What are the common causes of low back pain?
There are many of causes of low back pain. Low back pain can be caused by an injury, it can be caused by simple muscle strain, and it can also be caused by referred pain from internal organ systems including a kidney stone or a urinary tract infection. It can be caused by infection. It can also be caused by problems intrinsic to the spinal column. Low back pain can also be caused by a fracture in the back. Other intrinsic spinal causes include degenerative disc disease, annular disc tears, disc herniation, lumbar facet arthritis, as well as sacroiliac joint pain. These are all common causes of low back pain.
Low back pain is common and one of the most common reasons people visit their primary care doctor. Do not be surprised if your doctor doesn’t order an MRI or even X-rays when you see him or her for back pain. For simple back pain lasting less than a few weeks without any history of trauma or other concerning symptoms, the typical treatment is supportive, that is anti-inflammatory pain medications, such as Advil, Motrin or Alleve. Sometimes, stronger dose anti-inflammatories are needed such as a Medrol Dose Pack. Other commonly used treatments for back pain are a short course of physical therapy, massage, or chiropractic manipulation. I do not recommend narcotic pain medications for back pain as they mask pain, but do not treat the inflammation causing it.
Rarely is surgery ever recommended for low back pain. There are certain structural abnormalities causing low back pain such as degenerative scoliosis or spondylolisthesis that may benefit from surgical intervention. However, degenerative disc disease—the so-called “black disc” seen on MRI studies, has not been shown to be effectively treated with surgical intervention.
What is a pinched nerve?
A pinched nerve means that the nerve is being pushed upon or compressed by an external force anywhere along its course between the spinal canal and its’ final destination on the muscles or skin it innervates. Pinched nerves can be caused by any number of things. This includes bone spurs, disc herniation, enlarged or thickened ligaments in and around the spinal canal. The pinched nerve can also be caused by other causes farther away from the spine such as a cervical rib, a ligament or muscle in the shoulder, elbow, or wrist. Common syndromes caused by pinched nerve include carpal tunnel syndrome and cubital tunnel syndrome. Less common syndromes caused by a pinched nerve include thoracic outlet syndrome (a cervical rib), piriformis syndrome, Wartenberg’s syndrome, and tarsal tunnel syndrome.
Sometimes the cause or location of the pinched nerve is obvious to your doctor. In other cases, it is more difficult to determine which nerve and where it is being pinched, especially in certain patients who have peripheral vascular disease or who are diabetic. In these instances, your doctor may order a special study to better determine the nerve being pinched and its’ location. This study is called a nerve conduction study and EMG.
What are the symptoms of a pinched nerve?
Symptoms of a pinched nerve vary depending on which nerve is being pinched and where the nerve is being pinched. Symptoms of a pinched nerve classically in the lumbar spine are symptoms of sciatica, meaning pain and sometimes numbness radiating down into the buttocks to back of the thigh, the lower leg, and even into the foot. Symptoms of a pinched nerve can also include weakness in the leg and foot.
Symptoms of a pinched nerve in the neck are similar in that there may be pain, numbness, or weakness down the arm or shoulder blade. Symptoms of a pinched nerve at the level of the elbow usually only cause symptoms at the level of the elbow and below, so the patient may have pain, numbness, or weakness in the forearm and hand. A pinched nerve at the wrist such as carpal tunnel syndrome cause numbness in the thumb and index finger and eventually muscle atrophy in the hand.
In some cases, symptoms of pinched nerve are related to positioning. For instance, people who like to sleep with their elbows flexed may have a propensity for cubital tunnel syndrome as the ulnar nerve is more likely to be taught and pinched in this position over several hours in the night time. This is why one common treatment for cubital tunnel syndrome is night time splints.
What are the treatments for a pinched nerve?
There are many treatments for a pinched nerve depending on the severity of the symptoms and the objective findings that the doctor notes. Standard first-line treatments for a pinched nerve include antiinflammatory medications including sometimes steroids which decrease the inflammation around the nerve. Treatments can also include physical therapy, massage, acupuncture, chiropractic manipulation. Sometimes treatments may need to be more aggressive for a pinched nerve. In certain situations when there is associated weakness or muscle atrophy or unrelenting pain with nonoperative treatment, surgical decompression of the pinched nerve may be indicated. Surgery typically involves removing the offending antomic structure pressing on the nerve. Exactly which type of surgery will be needed once again depends on the nerve being pinched and where it is being pinched. The success of treatment for a pinched nerve varies with the nerve, the location of compression, and the duration and severity of symptoms. In most nerve compression syndromes that have not been present for a long period of time, an adequate surgical decompression has very predictable and overall good results.
