LOWER
BACK PAIN
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and
medical author. He graduated from Ross
University School of Medicine and has completed his clinical clerkship training in various
teaching hospitals throughout New York, including King’s County Hospital Center and
Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical
board exams, and has served as a test prep tutor and instructor for Kaplan. He has
developed several medical courses and curricula for a variety of educational institutions.
Dr. Jouria has also served on multiple levels in the academic field including faculty
member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert
for several continuing education organizations covering multiple basic medical sciences.
He has also developed several continuing medical education courses covering various
topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of
Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module
training series for trauma patient management. Dr. Jouria is currently authoring an
academic textbook on Human Anatomy & Physiology.
ABSTRACT
The lower back provides structural support, making it possible to engage in a wide
range of activities.
When lower back pain occurs, a patient’s mobility can be
significantly impacted. What seems like a minor case of back pain may indeed develop
into a chronic disorder that significantly affects the patient’s quality of life.
Understanding the anatomy of the lower back, as well as the causes of lower back pain,
will help healthcare professionals make diagnosis and treatment decisions that are vital
to the patient’s well-being.
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Continuing Nursing Education Course Director & Planners
William A. Cook, PhD,
NurseCe4Less.com Director
Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner
Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of
NurseCe4Less.com and the continuing nursing education requirements of the American
Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 14 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all CNE educational activities. All authors and course
planners participating in the planning or implementation of a CNE activity are expected
to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Nurses in all areas of health care are accountable to recognize signs and symptoms of
back pain in patients as well as colleagues in the workplace. Managing low back
requires specific training and continuing updates on how to effectively assess and
intervene in the alleviation of pain, and to advocate for a prevention plan.
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Course Purpose
This course will provide advanced learning for nurses interested in the management of
low back pain for patients, and for their colleagues and themselves.
Learning Objectives
1. Describe the structure of the lumbar region.
2. Differentiate between the upper back and the lower back.
3. Identify patient groups that are at high risk for lower back pain.
4. Differentiate between a sprain and a strain.
5. Describe the role of scar tissue in lower back pain.
6. Explain the symptoms of sciatica.
7. Describe the effects of a herniated disc.
8. Identify congenital skeletal deformities that put a patient at risk of lower back
pain.
9. Describe the symptoms that, in correlation with lower back pain, indicate a more
serious illness.
10. Identify common causes of infection that may cause lower back pain.
11. List the most useful diagnostic tools for diagnosing lower back pain.
12. List common treatments for lower back pain.
13. Identify medicinal treatments for lower back pain.
14. Explain the risks of opioids as a treatment for lower back pain.
15. Recognize the challenges in diagnosing fibromyalgia.
16. Differentiate between discography and myelograms.
17. Describe the limitations of using x-ray as a diagnostic tool for lower back pain.
18. Explain the different types of electrodiagnostic procedures.
19. List common surgical treatments for lower back pain.
20. Identify the gender differences in osteoporosis.
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Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses,
and Medical Assistants
Course Author & Director Disclosures
Jassin M. Jouria, MD has no disclosures
William S. Cook, PhD has no disclosures
Doug Lawrence, MS has no disclosures
Susan DePasquale, CGRN, MSN has no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
This course has been peer reviewed by Susan DePasquale, CGRN, MSN.
Review Date: October 20, 2013.
Release Date: October 25, 2013
Termination Date: October 25, 2016
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INTRODUCTION
Lower back pain, lumbar pain or lumbago is one of the most common complaints that
doctors encounter in their daily practice. This is not surprising since almost everyone
experiences it at some point in their lives. Statistics show that Americans spend a
staggering amount of $50 billion, if not more, annually for one reason or another due to
low back pain. Treatment, sick leave and loss of productivity are just among the
common reasons. In fact, it is the most common cause of job-related disability. It is also
only behind headache as the most common neurological ailment in the United States.
This course explores the broad pathology of lower back pain, diagnostic methods, as
well as its various treatment modalities. Because of the non-specific nature of lower
back pain, it is hard to pinpoint its exact cause and may be attributed to several
pathologic factors. Lower back pain may be acute or chronic, depending on the
pathology involved, which is why the course discusses extensively its pathology and
diagnostic approach.
Lower back pain refers to pain in the lumbar region of the spine. Its severity, onset and
duration differ individually. The pain may be slow in onset and duration or may be
constant or intermittent. It may resolve on its own or it may require medical intervention
(1).
The two types of lower back pain are: acute and chronic:
Acute lower back pain refers to a short-term duration of pain that usually lasts from a
few days to a few weeks. Mechanical forces such as trauma to the lower back or
arthritic disorders usually cause this type of back pain. Pain due to trauma may be due
to sporting and vehicular accidents, sudden movements, or wrong lifting techniques. Its
symptoms may range from mild to severe depending on the affected vertebra (2).
Chronic back pain refers to pain that lasts longer than a few weeks, usually more than 3
months, after its initial onset. It is usually a sign of a progressive and ongoing disease
such as the degenerative process found in osteoarthritis. Other causes may be
attributed to congenital defects.
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Structure and function of the lumbar region
In order to understand the pathology of lower back pain, it is important to understand
the complex parts and functions that make up the lumbar spine, the site of lower back
pain.
The spine is divided into four major segments, namely (1):

Cervical spine

Thoracic spine

Lumbar spine

Sacral spine
Originating from Latin, “lumbar” comes from the term ‘lumbus’ which means loin. It is a
term originally coined by Claudius Galen in the 2nd century. The word was initially used
to refer to both the joint as well as the bone of the spine.
The lumbar spine is a composite combination of vertebrae and multiple bony elements,
which are joined together with the help of joint capsules, ligaments, tendons, muscles
and nerves. It is innervated by nerves and supplied with an intricate network of blood
vessels. It consists of five lumbar vertebral components numbered from L1 to L5, which
are movable. The lumbar spine is composed of the anterior, middle and posterior
columns (1).
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The lumbar vertebrae are the largest of the true vertebrae. It forms a strong column of
support at the base of the vertebral column. The most important features of lumbar
spine are its (3):

Large size, and

Lack of transverse foramina and costal facets
Function
The lumbar spine is known to possess incredible strength. Some of its most important
functions are (3):

Protecting the spinal cord,

Protecting the nerve roots of the spinal cord, and

Lending flexibility to allow a variety of complex movements such as flexion and
extension.
The lumbar spine is capable of executing a wide range of motion, more than the
thoracic spine but lesser than the cervical spine. It is the lumbar facet joints that allow
movements such as flexion, extension and limited amount of rotation.
Lumbar vertebrae
Structurally speaking, the lumbar vertebrae are
tall
but
narrow.
The
three
functional
components of the lumbar vertebrae are (4, 6, 7):
1. The vertebral body,
2. The vertebral arch or neural arch, and
3. The
spinous
and
transverse
bony
processes.
Lumbar vertebral bodies
The lumbar vertebral bodies are connected together with the help of intervertebral discs.
The size of the lumbar vertebrae progressively increases from first to the fifth lumbar
(L1 to L5) vertebrae, which are indicative of the increasing loads absorbed by each
descending vertebra (4, 6, 7, 8).
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Intervertebral discal surface
A ring of cortical bone present on the outer boundary of the adult vertebrae is known as
the epiphyseal ring. The epiphyseal ring forms the growth zone in children and
adolescents, and holds the attachments of the annular fibrils in adults. A hyaline
cartilage plate is present within the epiphyseal ring (4, 6, 7).
Vertebral arch
The vertebral arch is made up of the following parts (4, 6, 7, 8):

Pedicles

Laminae

Bony processes
* Spinous
* Articular
* Transverse
The number of facet joints and ligaments that join these structures are enumerated in
the table below.
Parts of vertebral arch
Number of facet joints and ligaments
Pedicles
2
Laminae
2
Bony process
7
Spinous process
1
Articular process
4
Transverse process
2
Pedicle
The joint present on the posterior face, joining the arch to the posterolateral body is
called the pedicle. It is firmly fixed to the cephaled portion of the body. The concavity
present in the cephalad and caudal surface of the pedicel are known as vertebral
notches (4, 6, 7).
The function of the pedicle is to act as a protective cover for the cauda equine contents.
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Laminae
Laminae are strong and wide plates extending from the posterior-median side of the
pedicle. It is an elongated spinous process that is directed posteriorly from the joint of
the lamina.
There are two articular processes, namely; two superior and two inferior processes that
extend cranially and caudally from the joint between the pedicles and the laminae. The
zygophaseal joint is in the parasagittal plane. Two transverse processes also protrude
laterally. These are long, slender and strong in nature, with two tubercles, namely; the
inferior and superior articular tubercles located at the mammillary process and the
accessory process, respectively.
Lumbar vertebral joints
The zygopophysial joints are present between the
superior and inferior articular processes on the
adjacent vertebrae. Also known as facet joints,
they allow simple gliding movements. The region
between the superior articular process and the
lamina
is
known
as
pars
interarticularis.
Spondolysis is the condition, which results from a
lack of ossification in this region (4, 6, 7, 8).
Lumbar intervertebral discs
Constituting almost one quarter of the entire length
of the vertebral column, the intervertebral discs
make up the main connection between vertebrae.
Each disc is made up of a nucleus pulposus in
which reticular and collagenous fibers are inserted
and covered with the annulus fibrosus, which is a
fibrocartilaginous lamina. The annulus fibrosus is
further divided in three parts, namely (4, 6):
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
Outermost: the anterior fibers with the anterior longitudinal ligament

Middle: anterior and lateral fibers adding reinforcement and flexibility

Innermost: posterior longitudinal ligament can bear weak midline reinforcement in
the form of a narrow structure attached to the annulus, more so at the L4-5 and
L5-S1 regions.
The anterior and middle fibers of the annulus are present mostly in the anterior and
lateral regions but a few are also found in the posterior region. The annular fibers are
attached to the vertebral bodies and are arranged in the lamellae; the reinforcing
structure formed by the ligaments, which provides limited mobility to the vertebra (4, 6, 8).
Lumbar vertebral ligaments
The lumbar ligaments are (4):

Anterior longitudinal ligament

Posterior longitudinal ligament

Supraspinous ligament

Ligamentum flavum

Intratransverse ligament

Ileolumbar ligament

Intertransverse ligament

Interspinous ligament

Facet capsulary ligament
Anterior longitudinal ligament
The anterior longitudinal ligament is found on the ventral surface of the lumbar vertebral
bodies and discs. It is present in close association with the anterior annular disc fibers.
It broadens towards the bottom of the vertebral column. Its function is to maintain the
stability of the joints and restrict their extension movement.
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Posterior longitudinal ligament
The posterior longitudinal ligament is situated in the vertebral column, over the posterior
end of the vertebral bodies and discs. Its primary function is to restrict the flexion
movement of the vertebral column.
Supraspinous ligament
The function of the supraspinous ligament is to connect the tips of the spinous
processes of the adjacent vertebrae from L1 to L3. This ligament interconnects the
spinous processes extending from the root to the apex of the adjacent processes.
Ligamentum flavum
The ligamentum flavum connects the interlaminar interval and joins medially with the
interspinous ligament, laterally with the facet capsule and itself forms the posterior side
of the vertebral canal. It functions to maintain the constant disc tension.
Intratransverse ligament
The intratransverse ligament attaches to the transverse processes of the adjacent
vertebrae and also inhibits the lateral bending of the trunk.
Ileolumbar ligament
The ileolumbar ligament originates from the L5 transverse process and connects
posteriorly with the innermost lip of the iliac crest. Its function is to support the lateral
lumbosacral ligament in stabilizing the lumbosacral joint.
Lumbar spine musculature and vasculature
There are four muscle groups, which govern the functions of the lumbar spine. These
are divided into (5, 6):

Extensor

Flexors

Lateral flexors

Rotators
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The lumbar vertebra is supplied with blood by the anterolateral pair of lumbar arteries
originating from the aorta opposite the bodies of L1-L4. The venous drainage runs
parallel to the arterial supply. The venous plexus is formed by the veins along the
vertebral column inside and outside the vertebral canal (5, 6).
Risk factors for lower back pain
As mentioned in the introductory section above, lower back pain is one of the most
commonly occurring musculoskeletal problems seen in medical practice. At least 100
risk factors have been identified for lower back pain, a significant number of which is
attributable to a combination of individual and occupational factors
(9).
The most common causes of pain in the lower back are related to physical activities and
postural alignment related to a range of risk factors such as (9):

Demographic variables such as age, gender and occupation

Recurrent weight lifting

Use of vibrating equipment

Sedentary life style

Weakness of muscles of the abdominal wall

Obesity

Smoking

An increase in the lumbar lordosis

Scoliosis

Cardiovascular disorders

Low socioeconomic standard
At risk groups
Various research studies have confirmed that a substantial percentage of the adult
population who is suffering from lower back pain. This number mostly attributes their
symptom to their increasing age, female gender, rural habitation, low socio-economic
status and excessive smoking (9).
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However, studies have also found that there is an ever-increasing prevalence of lower
back pain among the adolescent and early adult population. The female gender is more
prone to suffering from lower back pain due to frequent physical and hormonal changes,
all of which also magnify their symptoms (10).
Lower back pain results from abnormal mechanics of the spinal column such as higher
spinal loads and lower stability of the spine, which are frequently seen in various
occupations that require heavy lifting and moving. The physical demands of a task
dictate the biomechanics of the spine, the effects such as stiffness or damping of the
trunk, and the mechanical neuromuscular response to the work related to equilibrium
and stability requirements.
Age
Increasing age equates to an increase in wear
and tear of various musculoskeletal structures
resulting in many anomalies of the spine such
as disc degeneration and spinal stenosis, all of
which may result in lower back pain. Studies
have found that people over the age of 30 or
40 are more susceptible to developing lower
back
pain
compared
to
their
younger
counterparts. People between the age group of
30 to 60 years are more likely to contract disc–related disorders while those over the
age of 60 mostly suffer from lower back pain due to osteoarthritis (10).
Aside from the normal degenerative processes at work in the incidence of lower back
pain among the elderly, comorbidity also plays an important role.
Prevalence of lower back pain in students
Studies have supported the fact that there is a relatively high and increasing evidence of
lower back pain among school-going children. The four major activities that significantly
contribute to the lower back pain are (10, 11):
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
Lifting or carrying of heavy loads such as heavy school bags

Bending forward

Sitting for over 30 minutes

Standing for more than 10 minutes or sports activities in school or during free
time
Additionally, lower back pain is more prevalent among female students, those who
smoke and who perform manual lifting and moving jobs outside school.
Occupational lower back pain
There have been studies done to examine the impact of work-related psychological and
mechanical stressors in the development of lower back pain in the general working
population. Physically demanding jobs, prolonged standing or awkward lifting are few of
the most important contributing factors to lower back pain. Those with the more severe
form of lower back pain are mostly involved in jobs requiring repetitive heavy lifting, use
of jackhammers or machine tools, and operating motor vehicles.
Specifically, exposure to certain repetitive biomechanical processes in the workplace
increases the risk of developing lower back pain, which are listed and illustrated below:

Bending or twisting

Kneeling or squatting

Prolonged standing

Heavy physical work

Nursing tasks
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Warehouse workers, movers, nurses and even primary caregivers are primarily
exposed to biomechanical stressors. Prolonged standing, sometimes for hours and
hours on end, is an important and consistent risk factor found among these working
groups.
Another consistent risk factor has been said to be lifting heavy loads using awkward
postures. One example is in nursing homes where nurses are required to lift and
manually handle patients in a regular basis for changing, transporting, and feeding
purposes (12). Another study has established beyond any doubt the relationship between
lower back pain and nursing tasks as a leading cause for absence due to sickness
among nurses. Another study has found an inverse, albeit, weak association between
the height of the nurse and prevalence of lower back pain (13).
People who work in a forward bending position without adequate support such as
gardening or manually lifting boxes off the ground, and those who squat or kneel are
exposed to excessive rotation and higher degrees of trunk flexion which in turn are
associated with lower back pain
(14).
Another stressor, psychological demands of highly
stressful jobs, has also been linked with greater incidence of lower back pain
(15).
In fact,
studies have suggested that stressful jobs actually cause increased muscular strain and
result in greater muscle tension and other physiological reactions that put people at
greater risk of developing lower back pain
(16).
Poor job satisfaction and lack of
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recognition at work are two other factors, which are attributed to contribute to the
prevalence of lower back pain in the general working population.
CAUSES
Etiology
As mentioned in the previous section, lower back pain may be due to biomechanical
factors at play. In this section, an overview is provided of a number of spinal conditions,
which may cause pain in the lower back. The discomforting pain may be caused due to
two types of causes, listed below:

Mechanical disorders: spinal disorders involving mechanical forces that resulted
to spinal injuries to the discs, facet joints, ligaments or muscles, causing lower
back pain.

