Back pain is one of the most common ailments; approximately 80% of the adult population will develop a significant episode of back pain sometime during their life. Fortunately, most of these will spontaneously resolve. However, approximately 10% to 20% will develop into significant chronic and/or recurrent episodes of back pain. Wear and tear conditions, such as degenerative arthritis and degenerative disc disease, are some of the most common causes. Low back joint restrictions and/or sacroiliac joint restrictions are also a common cause of acute low back pain. Muscle pulls and tears may also cause low back pain, but usually the symptoms from muscular causes are short-lived. Weak muscles, poor flexibility, and poor posture all aggravate underlying conditions and worsen symptoms. Uncommon causes of pain include infection, cancer, fractures, aneurysms, and/or internal organ problems.
The decision to have a MRI scan should be made by your health care provider after a careful history and physical examination. The vast majority of patients with arm/leg or neck/back pain will improve with time by themselves without having any sort of therapy or testing. Unless there is evidence of a significant neurological deficit, waiting for several weeks is desirable prior to obtaining a MRI scan. The MRI scan and associated findings can actually lead to significant confusion in terms of patient diagnosis when done immediately. If you are, however, suffering significant weakness, problems walking, or any trouble with your bladder, an MRI is essential.
The natural history of low back pain improves over a few days to one to two weeks. In fact, 90% of patients report that pain has subsided by two months without any intervention. However, 40% of patients develop significant recurrent symptoms within six months of the initial onset of symptoms. Fortunately, most recurrences are not disabling but may lead to chronic problems with intermittent episodes of exacerbation. Approximately 10% to 20% of patients who develop low back pain develop significant chronic low back pain which limits them.
The usual age of onset of severe low back pain is between 30 and 50 years of age. The most likely reason is that the degenerative process has begun, and individuals in that age range are still active enough to stress their bodies and place somewhat degenerative discs at risk for injury. It is also common in this age group for individuals to be very preoccupied with their life and occupation and in turn not take as good care of themselves as when they were younger. This leads to increased stress on the discs predisposing them to injury. The incidence of low back pain is equal between males and females. It is not uncommon for adolescents to experience low back pain. While this was previously thought to be a sign of severe potential problems, it is now recognized as common entity and usually not dangerous. Fortunately, it is often self-limiting as adolescents learn good body mechanics and participate in a proper strengthening and conditioning for their spine and overall body.
Traditionally, bed rest was the recommended treatment for back pain. However, recent studies show that bed rest is counterproductive and often detrimental in treating back pain. Bed rest allows muscles to de-condition and significantly slows the rate of recovery from acute back pain. The recommended activity modification for patients with back pain is to stop whatever activity causes back pain. Specifically, if bending and lifting cause back pain, then avoid bending and lifting. If a twisting motion, such as playing golf, causes back pain then stop playing golf. However, persons with back pain should remain as active as possible as long as they are not having pain. Bed rest should only be used in cases where the patient is having severe pain and cannot even tolerate simple activities of daily living, such as standing, walking, or sitting without suffering severe pain. In these cases, a very short course of bed rest combined with appropriate medication is often found to be beneficial. Bed rest should be limited to the amount of time it takes to get pain under control then the patient should be placed into an aggressive rehabilitation program consisting of strengthening and joint mobilization.
There are many causes of neck pain. Pain can be divided into three categories: mechanical (coming from the joint or the disc), radicular (coming from a nerve or nerve root), or myelopathic (coming from the spinal cord). Each spinal segment is composed of essentially three joints: the intervertebral disc in the front and the two facet joints in the back. These structures are very resistant to wear-and-tear for the first two decades of life but begin to wear out in our twenties. This mechanical pain is called degenerative disease and is the most common reason for neck pain. Radicular pain is usually sharp, electrical pain that goes down the upper extremity in a particular nerve pattern. It may be associated with numbness or weakness. It can be aggravated, or relieved by different motions or positions of the head or neck. Myelopathic pain refers to the symptoms from compression of the spinal cord. This type of pain is usually in both arms and can go down into the legs. It is associated with numbness or weakness in the extremities, problems with balance and coordination, difficulty with dexterity skills and can cause decreased control of your bowels and bladder. It is very important that you see a physician to address neck or arm pain and have a detailed history and physical exam performed. The physical exam should include an examination of the entire body, as well as the neurologic and vascular system, in order to determine exactly where pain is coming from.
