work any better for relieving pain than simply gradually resuming normal activity. Some patients consider spinal manipulation to be highly effective for chronic low back pain as well. A major 2003 analysis, however, reported that current evidence did not support the benefits of spinal manipulation over general medical care or physical therapy for either acute or chronic back pain. (It was better than sham therapy, however.) A large study is underway to determine its value for both acute and chronic low back pain.
Chiropractic or Osteopathy. Spinal manipulations are typically performed by chiropractors, but osteopathic doctors also perform them.

One in three people with low back pain seek treatment from a chiropractor. Chiropractic was founded in the US in the late 1800s and has been associated throughout its history with shamanism and folklore as well as with potentially genuine health benefits. There has not been a clear consensus even among its own practitioners about its specific goals. Nevertheless, there is a strong movement within the practice aimed at a scientific and realistic approach. The specific goal of chiropractors is to perform spinal manipulations to improve nerve transmission. Many studies have now confirmed that patients feel more satisfied with their chiropractic care than with treatment from general practitioners. (An analysis of studies reported that chiropractic treatment was beneficial, but not much better than sham treatments. Interestingly, standard medical treatments had worse results than both chiropractic and sham treatments.)

Osteopathy was also founded in the 1800s and also involves physical manipulation as its core approach to healing. Unlike chiropractic, however, osteopathy uses manipulation of the bones, muscles, and tendons to optimize blood circulation. In addition, the general direction of osteopathy over the years has widened to employ a broader range of treatments that now approach those of standard medicine. One 1999 study reported that osteopathy was as effective as medical treatment in relieving low back pain and patients required far less medication and physical therapy. Osteopathic treatment was also far less expensive.

Positive Emotional Effects. Both chiropractors and osteopaths offer verbal assurance and a precise treatment regimen. The direct physical connection through spinal manipulation reinforces the patient-practitioner relationship. The emotional effects of such connections may be as important for healing as the treatments themselves. Chiropractors offer a further psychological advantage, which is availability to their patients. Many medical doctors believe that because low back pain is self-limited and resolves the patient can wait for an appointment. A chiropractor, however, is more likely to see a patient promptly.
Adverse Effects. Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulations is low. It should be strongly noted, however, that serious complications (including stroke or spinal cord or neck injury) have been reported with manipulations of the neck. Although little research has been done on such complications, an English survey indicated that they are more frequent than commonly thought.
Some chiropractors overuse x-rays, particularly those of the full spine, which may have long-term harmful consequences. Patients should also be aware that some chiropractors use alternative treatments that have not been proven or rigorously studied. All patients should require objective evidence on the benefits of their treatments.
Other Noninvasive Procedures
Vertebral Axial Decompression. Vertebral axial decompression (VAX-D) may reduce pain and improve function in patients with chronic low back pain, including sciatic pain that radiates down the leg. The patient lies face down on a special table, clutching hand grips and wearing a pelvic harness. Movable parts of the contraption exert a traction-like action that alternately decompresses the spine, then relaxes, over one-minute intervals. Each session lasts about 30 minutes, and 10 to 20 sessions on successive days are often required. The procedure is thought to alleviate pain and enhance healing by relieving pressure within the discs, promoting the in-flow of oxygen, fluids, and nutrients to the spinal column. Some evidence supports its benefits, with reported success rates of around 70%. It is not yet covered by most insurers, however, and more studies are needed to confirm its benefits.
Acupuncture. Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small pins or exerting pressure on certain "energy" points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation known as Teh Chi, which brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. In any case, it may be specifically helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who has acupuncture should be sure it is performed in a reputable location with experienced practitioners who use sterilized equipment.
Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) employs a small device delivers electrical stimulation to deep tissues and nerve pathways near the spine. It has shown some initial promise for relief of chronic back pain and may also improve mobility and sleep. Treatment sessions are conducted in the doctor's office and last about 30 minutes. The device only became available in 2002, so experience is very limited. A correct pattern of stimulation appears to be important for optimal relief and needs to be determined.
Electric Nerve Stimulation. Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points. The standard procedure is to give 80 to 100 pulses per second for 45 minutes three times a day. The patients are barely aware of the sensation. Although a 2002 analysis of trials could find no direct evidence of benefit, small studies have reported some relief for chronic low back pain from either TENS or PENS. It is not known if these effects are long lasting. Neither approach is helpful for relief of acute low back pain in most patients.
Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax then the process is stopped. Discomfort is minimal. Small studies are reporting some help in relieving a number of condition the cause chronic pain, including low back pain.