Compressive disorders: spinal disorders resulting from pressure or irritation of
the spinal cord or nerves. This kind of irritation causes pain, numbness and
muscular weakness along the lumbar area where the nerve travels.
Mechanical spinal disorders cause irritation
of
lumbar
nerves
due
to
mechanical
pressure exerted by bones or tissues, or
disease affecting that section of the spine
extending from its root at the spinal cord to
the surface of the skin.
Nerve and muscle irritation
Some of the most common examples are
lumbar disc disorder, bone impingement,
and nerve inflammation caused by viral
infection.
The nerve irritation caused by
damaged discs between the vertebrae is due to either wear and tear of the outer ring of
the disc, or direct traumatic injury to the disc. The ensuing pain gradually radiates
towards the lower extremity when it is lifted. Bone impingement usually results from
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movement or growth of the lumbar spine that invades the anatomical space reserved for
the adjacent spinal cord and nerves. This results in compression of the spinal nerves,
leading to pain, which radiates down to the lower extremities. Lower back pain may also
be caused by muscular injuries, which result in nerve inflammation. Muscle strains in
the paraspinal muscle are one example. Another example is pressure or irritation on the
nerves leaving the spine that cause numbness and muscle weakness on the lumbar
region.
Sprain, strain or spasm
The lumbar spine bears a lot of the body’s weight during physical activities like walking,
and running. Lifting heavy loads can strain the lower back muscles while muscular
sprain or spasms to the same area may result in pain.
An injury to the muscles or a tendon is termed as a strain while stretching or tearing of a
ligament is called a sprain. As mentioned above, muscle strain to the lower back
muscles can result from improper lifting techniques, overstressing the back muscles,
overuse or prolonged repetitive movement of the muscles or tendons which can twist or
pull a muscle.
A sudden blow to the body or a sudden twist may lead to the stretching of ligaments
causing injury and pain in the lumbar region. The injury to the muscle or tendon often
referred to as strain may commonly result from chronic weakness, overuse or chronic
strain on the lower back. Sprain causes a joint to move abnormally, overstretching and
tearing the ligaments in the process. The tear in the ligaments causes blood loss from
the tissues around the joint, causing inflammation and pain in the area. The lower back
sprains are more severe in nature limiting the range of motion of the lower back and
causing painful spasms (18).
Spasms are sudden, forceful and continuous muscular contractions that often lead to
lumbar back pain. It is mainly caused by factors related to direct injuries to the muscle,
excessive physical activities such as exercise or a chronic strain. A muscle in spasm
(spastic muscle) becomes hard and tight due to the uncontrolled contraction of all the
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fibers. Muscles that provide protection to the spine may become contracted due to
chronic overuse, limiting the range of motion of its joints. Any disorder or problem in the
disc, bones or the facet joint may also lead the muscle to undergo spasm as a
protective measure to prevent any further damage to the spine. This protective spasm
may be chronic in nature and result in chronic and persistent pain in the lower back (23).
Sciatica
The sciatic nerve is a nerve that runs from the back through to the pelvis deep, and into
the buttocks. If there is pressure on one or more lumbar nerve roots, then pain may
develop in certain parts of the sciatic nerve, if not all. There are many disease
conditions, which may put pressure on the sciatic nerve resulting in lumbar pain such as
herniated disc, spinal stenosis, degenerative disc disease, spondylolisthesis or
abnormalities of the vertebrae. The lumbar pain due to sciatica may radiate from the
buttocks all the way down to the other lower extremities
(20).
Sciatica is best described as a symptom rather than a
diagnosis. In certain cases of sciatic pain, the muscles,
which are placed deep inside the buttocks, may put
pressure on the sciatic nerve. This nerve is known as
piriformis and the lower back pain resulting from this
condition is known as piriformis syndrome. It is generally a
result of an injury. The pain is due to the sciatic nerve compression or pinching of the
sciatic nerve, which causes the lower back pain on one side of the body that eventually
radiates to the buttocks, legs and feet (20).
Herniated disc
One of the most common causes of lower back pain is herniated disc, which is
sometimes referred to as slipped disc. A rupturing or thinning out of a vertebral disc in
the lumbar area, which protrudes out, ultimately leading to degeneration, marks this
condition. The degeneration is often very extensive that the gel inside the disc, which is
known as nucleus pulposus may escape outside.
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The damaged disc manifest in many forms, namely (17)

A bulge:
the nucleus pulposus pushes out from the disc, and uniformly distributes itself
symmetrically around the circumference.

A protrusion:
the nucleus pulposus pushes out slightly and asymmetrically in any of the
surrounding areas.

An extrusion:
the nucleus pulposus becomes inflated extending into the area outside the
vertebrae or completely escaping out of the disc.
The lower back pain is basically the result of the extrusion in which the gel or the
nucleus pulposus escapes out of the disc to compress the nerve root, especially the
sciatic nerve.
Sometimes there are abnormalities in the annular ring surrounding the disc. There are
tears in the ring causing disruption of the fibrous band containing a dense network of
nerves and high amount of peptides. People with degenerative disk disease are
frequently affected with heightened perception of pain due to the tear in the annular ring
(17).
Another syndrome associated with disc disorders is cauda equine syndrome in
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which the four nerve strands traveling to the lowest part of the lumbar region, i.e. cauda
equine, are impinged upon by a massive extrusion of the contents inside the disc. This
condition is an emergency situation, which may lead to severe complications of the
urinary or digestive system. The cauda equine syndrome causes a dull pain in the
lumbar area, causing symptoms such as urinary incontinence and inability to control
defecation (17).
Osteoarthritis
Osteoarthritis is defined as arthritis of the weight bearing joints such as hips and knees,
hands, feet, and spine. Osteoarthritic conditions of the bones and joints lead to lower
back pain which may be congenital, degenerative, or even due to the inflammatory
processes. Osteoarthritis of the spine is a degenerative inflammation of the facet joint,
which causes localized lumbar pain. The facet joint syndrome, commonly known as
osteoarthritis, is a major cause of lumbar pain. The overload and increased pressure on
the facet may be attributed to the degeneration of the disc and exposure of the articular
surface to damage, and wear and tear of the cartilage (16).
In spinal arthritis, the cartilage between the aligning facet joints in the posterior region of
the spine undergoes mechanical breakdown, resulting in the inflammation of the facet or
the zygopophyseal joints. These joints undergo progressive degeneration, creating an
increasing frictional lumbar pain resulting in a decreased range of motion, overall
mobility and flexibility of the back in proportion to the progression of the back pain. The
pain is usually triggered by routine physical activities like standing, sitting and walking.
The lumbar spine osteoarthritis is also called lumbosacral arthritis. As its name
suggests, it produces pain and stiffness in the lumbar spine and the sacroiliac joint,
which is present between the spine and the pelvis (19).
In severe cases of spinal osteoarthritis, the cartilage and fluid lubricating the facet joint
are completely destroyed, resulting in friction between the bones and leading to the
development of bone spurs, which occupy space in the foramen and press into the
adjacent nerve roots. A growing bone spur may also progress extensively so that it
projects into the spinal canal itself resulting in the narrowing of the canal, a condition
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called spinal stenosis. The degenerative process resulting in the formation of bone
spurs is a normal part of ageing and does not directly cause pain, although its
enlargement may cause irritation or entrapment of nerves passing through the spinal
structures, which cause pain (19).
Spondylolisthesis
When the lumbar vertebrae slip over one another, the resulting condition is termed as
spondylolisthesis. It causes mild to severe low
back pain among children and adults. In children,
it is the fifth bone in the lumbar region and the
first bone in the sacrum area that are usually
affected while in adults, the slip occurs between
the fourth and the fifth lumbar vertebrae. It may
be caused by a congenital defect in the spinal
area, a degenerative disease like arthritis, stress
or traumatic fractures, or even bone diseases
(24).
Studies have found that spondylolisthesis is the most common cause of back pain in the
lumbar region among the adult population aged below 50. On the other hand,
degenerative spondylolisthesis occurs more commonly at age 50.
Spondylolisthesis is categorized into different types according to their etiologic origins;
these are namely:

Congenital spondylolisthesis:
An abnormal bone function present at birth, which may result in an abnormal
arrangement of the vertebrae, predisposing it to higher risk of slipping.

Isthmic spondylolisthesis:
Small stress fractures in the vertebrae which may lead to a weakening of the
bone, causing it to slip out of place.

Degenerative spondylolisthesis:
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This is the most common type of spondylolisthesis and occurs as a result of
drying up of the discs due to the ageing process, which makes them less spongy
and less resistant to movement by the vertebrae.
Spondylolisthesis is marked by increased lordosis, which can develop into kyphosis
during the later stages of the disease as the upper spine falls off the lower spine. It may
also result in neurological damage, manifesting as leg weakness or altered sensations
in the lower extremities due to the pressure on the nerve roots. It is important to note
that the lumbar pain caused by spondylolisthesis often radiates down to the lower
extremities. The pain may manifest in the form of stiffness, muscle tightness, and
tenderness in the lumbar area where the disc has slipped
(17).
Additionally, it may cause muscle spasms in the hamstring muscles of the posterior
thighs. The slipped vertebrae pressing a spinal nerve may also lead to pain radiating
down the leg all the way to the foot. Generally, spondylolisthesis occurs only in one
level of the spine, though it can occur rarely at level two or three of the spine
simultaneously (17).
Fibromyalgia
Lumbar pain may also be attributed to fibromyalgia and other myofacial pain
syndromes. Fibromyalgia is a muscular pain, which results in back pain, fatigue and
tenderness at areas such as the neck, shoulder, hips, back, arms and legs. Some
factors which may lead to tender points in the lower back or shooting pain in the lower
back may be attributed to physical or emotional trauma, abnormal pain response, sleep
disorders or viral infections (21).
Fibromyalgia is a common pain syndrome. Though it is not related to a specific cause, it
still results in chronic pain encompassing a wide region of the body and nonspecific
tenderness in the joints, muscles, tendons and other soft tissues. Fibromyalgia is not
related to any specific anatomic disorder, and some scientists have attributed its
symptomatic manifestations to underlying and non-specific biochemical factors (22).
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Bone pathologies
The ageing process gradually decreases the strength of the bones, and tone and
elasticity of the muscles. The discs start losing its fluid and flexibility, reducing their
function as a protective cushion for the vertebrae.
Lower back pain is also known to reflect bone lesions such as multiple myeloma.
Osteoporosis and other bone diseases are other common factors that cause lower back
pain (29).
Bone lesions
Bone lesions are the oncologic causes of lower back pain, which may either be benign
or malignant spinal tumor. The spinal tumors are in close proximity to neural and
meningeal tissues, bone, and cartilage, all of which are capable of undergoing
neoplastic changes and metastasis. All spinal tumors cause back pain regardless of its
growth status i.e. whether they are malignant or benign. Osteosarcomas are commonly
present in the lumbosacral segment of the spine and result in lesions. Spinal
osteosarcomas are also seen in patients with Paget’s disease (31).
Bone metastases are cancerous cells, which spread from its site of origin to another
location in the body; in this case, the lumbar spine. It may cause pain and makes the
bone more vulnerable to fractures, even with the slightest of mechanical pressures. It is
usually characterized by the presence of increasing amount of calcium circulating in the
blood.
Metastases of the bone ultimately lead to lesions or injuries to the vertebral tissues of
the spine, causing pain. These lesions can be classified into two categories, namely;

Lytic lesions which completely destroy the bone material, and

Blastic lesions which fill the bones with more cells.
The cancerous cells attacking the vertebra disrupt the balance between the osteoclasts
(cells breaking down the bone) and the osteoblasts (cells developing and growing the
bone).
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Bone metastases are most commonly diagnosed in the back, pelvis, upper leg, ribs,
upper arm and skull. The damage or load on the periosteum causes the lower back
pain. Bone metastases also cause bone loss and hypercalcemia, the combination of
which is a life threatening condition
(32).
The Maffucci’s syndrome sometimes exhibits
bone axial lesions, which may also result in lower back pain (30).
Fractures
Vertebral fractures due to compression forces acting on the bones usually result in
lower back pain; this is especially true in those suffering from osteoporosis.
The lower back pain is sometimes an indication
that the bones forming the spine, vertebrae,
have been fractured. In most cases, the weak
and brittle bones that resulted from osteoporosis
are the main causative factor of the fracture, and
not the compressional forces themselves. It has
been found that the majority of men and women
over the age of 50 have a lower back pain that is
attributable to vertebral fractures (26).
Vertebral fracture is defined as “a vertebral bone in the spine that has decreased at
least 15 to 20% in height due to fracture.” The fractures may be located anywhere in the
spine but are most commonly found in the thoracic spine, especially in the lower
vertebrae of that region of the spine. These
fractures are generally classified as a wedge
fracture, crush fracture or burst fracture (25).
Wedge fracture
In a spinal fracture, the compression force is
generally exerted in front of the vertebra, making the
anterior part of the spinal bone to collapse while the
posterior remains largely unchanged, leading to its
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unique wedge-shaped structure. The so-called “Dowager’s hump” is a good example of
this type of fracture. It characterized by a stooped posture and a mechanically stable
fracture (26).
Crush fracture
A crush fracture differs from a wedge fracture in that in this case, the entire bone
breaks, instead of just the anterior part.
Burst fracture
Both the anterior and the posterior portions of the spinal bone being fractured
characterize a burst fracture, which results in an unstable fracture that may eventually
lead to a permanent deformity or a neurological disability. People with osteoporosis
have weak, thin and brittle bones that are vulnerable to fractures from light physical
activities. Such activities can subject these fragile bones to compression forces that can
very well result in spinal compression fractures. Generally, the compression fractures do
not cause pain but some are highly disabling in nature and cause extreme pain in the
lumbar region. In severe cases of osteoporosis, the vertebral fractures can even result
from innocent activities such as coughing, sneezing which lead to severe pain,
deformity of lumbar spine, immobility and disability, ultimately interfering with daily
activities (28).
Small and hairline spinal fractures may also eventually result in complete collapse of the
vertebra. This means that when the spinal vertebra incurs multiple small fractures, the
cumulative effects of these fractures are nonetheless painful and disabling. Moreover,
the compression fractures in the spinal vertebrae can have long term repercussions
such as permanently damaging the vertebrae by reducing its strength, shape and
functioning (26).
Osteoporosis
Osteoporosis is a prevalent musculoskeletal disorder, which also results in lower back
pain. It is characterized by reduction in bone mass and disruption of the
microarchitecture of the bone tissue. This condition leads to an increased incidence of
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bone
weakness,
which
may
eventually
cause
fractures or increase the risk of vertebral fractures.
Osteoporosis results in an increased risk of medical
complications inclusive of hip fracture, vertebral
deformities, and wrist fracture (35).
Lower back pain may be cited as the most common
symptom of osteoporosis, arising from vertebral
fractures. Lower back pain, as mentioned previously,
has severe impact on the quality of life. Studies have
reported that osteoporosis leading to lower back pain
is mostly prevalent among middle-aged women. The
high bone mineral density and associated degenerative diseases are known to cause
lower back pain in both the elderly and middle aged women (35).
It should be emphasized that even with decreased bone mass and abnormal structure
of the spinal vertebrae; there are no symptoms which are immediately visible. If the
bone is fractured, only then will symptoms such as lower back pain manifest. The
fracture, caused by osteoporosis, is also referred to as fragility fracture.
The external forces which destroy the already weakened bone structure range widely
from light forces such as those caused by daily activities to strong and violent forces
such as those incurred during trauma and fall accidents. The lower back pain following
such fractures many manifest either as acute or chronic pain. The acute lower back pain
is usually seen in fractures accompanied by rapid or gradual deformation of the bone
involved. Other fractures due to osteoporosis also result in chronic lower back pain,
which may gradually progress into dorsal kyphosis along with vertebral deformation.
Some studies have also reported that in certain cases, the deformation due to pressure
on the vertebral body develops and grows without any symptomatic lower back pain (28).
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Spondylosis
Spondylosis
refers to
anatomical changes
of
vertebral bodies and intervertebral disc spaces
associated
with
lower
back
pain
syndrome.
Osteoarthritis of the lumbar spine or spondylosis is a
non-specific degenerative condition, which affects
the disk, vertebral bodies, and related joints of the
lumbar spine.
The
degenerative
anatomical
changes
may
eventually lead to complications such as spinal
stenosis, in-growth of osteophytes, hypertrophy of inferior articular process, disk
herniation, bulging of the ligamentum flavum, and spondylolisthesis. Such complications
result in neurogenic claudication, which includes lower back pain, leg pain and also the
numbness and motor weakness in the lower extremities (27).
Spondylosis has been used to describe many degenerative conditions of the spine and
progression of the lower back pain. Some of these are listed below:

Facet joint osteoarthritis, which may cause lower back pain due to excessive
physical or prolonged physical activities.

