BACK PAIN: CAUSES OF BACK AND NECK PAIN

There are many different causes of low back and neck pain. You may feel pain in your back that is caused by organs not even near the back. This type of pain is called referred pain. For example, kidney pain is often felt in the back and even some forms of vascular problems can cause back pain. When you have back pain that is not getting better or the intensity is increasing, be sure to contact your doctor. The most common causes of back and neck pain are:

· Sprain and strain of the back or neck.

· Pain arising from the discs themselves called discogenic pain.

· Pain from bulging discs compressing exiting nerve roots or radicular pain, which can lead to sciatica from the back or pain radiating down from the neck to one or both arms.

· Pain from arthritis of the facet joints — the joints that hold the spine in alignment, also called facet joint syndrome.

· Pain from bony compression of the nerves of the spine called spinal stenosis

Sprain or Strain of the Spine

Fast Facts

· Sprain is an injury to the ligaments of the spine.

· Strain is an injury to muscles of the spine.

· Sprain and strain are the most common causes of back and neck pain in children and young adults.

· The symptoms and signs of sprain and strain are usually self-limiting — that is, relief of symptoms is expected to occur within a reasonable amount of time.

· More than 90 percent of people with low back muscle strain or sprain recover completely within one month.

Sprain is an injury to the ligaments of the spine. Strain is an injury to muscles of the spine. These injuries are the most common cause of back and neck pain in children and adults and are usually self-limiting — that is, relief of symptoms is expected to occur within a reasonable amount of time.

The symptoms of strain and sprain include back or neck spasm, stiffness and pain. This pain results from the stretching or tearing of the soft tissue of the back or neck (e.g., muscles and ligaments). Low back sprains or strains can be caused by a single event, such as lifting a heavy object, or can be due to repeated small injuries to the back. Adults with poor posture, individuals who are overweight or obese, workers who repeatedly lift heavy objects, workers who have constant vibrations around their work place, pregnant women, people who smoke, and older adults are at high risk for sprains and strains of the spine.

Typically, the symptoms of strain and sprain begin either immediately or develop within the first 24 hours after the injury. The ongoing pain of strain and sprain is caused by inflammation of the soft tissues, which causes release of pain-causing chemicals and tissue swelling. The spasm of strain and sprain is caused by muscles tightening in response to the injury to project the injured area. Symptoms can last for weeks.

Initially, treatment of a sprain or strain involves icing and rest, combined with anti-inflammatory medication (such as Advil or Naproxen), to relieve the pain and spasm. After this, you may slowly begin normal activities and exercise. It is important to start moving again. Resting your back for more than three days has been shown to cause more harm and should be avoided. After healing takes place, you may benefit from a back rehabilitation program that includes education about proper lifting techniques and stretching and strengthening of the back, leg and abdominal muscles. Surgery is never used to treat low back sprain and strain.

Patients with pain around the low back and upper buttocks, low back muscle spasm, and pain associated with activities that is relieved with rest do not need X-rays or other imaging studies such as CT scans or MRIs. If the pain lasts in spite of good treatment, you should talk to your doctor.

Discogenic Pain

Fast Facts:

· The intervertebral discs act as shock absorbers between the vertebral bodies in our spine.

· As we grow older, we lose fluid from the outer fibrous annulus of the disc.

· When we lose water from these discs, they become brittle and prone to crack, releasing pain-causing chemicals from the centers of the discs.

· The pressure or leakage from the nucleus of these pain-causing chemicals can cause constant irritation and pain, so-called, discogenic pain.

· Many people will say, "My back went out," to describe this type of pain.

Most episodes of f discogenic pain heal on their own so surgical interventions and non-surgical mini-invasive therapies should be limited to individuals who have persistent, disabling pain for more than three months, those who have failed all conservative therapies, and/or those who have persistent and increasing neurologic deficits, such as increasing weakness of the foot or legs.

The intervertebral discs act as shock absorbers between the vertebral bodies in our spine. As we grow older, we lose fluid from the outer fibrous annulus of the disc. Some of us lose this water quicker and earlier in life than others. Discs begin losing blood supply by age 20. When we lose water from these discs, they become brittle and prone to crack, releasing pain-causing chemicals from the centers of the discs. This is called disc degeneration.

Disc degeneration is loss of water and cracking of the disc. Sometimes, the outer layers of the annulus prevent nuclear fragments from moving outside of the disc (Figure 8, left); however, nuclear fragments may tear through the annular fibers, releasing chemicals into the spinal canal around exiting nerve roots (Figure 1, right). The irritation of nerve endings within the annulus can create referred pain to the back or neck, down into the buttock, thigh or leg; in the groin; or into the shoulders, arms and hands.

"My Back Went Out!"

