Back pain – Cause, diagnosis and treatment

Back pain is a common and often disabling complaint. The pain can radiate to the buttocks or upper legs. The pain usually comes on gradually, but sometimes it is acute and very intense. Certain postures and movements can become impossible. ‘Regular’ back pain is common and resolves on its own within a few days, and no clear cause is found. Sometimes a clear cause can be identified, such as a hernia or a vertebral fracture. This article discusses the diagnosis, treatment and alarm symptoms of back pain.

Table of contents

• Anatomy
• Idiopathic or non-specific back pain
• Other causes of back pain
• Hernia
• Vertebral collapse
• Spine fracture after trauma
• Ankylosing spondylitis

Spine anatomy / Source: Vsion, Wikimedia Commons (Public domain)

Anatomy

The human back consists of vertebrae, ribs and muscles. It describes the back part of the human body from the buttocks to the shoulders. The height is determined by the spinal column (Latin: Columna vertebralis), which consists of 7 cervical (neck), 12 thoracic (chest), 5 lumbar (lower back) vertebrae and subsequently the sacrum and tailbone. This is often abbreviated to, for example, C5 (the 5th cervical vertebra). The spinal cord runs through these vertebral bodies, a narrowing of which is called a spinal canal stenosis.

Seen from the neck, the spine has the shape of a double S. Its function is to absorb acute movements. Kyphosis is the name for a curvature such as is present in the thoracic and sacral parts, lordosis describes the shape of the curvature in the cervical and lumbar parts. Scoliosis is a twist in the axis of the spine. Hyperlordosis means a back that is too concave, while hyperkyphosis means a back that is too convex (hunchback-like).

Two different types of nerves run through the spinal canal, namely:

Overview of dermatomes / Source: Ralf Stephan, Wikimedia Commons (Public domain)

• Afferent nerves: These run towards the brain and contain sensory fibers. These transmit information about pain, for example
• Efferent (‘discharging’) nerves: These run from the brain towards the limbs, partly consisting of motor fibers that can, for example, make an arm move.

Between each vertebral body, except C1 and C2, there is an intervertebral disc (disc). In addition, nerves originate at each vertebral level. Each specific area of sensation (dermatome) correlates with a certain level of origin from the spinal cord. The same applies to the motor fibers. For example, a reduced reflex of the knees can indicate failure of a certain motor nerve pathway.

Idiopathic or non-specific back pain

Idiopathic means: without known cause. In the majority of patients with back pain, no clear objective cause can be found despite extensive research. However, this does not mean that the pain is not present. Approximately 95% of the back complaints presented to the GP are classified in this group. In general, in this group, without other complaints, it is not of added value to perform additional diagnostics such as a scan. The complaints generally recover spontaneously.
 

Tips to prevent back pain

The majority of non-specific back complaints are caused by incorrect loading. This is caused by lifting more than is bearable. Try to limit the number of kilograms you carry. Other tips to reduce strain on the back are:

• Lift from the legs with a relatively straight back, which minimizes the strain
• Keep the abdominal muscles tense while lifting with your back
• Carry the load as close to your body as possible
• Do not twist your back while lifting heavy objects
• Do abdominal and back muscle strengthening exercises
• Change your position frequently
• Use an ergonomic office chair that is adjustable
• Sometimes back pain can be prevented by avoiding rapid cooling of the back

Treatment advice for existing back pain

• Choose a good position, this is the position that causes the least pain.
• Keep moving as much as the pain allows. Recovery takes longer with complete immobilization, such as lying in bed all day. Frequently changing your position can often help.

If there is no recovery, exercises and advice from a physiotherapist can be of added value (for example Cesar or Mensendieck therapy). Painkillers: Take painkillers consistently, even if there is no pain for several hours. Build up and down gradually. Try to aim for the lowest possible dosage. People with cardiovascular or stomach problems and over the age of 70 should be extra careful with NSAIDs. When using medication, it is wise to consult with a doctor.

Tension

Sometimes back pain can be an expression of a high level of stress. If this is a cause, try to do something about it. It can help to manage time better, free up space for more relaxation and to discuss or solve problems.
Work environment An incorrect posture at work can be a cause of back problems. This can be discussed with the manager or company doctor, after which a solution can be found.

Prolonged pain

In case of long-term pain without an objective cause, a referral to a so-called pain clinic can be discussed with the GP. This can then explain the various pain-oriented treatment options

When to go to the doctor?