Spinal stenosis, which is characterized by the narrowing of the spinal canal due
to various causative factors which cause lower back pain.

Degenerative disc disease which results in dehydration and loss of function,
eventually resulting in lower back pain along with neck pain, and possibly leg
pain (33).
The most significant factors causing spondylosis are the wear and tear of the spine due
to overuse. Spondylosis is associated with a cascade of events, which start with
wearing down of the cartilage of the facet joints, causing a friction between the bones.
The friction produces osteophytes or bone spurs, which are initially aimed at restoring
equilibrium in the joint but ultimately, hamper mobility and range of motion of the joints.
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These osteophytes may even pinch the spinal nerves, which aggravates lower back
pain (34).
Skeletal irregularities
Skeletal irregularities such as abnormal curving of the spine may result in back pain. If
the curves of the spine are amplified, it will make the upper back look rounded
abnormally or create an abnormal arch in the lower back. A spinal condition that has
been known to result in back pain is scoliosis (37).
Structural failure of the lumbar discs in conjunction with advanced signs of ageing is
referred to as degenerated disc. Structural defects like endplate fracture, radial fissures
and herniation are reflective of impaired disc function. It is also important to note that
the structural failure is irreversible and progressive. These skeletal irregularities are also
known to advance through to the physical as well as biological processes, marking the
degenerative process. Spinal disc degeneration is easily detectible through imaging
studies, and is usually found in close association with lower back pain and sciatica (36).
Degradation of the spinal system may also result from injury and/or disease of any of
the associated systems and structure of the lumbar area. In response to these changes,
the neural systems of the spine bring about compensatory changes to initiate
appropriate changes in the lumbar spine, which may maintain the stability of the spine
but may also prove deleterious to the different components of the spinal system. The
primary instability of the lumbar spine has also been cited as one of the most common
causes of lower back pain. The secondary lumbar vertebral instability due to a disease
or an injury of the lumbar spine involving the disc for example osteoarthritis,
spondylolisthesis, nuclear ruptures into the neural canal is also a cause of lower back
pain.
Spinal degeneration
Degenerative disease of the lumbar spine or lower back negatively affects the spine and
involves a compromised disc, which is responsible for the lower back pain. The
degeneration is a multifactorial problem ranging from a simple wear and tear to
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traumatic injuries that initiate a cascade of events causing a spinal degeneration. This
degenerative cascade is even triggered by minor injuries, which ultimately wear out the
disc completely. In fact, it has been noted that with increasing age, varying degrees of
disc degeneration is normally seen. Spinal degeneration causes inflammation of the
lumbar spine, with abnormal micro-motion instability as the reason for the lower back
pain (42).
Structural failure alters the local mechanical environment of disc cells from the general
loading of the disc that result in their aberrant cell responses. Excessive mechanical
loading brings about a distortion of the structure of the disc and initiates a succession of
cell-mediated responses (inflammatory responses), which worsens the pain symptoms.
The severity and onset of disc degeneration is influenced by various factors such as:

genetic inheritance

age

inadequate metabolite transport, and

load on the disc
All factors further weaken the disc, ultimately bringing about structural failure while
performing routine physical activities (36).
The structural failures of the disc, which causes low back pain are (36):
1. annulus tears
2. disc prolapse
3. endplate damage and schmorl nodes
4. internal disc disruption, and
5. disc narrowing, radial bulging and vertebral osteophytes
Annulus tears
The lumbar spine is particularly vulnerable to injuries, especially tears such as:

circumferential tears,

peripheral rim tears, and
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
radial fissures
Compressive stress, bony outgrowths, trauma-related mechanical forces, and cyclic
loading of the disc during bending and compression are some of the causative factors of
these tears. The incidence of annular tears is not affected by age and may develop in
the presence of any of the factors causing it (36).
Disc prolapse
This type of condition affects the periphery of the
disc. It is also termed as disc herniation. Radial
fissures lead to migration of the nucleus pulposus in
proportion to annulus bringing about disc prolapse.
Disc prolapse or herniation proceeds sequentially in
the following manner:

Disc degeneration

Protrusion of the nuclear material

Extrusion of the nuclear content

Sequestration of the nuclear content
The disc prolapse may result from mechanical loading, which commonly affects
individuals between 30 to 40 years of age. The presence of fluid nucleus and
weakening of the annulus characterize it. The nucleus pulposus is forced downwards
through the radial fissure (36).
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Endplate damage and schmorl nodes
The weakest point of the spine when compressed is
the
vertebral
endplates,
which
accumulate
trabecular micro damage. With the ageing process,
the nucleus starts protruding inside the vertebral
bodies in later life. The endplate damage brings
about instant decompression of the nucleus, with
the annulus bearing the load bulges into the nucleus
cavity. The nucleus pulposus ruptures through the
damaged endplate, consequently resulting in calcium accumulation which creates what
is known as “Schmorl’s node” (36).
Internal disc disruption
In this type of structural damage, the anterior portion of the annulus is affected more
than the posterior portion. The inner annulus collapses into the nucleus. This type of
structural damage frequently occurs in ageing discs. Internal disc disruption is often due
to decompression of the nucleus succeeding an endplate fracture. The ageing cartilage
and the endplate are seen as detached from the underlying bone due to the loss of high
internal pressure compressing them (36).
Disc narrowing, radial bulging and vertebral osteophytes
Disc narrowing, radial bulging, and vertebral osteophytes are related to spondylosis.
Due to the ageing process, the nucleus pulposus extrudes into the vertebral bodies
causing a reduction in the nucleus pressure and rise in the vertical load on the annulus,
which ultimately bulges outward radially and even inward in certain situations. These
changes are accompanied by loss of the nucleus pressure, which manifests as collapse
of annular height. This loss in height prevents the separation of adjacent neural arches,
with the annulus collapsing on old discs, and contributing to more than 50% of the
compression force on the lumbar spine. This is why narrowed discs are also seen in
relation with osteoarthritis in the apophyseal joints and with osteophytes circulating on
the edge of vertebral bodies (36).
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Spinal stenosis
Spinal stenosis, as defined previously, is the narrowing of the spinal canal resulting in
impingement on the neural structures by the bone and soft tissues surrounding it. The
most common reason for lumbar spine surgery in
adults over the age of 65 years can be attributed
to spinal stenosis
(44).
Additionally, it often results
in neurogenic claudication. It is another important
cause of lower back pain aside from disc
protrusion
and
root
entrapment
due
to
degenerative changes (40).
Stenosis can result from many degenerative
conditions such as osteoarthritis or degenerative
spondylolisthesis. These conditions lead to clogging of spinal nerves in the lumbar area,
narrowing the canal and ultimately leading to claudication and pain in the leg (41).
Lumbar spinal stenosis refers to the narrowing of the lower spinal canal in the lumbar
region due to either bone or tissue growths or both blocking the size of the openings in
the spinal bone. The narrowed passage compresses and irritates the nerves coming out
of the spinal cord. In extreme cases, even the spinal cord is affected; either compressed
or irritated which leads pain, numbness or weakness in the legs, feet and buttocks (43).
Additionally, there is also enlargement of the facet joints leading to compression of the
spinal nerve roots in the lower back, which also contributes to lumbar pain
Ageing is one of the most common causes of lumbar spine stenosis
(41).
(41).
The various
factors, which lead to spinal stenosis are those related with alterations in the shape and
size of the spinal canal. Some of the most frequent factors causing lumbar spinal
stenosis are:

thickening of the ligaments

formation and development of bony spurs compressing the spinal cord,
especially in those suffering from osteoarthritis, and

slipping of the discs backwards into the spinal canal.
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Other conditions can play a significant role in the development of spinal stenosis.
Examples of such conditions are bone diseases such as Paget’s disease, ankylosing
spondylitis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis, all of which
lead to softening of the spinal bone or excessive growth of the bone (43).
Younger individuals with spinal injury or curvature of the spinal canal may also
eventually develop lumbar stenosis. When patients with spinal stenosis stand, the
space reserved for the blood supply of nerve roots is significantly decreased, resulting
in pooled blood which irritates the nerves and cause pain. However, it should be noted
that lumbar stenosis rarely causes permanent nerve damage (41).
Lumbar stenosis is classified into three different types:

Lateral stenosis

Central stenosis

Foraminal stenosis
Lateral recess stenosis
This is the most common type of lumbar
stenosis. In this case, a nerve root leaving the
spinal canal faces compression from either a
bulging disc or protruding bone, which extends
beyond the foramen (41).
Central stenosis
This
type
of
lumbar
stenosis
causes
compression of the cauda equine nerve roots
especially when there is a blockade of the
central spinal canal (41).
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Foraminal stenosis
This type of stenosis occurs when bone spurs entrap or compress a nerve root in the
lumbar region. Sometimes, the opening from where the nerve root leaves the lumbar
spinal canal may also be blocked.
Other conditions causing low back pain
Infections are also known to cause localized pain in the lower back. Serious and
destructive diseases but uncommon in nature are also instrumental in causing back
pain. These include malignancy, infection, ankylosing spondylitis and epidural abscess.
The occurrence of back pain can also be owed to the presence of musculoskeletal
disorders, peptic ulcers, pancreatitis, pyelonephritis, aortic aneurysms and some other
serious conditions (52).
Infections
Spinal infection is generally a serious condition, which may be initially dormant then
slowly progress to an active state. It may also exacerbate into sepsis immediately and
exhibit rapid symptom progression. The back pain associated with spinal infection is
similar to and may be mistaken for discitis or osteomyelitis, although distinguishing it
from the idiopathic pain can very challenging for the clinician.
Tubercular infection due to Mycobacterium can cause lower back pain. It can very well
progress, albeit rarely, into tuberculous vertebral osteomyelitis (52).
An inflammation of the spine diagnosed as spinal infection should cause alarm to any
clinician
(49).
Researchers have suggested that chronic lower back pain may arise from
bacterial infection. The discs that are infected with anaerobic bacteria can later on
develop into bone edema in the adjacent vertebrae following disc herniation. The
bacteria infecting the gums and skin, Propionibacterium acne, can also spread to the
lower back and result in pain
(45).
The male condition, benign prostate hyperplasia
(BPH), can trigger lower urinary tract infection, which can spread and infect the spine
and also cause lower back pain.
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Acute spinal infections are usually pyogenic in nature while the chronic infections can
either be pyogenic, fungal, or even granulomatous. Common infections from any
bacterial or fungal source can spread to the spine such as dental abscess, pneumonia,
and urinary tract infection. The infection is subtle at the beginning and usually only
causes localized pain in the back at the area of involvement. The resulting spinal pain
has the tendency to be aggravated with increased physical activity and load on the
spine (e.g. carrying heavy objects). The spinal infection generally manifests as back
pain accompanied by weight loss, fatigue, fevers, and night sweats. The pain is focal in
nature and may be experienced by the patient when changing positions such as from
sitting to standing. Focal kyphosis can also appear in the case of vertebral collapse (52).
Infections of the deep tissues of the lumbar spine are also known to cause lower back
pain and leg pain. Some of the most common infections of the lumbar spine are
osteomyelitis, discitis, epidural abscess, and postoperative wound infections. Deep
tissue infections that do not involve the disc space directly can also lead to lower back
pain (51).
Vertebral infection
An infection of the vertebral body is known as vertebral osteomyelitis and mostly affects
young healthy individuals. The infection usually spreads to the lower vertebral body
through vascular pathways. Batson’s plexus (veins in the lumbar spine) drain into the
pelvis and are easy routes for bacteria to travel through, enter, and infect the spine. This
is why uroscopic procedures commonly result in spinal infections.
There are many risk factors for the development of osteomyelitis such as increasing
age, IV drug use, and immunosuppression such as those seen in patients with diabetes
mellitus, AIDS, malnutirition, cancer, and those who underwent organ transplantation.
The microrganisms which most commonly infect the spine are Staphylococcus aureus
and Pseudomonas spp. Infections caused by Mycobacterium tuberculosis are also
known to cause infections affecting the lower back that result in debilitating symptoms.
Most of the infections of the vertebral body are localized in the lumbar spine owing to
the limited blood circulation in this spinal region (58).
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Lyme disease
Lyme disease is a chronic infection affecting the skin, joints, and the nervous system
including the spine. Spirochete bacteria, manifesting initially as a rash following a tick
bite, cause it. The skin lesions develop into multiple annular secondary lesions
accompanied by other symptoms such as malaise and fatigue, headache, fever and
chills, general achiness and regional lymphadenopathy. Some patients also show
meningeal irritation, mild encephalopathy, migratory musculoskeletal pain, hepatitis,
generalized lymphadenopathy and splenomegaly, sore throat, cough, and testicular
swelling (54).
Patients diagnosed with Lyme disease also develop brief episodes of joint, periarticular
or musculoskeletal pain following skin lesions. Later on, they develop into chronic
synovitis characterized by erosions and permanent joint disability. Lyme arthritis ranges
from mild and subjective joint pain to intermittent attacks of arthritis, and sometimes
even to chronic erosive manifestation of the disease (53).
Shingles
Varicella zoster virus, the causative agent of shingles, infects certain spinal levels,
which eventually cause lumbar pain. The virus is known to lie dormant in the body for
many years following the initial chickenpox infection. Once the virus is activated again, it
infects and spreads to various parts of the body including the spine, causing nerve
damage that manifests as numbness, itching, severe pain, and the characteristic
blistering rashes. Shingles typically start with a highly sensitive, band-like rash
appearing on the skin followed by an intense discomfort of the same area, burning and
painful sensations, and itching on the back. The most commonly affected areas are the
trunk, neck and back.
There are a variety of factors which trigger the infection including emotional stress,
increasing age, immune deficiency, and cancer. Persons of advanced age are more
likely to experience the debilitating irritating rash sensations, severe herpetic neuralgia,
and vision impairment that follow the infection (46).
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Epidural abscess
Spinal infection can also progress to epidural abscess, which manifests initially as a
localized spinal pain that slowly develops into radicular pain, weakness, and ultimately,
paralysis. Epidural abscess is generally a complication of osteomyelitis, bacteremia,
and postoperative infection. The common causative organisms are Staphylococcus
aureus, Streptococci and Gram-negative bacilli. The characteristic feature of spinal
epidural abscess is its progression from spinal ache to radicular pain leading to
weakness and eventual paralysis. The disease has serious complications and may be
accompanied by fever, local tenderness, and lower back pain (47).
Other problems that can also cause back pain in the lumbar region are ankylosing
spondylitis, cauda equine syndrome, and rheumatoid arthritis. Added to this list are
some rare bone disorders, tumors, and other disorders which exert pressure to the
spine resulting in lower back pain (50).
Cauda equine syndrome
Cauda equine syndrome is a relatively rare but very serious medical emergency
involving the spinal cord. Its name was
derived from the nerves at the end of the
spine that visually resemble a horse’s tail
as they extend from the spinal cord down to
the back of each leg. The nerves at the end
of
the
spinal
cord
are
subjected
to
excessive pressure and inflammation. If left
untreated, it will ultimately progress to
permanent paralysis, impaired bladder and
bowel control, mobility difficulties, and
various other related neurological and physiological problems (59).
Lower back pain which is localized in a particular area is one of the symptoms of cauda
equine syndrome; along with progressive weakness in the lower extremities, loss of
sensation in the saddle area, urinary or bowel incontinence, and sharp stabbing pain on
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the legs
(59).
There are various factors responsible for the compression of nerves in the
lumbar spine including lumbar herniated disc, lumbar spinal stenosis, vertebral collapse
due to metastatic infiltration, spinal subarachnoid hemorrhage, acute extradural
hematoma, ankylosing spondylitis, infections in the spinal canal, tumors or trauma, and
injury affecting the lower back.
Spinal dural arteriovenous fistulas
This condition is a distinct malformation of the spinal vasculature generally located in
the lower lumbar or thoracic spine. It usually affects middle aged and older men. Its
symptoms include lower back pain and symptoms similar to spinal stenosis (48).
Spinal arachnoiditis
Spinal arachnoiditis most commonly affects the lumbosacral region, although it can
occur anywhere in the meninges. It is characterized by thickening of the arachnoid and
adherence to the pia mater and dura mater. It can affect a single nerve root or multiple
nerve roots in the cauda equina. As the condition progresses, it can even restrict the
spinal cord itself.
There are several causative factors that result in the development of spinal
arachnoiditis, including the following:

intrathecal drugs or chemical agents such as radiation, spinal and epidural
anesthesia,

infections such as tuberculosis, cryptococcus, syphilis, viral infections,

trauma such as spinal surgery, vertebral injuries or lumbar disk herniation, and

spinal subarachnoid hemorrhage.
The symptoms of spinal arachnoiditis are persistent lower back pain, which can later
radiate to both legs and result in motor and sensory disorders. The symptoms may
appear within days of the damage or take years to appear. More than one lumbar or
sacral nerve root is usually involved in this disorder (48).
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Ankylosing spondylitis
Ankylosing spondylitis is a type of arthritis, which usually progresses into chronic
inflammation of the spine and sacroiliac joints. It also affects other joints and organs in
the
body
such
as
eyes,
lungs,
kidneys,
shoulders, knees, hips, heart, and ankles;
however, the primary affected region is the axial
skeleton and its ligaments and joints. It typically
results in stiffness, joint soreness, and pain
around the spine and pelvis. It ultimately brings
about a complete fusion of the spine.
The patient usually experiences pain symptoms
once the spinal vertebrae start to fuse together
as a result of calcium accumulation in the
ligaments and discs between each vertebrae. In
this type of condition, there is a complete loss of
mobility and greater susceptibility to fractures and injuries.
Ankylosing spondylitis occurs more frequently among males, especially younger adult
males. It starts at the sacroiliac joints, before moving to the spine. The long-term spinal
joint inflammation results in calcification of the ligaments around the intervertebral discs
and ligaments, which eventually restricts their movement.
The final stage is the complete fusion of the vertebrae, which is known as ankylosis.
The severe pain symptoms of ankylosing spondylitis manifest on the lower back,
buttocks, hips, and thighs (57).
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune disease that can occur at any age. It refers to
the destruction of the joints in the body at the neck and lumbar region of the spine,
although it most commonly affects the former than the latter. It can lead to neck pain,
back pain or pain that radiates into the legs and arms. The destruction of the spine can
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also result in compression of the spinal cord and spinal nerve roots, which contributes to
the development of lower back pain
(56).
The most significant causative factors of
rheumatoid arthritis are infections, heredity, and hormonal changes (55).
The symptoms of rheumatoid arthritis are similar to those of osteoarthritis. The pain and
inflammation are usually focused on the base of the skull or lower back. It also affects
the ability to walk
(56).
The disease is known to progress gradually; generally starting
with minor joint pain, stiffness, and fatigue (55).
Other conditions that contribute to the development of lower back pain are abnormal
aortic aneurysm, psoriatic arthritis, kidney infection, kidney stones, problems related to
pregnancy, endometriosis, ovarian cysts, ovarian cancer, and uterine fibroids (60).
SYMPTOMS OF A MORE SERIOUS DISEASE
Sometimes, lower back pain is accompanied by rare symptoms associated with more
serious conditions, some of which pose a life-threatening risk to the patient and require
immediate medical attention.
Some of these symptoms are outlined below:

Progressive weakness of the leg

Loss of bowel or bladder control

Weight loss along with pain

Neurological impairment

Severe and acute stomach pain accompanied with a lower back pain, and

Fever with increasing pain intensity, which cannot be alleviated with the use of
oral NSAIDs (61).
These symptoms are associated with spinal tumor, infection, fracture, and cauda equina
syndrome. Thus, an unexplained weight loss and fever accompanying lower back pain
may be a result of malignant disease such as multiple myeloma or a metastatic disease.
Fever with lower back pain may indicate connective tissue disease such as systemic
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lupus erythematosus, urinary retention, and bladder or bowel incontinence. Severe and
progressive weakness of the lower extremities may suggest cauda equina syndrome or
spinal stenosis (62).
Infection
A fever (>100°F or 38°C) present in patients with lower back pain is indicative of an
infection. There are many pathways for an infectious microorganism to enter the spine.
It is not uncommon for individuals with a compromised immune system or postoperative status to develop infections more quickly. Generally, a compromised immune
system is a result of insulin dependent diabetes mellitus, organ transplantation,
acquired immune deficiency syndrome (AIDS), malnutrition, and even cancer
(61).
Sometimes, spinal infections lead to epidural abscess which can put pressure on the
nerves in the cervical, thoracic and lumbar spine, all of which may eventually lead to
gross dysfunction of the nerve roots causing paraplegia or quadriplegia. The most
common organisms affecting the spine are Staphylococcus aureus, Pseudomonas spp.,
and Mycobacterium tuberculosis (58).
Post-surgical and other wound infections are frequently seen in patients with diabetes or
those with weak physical health. The onset of infection is usually slow, taking usually
about 1 to 2 weeks to completely develop. The symptoms usually include fever,
redness, and inflammation around the incision and wound areas. Also, a change in
wound drainage and fluid consistency is indicative of an active infection. The fluid from
the wound can become thick and yellow with delayed healing. Post-surgical spinal
infections respond well to antibiotic treatment when caught early; in rare cases, the pus
needs to be surgically extracted out to prevent further spread of infection (61).
Vertebral osteomyelitis or vertebral bone infection can also result in fever. This type of
infection spreads to the spine through the blood circulation. The veins present in the
lumbar spine, known as Batson’s plexus, drain the pelvis and allow the bacteria to
directly enter the spine (58).
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Several procedures like colonoscopy, cystoscopy, and other diagnostic tests using a
thin telescope to inspect the bladder can facilitate the spread of infection. Intravenous
drug use, long-term use of steroids, and dental surgery can also play an instrumental
role in introducing infectious microorganisms into the bone and subsequently, the spinal
structures.
The sensitivity of fever has been found to be disappointing in patients with spinal
infections; Whereas, spine tenderness in response to percussion is sensitive for
bacterial infection (65).
Cauda equina syndrome
Cauda equina syndrome is characterized by varying degrees of urinary and bowel
incontinence, sensory loss in the perineal area, and motor weakness in the legs. The
cauda equina syndrome is caused by direct or indirect trauma, ischemia, infection, and
neurotoxic reactions (68).
The symptoms of cauda equina syndrome are classified as:
1. Motor
2. Sensory, and
3. Sphincter manifestations
The abnormal neurological perceptions associated with cauda equina syndrome include
lower back pain, sciatica, saddle, and perineal hypoaesthesia or anaesthesia,
decreased anal tone, and absence of ankle, knee and bulbocavernous reflexes, along
with a bladder and bowel dysfunction. An early diagnosis and decompression of the
cauda equina is of utmost importance to minimize the residual neurological deficit (66).
Specifically, the motor manifestations seen are weakness of lower limbs, decreased
range of motion, evidence of hypotonia in the limb and other muscle groups, and
reduced or lack of reflexes. The sensory symptoms manifest as paresthesias and
objective sensory loss of dermatomal and myotomal distribution. The symptoms
associated with sphincter involvement are difficult micturition, retention of urine, failure
of filling of the viscous or loss of urethral sensation, and sometimes stress incontinence.
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The most commonly observed bowel symptoms are constipation, rectal distention, and
loss of anal sensation (69).
The terminal vertebrae of the adult spinal cord is at the L1-L2 with the terminal lumbar
and sacral nerve roots in the spinal canal forming the cauda equina at the distal end.
Cauda equina syndrome caused by a herniated lumbar disc has the following features:

Perineal anesthesia

Lumbosacral root sensory deficits
Patients who suffer from back pain and urinary incontinence are measured for their
urinary post void residual volume. A value more than 100-200 mL is suggestive of
urinary retention. Cauda equina syndrome is the perfect indication for an immediate
surgical decompression, laminectomy with mild traction of the cauda equine, and
discectomy. The success of the treatment largely depends on how soon the patient
received immediate surgical intervention (67).
Some of the problems associated with this large, space occupying lesion in the canal of
the lumbosacral spine is its unclear pathophysiology, subtle initial signs and symptoms
which makes early diagnosis challenging, and often late findings of decreased rectal
tone. Hence, postoperative spine patients with residual back or leg pain that is not
alleviated by analgesics, especially when urinary retention is present, should be highly
suspected of having cauda equine syndrome (70).
Multiple myeloma and malignancies
Bone metastases are related to significant morbidity including pain, impaired mobility,
increased calcium levels, pathological fracture, compression of spinal cord and nerve
roots, and bone marrow infiltration. The major complications of metastatic bone
destruction causes bone pain radiating from the back to the lower limbs. Hypercalcemia
also occurs in pathologic fractures and spinal cord compression (64).
There are many symptoms associated with bone cancer such as bone pain, localized
swelling and inflammation in the lumbar spine, unexplained weight loss, fatigue, fever,
and even anemia. The malignancy may start from the bone and spread to other parts
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(primary) of the body or spread from the other parts of the body to the bone
(secondary). The two cancerous malignancies that cause these symptoms are
osteosarcoma (cancer of the bone tissue) and chondrosarcoma (cancer of cartilage).
Metastasis usually develops due to the interactions between tumor cells and bone cells
that lead to disruption of normal bone metabolism and increased osteoclastic activity.
The clinical course of metastatic bone disease in multiple myeloma results in skeletal
complications, bone pain, fractures, hypercalcemia, fever, and weight loss; all of which
adversely affect the quality of life (63).
Malignant neoplasm (primary or metastatic) is the most common malignant disease
affecting the spine. Unexplained weight loss, pain symptoms lasting greater than one
month, and failure to improve with traditional NSAIDs therapy are some of the most
common signs and symptoms. Patients with lower back pain due to cancer usually
complain of persistent pain unrelieved by bed rest. The physical examination does not
contribute much to the early detection of underlying bone cancers except in their later
stages (65).
Sciatica
Pain due to nerve root irritation is indicative of sciatica. The pain is characterized by
sharp and burning sensations radiating down to the
posterior and lateral aspect of the leg, foot, and
ankle. Coughing and sneezing enhance the pain.
When disc herniation occurs, the leg pain is more
prominent than the back pain (65).
Spinal stenosis
The characteristic clinical feature of spinal stenosis
is neurogenic claudication. It is characterized by
pain on the legs and neurological deficits occurring
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while walking. Neurogenic claudication occurs while standing, with a tendency to
worsen with coughing and sneezing. Increased pain on extension of spine is
characteristic of spinal stenosis (65).
DIAGNOSIS
Before suggesting any diagnostic test to patients, clinicians need to look into the various
signs and symptoms manifested and narrated by them. Both the subjective and
objective lower back symptoms of the patient are helpful in making the right clinical
decision, i.e. whether to go ahead with other various diagnostic tests or start treatment
right away.
The exact site of pain in the lower back, pain intensity, the type of pain (e.g. burning,
stinging, crawling), origins of the pain sensations, and the aggravating and ameliorating
factors are standard questions usually asked by the clinician. In case of nonspecific
pain, the patient is usually put on 3 weeks of conservative treatment, usually with pain
medications.
If symptoms do not disappear spontaneously or by rest even after 3 weeks of treatment,
the clinician should proceed with various diagnostic tests in order to pinpoint the exact
cause of pain. Some of the most commonly used diagnostic tests are:
1. Spinal x-ray
2. Myelography
3. Computed tomography scan (CT scan)
4. Magnetic resonance imaging (MRI)
5. Electro-diagnostic tests such as:

Electromyography(EMG)

Nerve conduction velocity (NCV)

Evoked potential studies (EP studies)
6. Bone scan
7. Thermography
8. Ultrasound imaging (USG)
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Spinal x-ray
Spinal x-ray is also known as lumbosacral x-ray
and lumbar spine film. It is a non-invasive
diagnostic test widely used to take pictures of the
lumbosacral
region
to
visualize
suspected
fractures, inspections, deformities (e.g. scoliosis),
and other skeletal disorders of the bones, discs
and joints.
Spinal x-ray is usually suggested after a thorough
examination of the back, gluteus region, spine,
and recto-pelvic regions of the patient by the physician, physiotherapist and chiropractor
(103, 104,105).
Spinal x-ray is ordered when the patient has the following symptoms (103,104,105);

Constant, extreme and sharp pain on the lower back that is not relieved
spontaneously within a couple of days or by rest;

Pain is relieved only with the use of NSAIDs then persists after two weeks;

Hyperaesthetic and sensitive lower back;

Stubborn and stiff lower back;

Crawling, tingling sensations in the lower back and lower extremities like hip,
thighs, leg, foot, and big toe;

Loose, weak, and tired lower back and extremities;

When the patient is not relieved by massage, heat therapy (fomentation), hot
baths and even physiotherapy exercises; and

When all of the above complaints are seen in elderly people with fragile bones.
The image obtained by spinal x-ray of the lumbosacral region will show the five lumbar
vertebrae and five fused sacral vertebrae. Beam of ionizing radiations are passed
through the lower back followed by capture of 4-5 images. X-ray plates taken are
visualised in good light. Bony radio opaque vertebra will appear white; soft tissues,
muscles (e.g. erector spinae) and the spinal cord grey, and the air black.
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Condition and diseases diagnosed using spinal x-ray are:

Fractured, cracked torn bones:
Stress and compression fractures of the lower vertebrae are commonly seen in
athletes such as weight lifters, gymnastics, and footballers who frequently over
stretch their lower back;

Spondylolisthesis:
It is also known as subluxation wherein the normal anatomical position of the
spine is altered. On X-ray image, the vertebra will appear to have slid down from
their actual position;

Disc degeneration:
Degenerated intervertebral discs can be seen on the X-ray plate. They are the
senile progressive changes on the vertebra and cartilage due to ageing and
repeated micro-injuries;

Hereditary and congenital structural abnormalities:
These involve the spine vertebra such as those seen during extension and back
flexion;

Misalignment of the spine:
Vertebral malformations such as kyphosis, scoliosis, lordosis, and kyphoscoliosis
are seen on the X-ray image. The table below summarizes the findings of each
vertebral malformation:
Vertebral malformation
Kyphosis
X-ray finding
increased convexity or outward curvature of upper and lower
back
Scoliosis
lateral or side to side curvature of spine
Lordosis
outward arch or curving of lower back
Kyphoscoliosis
both sideward and outward curvature of lower back

Narrowing of intervertebral joints, osteoporotic, and corrosive changes of
vertebrae; and

Tumors and masses in the spinal canal and surrounding tissues.
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All of the above conditions and diseases produce lower back pain. Spinal x-ray is most
helpful in their differential diagnosis (103,104,105).
It is also helpful to know which conditions and diseases cannot be ruled out by spinal xray. This is especially true when the lower back pain is due to injury to the soft tissues,
muscles of the lower back, and spinal nerves since these structures are not clearly
visible on X- ray films. Examples include (103,104,105):

Sciatic neuritis:
this is characterized by burning and electrifying pain that radiates from the lower
back-gluteal region-hamstring muscles-leg-foot;

Disc prolapse:
this is due to the degeneration of intervertebral discs that slip into the
intervertebral foramen, which put pressure on the spine and cause pain; and

Spinal stenosis:
the narrowed spinal cavity compresses the spinal nerves and causes lower back
pain.
There are several reasons why x-rays are the most frequently ordered imaging study.
They are advantageous to use in clinical settings because they are (103,104,105):

Rapid

Cheap

Non invasive, non surgical

No much preparation required before x-ray is performed

Easily available

Universal
Spinal x-rays also have several limitations and disadvantages, namely (103,104,105);

Exposure to hazardous ionizing radiation

Risk of radiation exposure such as congenital malformation, cancer, tumour,
growth retardation, and infertility;
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
Minimal diagnostic value in lower back pain when the pain is due to soft tissue or
nerve involvement since these structures are not clearly visible and identifiable
on x-ray films.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure, as follows:

Patient may be asked to lie down on the x-ray table or stand during the
procedure.