WHAT IS THE ROLE OF EXERCISE AND PHYSICAL THERAPY IN LOW BACK PAIN?
Resuming Activity After Acute Back Pain
Exercise is not helpful for acute back pain. In fact, overexertion may be as unhelpful as prolonged bed rest during recovery. In one study, for example, recovery was slower for patients who immediately embarked on flexibility exercises than for those who gradually resumed normal activity. An incremental aerobic exercise program (e.g., walking, stationary biking, swimming), however, may begin within two weeks of symptoms. Jogging is usually not recommended, at least not until the pain is gone and muscles are stronger.
Patients should avoid exercises that put the lower back under pressure until the back muscles are well toned. Such exercises include leg lifts done in a prone (face-down) position, straight leg sit-ups, and leg curls using exercise equipment.
It should be stressed that incorrect movements or long-term high-impact exercise is often a cause of back pain in the first place. People vulnerable to back pain should avoid activities that put undue stress on the lower back or require sudden twisting movements, such as football, golf, ballet, and weight lifting.
In all cases, patients should never force themselves to exercise if, by doing so, pain increases.
The Role of Physical Therapy
Physical therapy with a trained professional may be useful if pain has not improved within the first three weeks. It is, in fact, important for any person who has chronic low back pain to have an exercise program guided by professionals who understand the limitations and special needs of back pain and who can address individual health conditions. One study indicated that patients who planned their own exercise did worse than those in physical therapy or physician-directed programs.
Physical therapy typically includes the following:

The first stage involves patient education and training the patient in correct movement. Sometimes heat or electro-therapies (such as therapeutic ultrasound or low-energy lasers) are employed, although their benefits are unproven.

If back pain persists beyond five weeks, physical therapy is used for rehabilitation. It employs exercises to help the patient keep the spine in neutral positions during all daily activities.

Exercise for Chronic Back Pain
Exercise plays a very beneficial role in chronic back pain. In fact, starting intensive exercise four to six weeks after a first back surgery is very helpful for speeding up recovery. Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support and neutralize the spine. Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but they also alter and improve the patients' attitudes toward their disability and pain.
Unfortunately, there is insufficient evidence to determine which specific exercises will best help the patient. Some exercise programs that have studies with some success for prevention or treatment of chronic low back pain include the following:

Low Impact Aerobic Exercises. Low-impact aerobic exercises, such as swimming, bicycling, and walking, can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. In one study, for example, pregnant women who engaged in a water gymnastics program had less back pain and were able to continue working longer.

Lumbar Extension Strength Training. Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, improve lower back mobility, strength, and endurance, and enhance flexibility in the hip and hamstring muscles and tendons at the back of the thigh. [For examples of some good exercises for the back, see Box.]

Yoga, Tai Chi, Chi Kung. Practices originating in Asia that combine low-impact physical movements and meditation may be very helpful. They are designed to achieve a physical and mental balance and can be very helpful in preventing recurrences of low back pain. Pilates, an exercise practice that uses yoga principles, may be specifically helpful and deserves further research.

Flexibility Exercises. Whether flexibility exercises alone offer any significant benefit is uncertain. One study suggested that any benefits derived from flexibility exercises are lost unless the exercise regimens are sustained.
Retraining Deep Muscles. Of interest are studies that are finding a link between low back pain and impaired motor control of deep muscles of the back and trunk. According to these studies, contraction exercises specifically designed to retrain these muscles may be effective for patients with both acute and chronic pain.