Furthermore, depending on where the nerve is being pinched, a different type of surgeon will likely surgically decompress the nerve. If the nerve is being pinched around the spine, a spine surgeon can perform the procedure. If the nerve is being pinched further down the arm or leg, a hand surgeon, or another type of extremity surgeon may be more appropriate to perform the surgery. Your orthopaedic surgeon will know who is most appropriate to perform the surgery.
What is a herniated disc/Slip disc?
Between each vertebral body there is a disc, a softer fibrous material than bone that gives the spine the ability to move in multiple planes—flexion and extension, lateral bending, and rotation. The disc which gives the spine so much of its ability to move, also puts it at risk for failure. A disc herniation is a failure of the disc. A herniated disc is disc material that abnormally comes out of the disc into either the spinal canal or the opening next to the spinal canal where a nerve is travelling, called the foramen. This can happen due to a sudden traumatic event or it can occur over time with repetitive activity. The disc is bordered by ligaments in front and in back of it. Disc material typically herniates through the weaker area next to the stronger to the ligaments. The disc may remain attached to the unherniated disc material or it may be an entirely free fragment in the spinal canal. Small disc herniations may be asymptomatic and clinically unsignificant, large ones may compress on the spinal cord or nerve roots and cause severe symptoms, and over time, the disc space may collapse if enough material has degenerated.
How do I get a herniated disc/Slip disc?
Herniated discs can occur for multiple reasons. A sudden traumatic event such as lifting a heavy object, may put enough pressure on the disc to cause a herniation. Repetitive pressure on the disc can also cause herniation. Some people are more prone than others to have disc herniations. We do not know the exact reasons for this. When the disc herniation occurs, there is a tear in the annulus, the material that surrounds the disc. When a disc herniates, there is often an inflammatory response locally, which causes pain both in the back and depending on where the disc herniation is and what it is pressing on, pain down the arm or leg.
What are the symptoms of a herniated disc?
A disc herniation can present in a variety of ways and not all herniations are the same. Symptoms can vary depending on the the location, size, and duration of the disc herniation. Sometimes people do not have any symptoms from a herniated disc and it is an incidental finding seen on MRI. Sometimes they have back pain. Disc herniations in the neck can cause pain, numbness, and or weakness down into the shoulder, shoulder blade, or arm; disc herniatons in the thoracic spine can cause pain radiating from the back into the chest, mimicing a heart or lung problem. Disc herniations in the lumbar spine can cause classic sciatic symptoms, including pain, numbess, or weakness down into the buttocks, back of the legs, and into the feet. Symptoms like these may improve or worsen with time, and certain anti-inflammatory medications may quicken the duration of severe symptoms. Symptoms may also improve with time with time. They may also recur with time.
If a disc herniation in the neck is large enough it may cause balance issues and problems walking by pressing on the spinal cord. Disc herniations that are large enough in the thoracic or lumbar spine may also cause balance and walking difficulty as well as bowel or bladder problems. Disc herniations like these have more predictably good outcomes with surgical decompression. In cases like these the surgery is meant to halt progression of neurologic decline although some people actually improve neurologically after surgical impression.
What is the treatment for a herniated disc?
Treatment largely depends on the symptoms and physical examination findings. In most cases when a herniated disc is causing pain and numbness, treatment is non-operative. Non-operative treatments can include a short period of rest, physical therapy, chiropractic manipulation, massage, lumbar corsette or soft cervical collar, or acupuncture. The evidence for the effectiveness of these treatments varies. I do not recommend chiropractic manipulation of the neck especially in someone who has not had any evaluation by a spine surgeon prior; however, chriropractic manipulation may be of benefit in the low back. Medical treatments include anti-inflammatory pain medications, such as Advil, Motrin, Alleve, naprosyn, and in some cases a Medrol Dose Pack if symptoms are severe enough. Although a very short course of muscle relaxant may be helpful, I recommend against any narcotic treatment for disc herniation as it has no anti-inflammatory effect and is easily addictive.