Patient must remain still in proper position during the procedure to avoid blurry
images.

Ornaments, metals objects, and all other radio-opaque substances must be
removed.

Pregnant patients with lower back pain should not undergo x-ray procedures.

Very young children should not be exposed to x-rays since the radiation may
retard their growth.

Efforts are made to ensure that the patient is only exposed to the minimum
amount of radiation

If only the lower back requires radiation exposure, then other body parts are
covered by special clothes and materials to avoid unnecessary exposure.
Myelography
Myelography is an invasive procedure which enhances the diagnostic value of x-rays
and CT scan of the spinal cavity using contrast dyes. They are generally referred to as
special x-ray studies of the spinal cord and canal.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:

Ornaments, metallic pins, mouth dentures and other metallic objects are
removed prior to the start of myelography.
The steps of the procedure are enumerated below (103,104,106):
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1. The patient lies on the stomach on the x-ray table while the site of injection is
selected and cleaned.
2. Local anaesthetic agent is administered to the selected site of injection.
3. A barium or iodine contrast dye is injected into the lower spinal canal with the
help of a spinal needle. Specifically, it is injected into the subarachnoid space.
4. Needle is withdrawn. The x-ray table is tilted downwards to allow the dye to flow
freely through the spinal canal.
5. An x-ray or CT scan of the lower spinal canal is taken.
6. Lastly, the patient is released and advised to keep the head elevated. The dyes
are flushed out through micturation and defecation within the next couple of days.
Flouroscopy is used to project these radiographic
images into video format onto the computer
screen. These images taken are known as
myelograms. The barium or iodine dye highlights
the injured areas of the spinal cord, nerve roots,
blood vessels, and subarachnoid space on the
x-ray images. CT myelography can also be
immediately performed while the dye is present in
the spinal canal.
Conditions and diseases diagnosed using myelography are those associated with
abnormalities of the spinal cord, nerve roots, surrounding meninges, and intervertebral
discs, namely (1, 2, 4):

Herniation and protrusion of intervertebral discs which put pressure on spinal
nerves and nerve roots, causing pain;

Spinal stenosis;

Excessive osteophytes , bony spurs, and thickened ligaments;

Malignant and benign tumors in the spinal canal;

Inflammation of the sacroiliac joints;

Inflammation of the arachnoid membrane; and

Infected vertebra, intervertebral discs, meninges, and other soft tissues.
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There are several reasons why myelography is advantageous to use in clinical settings,
namely (103,104,105);

It enhances the diagnostic value of X- ray and CT scan by highlighting the lessvisible structures;

It is useful in patients in whom MRI is contraindicated such as patients having
pacemakers and hearing aids; and

It is useful in people who are candidates for lower back surgery and have
inconclusive diagnostic test results.
Myelography also has several disadvantages, namely (103,104,105):

Exposure to ionizing radiations;

Contrast dyes such as barium and iodine can cause allergic reactions in patients
who are allergic or idiosyncratic to these dyes. Signs and symptoms such as
fever, headache, itching and redness on skin, gastritis, nausea, vomiting,
sneezing asthmatic wheezing, difficult micturation and defecation are indicative
of allergic reaction. Serious side effects such as convulsions occur but rarely
following myelography;

Inflammation, bleeding, and infection may occur at the site of injection;

The administration of dye (injection) can sometimes cause pain leading to patient
anxiety; and

Soreness at the site of injection.
The limitations of myelography are listed below as:

It cannot be performed on patients with known allergy to contrast dyes;

It cannot be performed on patients on antidepressant and antipsychotic drugs
since these react with iodine and barium dyes, causing serious side effects;

It cannot be performed on patients with congenital or acquired structural
abnormalities of the spine because of the lack of available safe injection site;

It must be cautiously performed on patients with bleeding tendencies such as
those who are on anticoagulant medications (e.g. warfarin and aspirin);

It is hazardous to pregnant patients as both dye and radiation can harm them;
and,
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
Its diagnostic value in pinpointing the exact cause of lower back pain is only
limited to associated conditions and diseases within the spinal canal.
Computed tomography scan (CT scan)
CT scan is a medical imaging procedure that makes use of computerized x-rays to
obtain tomographic images of specific areas of the body. The images produced are
three-dimensional (3D).
CT produces a volume of data that can be manipulated in order to demonstrate various
bodily structures based on their ability to block the x-ray beam.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:

Metallic pins, ornaments, mouth dentures, and other metallic objects must be
removed;

Patient is required to wear loose and comfortable clothes; and

Patient is laid on the examination table which slides into the CT scanner. Once
inside, the patient must remain still while images are being captured.
The scanner is equipped with x-ray throwing tubes and a detector which detects the
amount of radiation absorbed by the organs and
body parts. Modern computers process the data
and produce cross-sectional and two-dimensional
detailed
images
of
the
intervertebral discs, soft
spinal
vertebra,
tissues, and blood
vessels. If a radiocontrast is to be used, clinicians
need to ascertain the absence of patient allergies
to the specific dye and drugs used.
The specific diseases and conditions associated with lower back pain which can be
diagnosed using CT scan are (103,104),107):
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
Structural damage to the spine, vertebra, intervertebral discs, soft tissues, and
muscles;

Degeneration of spinal structures including the spinal canal;

Benign and malignant tumors in and around the vertebral column;

Metastatic overgrowth in the vertebral column from pelvic organs such as the
prostate;

Protrusion of intervertebral discs;

Osteoporotic and senile degeneration of the spinal canal in the elderly.

Fragility of lumbosacral and iliac bones and joints;

Congenital structural abnormalities of the spine;

Spinal stenosis;

Arthritic conditions affecting the spinal bones and joints; and

Abscess in the lower back
CT scan has the following advantages (103,104,107):

Very reliable

Relatively simple

Quick

Non-invasive

Pain-free

Safe for patients with implant such as pacemakers, stents, and hearing aids

Convenient follow up on the post-surgical status of the spine

A biopsy specimen from any part of the lower spine can be taken with the help of
CT scan. This is especially useful in cases where the presence of malignant cells
in the spinal canal is strongly suspected.
The limitations of CT scan are listed below as (103,104,107):

It is not safe for pregnant patients due to the possibility of fetal exposure to
ionizing radiation;

It is not recommended in growing children since it can retard growth;

The use of contrast dyes is not recommended in nursing mothers since these
can be transmitted to newborns via breast milk; and
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
Barium and bismuth metals interfere with generation of clinically useful images.
Magnetic resonance imaging (MRI)
An MRI scan is a non-invasive imaging test that uses powerful magnets and radio
waves to create images of the body. Unlike the previous diagnostic imaging studies
discussed previously (spinal x-rays, myelography and CT scan), it does not use
radiation (x-rays). It is considered to be a very accurate test for diagnosing specific
causes of lower back pain.
A single MRI image is called a slice, which may either be stored on a computer or
printed on film. A single MRI exam can produce dozens of images. The MRI chamber is
the cylindrical tube structure that creates magnetic, radio waves that surrounds the
patient’s body.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:

Metallic pins, glasses, ornaments, and piercings must be removed from the body;

Patient is required to wear loose and comfortable clothes;

Patient must remain still during scanning. Very young children may be sedated, if
necessary.

The patient is laid on the examination table which is passed through the MRI
chamber. The magnetic waves generated bring the water molecules in the spinal
and muscle tissues into correct alignment.
The radio waves are then passed through spinal
tissues, vertebrae, and muscles. They identify the
relaxation and random movement of molecules
within the spinal tissues from the inline alignment
created by magnetic field. The resonance and
signals created are processed by the computer
scanner which then produces three dimensional
(3D) images of the spinal vertebrae, intervertebral
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discs, intervertebral space, cerebrospinal fluid, spinal muscles, and other tissues. The
images of spinal canal are visible on sagittal, axial, and coronal planes.
In cases where a radiocontrast is needed to enhance the images of an MRI scan, the
dye used is gadolinium which is injected into the spinal canal via an intravenous
administration.
The specific diseases and conditions associated with lower back pain which can be
diagnosed using an MRI scan are (103,104,108):

Protrusion and herniation of degenerated intervertebral discs;

Abnormal structural deformity of the spinal canal;

Abnormal alignment and position of the spine such as kyphosis, scoliosis,
lordosis, and kyphoscoliosis;

Compression fractures;

Nerve root compression;

Benign and malignant overgrowth, tumors, soft tissue masses;

Metastatic malignant cells in the spinal canal from pelvic, rectal, respiratory or
abdominal organs

Severe prominent inflammatory changes to the spinal cord; and

Abnormalities of the spinal nerves affecting the muscular movement.
An MRI scan of the spine has the following advantages
(103,104,108):

Safe;

Accurate and reliable;

High diagnostic value;

Clear view of the spinal canal regardless of the type and severity of disease and
injury;

Spinal surgeries immediately following an MRI scan can be performed;

Post surgical improvement and deterioration of spinal conditions can be
assessed quickly;

Bleeding, infections, and scarring post surgery can be easily seen;
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
Helpful in pinpointing exact locations of injection sites of steroid medications in
patients with chronic back pain; and,

No allergic reactions to the contrast dye are seen. Gadolinium does not trigger
allergic reactions unlike other contrast dyes (e.g. iodine, barium) used in other
imaging studies.
An MRI scan is also associated with a few adverse effects, namely (103,104,108);
a) Drowsiness and dizziness following administration of gadolinium;
b) Abnormal functioning of the implanted metallic equipments such as pacemakers,
artificial joints, and stents due to exposure to magnetic waves; and
c) Claustrophobia in vulnerable patients when delivered inside the MRI chamber.
The limitations of an MRI scan are (103,104,108):
a) It is not recommended for pregnant patients due to possible fetal magnetic wave
exposure;
b) Contrast dyes are not recommended for use in nursing mothers since they may
be ingested by the feeding infant through breast milk.
c) Heightened sensitivity to movement which requires the patient to be still
throughout the entire scan to avoid production of blurry images;
d) Lesser diagnostic value than CT scan and spinal x-rays in vertebral fractures and
injuries;
e) Longer procedure duration;
f) Greater patient expense.
Electrodiagnostic test
Electrodiagnostic tests make use of the electrical signals that are produced by nerves
and muscles and delivered to the brain. Injuries and diseases interfere with the
conduction of these signals and are measured using three specific testing techniques,
namely:
a) Electromyography (EMG)
b) Nerve conduction velocity (NCV)
c) Evoked potential studies
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These tests determine the following (103,104,109):

Presence or absence of trauma to the spinal nerves;

Onset and duration of injury;

Extent of nerve damage i.e. whether it is reversible or not;

Exact location of the nerve injury;

Extent of muscle damage i.e. whether the muscles are weakened, flaccid or
paralysed;

Integrity of motor and sensory pathways i.e. absence or presence of neurological
deficits.
Electromyography (EMG)
Electromyography is one type of electrodiagnostic test. Also known simply as
myography, it is a minimally invasive procedure that makes use of fine needles placed
in a specific muscle to record its electrical activity. The test determines the ability of
spinal muscles such as latissimus dorsi, sacrospinalis, and gluteal muscles to respond
to nerve stimulation. The muscular responses are represented in a graph or numeric
form on the computer monitor.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:
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
The patient must be asked about any medical history of coagulation disorders or
bleeding tendencies such as haemophilia. If present, this procedure must be
avoided.

Implant devices such as pacemakers, stents, and shunts can interfere with the
results of the procedure.
EMG must be carried out in a warm room since chilly and cold temperatures can alter
the muscular response to the test. Fine pointed needles (electrodes) are pricked into the
spinal muscles, after which the patient is told to move, flex, extend or contract the
muscles of lower back. These actions stimulate the nerve cell, eliciting a spinal
muscular response.
Normally, when the spinal muscles are at rest or healthy, no
electrical response is seen. But when the spinal muscles flex, contract or diseased,
varying degrees of electrical response are seen. These responses can help determine
whether the spinal muscles are bending forward and backward properly or not, and
healthy or injured.
EMG to the lower back is suggested to the patient when he/she has following symptoms
are (103,104,109):
a) Cramping, burning, sharp pain in lower back and lower extremities;
b) Weakness, flaccidity in lower back muscles; and
c) Tingling, numbness in lower back and lower leg, feet.
Conditions and diseases causing lower back pain that can be diagnosed with the help of
EMG are listed below as (103,104,109):

Sciatic Nerve dysfunction;

Femoral nerve dysfunction;

Peripheral neuropathies;

Neurological dysfunction and muscular dystrophy due to associated disease
complications such as AIDS;

Muscular dystrophy and degeneration in auto immune disease such as
myasthenia gravis;

Nerve root impingement; and
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
Polio.
The advantages of EMG in diagnosing causes of lower back pain are as follows (1,2,7):
a) It requires minimal piercing, and,
b) It elicits minimal pain
EMG is also associated with a few adverse effects, namely (103,104,109):

Pain and discomfort in highly sensitive patients and young children;

Prolonged pain and tenderness lasting a few days following the procedure;

Bleeding tendencies in hemophilic patients; and

Infections at the needle piercing site accompanied by altered blood count.
The limitations of a EMG are (103,104,109):

It should be very carefully performed or avoided in patients on anticoagulant
drugs such as warfarin and aspirin; and,

Muscular responses vary from person to person

NSAIDs such as like ibuprofen and naproxen can alter the results of the test.
Nerve conduction velocity (NCV) test
The nerve conduction velocity (NCV) test determines the speed and power of electrical
impulses travelling through nerves. Unlike EMG, it is a non-invasive procedure.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:

Patients must avoid stimulants such as coffee, drugs, alcohol, and tobacco
because they alter nervous and muscular functions. Abstinence of at least 3
hours is needed.