Yes. Smoking accelerates the degenerative process of disc degeneration. The spinal discs do not have a naturally abundant blood supply. Smoking causes blood vessels throughout the body to become smaller, reducing the amount of blood and thus oxygen and nutrients delivered to tissues. The discs are greatly affected since they already have a poor blood supply. Smoking has also been linked to increased perception of pain amongst people who undergo treatment. Because of increased pain, it is associated with increased use of narcotics in trying to control pain and increased dissatisfaction with non-operative and operative treatment of back problems and other orthopedic disorders. In patients who undergo surgery, the overall success rate is much lower in smokers when all other factors are equal. The bottom line is that we know that smoking causes heart disease, lung disease, vascular disease, and cancer. In addition, smoking is linked to increased perception of pain and spinal problems.
A spinal disc is the ligamentous structure that attaches one vertebra to the next adjacent vertebra. The purpose of the disc is to allow for motion of the spine. Many people consider the disc to be a “shock absorber” between the bones of the spine. This is just one purpose of the disc. Another important function of the disc is to allow for motion in the spine. The disc is a very tough ligament that allows the spine to move in multiple directions, i.e., flexion, extension, side-bending to the right or left, rotation to the right or left, and distraction and compression along the axis of the spine. A healthy disc has a soft central portion, which is often likened to a jelly-like center. The outer portion of the disc consists of very tough ligaments arranged circumferentially. It is made of multiple layers crisscrossing as they encompass the jelly-like center. This very tough outer ligamentous portion allows the spine to move in multiple directions. The disc itself lacks any specific blood supply or nerves within the disc. However, the outside of the disc is richly innervated with nerve fibers. These nerve fibers on the outside of the disc if stimulated or irritated can cause severe back pain. Learn more about spine anatomy!
The nerves that supply pain sensation to the outside of the disc are different than the nerves that pass behind the disc and travel down into the extremities. Pain or irritation of the nerves that innervate the outside of the disc produce central back pain if the disc is located in the low back. If the disc is located in the neck, then neck pain is produced. Injury to the disc can cause pain in several ways. First, the injured disc can be painful just by tearing the outer portion of the disc and irritating the nerves that innervate the outer edge of the disc. This is called an annular tear. Secondly, the injured disc may begin to degenerate, causing enzymes to be produced. These enzymes can leak out of the disc and further irritate the nerves on the outside of the disc. This is a common cause of chronic back pain. Third, the injured disc is often weakened and does not function properly. Specifically, it does not prevent abnormal motion of one vertebra in relation to the next. For example, if a knee ligament or shoulder ligament were injured and stretched, the individual would lose support in that knee or shoulder. The same happens at a microscopic level in the back when a disc is injured. This allows for micro-translational movements of the disc causing irritation of the nerves that innervate the disc, as well as of the surrounding facet joints and supporting tissues. This micro-instability further accelerates the degenerative process and increases production of degenerative enzymes that aggravates back pain. This is the most common scenario present in chronic low back pain situations. An injured disc can also cause a piece of disc tissue to break off and compress surrounding nerves as they pass to the lower extremities. Pinching of these nerves usually causes leg pain if the pinch is in the low back or arm pain if it is in the neck; however, depending upon the position of compression, they may also cause central pain in the neck or in the low back.
A normal healthy disc has a usual height and shape. The center of the disc has a high water content and acts as a tall shock absorber. As a disc begins to degenerate and lose its normal water content, it loses some of its ligamentous strength. With this loss of water content, there is usually a loss of disc height. When the disc becomes shorter it causes the edge of the disc to protrude beyond the edges of the bone. This is comparable to letting air out of a car tire. As a car tire loses air, the tire broadens out as it loses height. The same is true for a disc. When the disc extends beyond the normal edge of the bone by greater than 50% of the circumference, it is termed a bulging disc. A bulging disc may pinch a nerve, causing extremity pain. More often than not, a bulging disc is associated with back pain.