If symptoms are refractory to the treatments described above, the next step would be an evaluation for an epidural steroid injection. I typically do not advocate for epidural steroid injections in the cervical spine but they can be very helpful in the lumbar spine to alleviate symptoms. With any invasive procedure there are risks associated with it including infection, vessel, or nerve injury.
As a last resort, if radicular symptoms are severe and unrelenting and refractory to the above treatments, consideration can be given for surgical decompression. Depending on the location and severity of the disc herniation as well as lack of any associated spinal pathology, surgical decompression may be a microdiscectomy in the lumbar spine or a foraminotomy in the cervical spine. These are minimally invasive procedures that require no hospital stay or one night in the hospital in almost all cases.
What is spinal stenosis?
Spinal stenosis is an abnormal condition of the spine in which the spinal canal becomes pathologically narrowed which compresses on the nerves in the spinal canal and sometimes the spinal cord depending on the location of the spinal stenosis.
Spinal stenosis can be congenital, that is, it has been present since birth. Congenital spinal stenosis is due to anatomic abnormalities in the spinal column, that make the spinal canal and the space available for the spinal cord and nerve roots to travel smaller than it should be. In the cervical spine, congenital spinal stenosis may be a contraindication to playing certain contact sports such as football, as the athlete may be at higher risk for spinal cord injury if he or she injures the neck.
Spinal stenosis can also be associated with degenerative conditions of the spine. As people get older, the spine may become arthritic, discs may bulge, and ligaments in the spine may thicken or calcify. The combination of these things may compress on the spinal cord or nerve roots.
Symptoms of spinal stenosis vary with the location of the spinal stenosis. In the cervical spine, spinal stenosis can cause gait abnormalities, falling over, numbness, tingling, and weakness in the hands and legs. Lower down in the spine in the thoracic and lumbar spine, spinal stenosis can cause pain in the legs, loss of bowel or bladder function, and numbness and tingling in the legs if it is severe enough. Spinal stenosis can also be associated with back pain itself.
Some people with spinal stenosis experience severe symptoms in the legs when walking a short distance. The pain may be relieved by sitting down or leaning forward. This may be referred to as neurogenic claudication.
What caused my spinal stenosis?
There are varying reasons why people develop spinal stenosis. Some people are genetically predisposed to spinal stenosis where their anatomy is abnormal and the spinal canal is what is called congenitally stenotic. This is called congenital spinal stenosis. Some diseases or syndromes are associated with congenital spinal stenosis. Achondroplastic dwarfs have a higher propensity for spinal stenosis because their pedicles are smaller than normal, which narrows the spinal canal. You do not have to be an achondroplastic dward however to have congenital spinal stenosis. It is increasingly recognized as a common clinical pathology among spine surgeons.
Spinal stenosis can also occur due to arthritis in and around the spinal canal as well as multiple disc herniations as well as enlargement of the ligaments and tissue within the spinal canal.
To some degree, all forms of spinal stenosis are hereditary. So yes, you can blame your parents for your problem! However, thankfully, in most cases there are very effective treatments for spinal stenosis.
What are the treatments for spinal stenosis?
Treatments for spinal stenosis may vary depending on the symptoms and severity of the condition. In most cases, spinal stenosis is initially treated non-operatively. Spinal stenosis can have periods of minimal to no symptoms and then periods of increasing pain and even difficulty walking due to pain. When symptoms are severe, non-operative treatments can include a short period of rest, physical therapy, chiropractic manipulation, massage, lumbar corsette or soft cervical collar, or acupuncture. The evidence for the effectiveness of these treatments varies. I do not recommend chiropractic manipulation of the neck especially in someone who has not had any evaluation by a spine surgeon prior; however, chriropractic manipulation may be of benefit in the low back. Medical treatments include anti-inflammatory pain medications, such as Advil, Motrin, Alleve, naprosyn, and in some cases a Medrol Dose Pack if symptoms are severe enough. Although a very short course of muscle relaxant may be helpful, I recommend against any narcotic treatment for spinal stenosis as it merely masks pathology and is easily addictive.