The test is safe for hemophilics and those on anticoagulant therapy.
The test must be conducted in a room that is warm and comfortable since chilly
temperatures can alter the nervous response.
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The NCV test is carried out using two rods which
are placed on the skin and muscles of the spine.
The first rod is used to send out impulses to
stimulate the nerves being tested. The result is a
mild electric shock. The second rod transfers the
response produced by the nerves to the first rod.
The transferred stimulus is recorded on a
computer monitor. The speed and time at which
the signals used to reach one electrode from the
other is also recorded.
The results of the test depend on several factors, namely (103,104,109):

Anatomy and health of the nerves

Diameter of nerve, and

Layer of fat surrounding the nerve
NCV is indicated in persons with the following signs and symptoms (103,104,109):

Tingling, burning, and electric shock-like pain in the lower back and extremities,

Hyperaesthetic lower back, and

Chronic pain in the lower back and legs.
The conditions causing lower back pain that can be diagnosed with the help of NCV are
spinal nerve damage and dysfunction such as (103,104,109):

Pinched nerves

Femoral nerve dysfunction

Myopathies in diseases such as myasthenia

Lambert Eaton Syndrome

Spinal code damage

Spinal nerve root damage

Disc prolapse

Conduction block

Axonopathy
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
Demyelination
The benefits of NCV are as follows:

It is non-invasive

It can be easily done in both adults and children
The major limitation of NCV is that healthy nerve cells are best detected, possibly
masking damaged spinal nerves through normal NCV test results.
Evoked potential (EP) studies
EP studies are done when there is a confirmed involvement of the central motorsensory nervous system in the pathology of lower back pain.
EP studies are done when the patient presents with the following manifestations
(103,104,109):

Neurological symptoms such as burning, stinging, and electrifying pain in the
lower back

Unable to stand or bend too long

Unable to bend forward or backward easily due to pain, weakness and
tenderness in spine
There are two types of evoked potential studies, namely:
1) Somatosensory EP studies,
2) Laser evoked EP studies, and
3) Dermatomal EP studies
There are two rods used in EP studies. One rod is used to stimulate the nerves and
transmit sensations from the periphery to the centre. The other rod is placed on the top
of skull to measure the velocity at which these sensations reach the brain. Essentially, it
is the sensory pathway of the spinal nerves that is stimulated in somatosensory evoked
potential studies. In dermatomal evoked potential studies, rods are placed anywhere on
the skin, along the sensory pathway of spinal nerves.
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EP studies are helpful in determining the location of nerve damage, i.e. whether it is in
the motor system (conduction from centre to periphery) or in the sensory system
(conduction from periphery to centre) (103,104,109):
The conditions and diseases diagnosed with the help of EP studies are (103,104,109):

Radiculopathy of spinal cord

Spinal compression
In somatosensory evoked potential studies, a delayed response found from the proximal
nerve roots indicates damage of the S1 (sacral) spinal nerve root. The delayed
response is seen in the form of H reflex on the screen. H reflex provides reliable
information on the involvement of S1 nerve root in lower back pain. Damage to S1
spinal nerve roots can sometimes be seen in the form of F waves.
Laser evoked potential (LEP) studies
LEP studies, as the name suggests, makes use of infrared laser stimuli that is passed
on to the spinal canal to create clear images
(112).
The major limitation of evoked potential studies is its lack of usefulness in diagnosing
causes of acute back pain. Its clinical value is most apparent in the diagnostic
evaluation of chronic pain (112).
Bone scan
A bone scan is an invasive procedure that makes of radionuclides to create images of
bones. It is also known as bone scintigraphy.
Prior to the procedure, the radiographer and clinician need to inform the patient of the
following information about the procedure:

Patient is asked to urinate prior to the start of the procedure since the presence
of urine in the bladder can interfere with the proper visualisation of pelvic bones.

Metallic ornaments, pins, and piercings should be removed prior to the scan.
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The procedure proceeds as follows:
1. Site of the injection is chosen and cleaned.
2. The radioactive dye, also known as radioactive “marker” or “tracer”, is injected.
3. Patient is passed through the scanner machine for the bone scan three hours
after the injection of the radioactive dye.
4. Patient positions are altered to allow scanning from different angles.
5. After the procedure, the patient is asked to drink copious amount of water to flush
out the radioactive dyes.
An even distribution of the radioactive dye into the pelvic bones generally means the
structures are healthy. There are certain regions of the bones that absorb very little, if at
all, any of the radioactive dye. These regions do not appear on the image generated by
the scanner, and are referred to as dark or cold places. On the other hand, the regions
which absorb and accumulate any of the radioactive dye will appear on the image, and
are referred to as bright or hot places.
The abnormal distribution pattern of radioactive dyes used in the bones is indicative of
pathologies related to bone metabolism of the spinal bones (103,104,110).
The conditions and diseases diagnosed with the help of bone scans are as follows
(103,104,110):

Ischemic and necrotic bones such as those seen in multiple myeloma wherein
plasma cells multiply in malignant manner;
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
Inflammatory conditions which appear as bright regions. These regions indicate
rapid growth and repair such as those seen in arthritis, over growth of spinal
bone, tumors in bone tissues, and infection;

Paget’s disease involving the spinal vertebrae;

Diffuse and occult injuries to the spinal vertebra. Stress fracture or compressed
fractures often seen in athletes;

Osteoporosis, osteomalacia, and osteodystrophy;

Altered blood metabolism and decreased blood supply to spinal bones;

Structural spinal bone
changes
due
to
metabolic disorders such
as
hyperparathyroidism; and,

Metastatic activity of adjacent malignant cells involving the prostate, mammary,
renal, and pleural tissues.
The benefits of bone scans in diagnosing causes of back pain are (103,104,110):

It helps determine the onset of the injury.

It helps in the visualization of spinal bones which are not normally seen in x-rays.

It is instrumental in the early diagnosis of spinal bone lesions.

It can help the clinician find the exact cause of lower back pain that was
otherwise missed by other diagnostic tests.
The disadvantages of bone scans are (103,104,110):
a) Its invasive nature may prove to be painful and uncomfortable for young children
and patients highly sensitive to pain;
b) The use of radioactive dyes can trigger allergic reactions in vulnerable and
idiosyncratic patients. Reactions may vary from mild to severe and manifest as
skin rashes, irritation, headache, blurred vision, nausea, vomiting, fever, and
convulsions.
The limitations of bone scans are (103,104,110):
a) It is not safe to use on pregnant patients because of the use of radioactive dyes
which can cause serious fetal harm.
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b) It is not safe to use on nursing mothers since the radioactive dye can pass
through breast milk and be ingested by feeding infants.
c) It requires a gap time of about 4 days before it can be performed in patients who
previously underwent diagnostic tests using bismuth and barium.
d) Its inability to distinguish structural lesions clearly. CAT scan, MRI or tissue
biopsy is required following the bone scan to study these lesions further.
e) It is a time-consuming procedure, with the preparation taking about 3-4 hrs and
the scan about 1 hr.
Thermography
Thermography, also known as digital infrared thermal imaging (DITI), is a non-invasive,
non-contact diagnostic imaging method that uses body
heat to capture images of the body structures.
Thermography
uses
infrared
rays
detectors
to
determine the relative heat and temperature of tissues.
Altered heat is indicative of disease or pathology which
causes pain. Every organ has different temperature in
the body and temperature in the left and right portions
of the body is also different. Since every tissue can
generate its own heat, small alterations in the heat signatures of organs and tissues is a
red flag, indicating infection or pathological damage.
The initial cause of pain can be identified using thermography. The pain intensity level is
recorded and presented graphically on the screen. It determines whether the pain is due
to abnormalities in the spinal canal or pathology involving the surrounding tissues. It
also determines whether the pain is referred from other tissues or is limited to a local
area (103,104,111).
The conditions and diseases diagnosed with the help of thermography are
(103,104,111):

Injury to spinal muscles, ligaments, tendons and other soft tissues of the body

Infection such as abscess in the spinal muscles, and tendons

Inflammation of the spinal canal and surrounding tissues
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
Nerve root compression. Nerve damage due to compression will show a
decreased temperature in that zone on the screen.
The benefits of thermography are:

It is safe to use in both children and adults

It is relatively easy and comfortable for patients

It is painless

It is non-invasive

It can be safely performed on pregnant women since no harmful ionizing
radiations and magnetic waves are used

It can be safely performed on very young children who cannot narrate verbally
their exact signs and symptoms

It helps in distinguishing the pain into two types, based on their sites of origin
The two types of pain distinguishable by thermography are
(103,104,111):
1. Type 1 (specific pain): severe pain due to involvement of the spinal cord
2. Type 2 (non-specific pain): less severe pain usually due to muscular overload,
muscular sprain, over stretching of muscular tissues, and ligament injury.
Ultrasound
Ultrasound, also known as sonography,
is a non invasive method that transmits
high-frequency sound waves, through
body tissues. The echoes are recorded
and transformed into video or images of
the internal structures of the body. They
create images of soft tissue structures,
such as the gall bladder, liver, heart,
kidney, female reproductive organs, and
blockages in the blood vessels.
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In diagnosing causes of lower back pain, sound waves are thrown on the spine and
surrounding tissues through a probe. The echoes produced and reflected from the
spinal tissues are converted into black and white images on the monitor. The Doppler
technique can be used in conjunction with ultrasound to determine the amount of blood
circulation to the spinal canal and its surrounding tissues (e.g. presence of ischemic
disease).
The following conditions and diseases are diagnosed using ultrasound:

Injuries to the tendons, ligaments and other soft tissues

Ischemic condition of the spinal canal
The benefits of ultrasound in lower back pain are (103,104):

It is useful in determining the proper site for insertion of needle and catheter in
the spine (epidural space). Catheters are inserted into the spine for the
administration of anesthetics prior to various spinal surgeries such as Caesarean
Section and abscess removal from the spine.

It is instrumental in determining the correct location and depth of spinal needle
insertion during surgical removal of epidural abscess and biopsy of spinal
tissues.

It is a useful diagnostic tool in obese children and adults with scoliosis, kyphosis
or kyphoscoliosis prior to corrective spinal surgery.
A major drawback of ultrasound is its inability to visualize bony congenital deformities
and injuries (e.g. fractures) that cause lower back pain. Bones are not visible via
ultrasound (103,104).
TREATMENT AND MANAGEMENT
The treatment and management of lower back pain consists of five general approaches,
namely. These are listed below and discussed in detail in this section.
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1. Physical therapy
2. Surgical interventional therapy
3. Non-surgical interventional therapy
4. Pharmacotherapy
5. Alternative therapy
Physical and
alternative
therapies
Acupuncture
Traction
Exercises
Surgical
interventional
therapy
Vertebroplasty
Foraminotomy
Kyphoplasty
Spinal
manipulation
IDET
TENS
Spinal laminectomy
Ultrasound
Biofeedback
Nucleoplasty
Radiofrequency
lesioning
Non-surgical interventional
therapy
Pharmacotherapy
Spinal cord stimulation
Epidural steroid injections
Facet joint corticosteroid
injections
Botulinum injections
NSAIDs
Weak opioids
Strong opioids
Spinal fusion
Discectomy
Anticonvulsants
Antidepressants
Other
off-label drugs
Cognitive
behavioral
therapy
General guidelines for treating lower back pain
Low back pain is undoubtedly one of the most commonly encountered medical
problems, and in the United States it is estimated that an annual cost of over a $100
billion in spent either directly or indirectly for diagnosing and treating back pain. For this
reason, local guidelines have been developed to thoroughly investigate and treat
conditions causing back pain. The overview of these guidelines includes a thorough
history of current and past problems, the nature and duration of which should be
ascertained, and also a detailed examination of the back at the initial visit.
The doctor should ask patients for any alarming manifestations that may indicate a
serious underlying disease; these signs and symptoms are called red flags. Red flags
for back pain include history of trauma, cancer, unintentional weight loss, use of
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immunosuppressive drugs (including steroids), AIDS, IV drug usage, osteoporosis, age
more than 50 years, focal neurological deficits, and also history of pain progression.
With the above information, the clinician will then be able to make more sense of the
patient’s pain symptoms. The clinician can categorize the patient to having either
nonspecific lower back pain, lower back pain secondary to radiculopathy or spinal
stenosis, or low back pain secondary to a specific cause (which is indicated by
presence of red flag symptoms).
Once the cause has been identified, evidence-based order sets will help the physician
guide the patient through the assessment, and management and follow up plans. A
follow up evidence-based order sets should again be obtained after 4 weeks of therapy
to help the physician assess the patient’s symptom progression or lack thereof, and
make appropriate clinical decisions such as whether to pursue further therapy or
consider other therapeutic interventions.
There are various management guidelines that clinicians can follow to assess patients
with back pain. One example is the UK’s National Institute of Health and Care
Excellence (NICE) Pathway for low back pain below (71): The evidence based order sets
contain valuable information on the need for targeted therapy of specific conditions
causing lower back pain. Specific causes of low back pain that are not covered in the
NICE pathway are malignancy, infection, fracture, and ankylosing spondylitis and other
inflammatory disorders. A clinician who suspects that there is a specific cause for their
patient's low back pain should arrange the relevant investigations
(71).
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As mentioned in the “Diagnosis” section, MRI should only be ordered for non-specific
low back pain in the context of a referral for an opinion on spinal fusion. The clinician
should consider MRI if one of these diagnoses is suspected (71):

spinal malignancy

infection

fracture

cauda equina syndrome

ankylosing spondylitis or another inflammatory disorder.
After a thorough assessment, the clinician can then provide patient counseling to
promote self-management of pain. Topics to be discussed include but are not limited to
the following (71):