Specific Exercises for Low Back Strength
Perform the following exercises at least three times a week:
Partial Sit-ups. Partial sit-ups or crunches strengthen the abdominal muscles.

Keep the knees bent and the lower back flat on the floor while raising the shoulders up three to six inches.

Exhale on the way up and inhale on the way down.

Perform this exercise slowly eight to ten times with the arms across the chest.

Pelvic Tilt. The pelvic tilt alleviates tight or fatigued lower back muscles.

Lie on the back with the knees bent and feet flat on the floor.

Tighten the buttocks and abdomen so that they tip up slightly.

Press the lower back to the floor, hold for one second and then relax.

Be sure to breathe evenly.

Over time increase this exercise until it is held for five seconds. Then, extend the legs a little more so that the feet are further away from the body and try it again.
Stretching Lower-Back Muscles. The following are three exercises for stretching the lower back:

Lie on the back with knees bent and legs together. Keeping arms at the sides, slowly roll the knees over to one side until totally relaxed. Hold this position for about 20 seconds (while breathing evenly) and then repeat on the other side.

Lying on the back, hold one knee and pull it gently toward the chest. Hold for 20 seconds. Repeat with the other knee.

While supported on hands and knees, lift and straighten right hand and left leg at the same time. Hold for three seconds while tightening the abdominal muscles. The back should be straight. Alternate with the other arm and leg and repeat on each side eight to 20 times.

Note: No one with low back pain should perform exercises that require bending over right after getting up in the morning. At that time, the discs are more fluid-filled and more vulnerable to pressure from this movement.

WHAT ARE THE SURGICAL AND INVASIVE TREATMENTS FOR SEVERE AND CHRONIC LOW BACK PAIN?
Injections
Injections of different substances are sometimes used to treat low back pain caused by nerve impingement. The injection is usually an epidural, which is directed into the spaces between the outer membrane of the spine and the vertebrae. None of these substances cure the problem.

Corticosteroids. A one-time injection of a corticosteroid (commonly called a steroid) is directed as close to the injured location as possible. Corticosteroids reduce inflammation and this approach may short-cut sciatic pain until the body heals itself. This is a temporary, not permanent, solution. Studies that measure the benefits of steroids on sciatica or low back pain, however, are conflicting. In fact there is some evidence that patients can experience a rebound effect within a few months and the pain returns. Some experts have also raised concerns that even a single injection can cause serious and painful side effects, including meningitis and inflammation, although such risks are very low.

Hypertonic saline (salt water solution). Epidural injections of saline are being investigated for breaking up scar tissue. One 2001 study compared targeted injections of saline and steroids directed at the nerve root. Although steroid injections had more immediate benefits, both offered improvement, and by three months, patients who had saline injections experienced less pain than the steroid group.

Local anesthetics. Injections of anesthetics such as xylocaine or bupivacaine may help some patients, although studies on their benefits are mixed.

Botulinum. Injections of botulinum toxin (Botox) in the lower back are under investigation. Very small amounts of the bacterial toxin, which is commonly used to smooth out wrinkles, temporarily paralyze muscle tissue. Some research suggests they may be very helpful in relieving chronic low back pain and sciatica caused by piriformis syndrome. Studies have reported that Botox relieved pain by at least half in between 60% and 78% of patients, compared to between 12% and 28% who reported the same benefit from placebo. The participants experienced no adverse effects. In a 2001 study, however, the benefits of Botox injections did subside by six months.