The pressure or leakage of these pain-causing chemicals can cause constant irritation and pain. Sometimes, any activity that increases pressure on the discs themselves, such as sitting, flexing forward or standing will increase pain. Prolonged sitting or lifting movements can create inflammation, initiating a painful episode that may last days to weeks, or even more. This sudden episode is probably caused by a leakage from the nucleus resulting in a sudden sharp, searing pain brought on because the nucleus has herniated further into the annulus. Many people will say, "My back went out," to describe this type of pain.

Discogenic pain may be treated using ice, heat, pain relievers, anti-inflammatory medications and bed rest for one to two days. It also may be treated using interventional therapies, such as surgery and minimally invasive procedures.

Because most cases of discogenic pain heal on their own within a reasonable amount of time, surgical interventions and non-surgical mini-invasive therapies should be used only for individuals who have persistent, disabling pain for more than three months, those who have failed all other therapies, and/or those who have persistent and increasing neurologic deficits such as increasing weakness of a foot or leg.

The surgical option for discogenic pain is removal of the disc and fusion of the vertebra above to the one below. Because fusion surgeries can cause pain, minimally invasive procedures often are used to relieve pain and discomfort from discogenic pain.

If there is no neurologic damage such as weakness of the foot or hand, leg, arm or hip, or if the pain does not limit an individual's activities of daily living, more conservative therapies should be used before invasive therapies.

Pain Treatment Continuum for Back and Neck Pain

An example of a pain treatment continuum that starts with least invasive to more invasive therapies. Physicians should use a treatment continuum unless a patient needs emergency surgery.

· Minimal rest then exercise

· Over-the-counter pain relievers

· Non-steroidal anti-inflammatory drugs

· Relaxation and biofeedback

· Physical therapy

· One week of opioid therapy

· Membrane stabilization

· Epidurals, facet joint blocks, etc.

· Mini-invasive therapies: IDET, nucleoplasty, annuloplasty, etc.

· Surgery, if warranted

· Opioids

· Spinal cord stimulation

· Intrathecal therapies

Sciatica

Fast Facts

· Sciatica is the word used to describe pain that starts in the back and moves down the thigh and outside of the leg.

· Sciatic pain results from damage to or pressure to the nerves that make up the sciatic nerve.

Sciatica is the irritation of the sciatic nerve, which results in pain or tingling running down the outside of the leg. The sciatic nerve is made up of nerves from the lower lumbar and sacral vertebrae. These nerve roots leave the spine through holes called the neural foramina (Figure 10). These nerve roots can be irritated by compression from bulging discs or from excess bone or soft tissues surrounding the hole. Irritation of a nerve root leading to pain or poor function of the nerve root is called a radiculopathy.

The specific surgical treatment of an irritated nerve root ( i.e., radiculopathy) that leads to sciatica is either microsurgical or surgical removal of the bulging disc or widening of the hole from which the nerve root exits in a procedure called foraminotomy.

Surgery should be performed only if there is neural damage and neural dysfunction, such as "foot drop" or weakness of the leg or if pain is disabling and has not gotten better with conservative therapies. To enter the bony spinal canal, the surgeon will surgically remove the lamina (the bony roof of the spinal canal) in a procedure called a laminectomy or put a hole in the lamina in a procedure called a laminotomy. After the surgeon enters the canal, he or she then either removes the disc (discectomy) or widens the foramen surgically (foraminotomy).

Facet Joint Syndrome or Facet Arthropathy

Fast Facts:

· Pain from facet joints is not constant and only occurs several times a year.

· Most people experience tenderness over the inflamed facet joints and some loss of motion in their spinal muscle flexibility.

· There will typically be more discomfort when a person leans backward slight.

· Lumbar facet joint problems, which occur in the lower back, cause pain that often radiates down into the buttocks and the back of the upper leg. This referred pain rarely occurs in the front of the leg or below the knee.

· Individuals with lumbar (lower) facet disease may have to limit the amount of time they stand. Sitting and riding in a car may be impossible because of facet pain.

· In cervical facet joint problems, which occur higher in the back and into the neck, the pain feels like a deep ache.

· When facet joint syndrome is severe, a person may experience constant muscle spasms and the fatigued muscles begin to hurt themselves, which results in a vicious cycle of pain and muscle weakness.

· Most people with facet joint pain do not experience leg or arm weakness.

Discs, facet joints and ligaments link the 33 vertebrae that make up the spinal column. The facet joints allow movement forward and backward and rotation of the back and neck.

Each nerve that exits the spine in the back, mid back and neck gives off small branches that go into the facet joints or into the fibrous capsules around the joints.

The nerves to the joints transmit pain signals that may result from a combination of factors, including inflammation and mechanical joint stress. Mechanical joint stress is the moving of the bones of the joint on one another. Also, disc space narrowing that occurs when discs dry up can cause the facet joints to undergo abnormal movement, which can cause abnormal stresses and cause mechanical nerve root impingement. The end result is pain.