A herniated disc occurs when a portion of the disc extends beyond the edge of the normal bony edges and measures less than 50% of the circumference of the disc. A disc herniation usually occurs when the outer lining of the disc becomes torn, allowing a portion of the disc material to express out of the normal confines of the disc itself. If this disc material extends out and pinches one of the nerves passing by as it goes to an extremity, it often produces radicular pain into that extremity. Specifically, if a part of the disc extends out of the disc in the low back and pinches one of the nerves to the leg, pain will extend down into the leg in a specific pattern to that nerve. This is called radiculopathy. If disc material that has herniated does not pinch or irritate a nerve going to an extremity, often there will be no leg symptoms. In fact, there may be no symptoms or just back pain.
A disc is the shock absorber between adjacent vertebrae. When it deteriorates, it may “bulge”, “slip”, “rupture” or “herniate” and press on the spinal cord or nerve roots. Herniation means that a piece of disc is somewhere it does not belong.
Bulging discs are extremely common. The incidence of significant disc changes on an MRI scan is almost identical to the age of the patient. For example, if one hundred 40-year old patients underwent MRIs of the cervical spine, approximately 40% of them would show some degenerative disc changes. While these changes are technically abnormal, they are extremely common and occur as a consequence of the normal aging process.
Some disc herniations occur during injuries, such as motor vehicle accident, excessive lifting episodes or falls. In those instances, the mechanism of injury is obvious and pain will develop soon after the event. More often, patients develop a herniation without an obvious trauma. In those instances, it is postulated that the herniation developed due to cumulative effects on the disc. A series of relatively minor injuries may have accumulated to the disc where the disc was weakened to the point of herniation.
A herniated disc is defined as a disc where the outer lining has been torn, and the inner soft disc material has expressed out of the tear. Often this compresses the adjacent nerve roots. This pressure on the nerve roots tends to cause low back pain and leg pain which can be accompanied by numbness and weakness. When disc herniations are very severe, they can even affect the function of the control of the bowel and bladder. This is called cauda equina syndrome and tends to be a very unusual complication of disc herniation. This is an emergency and needs immediate medical attention.
Many people have discs that are degenerative or abnormal and yet experience no symptoms. It is also possible that they may have had symptoms at one time, but symptoms improved without any specific intervention. Many times, these degenerative discs are not painful at all until some significant injury or trauma damages them further, leading to significant instability and pain. The bottom line is just because a disc is abnormal does not mean it has to be painful.
A whiplash injury to the cervical spine can cause damage to the muscular or ligamentous structures of the spine. If the whiplash does injure the outer annulus of the disc, this can contribute to a herniated disc of the neck. It is extremely unlikely that a whiplash injury would cause a herniated disc in a previously normal disc. The more common situation is that someone already has significant degenerative disease of their spine and is involved in some sort of traumatic incident which exacerbates their preexisting symptoms.
Degenerative disc disease is basically arthritis of the disc. The disc serves as a “cushion” between the bones of the spine. With age, stress and strain disc can become arthritic and “wear out.” In this situation, these discs are termed degenerative. The first line of treatment is conservative often including anti-inflammatory medications, physical therapy and education on how to strengthen and stabilize the spine. Patients learn how to prevent placing great amounts of stress on the back and how to lift properly to protect the back.
True lumbar instability occurs when the supporting ligaments, discs and joints of the spine are damaged to the point they can no longer hold the bones together. As the vertebrae move out of alignment, they can pinch nerves and cause leg pain and weakness. The abnormal motion is microscopic and can be measured on standing bending x-rays.
Spinal stenosis is a condition that affects the elderly. It is the most common spinal condition leading to surgery in people over the age of 60. In this condition the spinal canal is narrowed to a degree where the spinal cord or nerve roots may be compromised. The pinching results from a combination of disc bulging, hypertrophy or enlargement of the facet joints and thickening of a ligament called the ligamentum flavum. The resulting symptoms of pain, numbness, and weakness are called neurogenic claudication. These symptoms are more diffuse than those associated with disc herniations due to the involvement of many nerve roots as opposed to a single root. The symptoms are aggravated by standing and walking, which increase the curve of the lumbar spine. This causes thickening of the ligamentum flavum and narrowing of the spinal canal. Sitting relieves symptoms by straightening the spine and stretching the ligament to open the spinal canal.