Discectomy
Discectomy is the surgical removal of the diseased disc, which then relieves pressure on the spine. The procedure has been performed for 40 years with increasingly less invasive technique being developed over time. Oddly, few studies have been conducted to determine its real effectiveness. Although in appropriate candidates it provides faster immediate relief than medical treatment, long-term superiority (over five years) is uncertain. A number of minimally invasive variations are now available.
Microdiscectomy. Microdiscectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disc tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.
Other less invasive procedures that are available including the following:

Endoscopic Discectomy. Endoscopy employs a catheter (a thin tube) that contains tiny cameras and surgical instruments that are inserted through small incisions. Various endoscopic approaches are proving to be useful for back surgery.

Percuteneous Discectomy. Percutaneous discectomy (PAD). This approach uses a tube with a device at the tip that cuts away some of the nucleus pulposus and a vacuum that then sucks this gelatinous matter out.

Laser Discetomy. A number of investigative surgical procedures employ lasers. For examples, endoscopic laser foraminoplasty (ELF) uses lasers to locate the likely source of pain and remove diseased tissue. The incision requires little more than a Band-Aid and complications are minimal. Long term benefits are unknown, however.

It is not clear yet if any of the these less invasive procedures are any more effective than the standard microdiscectomy.
Complications and Outlook. Many patients still have back pain after discectomy that delays discharge from the hospital. Narcotics are usually needed. Adding an injected NSAID may speed resolution of pain.
Scar tissue is a significant problem, since it can cause persistent low back pain afterward. Anti-scarring agents or certain devices may help reduce surgical scars and thereby postoperative pain. Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for reoperation.
Patients now often remain in bed only three or four days after disc surgery. It may take four to six weeks for full recovery, however. Gentle exercise may be recommended at first. Starting intensive exercise four to six weeks after a first-time disc surgery appears to be very helpful for speeding up recovery.
Laminectomy
Operations that remove a vertebra (laminectomy) or shave off part of one (laminotomy) may be used in certain cases of spinal stenosis or spondylolisthesis to decompress the nerve. They may also be used to remove benign tumors on the spine. In a 2002 study laminectomy achieved a 68% improvement compared to 33% in patients not given surgery.
Although either procedure often brings immediate relief from pain, a 1999 statistical study suggested that it is inappropriately performed in 60% or more of sciatica cases. There are small risks to the operation and it is not always successful. Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative patients. Minimally invasive variations are under investigation.
Spinal Fusion
In some case in which abnormal vertebrae position or movement is responsible for severe and chronic back pain, such as spinal stenosis or spondylolisthesis, surgeons may fuse vertebrae together. Fusion employs a bone graft or some other device to join the vertebrae together. In a 2001 study of patients with severe long-term back pain, 33% of patients who had spinal fusion had less back pain after two years, compared to 7% who received conservative treatment with physical therapy. Pain improved most in the six months following surgery. The patients who had surgery also had less disability and depression.
Many spinal fusion surgeries use a tiny hollow metal cage, which is implanted into the disc space. Bone is then removed from the patient's hip and packed inside the cage. Over time the bone grows through the holes and around the device, fusing the vertebrae. Alternatively, rather than performing a bone graft, the cage is filled with a sponge-like material containing a genetically-engineered protein called InFuse (rhBMP-2) that promotes bone to grow.
A number of video-assisted techniques have been developed that are less invasive than standard "open" surgical approaches, which uses wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches and some medical centers have abandoned them.
Other Techniques