If symptoms are refractory to the treatments described above, the next step would be an evaluation for an epidural steroid injection. I typically do not advocate for epidural steroid injections in the cervical spine but they can be very helpful in the lumbar spine to alleviate symptoms. With any invasive procedure there are risks associated with it including infection, vessel, or nerve injury.
As a last resort, if symptoms are severe and unrelenting and refractory to the above treatments, consideration can be given for surgical decompression. Depending on the location and severity of the stenosis as well as lack of any associated spinal pathology, surgical decompression may be a laminectomy with or without a fusion. Fusion is reserved for structure abnormalities of the spinal column in addition to the stenosis. There is much research devoted to spinal stenosis and other newer forms of treatment are actively being investigated.
What is scoliosis?
Scoliosis is a condition in which the spinal column becomes rotated and curved. It has been recognized in human beings since the beginnings of history and some of the most famous people in history had scoliosis, including kings, statesmen, soldiers, and athletes. There are different forms and severities of scoliosis. Congenital scoliosis occurs in very young children and is due to a vertebral anomaly. If the anomaly is not symmetric on both sides of the spine, there is a chance scoliosis will develop as the child’s skeleton grows and develops. Adolescent idiopathic scoliosis is another form of scoliosis that is first noticed in the adolescent years. Scoliosis can also occur in adults. This may be the adult continuation of the adolescent form or it may be a degenerative form of scoliosis that just like arthritis in knees and hips, some older adults have a propensity to develop this form of scoliosis.
What causes scoliosis?
We do not fully know all the causes of scoliosis.
Congenital scoliosis, the form which occurs in young children, is caused by an anomaly of the vertebral column that causes asymmetric growth of the spinal column.
There is a large body of research devoted to the causes of adolescent idiopathic scoliosis and we are still actively studying the exact molecular basis of it. However, we know that there is a hereditary component of it. That is, if your mother, father or sibling has scoliosis, there is a higher likelihood that you will have it. It does not necessarily mean that yours will be to the same degree as theirs—it may be worse or it may be less severe as theirs.
In some cases, scoliosis can also be caused by trauma to the spine itself. People with spinal cord injuries and children with cerebral palsy are also prone to scoliosis.
In older adults, scoliosis can occur as part of a degenerative process. This is much like shoulder, hip, or knee arthritis. The spine is composed of many small joints, including intervertebral discs and facet joints. As these start to degenerate with age, the same arthritic processes that occur in other joints can occur in the spine. With time, as these spinal joints collapse, there can be a rotation and curvature that develops in the spine. This is called adult degenerative scoliosis and it is a challenging problem and a topic of much debate in the spine literature today. Research is devoted to finding the exact causes and ways of preventing the severe degeneration seen in late forms of degenerative scoliosis.
How do I know if I have scoliosis?
Depending on your age, scoliosis may be diagnosed at a young age if congenital, on a screening exam in school if adolescent idiopathic scoliosis, or by your doctor as an adult. A relatively small curve can be obvious to teens, family members, and friends. The screening exam performed in schools is a forward bend test, in which an asymmetry of the ribs is noticeable. This may prompt the school nurse to refer the child to a pediatrician who may take xrays to confirm the diagnosis. X-rays are diagnostic of scoliosis.
In adults who have a degenerative type of pattern, they may have been aware of it since they were teens—in which case it was actually an adolescent idiopathic scoliosis that was treated non-operatively. Alternatively, back pain or sciatic type pain may prompt the patient to seek a back specialist who may then diagnose adult or degenerative scoliosis. Once again, the diagnosis is made with xrays of the spine.
What is the treatment for scoliosis?
Treatments for scoliosis vary depending on the patient, the form of scoliosis, the severity of the curvature, and any related symptoms.
Congenital scoliosis if caused by a vertebral anomaly and if severe enough, almost always requires operative intervention at an early age in order to halt progression. Surgery entails resection of the anomaly and fusion at the level or levels affected. Children with congenital scoliosis are also at a higher propensity for other medical problems, including heart, kidney, and lung problems and therefore I will typically order a full medical workup on children I see with congenital scoliosis if it has not been done already.