Facet joints are in almost constant motion with movement of the spine and they commonly wear out or become degenerated in many patients. When facet joints become worn out or torn, the cartilage between the bones of the joint may become thin or even disappear entirely. This may lead to arthritis of the joint. This joint arthritis is the cause of considerable back or neck pain when an individual moves, especially when he or she first gets up in the morning. This early morning pain typically improves after getting up and moving around, but commonly worsens again at the end of the day. This condition is called "facet joint disease" or "facet joint syndrome."

When facet joint inflammation is at its peak, the symptoms of the disease might closely imitate those of a herniated disc, a deep infection, a fracture or a torn muscle of the spine (sprain)

Treating Facet Joint Syndrome

A number of treatments have been used successfully to break the cycle of recurring, severe facet joint pain. Many of these treatments give temporary relief, but often do not provide long-term relief of pain.

Treatment of facet joint pain can be conservative, invasive and/or a combination of both conservative and invasive treatments. Treatment should be guided by the use of a pain treatment continuum.

There are a number of conservative treatment options that can be used to specifically alleviate the pain of facet disease, allowing rehabilitation of the spine.

Conservative Therapies for Facet Pain

· Specific, targeted exercises, with instructions by a trained physical therapist or other health care provider (physiatrist).

· Good posture and body mechanics. A very useful posture when standing or sitting is the pelvic tilt — where one pinches together the buttocks and rotates forward the lower pelvis — and holding that position several seconds, done several times per day.

· Support for the low back when seated or riding in a car (e.g., pillows).

· Heat (e.g., heat wraps, a hot water bottle, hot showers) or cold (e.g., cold pad, ice packs) applied to the back may help alleviate painful episodes.

· Changes in daily activities (e.g., shortening or eliminating a long, daily commute) and adding frequent rest breaks can be helpful.

· The use of non-steroidal anti-inflammatory medication, such as ibuprofen or Naproxen, and muscle relaxants may help reduce the level of pain.

· Osteopathic manipulations may provide some relief.

More lasting relief of facet joint pain can be obtained by destroying the nerves that go into the joints with heat in a procedure called radiofrequency thermolysis. This can be accomplished by a pain physician using a special needle and apparatus that heats the end of the needle, destroying the nerve that is causing the pain.

Spinal Stenosis

Fast Facts:

· Spinal l stenosis is the narrowing of the spinal canal.

· There are two types of spinal stenosis. The more common type, called aquired spinal stenosis, occurs in the elderly. A person is born with congenital spinal stenosis, which is rare.

· With the acquired type, patients usually experience an achy pain when walking that is relieved by rest and sitting.

· Unlike disc disease and other kinds of backache, spinal stenosis generally becomes more painful over time.

· The treatment of spinal stenosis consists of both conservative therapies and surgical interventions. Conservative therapies include rest and eventually exercise, pain relievers, anti-inflammatory medications and support from a flexion corset or back brace. If these treatments fail, a surgical procedure called a spinal decompression may be the only answer.

Spinal stenosis is the narrowing of the bony canal within the spine. This canal, called the spinal canal, contains the spinal cord and spinal nerves.

When the spinal canal narrows, it places pressure on the spinal nerves, causing pain. People with spinal stenosis often describe their pain as an ache or electrical feeling down the arm or down the leg. If you have spinal stenosis, you may experience increased leg pain when you walk. This pain may be relieved when you rest.

There are two types of spinal stenosis — congenital and acquired. Acquired stenosis usually is related to older age and results from the thickening of the facet joints due to disc degeneration, disc space narrowing and excess bone deposits due to inflammation. Congenital stenosis occurs from birth and is extremely rare.

Spinal l stenosis usually affects the elderly. Symptoms include back pain with leg pain and weakness that occurs when you walk. The pain may become increasingly severe with standing and walking, and can usually be relieved by a short period of rest. The symptoms of weakness, pain, pins and needles, coldness or loss of sensation in the limbs are caused by bone compressing nerve tissue. Unlike disc disease and other kinds of backache, spinal stenosis generally becomes more painful over time.

Your physician will use an X-ray, CT scan, EMG or MRIs to diagnose spinal stenosis. The symptoms of spinal stenosis may mimic the symptoms of peripheral vascular disease. Your doctor may order a Doppler test to determine if you have that disorder.

The treatment of spinal stenosis, like the treatment of other painful back disorders, consists of both conservative therapies and surgical interventions. Conservative therapies include rest and eventually exercise, pain relievers, anti-inflammatory medications and support from a flexion corset or back brace. If these treatments fail, a surgical procedure called a spinal decompression may be the only answer. During this operation, the surgeon frees up the compressed nerve elements by removing the roof of the spine (the lamina) and/or by widening the exiting canal (the foramina). In some cases, spine fusion is necessary. Surgery can offer an 80 percent to 85 percent chance of improvement, but sometimes surgery can make things worse for some people.