Intradiscal Electrothermal Treatment (IDET). Intradiscal electrothermal treatment (IDET) is a promising outpatient procedure for very select patients. It employs a hollow needle that is inserted into the painful disk. An electric wire passed through the need heats the injured tissue, specifically the annular ring nerve fibers. Heat is applied for about 15 minutes. After healing, the disc is toughened, shrunk, and desensitized. Healing takes several weeks and pain relief is not immediate. In fact, it may increase temporarily. Although most studies to date on IDET are positive, some show no significant reduction in pain. Most studies also have flawed methods, and better research is needed to determine if and who it will help. Currently, obesity is the only factor highly associated with failure.
Radiofrequency Nerve Destruction. Radiofrequencies are being used to destroy nerves involved in the facet joints (or z-joints), which connect the vertebrae. Evidence is still weak on its benefits. A 2003 analysis suggested that it may be beneficial, however, for relief of neck pain and possibly for low back pain caused by problems in the facets joints. To date, thee have been few side effects, but some (such as serious infection) have been reported.
Nerve Blocks. A number of surgical techniques are available for relieving pain by impairing nerves that are causing pain due to impingement. In one 2000 study that used electrical stimulation to block the nerves, 60% of the patients reported at least 90% relief of pain after a year, and 87% reported at least 60% relief.
Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into damaged vertebrae under endoscopic and x-ray guidance. It is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer. Success rates of 73% to 90% have been reported. Serious complications occur in fewer than 1% of cases.
Artificial Disc Replacement. Total disc replacement is an investigative procedures for some patients with severely damaged discs. The technique implants artificial discs (ProDisc, Link, SB Charite) consisting of two metal plates and a soft synthetic core. The surgery can be performed using a minimally invasive laparoscopic procedure, which is performed through tiny cuts using miniature tools and viewing devices. A study in 2003 was the first to suggest that it may eventually achieve results that are comparable to standard surgeries for disc herniation. It is still experimental, however.
An artificial cushioning device called the prosthetic disc nucleus (PDN) replaces only the inner gel-like core (nucleus pulposus) within the intervertebral space, rather than the entire disc. It, too, is showing promise in early studies.
WHERE ELSE CAN INFORMATION ABOUT LOW BACK PAIN BE OBTAINED?
American Physical Therapy Association (www.apta.org). Call 800-999-2782.
American Academy of Orthopaedic Surgeons (www.aaos.org). Call 800-346-AAOS.
President's Council on Physical Fitness and Sports (www.fitness.gov). Call 202-690-9000.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (www.nih.gov/niams). Call 301-495-4484.
National Institute for Occupational Safety and Health (www.cdc.gov/niosh/homepage.html). Call 800-356-4674.
American Chronic Pain Association (www.theacpa.org). Call 916-632-0922.
National Chronic Pain Outreach Association. Call 540-862-9437.
American Pain Society (www.ampainsoc.org). Call 847-375-4715.
International Association for the Study of Pain (www.iasp-pain.org). Call 206-547-6409.
The National Association for Chiropractic Medicine (www.chiromed.org). Call 281-280-8262.
BackCycler (www.backcycler.com). Call 800-959-3746.
North American Spine Society (www.spine.org). Call 708-588-8080.
Arthritis Foundation (www.arthritis.org). Call 800-283-7800.
Two good sites for information on the back are www.spine-health.com and www.spineuniverse.com.
The International Intradiscal Therapy Society (www.iits.org).
International Spinal Injection Society (www.spinalinjection.com).
The following site offers resources for injured workers: www.workerscompensationinsurance.com.
Illustrations of back surgery are available at www.spine-surgery.com and www.yoursurgery.com.
Find an Orthopaedic surgeon at http://63.141.36.80/memdir/public/memdir.cfm.
Find a Neurosurgeon at www.neurosurgery.org/health/findaneurosurgeon.html.
Find a pain facility at www.ampainsoc.org/facility/index.htm.
Find a physical therapist at www.apta.org/Consumer/ptinyourstate.

Sincerely:

Joseph Saponaro, MD, DABIM, FACP, CPI, CCI, CCRI, CCRC, CCRP
Board Certified Internist, JPMC
Principal Investigator, DSI
Diplomat American Board of Internal Medicine
Fellow American College of Physicians
Certified Physician Investigator by the AAPP
Certified Clinical Investigator by the DIA
Certified Clinical Research Investigator by the ACRP
Certified Clinical Research Coordinator by the ACRP
Certified Clinical Research Professional by SoCRA
Member: The American College of Preventive Medicine

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