There are a number of symptoms that require a doctor’s visit. This is, for example, when things are not getting better but actually worse and when exercise is still not sufficient after three weeks. In addition, there are a number of alarm symptoms that may indicate another cause, such as: urinary problems (for example incontinence), pain radiating to the knee, reduced feeling or strength of the legs or feet.

Other causes of back pain

In a number of cases there is a clear and objective cause of the back pain. These include a hernia, a vertebral collapse due to osteoporosis, a vertebral fracture after trauma and ankylosing spondylitis.

Hernia: Light blue intervertebral disc compresses the nerve root / Source: Blausen.com staff, Wikimedia Commons (CC BY-3.0)

Hernia

A hernia of the back describes the condition in which an intervertebral disc bulges. The condition is also known as hernia nuclei pulposi (HNP). After this, the nerves running from or towards the spinal cord can become pinched, resulting in sensory and motor disorders. Examples include numbness in the leg or the inability to lift the foot.

This condition is accompanied by back pain, but usually the pain in the leg is prominent, often extending to the lower leg. The pain is sharp in character and has a dermatome distribution. Usually, pressure-increasing moments such as coughing, sneezing and straining worsen the complaints. Depending on the location of the tightness, reflexes may respond less well.

In general, treatment recommendations do not differ from those for low back pain. The same alarm symptoms also apply to contact us immediately.

Diagnostics

In case of long-term complaints or doubt about the cause, additional research can be performed, usually in the form of an MRI of the spine. This shows the location of the pinched nerve root.

Therapy

In general, a hernia has a self-limiting course. A possible treatment is a so-called laminectomy, which reduces the pressure on the nerve root through surgical treatment. This intervention is not without risks and the added value is generally difficult to predict in advance.

X-ray back with collapsed vertebral body (third vertebral body from the bottom (L3) has loss of height) / Source: Lucien Monfils, Wikimedia Commons (CC BY-SA-3.0)

Vertebral collapse

This fracture mainly occurs in women of advanced age. The most common underlying cause is the presence of osteoporosis (bone loss). This increases the risk that a bone fracture will occur in the event of (minimal) trauma. There is often a shortening of the length, and there is also throbbing pain in the back at the location of the fracture. A spinal collapse can be a source of pain for years, but can also be asymptomatic.

Diagnostics

Most fractures can be seen with a conventional x-ray.

Therapy

Regarding the medication for the pain, it is no different than for non-specific back pain. In addition, agents can be given to prevent further osteoporosis, such as vitamin D and calcium tablets. Physiotherapy plays an important role in this. Forms of treatment through surgery include balloon kyphoplasty (reducing the height difference at the site of the fracture using a balloon) and vertebroplasty (achieving the same goal using cement injection). These are performed by an orthopedic surgeon.

Spine fracture after trauma

After a high-energy trauma there is a risk of a fracture of the spine. This usually causes a lot of immediate pain. This fracture can be caused by, for example, a car accident or a fall from a great height. There are many types of fractures that can be described, each with their own risk of instability. The treatment and possible stabilization also depend on this. A serious complication of a traumatic spinal fracture is spinal cord injury. The spinal cord protected by the spinal column is damaged to such an extent that sensation and motor skills distal to the injury are lost.

Ankylosing spondylitis

This disease is also known as ankylosing spondylitis. This involves chronic inflammation of the spine and pelvis. It is an often underestimated diagnosis, the age of onset is usually between 15 and 35 years and more often in men than women.
The complaints that may indicate this include:

• Low back pain and stiff joints
• Long-term joint inflammation, for example the knee
• Inflammations of the Achilles tendon
• The presence of psoriasis (skin disease) or intestinal inflammation (e.g. Crohn’s disease or ulcerative colitis)
• The stiffness decreases during the day after exercise

X-ray back with ‘bamboo spine’ phenomenon / Source: Stevenfruitsmaak, Wikimedia Commons (CC BY-SA-3.0)

The diagnosis can be made through blood tests (inflammatory values) and imaging tests (such as MRI and X-ray of the spine). Typical of this is the so-called ‘bamboo spine’ phenomenon on an X-ray. The entire spinal column ossifies.

Treatment consists of anti-inflammatory drugs such as NSAIDs and so-called TNF-alpha inhibitors. Physiotherapy also plays an important role. In particular, preventing an unnatural curvature of the spine is vital.