In most cases of adolescent idiopathic scoliosis, it is not severe and is treated without surgery. If the curve is large enough, a brace may be ordered in order to try and prevent the curve from progressing while at the same time allowing the spine to grow and children who still have significant growth remaining. However, with large curves that are progressing over time, surgery may be the best option to halt progression. Surgery in adolescent scoliosis typically occurs toward the end of the skeletal growth so as to not interfere with further growth. The most commonly used surgical treatment involves a fusion procedure in the back using screws, rods, and different forms of bone graft.
For adult degenerative scoliosis, treatments vary depending on symptoms and severity. Early on in the process, non-operative methods may help alleviate symptoms of back or leg pain. Non-operative methods include anti-inflammatory medications, physical therapy, acupuncture, chiropractic treatment, and epidural steroid injections. However, with more severe symptoms and in patients who have failed a reasonable course of non-operative treatment, surgical intervention may be warranted. There is still much debate within the academic spine surgeon community of what type and how extensive surgery for degenerative scoliosis should be. This is why it is important to pick a good spine surgeon who is up to date with the latest outcomes and techniques for treating complicated cases of degenerative scoliosis.
In more elderly patients with degenerative scoliosis, surgery is usually not a great option. Elderly patients often have heart, lung, and other medical problems that make the type of surgery effective for degenerative scoliosis relatively high risk. In these cases, the surgical options are more limited and non-operative treatment is the only reasonable option.
What is kyphosis?
Kyphosis is a type of curvature of the thoracic part of the spine when viewed while looking at the patient’s side profile. Kyphosis by itself is not abnormal. In fact, in the thoracic spine kyphosis up to a certain degree is normal and expected. However, kyphosis that is more than the normal degree is considered pathologic. Too much kyphosis can cause the person to appear hunchbacked, to lean forward while walking, unable to hold up the head.
Too much kyphosis in the thoracic spine is relatively common in teens. We do not know all the reasons for this but much like scoliosis, there is likely a strong hereditary component to it in teens. This is commonly called Scheurmann’s kyphosis. In most cases, the kyphosis seen with Scheurmann’s is accompanied by increased lordosis in the lumbar spine to compensate for the deformity.
Kyphosis that occurs in the neck or lumbar spine is pathologic as the normal curvature of the lumbar and cervical spine is lordotic, the exact opposite of kyphosis. Kyphosis in the lumbar and cervical spine may be due to different reasons, including trauma, as a result of prior spine surgery, or as part of a degenerative process. In the cervical spine, people who are kyphotic may have different degenerative conditions including anklylosing sponylitis, diffuse idiopathic skeletal hyperostosis, or severe arthritis. People who have had previous cervical laminectomy without fusion are at particular risk for progressive kyphosis as the normal tension band stabilizing structures of ligments and bone in the back of the cervical spine have been removed. This is a problem that has been recognized over the past decade in these patients. The same problem described for the cervical spine can happen after uninstrumented decompression in the thoracic and lumbar spine as well. When the surgeon is performing a lumbar decompressive operation, he must be careful not to injure stabilizing structures, which may cause instability or kyphosis. In the thoracic spine, this problem is very common and therefore I recommend fusion for all thoracic decompression procedures.
What is the treatment for kyphosis?
In most cases when it is not severe, kyphosis can simply be watched with serial examinations and radiographs. In adolescents who still have a significant amount of growth remaining, bracing may need to be used. Physical therapy and postural training to some extent may also help. In rare instances when kyphosis progresses rapidly, it may best be treated with surgery in order to halt progression in patients who are near the end of skeletal growth.
In adults with severe fixed kyphosis with associated neurologic symptoms, kyphosis may need to be treated with surgery, including osteotomies where bone is removed and then the spine is carefully realigned to a more normal alignment. This takes pressure off neurologic structures and allows the patient to stand upright.
Also kyphosis occurring after a prior surgery often needs to be treated surgically. The kyphosis in this instance may be due to multiple causes including patient bone quality and failure of fusion. This is why it’s important for the surgeon to do the right surgery initially in order to lessen the likelihood of needing more surgeries. Even in the best planned and performed operation, kyphosis can still occur postoperatively.
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