There are many therapies available to help alleviate pain. Medications include anti-inflammatory agents, oral steroids, and muscle relaxers. Injections targets at the source of dysfunction can be helpful when medications fail. Physical therapy, massage, acupuncture and chiropractic care are all valuable alternatives. Topical creams, ice and heat, ultrasound and electrical stimulation may also be helpful. Determining the proper treatment plan depends upon the specific patient.
It is important to realize that neck and arm pain related to cervical disc disease is often a benign condition that will resolve with rest, medication, and sometimes physical therapy. If you are suffering from neck or arm pain related to cervical disc disease, it would be best to be evaluated by a spine specialist. Then, after other potentially more serious conditions have been ruled out, one can begin a program of neck rehabilitation. This consists of a workplace evaluation to maximize office ergonomics. Also, important sleep and rest habits must be included. Lastly, alterations in work around the home or recreational activities can alleviate much of the problem.
While degenerative disc disease and spine disease has a large genetic component, there are actions you can take to prevent or decrease odds of developing back pain requiring surgery. In addition to putting extra strain on your neck and back, extra weight increases stress on other organs and can lead to medical conditions such as heart disease and diabetes. Excess weight accelerates degenerative forces in the spine, as well as in the hips and knees. Losing weight can help protect your spine, and at the same time benefit your overall health and well-being. Shedding extra pounds can decrease the amount of stress that is put on a herniated or degenerative disc and may protect it for years to come.
If pain is progressive, severe, and disabling, surgery is strongly considered. Numbness, tingling, and weakness are all possible signs of nerve compression and may indicate a need for surgery before nerve damage becomes permanent. Pressure on the spinal cord can be very dangerous and may require surgery. Surgery may be preventative if the spinal cord is at risk of being damaged. Surgery may also be needed if there is significant deformity of the spine.
If pressure on a nerve or the spinal cord lasts for a long period of time, it is possible that the changes in the nerve or spinal cord can become permanent. This would generally be the case in someone who had significant weakness or clumsiness as symptoms of spinal degeneration. For patients who primarily have neck pain, there is probably little chance of permanent damage if surgery is delayed, as long as their problem is related to simple degeneration. Of course, patients with cancer, infections, fractures, or instability involving the spine may need much more urgent attention. In general, the longer nerve compression or spinal cord compression exists, the chance of a complete recovery becomes less and less.
The decision to perform a fusion surgery for patients with disc disease is complex. Decisions are made depending on the shape of your spine, the nature of disc disease, and your symptoms. There are both anterior and posterior approaches to taking pressure off the nerves that do not require a fusion. However, fusions are commonly performed and are extremely useful in patients with significant loss of disc space height, deformity of their spine, significant pain in addition to extremity symptoms.
This depends on where the spine is fused and how many levels are involved.
In the low back, approximately a third of your flexibility to bend forwards comes from your back, the remainder divided between your hips and hamstring flexibility. Each lumbar spinal segment then contributes 1/5th of motion. Many patients who can touch their toes prior to a one level lumbar fusion surgery are still able to touch the tops of their feet afterwards.
When bones fuse together at one or more levels, some stress of motion will be transferred to adjacent spinal levels. There is a suggestion that this may cause accelerated breakdown at the adjacent spinal levels, although this has not been proven.
All patients have some pain after surgery. The use of a muscle splitting approach, such as an operation in the front of the neck, seems to significantly decrease pain after surgery. The use of allograft bone rather than the patient’s own hip bone can also decrease pain after surgery. Some people will have hoarseness and a sore throat for a short period of time either due to neck surgery or from being intubated during surgery. Generally, with medications people can go home within a day or so after of surgery. The majority of patients with radicular symptoms improve dramatically.
The risks of any surgery include: bleeding, infection, and the risk of general anesthesia. Anterior approaches to the spine entail dissection through the anterior neck involving structures such as the trachea, the esophagus, and the carotid arteries. Any of these structures could potentially be injured by the surgical approach. In spine surgery, work is done next to the spinal cord and nerve roots. These structures could be injured and may cause weakness or numbness in the arms, as well as potential as bowel, bladder, or sexual dysfunction. The vertebral artery is close by and can also be injured during resulting in a life-threatening stroke. The risk of a serious complication from a cervical discectomy is extremely low.