information on the nature of non-specific low back pain,
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
activities that may help strengthen muscles and alleviate the pain.
Essentially, clinicians need to encourage patients to stay physically active and to
exercise. They should include an educational component consistent with this pathway
as part of other interventions. When considering recommended therapies, clinicians
need to take into account the patient’s expectations and preferences, though this might
not always predict a better treatment outcome (71).
Generally speaking, nonspecific low back pain that is not associated with the presence
of any red flags and is experienced for less than 6 weeks can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, and
paracetamol. If the physician deems it necessary, a second option is available with the
use of weak and strong opioids. They should be offered pamphlets/leaflets that help
educate them about their condition and choice of occupational or physical therapy. They
should be re-assessed after 6 weeks following the initial assessment and start of
therapy (71).
Similarly, patients who present with low back pain that is secondary to radiculopathy or
spinal stenosis can be treated with the aforementioned medications, and in certain
cases with gabapentin.
Patients who present with the above mentioned red flags should be assessed
thoroughly with imaging studies and laboratory tests. Patients with suspected fractures,
bone infections such as discitis and osteomyelitis, and malignancy are the group most
likely to benefit from this extended diagnostic assessment. Depending on the clinical
scenario, a number of different tests may prove beneficial. Typically, MRI scans with or
without contrast are adequate imaging modalities that help pinpoint the underlying
musculoskeletal causes. In cases where MRI scans are unavailable or contraindicated,
CT scans may be used instead. For suspected specific conditions, technetium bone
scan, lumbar spine radiography, and inflammatory marker tests like erythrocyte
sedimentation rate (ESR) and/or C-reactive protein may also be performed.
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In cases where a patient exhibits progressive symptoms or presents with focal
neurological deficits, further imaging studies may need to be performed. These studies
may include (in addition to MRI) myelography and postmyelography CT of the lumbar
spine. A further need for lumbar spine CT with or without intravenous contrast may also
arise. In certain other cases, electromyography/nerve conduction velocity studies may
also need to be performed for accurate diagnosis (72).
It is expected that these guidelines would reasonably provide an appropriate assistance
in developing a care plan that significantly benefits the patient by reducing the number
of unnecessary imaging studies. This would reduce the inappropriate use of narcotic
and opioid drugs, and also by potentially decreasing the number of unnecessary and
inappropriate invasive procedures.
Ice and Heat
The treatment of back pain depends on a number of factors such as its cause, type,
duration, and severity.
Ice and heat packs are common and effective methods of
treating acute and sometimes sub-acute back pain. Heat packs are typically not
recommended when swelling accompanies back
pain especially immediately after the occurrence of
injuries. Heat causes vasodilation, which may
increase the swelling. In the initial hours (up to 4872) following an injury, ice or cold packs can be
placed on to the affected area to reduce the pain.
Swelling or inflammation ensues following direct
trauma to the blood vessels of the back. Swelling
occurs when blood leaks from the damaged
capillaries and accumulates in the surrounding tissue spaces; this causes the visible
swelling. Ice or cold packs help constrict the blood vessels and reduce the extravasation
of serum and blood, which in turn reduces the inflammation. Once the swelling dies
down following application of cold packs, the pain also significantly goes down. First aid
responders will do well to remember not to place ice packs in direct contact with the skin
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since doing so predisposes the patient to the risk of cold burns or frostbites. Placing a
cloth between the two surfaces and limiting the amount of cold exposure minimizes this
risk. Ice packs should be placed for 15-20 minutes up to 3-4 times a day. It is generally
recommended to alternate the use of ice and heat packs in order to provide immediate
optimum pain and inflammatory relief.
As mentioned previously, heat packs are best avoided in the initial hours of injury as it
causes further vasodilation of the vessels, which encourages further tissue
inflammation. However, once the inflammation has reduced, heat packs and electric
heat pads may then be used to treat the pain. Electric heat pads should be started and
maintained on low temperatures to avoid
burns. Other effective methods of delivering
heat
include
hot
water
bottles,
microwaveable gel packs, saunas, and
treatment with steam. Some people have
also reportedly benefited from taking hot
showers.
Studies show that heat therapy can have
the most prominent effects during the first
week following an injury. Evidence also suggests that superficial heat therapy can help
with acute and sub-acute lower back pain especially if it is accompanied by proper
exercise, which improves musculoskeletal function
(73).
A trial conducted in 90 patients
showed significant relief of acute back pain following application of heat blankets. There
is however conflicting evidence to suggest the superiority of either treatment (ice and
heat) in opposition to one another (74).
Bed Rest
Bed rest is commonly advised or sometimes self-prescribed by many individuals
following acute lower back pain to reduce the pain and muscle stress. However, no
significant evidence exists to suggest that bed rest benefits patients suffering from acute
lower back pain. On the contrary, some evidence actually point towards the opposite i.e.
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it is actually slightly advantageous to stay active through mild exercises in these
circumstances. Studies have verified that patients suffering from lower back pain and
sciatica actually experience greater pain intensity and decreased functional recovery
following bed rest (75).
Exercise
Exercise has innumerable health benefits, which include improved cardiovascular
functioning, reduced risk of chronic illnesses such blood pressure, type 2 diabetes, renal
disease, and even certain types of cancers. It has also been shown to be beneficial in
improving self-esteem, regulating mood, and improving symptoms of depression.
Similarly, patients with lower back pain can benefit from daily-targeted exercises
through improved functionality and reduced pain symptoms. However, it should be
remembered that the type of exercise plays an important role in determining the benefits
of exercise on patients. Additionally, the type of back pain also determines which
exercises must be avoided.
Targeted exercises are generally recommended and to be started within 1-2 weeks after
onset of initial pain symptoms. Patients should keep in mind to always start with mild
exercises and to avoid activities that increase their pain intensity. Specifically, patients
with lower back pain will do well to remember to stay away from high impact exercises
such as running since it can very well exacerbate the pain. Exercises with maneuvers
that target the trunk region are also best avoided in the initial couple of weeks following
the onset of symptoms.
It is also important for to patients stick with light to moderate exercises. Low impact
aerobic exercises and swimming are generally advised. Exercise techniques usually
target endurance, strength, and flexibility. The techniques used in these exercises
augment the physical capacities of patients, and strengthen their muscles.
Some of the popular exercise routines that benefit patients with back pain are described
below
[76].
These exercises are generally best started only following the advice of a
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clinician or physical therapist. Additionally, patients are advised to stop if they develop
pain at any time during the exercises.
Bottom to heels stretch
This type of exercise aimed at stretching and mobilizing the spine. Patients are advised
to kneel on all fours and keep their knees under the hips and hands under the
shoulders. The goal of the exercise is to slowly
retreat the back while maintaining the natural
curve of the spine.
Correct positioning is
mandatory and patients are advised only to
stretch as far as they are comfortable. Patients
with knee problems are advised to avoid this
type of exercise.
Knee rolls
Knee rolls also help in stretching and mobilizing the spine. Patients are advised to lie on
their back while keeping a cushion beneath the
head for comfort. The knees are kept together
and bent. The arms are outstretched with both
shoulders placed on the ground. The knees are
then rolled onto one side followed by a similar
movement of the pelvis. This position is held in
place
for
one
deep
breath.
The
same
maneuver is to be performed on the other side.
The exercise is usually repeated 8-10 times
per side to achieve the beneficial results.
Patients are advised to remember to alternate the exercises between the two sides, as
well as to keep pillows between the knees for cushioning effect and comfort.
Back extension exercises
Back extension exercises also target the spine, stretching and mobilizing its muscles.
Patients are advised to lie on their stomach and prop themselves onto their elbows. The
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shoulders and back are kept in an optimal position by keeping the shoulders drawn
back and the neck elongated and stretched. This position serves to lengthen the spine.
In back extension exercises, patients are advised to keep their hips on the ground and
to avoid bending the neck backwards as this may cause discomfort or worse, injure the
neck muscles.
Deep abdominal strengthening
This is done by lying flat on the back and placing a small cushion beneath the head to
slightly lift it. The knees are bent and the feet
placed hip-width apart. The upper body is
then kept maximally relaxed. The technique
involves drawing up the muscles of the
abdomen and back during exhalation. It
should be remembered that this exercise
serves to gently tighten the lower abdomen
musculature and should not be done using
more than 25% of the patient’s maximum
strength. It is also important to remember to
relax the shoulders and the neck.
Pelvic tilts
These exercises also aim to stretch and strengthen the muscles of the lower back. The
startup position is similar to the one adopted for deep abdominal strengthening in which
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the patient lies flat on the back with a cushion beneath the head and the feet flat and hip
width apart. The patient then proceeds to flatten the back further towards the floor and
at the same time, contract the abdominal musculature and the back gently pushed
towards the feet in order to attain a slight arch of the back. This position contracts the
back muscles. The exercise is repeated, beginning with the starting position. It is ideally
repeated 10-15 times, moving the pelvis back and forth in a subtle rocking motion.
These exercises are believed to help patients alleviate their symptoms of lower back
pain. In fact, there is a study that further supports the beneficial effects of non-weight
bearing exercises such as those mentioned above on females suffering from chronic
non-specific back pain. This study also found that such exercises help improve
functional status, relieve pain intensity, and restore the normal range of motion and
allowing lumbar flexion and extension in females suffering from non-specific chronic
lower back pain [77].
Another study conducted in Canada focused on the use of a specific type of exercise
machine that can help train the back muscles for better endurance. The study showed
the machine to be effective in both healthy individuals and patients suffering from nonspecific back pain. Poor back muscle endurance is often associated with lower back
pain, and is seen to be the group that could benefit the most from this invention
[78].
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Exercises are undoubtedly effective in reducing pain symptoms of the lower back. As
mentioned earlier, there have been studies conducted in the past that show the benefit
of mild to moderate exercises in patients with back pain as compared to bed rest in
terms of improvement in functional status. Moreover, there are no evidence-based
studies that show the superiority of bed rest to exercise for alleviating pain in the same
patient group.
Spinal manipulation
Spinal manipulation, also known as spinal manipulative therapy and chiropractic
adjustment, is a manual therapy technique practiced by many health care professionals
including chiropractors, osteopathic physicians, naturopathic physicians, physical
therapists, and sometimes also by medical doctors to help patients alleviate their
symptoms of lower back pain. The technique involves deliberate delivery of force to the
synovial joints of the lumbo-sacral and sacroiliac regions to treat the related conditions
of lower back pain. The technique is not
limited to these joints and is performed on
other joints in the body for other pain
symptoms (e.g. neck pain).
Spinal manipulation basically refers to the
local application of a single quick and forcible
movement of small amplitude to the targeted
joints. The movement is often termed as a
‘high velocity thrust’, with the patient carefully
positioned prior to its delivery. It is generally considered to be a quick and safe
intervention that has the potential to provide relief from back pain. It is especially
effective in alleviating the symptoms of acute back pain, more so than chronic back
pain.
Despite its popularity, evidence of its effectiveness is debatable i.e. its quantifiable
benefit in the treatment of lower back pain symptoms. There are different approaches
towards spinal manipulation and no solid guidelines have been established owing to the
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varied individual responses to this type of treatment. Some people do not recommend
this treatment at all whereas others recommend it as a last resort treatment in cases
when patients do not respond to other conventional forms of therapy.
A large systematic review conducted to test the effectiveness of spinal manipulation in
treating lower back pain concluded with promising results. The review itself was thought
to be the first of its kind and was published in 2012. It included 6 studies that met the
study criteria. The most prominent results featured in this review included varying
degrees of beneficial effects seen in patients receiving spinal manipulation therapy with
minimal adverse effects being reported. Moreover, it was seen that patients undergoing
spinal manipulation for lower back pain reported less use of pain medication, decreased
visits to health care professionals, and also lower rate of yearly absence from work.
Some of the individual studies analyzed in this review concluded that significant
improvement was seen in disability scores of patient’s up to 6 months post treatment
with spinal manipulation (79).
The review showed that most studies concluded a notable improvement in patients who
underwent spinal manipulation for their lower back pain. However, the degree of
effectiveness varied between patients. Although the review mostly favored the use of
spinal manipulation for lower back pain, it also found one study, which reported the
adverse effects of spinal manipulation. The study particularly showed that non-thrust
manipulation was observed to have a worst outcome than two experimental thrust
manipulation groups
[79,80].
For the purpose of clarification, the non-thrust group
comprised of individuals given posterior to anterior mobilizations to the L4-L5 spinal
processes. Patient feedback on this procedure was largely negative which may be due
to the irritating effects to the patients.
Another systematic review conducted on the adverse effects of spinal manipulation
similarly concluded that serious or severe complications of this procedure are rare [81].
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Many patients also reported improvement in their pain scores for up to four weeks. One
study in particular reported improvement of temporal pain summation in patients
receiving manipulation over lower back extension and stationary cycling.
Another systematic review conducted in the US and published in 2010 showed similar
promising results of spinal manipulative therapy use in patients with acute lower back
pain. This review concluded that evidence from recently conducted trials supported the
use of spinal manipulation in patients with cute lower back pain. Patients receiving 5 to
10 sessions spread over a period of 2 to 4 weeks showed comparable and some even
superior evidence of improvement in acute lower back pain symptoms to other forms of
treatment (e.g. medication, self-management, and exercise therapies). The review even
proposed that patients, not benefitting from self-care alone, to be offered spinal
manipulative therapy as a treatment option by their health care professionals [82].
Another study conducted in Egypt in 2011 showed that patients receiving sustained
spinal manipulative therapy for lower back pain showed greater improvements in their
pain symptoms and disability scores compared to individuals receiving single or short
term sessions. The study was divided into three groups:
1. Group 1:
Patients receiving 12 sessions of spinal manipulative therapy over a month
2. Group 2:
Patients receiving 12 sessions over a month and no treatment thereafter
3. Group 3:
Patients receiving 12 sessions of spinal manipulative therapy over one month
and then maintenance manipulation therapy every 2 weeks for a period of 9
months.
The study concluded that Group 3 patients benefited the most from this technique. Their
pain and disability scores showed marked improvement compared to the nonmaintained group. It also concluded that patients who received no maintenance therapy
following the study period maintained their improved pain and disability scores and did
not revert back to pre-treatment numbers. From this study, it is safe to conclude the
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valuable role of maintenance therapy in patients receiving spinal manipulation for
chronic lower back pain [83].
Non-surgical interventional therapies
Patients with chronic lower back pain who failed to respond to conservative treatment
are strong candidates for interventional therapies. There are two types of therapies that
fall under this broad category; they are namely:

Non-surgical interventional therapy

Surgical interventional therapy
Each one requires an invasive approach to delivering treatment at the target site to
provide pain relief. As mentioned previously, non-surgical interventional therapy
consists of spinal cord stimulation, epidural steroid injections, facet joint corticosteroid
injections, and botox injections.
Spinal cord stimulation (SCS)
Spinal cord stimulation is a procedure performed using a device to deliver electrical
signals to the spinal cord to achieve relief for chronic pain. The device used is called a
spinal cord stimulator.
The procedure involves implantation of stimulating electrodes into the epidural space
and placement of an electric pulse generator in either the gluteal or lower abdominal
region. These two devices, along with a generator remote control, are connected
through wires. There are different theories through which spinal cord stimulation
achieve pain relief. For instance, in neuropathic pain, it has been proposed that it
suppresses hyperexcitability of neurons; thus, changing the local neurochemistry of the
dorsal horn.
Experiments have shown that in such circumstances, there is a decreased production of
excitatory amino acids, aspartate and glutamate, and an increase in serotonin and
GABA (gamma amino butyric acid) levels. On the other hand, this mechanism is not
observed in patients with ischemic pain. When spinal cord stimulation is performed on
patients with ischemic pain, beneficial effects seem to arise from the restoration of
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balance to the oxygen demand-supply of the ischemic area. This in turn may be a result
of sympathetic system inhibition and/or through vasodilation.
Spinal cord stimulation comes with a wide range of complications including:

Infections

Headaches

Paraplegia

Death
Because of the severe complications that can occur from this procedure, however low
their risk may be, it is reserved only as an alternative and last course to conservative
treatment of lower back pain. It has been suggested that patients with persistent and
disabling lower back pain despite undergoing surgery for herniated discs (with no
evidence to support a persistently compressed nerve root), may be good candidates for
spinal cord stimulation. This subset of patients needs to be made aware of the risks and
benefits of the procedure to help them make an informed decision regarding their
treatments. Long and short-term complications of the procedure should be thoroughly
discussed with these patients [157].
Epidural steroid injections
The practice of injecting steroids into the epidural space is a common practice in the
treatment of radicular lower back pain. The goal of the therapy is to provide a strong
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anti-inflammatory (steroid) medication into the space to achieve adequate analgesia. It
is usually given for back pain that is secondary to nerve impingement or disc herniation.
However, it is not a first line treatment option
and should not be given before other treatment
modalities
(including
conservative
management) have been tried and tested.
Patients with radicular back pain that is
secondary to a herniated disc should be
offered a detailed discussion of the pros and
cons of epidural steroid injections as a possible therapeutic modality [157].
Facet joint corticosteroid injection
A facet joint injection delivers a dose of corticosteroid medication into the facet joints to
anesthetize them and block pain perception. The major indications for facet joint
injections include:

Clinical suspicion of facet syndrome

Tenderness over these joints

Chronic lower back pain without radiological evidence of any disease

Persistent pain after spinal fusion surgery
It should be remembered that this treatment modality has not been supported by
evidence-based data as a superior method of
treating lower back pain.
A study published in 2011 supported the use of
facet joint injection as a diagnostic and treatment
modality in chronic lower back pain. It found that
when
these
injections
are
delivered
under
fluoroscopic guidance, they exhibit high accuracy
and effectiveness. It suggested the benefit of facet joint corticosteroid injection in shortterm pain relief. Also, the procedure was found to exhibit very limited long-term benefit
in pain relief [62].
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Botulinum (Botox) injection
Botulinum toxin A (BTX-A) is a substance produced by the bacteria Clostridium
botulinum, a bacteria commonly implicated in food poisoning. It is a neuromuscular
blocking agent that blocks acetylcholine, a neurotransmitter primary responsible for
muscular contractions. The toxin, when injected in small amounts into the painful
muscles, can relieve spasms by interfering with their nerve conduction pathway.
BTX-A’s supposed positive role in pain management was originally only attributed to its
inhibition of acetylcholine release from the synapse, affecting motor endings but sparing
sensory neurons. However, preclinical studies have also
demonstrated the effects of BTX-A on nociceptive neurons,
suggesting its ability to produce analgesia as a secondary
effect that may be the result of muscle paralysis, enhanced
circulation, and release of nerve fibers under compression
by abnormally contracting muscle.
For most limb muscles, motor point stimulation is generally
used to identify muscles, especially the smaller muscles in
the forearm. For the clinician who is new to the procedure, the use of simple, audio-only
electromyography may help enhance the clinician's understanding of functional anatomy
and make informed decisions on injection localization. For muscles requiring
electromyographic guidance, a cannulated monopolar needle cathode, through which
BTX-A can be injected, is used. Surface reference (anode) and ground electrodes
should be placed near the cathode needle (159).
The patient is placed in a position that allows for the targeted muscle to be relaxed so
that the motor point can be easily located. BTX-A is then given after aspiration to
prevent intravascular injection. Alcohol, if used to clean the skin, should be allowed to
dry completely to prevent deactivating the BTX-A. The use of operating rooms or
special procedure (sterile) rooms equipped with monitoring devices for the purpose of
intramuscular injections using small caliber needles is not necessary. Most patients can
be treated safely in an office setting by trained clinicians (159).
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Good quality evidence is missing in supporting the role of botulinium toxins in treating
back pain. However, small-scale studies conducted over the years have reported its
clinical benefits. A Cochrane review identified one study, consisting of 31 participants
that showed BTX-A to be superior to saline injections in the treatment of pain at 3 and
8-week intervals. Patients who received these injections showed marked improvement
in their functional status eight weeks after first receiving them
[160].
Lastly, severe side
effects have also been reported with BTX-A injections, limiting its promising role in pain
management.
In cases where patients do not respond to conservative treatment and non-surgical
interventions, surgical procedures may be the only course of action left to take. Surgical
interventions include but are not limited to spinal laminectomy, spinal fusion,
vertebroplasty, kyphoplasty, discectomy, foraminotomy, and nucleoplasty.
Spinal laminectomy
Lower back pain can range from being mild or dull to irritating, severe, and disabling,
depending on the patient, circumstances, and underlying cause. Patients with disabling
back pain that seriously threaten or undermine their functional abilities (e.g. nerve
damage or bone pathologies that indicate surgical intervention) are generally good
candidates for surgical treatment if their pain is refractory to non-invasive therapies.
One such surgical treatment is a procedure called spinal laminectomy.
Laminectomy is typically performed to release pressure from the spinal column, treat
disc herniation and similar related issues, and to remove tumors that impinged on the
nerves
of
the
spine.
The
procedure basically
comprises of removing the bony posterior part of the
vertebra overlying the spinal column, or the lamina
(85).
The procedure usually requires overnight hospital
stay and depending on the surgeon, may be
performed under general or spinal anesthesia. The nerve compression is released by
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cutting out the bony growths/spurts/tumors. The surgeon may also choose to do a
spinal fusion in the same operation if deemed necessary. This involves the fusion of two
bones to provide adequate support to the spinal column. Although the procedure is
seen to benefit a number of patients with different underlying medical conditions, it does
carry the risk of complications stemming from the use of general anesthesia, surgeryinduced spinal nerve damage, bleeding, infections, and blood clots in the legs and
lungs. There may be other risks not mentioned. In order to be safe, it is always
advisable to discuss the possible risks of the operation with the surgeon in order to
obtain a focused risk assessment pertaining to the patient’s specific underlying disorder
(85).
A study conducted in the UK and published in August 2013 found laminectomy to
exhibit pain-relieving effects on patients with back pain secondary to lumbar spinal
stenosis. These patients also showed a significant decrease in lower back pain scores
as early as six weeks following the procedure, which was sustained up to a year. Lastly,
these patients also reported lower disability index scores (86).
Spinal fusion
Spinal fusion is another surgical technique that involves the fusion or joining together of
two or more vertebral bodies, thereby effectively restricting any movement between
them. This can be done using supplementary bony tissue, from either the patient (auto
graft) or a donor (allograft), to enhance the osteoblastic activity of the bony tissue to
promote fusion.
Spinal fusion is indicated to reduce pain associated with frictional forces of two spinal
bones rubbing together, correct any underlying deformity, and provide greater stability
to a weakened spine. Examples of conditions requiring spinal fusion include (90):

Broken vertebrae (not all vertebral fractures require surgical intervention, in fact
only those causing spinal instability would require spinal fusion)

Deformities of the spine such as kyphosis and scoliosis

Severe arthritis of the spine or spondylolisthesis wherein one vertebra slips
forward on to the vertebra placed below it.
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
Weak spine due to the surgical removal of herniated discs. Spinal fusion
provides stability to the spine.

Chronic back pain that cannot be attributed to a specific disease or disorder.
However,
there
are
controversial
views
about
the
effectiveness
and
appropriateness of this procedure in patients with nonspecific but chronic lower
back pain.
When other surgical interventions are also indicated such as foraminotomy,
laminectomy or discectomy, these are
almost always done prior to the spinal
fusion. The procedure involves the patient
being put under general anesthesia, and
then the surgeon exposing the spine
through an incision on the back (or
sometimes
on
the
side).
The
two
vertebrae are then fused together by
placing the graft material on the back of
the spine or between them. Finally, surgical cages, plates, rods or screws may be used
to hold the vertebrae in place and facilitate proper tissue healing. The surgery usually
lasts between 3-4 hours.
Spinal fusion, like other invasive interventions, is also associated with a number of risks,
namely (90):

Complications due to general anesthesia

Post-operative infections

Poor wound healing

Bleeding

Blood clots

Injury to the adjacent spinal nerves and blood vessels,

Pain may be felt at the site where the supplementary bony tissue was obtained.
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A paradoxical back pain is also a risk associated with spinal fusion stemming from
surgical complications. This happens due to the shift of stress from the fused vertebrae
onto other adjacent parts of the spine, which in turn accelerates the degenerative
process of wear and tear, and ultimately causes back pain.
A systematic review of 25 studies that was published in 2008 found that spinal fusion is
especially clinically useful in patients with degenerative disc diseases such as
spondylolisthesis. Specifically, the study found it to substantially improve disability
scores in this particular patient group. However, the procedure is ineffective in patients
with chronic lower back pain, showing no marked improvement in their disability scores
post-surgery [91].
Although a study published in 2001 in Sweden advocated the use of spinal surgery in
patients with chronic lower back pain [93], a more recent meta-analysis published in 2013
suggests that spinal fusion is no more effective than conservative treatment in
improving disability scores in patients with chronic lower back pain. The review also
states that further studies on the subject are also likely to suggest similar outcomes
[92].
Kyphoplasty
Kyphoplasty, also called balloon kyphoplasty, is used to treat or stop the pain caused by
spine compression fractures or a collapse of the bones. The fractures are usually a
result of osteoporosis (a weakening of the bone), cancer or an injury that caused the
bone to break. The goal is to restore the height of the vertebral body, stabilize the
bones, align the spine and alleviate pain. The procedure may be performed either in a
hospital or an outpatient clinic. Treating one fractured vertebra with balloon kyphoplasty
may only take about an hour (94).
Patients should first consult with the interventional radiologist a few days before the
procedure. Patients may be asked to stop certain medications, such as aspirin,
ibuprofen, non-steroidal inflammatory drugs or blood thinners such as warfarin and
Coumadin. These medicines make the blood hard to clot. If patients are taking any
medication, they should ask their doctor if it is allowed. Patients should inform the
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radiologist and clinical staff members if there’s a chance of pregnancy and allergic
reactions to local or general anesthesia and x-ray dye, which is a contrast media.
Smoking and drinking a lot of alcohol should also be stopped. On the day of
kyphoplasty surgery, patients may also be asked not to eat or drink several hours prior
to the test (94).
On the day of the surgery, patients should wear
comfortable clothes and shoes. They should also
bring a list of their medications and avoid bringing
jewelry and valuables.
The procedure begins with the induction of
anesthesia. First, the back area is cleaned and
sterilized. Local or general anesthesia is then
applied. A small incision is made in the back area
and a hollow needle, called a tracer, is placed
through the incision until it reaches the fractured
vertebra. Interventional radiologist may perform intraosseous venography examination
to make sure that the needle is positioned in the correct area. Most interventional
radiologists, however, skip this part and proceed directly with kyphoplasty (94).
A balloon, also called a bone tamp, is inserted through the hollow needle. The balloon is
then carefully and gently inflated in the vertebral body. A hole or cavity is created and
the bone is pushed back to its normal shape and height. The balloon tamp is then
removed.
After the balloon removal, bone cement (polymethylmethacrylate) is injected under low
pressure into the space or void created by the balloon. Polymethylmethacrylate (PMMA)
quickly hardens and the bone is stabilized. The needle or trocar is then removed. The
skin incision is covered with a bandage.
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The results include the alignment of the spine and restoration of the vertebrae height.
After the procedure, back pain is generally relieved.
To perform the procedure in the correct area, real-time images are needed. Fluoroscopy
is the most commonly used imaging technique. Modern fluoroscopy consists of an x-ray
image intensifier, fluorescent screen and CCD (charge-coupled device) video camera.
After the surgery, patients will be closely observed in the recovery room. Patients can
go home after the surgery but others may choose to spend another day in the hospital.
It is recommended not to drive, unless approved by the doctor. Patients may arrange
transportation from the hospital or outpatient clinic. They should be able to walk after
the surgery but it is recommended to stay in bed for 24 hours. After a day of bed rest,
the patient can return to daily activities but should not do heavy or strenuous work for at
least 6 weeks. If there is pain in the skin incision, ice may be applied to the wound
(94).
One of the advantages of kyphoplasty is that the bone cement, which is
polymethylmethacrylate, used in the procedure is viscous. It thus decreases the
possibility of cement leak into other parts of the vertebra, including the sensitive spinal
cavity (94).
The balloon inflation within the bone reduces deformity, which may lead to hunchback
appearance, for the balloon restores the height of the vertebra. The procedure is also
viewed as minimally invasive which results in less operative trauma and shorter hospital
stays. Patients can usually go home after the operation on the same day. Less tissue
damage and blood loss will result due to smaller incisions.
After the surgery, patients experience less pain; and, in fact, most of them feel painfree. There is also faster recovery and reduced complications after the surgery.
The benefits also include mobility improvement and better quality of life. The patient
does not need physical therapy and can return to normal physical activities.
Consequences of future vertebral fracture are also reduced. The risk of pneumonia is
reduced because the patients can get out of bed after the procedure (94).
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Although balloon kyphoplasty procedure is minimally invasive, there are also associated
risks. Because there is a skin incision, infections may occur. Risks also include allergic
reactions to anesthesia or medication. Bleeding, infection, breathing and heart problems
due to anesthesia may also result.
Malpositioned instruments during the procedure may cause nerve damage and spinal
cord injury. The bone cement (polymethylmethacrylate) used can leak to surrounding
areas. This is not serious unless it moves to dangerous locations such as the spinal
cord and lungs resulting to infections. But these cases are very rare
(94).
Vertebroplasty
Vertebroplasty, like kyphoplasty, is a medical procedure used to treat painful vertebral
compression fractures (VCF) due to osteoporosis, cancer, metastatic tumor or an injury
causing the bone to crack or collapse. The only difference is that in vertebroplasty, no
balloon or bone tamp is used (113).
Osteoporosis, which is mostly the cause of VCF, is the thinning and weakening of the
bones due to the loss of normal density, mass and strength of a bone. This causes
bones to become porous and easy to break. This disease can cause one or more
vertebrae to collapse leading to compression fractures.
Vertebroplasty is also a minimally invasive procedure, which means that it is not as
invasive as an open surgery, for only a small nick on the skin is made. Stitches are not
needed after the surgery, as a band-aid will work.
This procedure may be recommended if a person is
experiencing severe pain for 2 months or more that
is not alleviated by pain medicines, physical therapy
and bed rest. The procedure may be performed in a
hospital or an outpatient clinic (113).
An evaluation of the patient will be performed
including blood test, diagnostic imaging, physical
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exam, spine x-rays, bone scan or MRI. Patients may be given bone-strengthening
medication.
A few days before the surgery, patients should inform their doctor about the medications
they are taking, including herbal supplements, and if they are drinking a lot of alcohol.
Women must also make it known if there is a chance of pregnancy to prevent over
exposure to radiations such as x-ray, which can affect the baby
(113).
Patients may also
be asked to stop smoking and taking medications, such as aspirin, coumadin, ibuprofen,
warfarin and other blood thinning medicines. They should ask their doctor what
medicines are allowed to take.
Several hours before the surgery, patients will be asked not to eat or drink anything.
Medicines given by the doctor may be taken with only a small amount of water. Patients
should wear comfortable clothes and shoes and avoid bringing valuables. Blood tests
will be done to ensure normal blood clot.
Patients will lie down on the table facing down. A monitor will be connected to track
heart rate, pulse and blood pressure. An intravenous (IV) line will be inserted into a vein
in the arm to give moderate sedative medication. Medicines for nausea, pain and
infection (antibiotics) may be given (114).
The back area will be cleaned or sterilized and then shaved. Local anesthesia will be
injected into the skin and tissues near the fracture. A small incision in the skin is made
and a hollow needle called a trocar will be inserted until the tip reaches within the
affected vertebra. To ensure correct positioning of the needle, real-time x-ray images
are used.
Orthopedic cement is then injected. The most commonly used bone cement is the
polymethylmetacrylate (PMMA), which is viscous, toothpaste like material. This bone
cement hardens quickly, usually within 20 minutes. After the cement injection, the trocar
is removed. To check the distribution of bone cement, x-rays may be performed. After
this, pressure will be applied and the skin incision covered with a bandage. The IV line
will then be removed (114).
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Patients may go home after the surgery or may choose to spend another day in the
hospital. It is recommended not to drive after the surgery, so patients should arrange
transportation from the hospital or outpatient clinic prior to the surgery
(114).
They should
be able to walk after the surgery however a 24-hour bed rest is advised. After a day of
bed rest, patients should be able to go back to their normal activities; and, strenuous or
heavy work should be avoided for at least 6 weeks.
To alleviate pain caused by the skin incision, an ice pack may be applied on the skin
covered with cloth. This may be done for 15 minutes per hour. The bandage should not
be removed for 48 hours. Patients should also consult their doctor first before retaking
medications such as blood thinners.
Follow-up visits may be recommended by the interventional radiologist to discuss side
effects experienced by the patient and conduct physical check-up, blood test and
imaging procedure.
Vertebroplasty is a minimally invasive procedure so there is less operative trauma,
faster recovery and shorter hospital stays. In most cases, patients stay only a day in the
hospital or outpatient clinic. Only a small nick in the skin is made, so there is less tissue
damage, blood loss and scarring (114).
Most patients experience immediate pain relief. For others it may take a few days to feel
pain-free. About 75 % of patients who have undergone vertebroplasty have improved
mobility and became more active. Thus, the consequences of osteoporosis are
reduced. The risk of pneumonia is also lessened because patients are able to get out of
bed after the surgery.
Patients can perform normal daily activities without any physical therapy or
rehabilitation. They also need fewer pain medications. In general, vertebroplasty is safe
and effective and results to a better quality of life
(114).
Like any other procedures or
surgeries, vertebroplasty, although minimally invasive, has risks too. During the
procedure, the skin is penetrated, so infections may occur. The risk of infection,
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however, is less than 0.1 %. Allergic reactions to anesthesia, x-ray dye (contrast media)
and other medications may arise (114).
A small amount of bone cement can leak to surrounding areas, which is not really
serious, unless it goes to dangerous locations such as the spinal cavity or the blood
vessels of the lungs. The problem of cement leakage is more common in vertebroplasty
than kyphoplasty (114).
After vertebroplasty, about 10 % of patients may develop additional vertebral fractures.
They may experience relief from pain for a few days after the procedure but the pain
comes back again soon. Bleeding, infection, neurological symptoms and increased back
pain may also occur. Paralysis is a very rare case (114).
Discectomy
A discectomy, also called discotomy or open discectomy, is the partial or complete
removal of herniated, degenerated or ruptured disc that presses on the spinal cord or a
nerve root. The stressing and pressing on the spinal cord can cause much pain.
The spinal column is composed of inter-locking vertebral bones and between those
vertebrae is a flexible, cartilaginous plate called intervertebral disc. Intervertebral disc
acts as a cushion that prevents interlocking vertebrae from rubbing each other and
producing friction, which may cause bone degeneration
(95).
As discussed previously, a herniated disc is the bulging out of the jelly-like, central
portion of the spinal disc called nucleus pulposus as a result of the tear in the outer ring
of an intervertebral disc. In discectomy, the nucleus pulposus is surgically removed.
Age, diseases, lifting injuries, repetitive straining, spine trauma and deformities may
contribute to the tearing and wearing of intervertebral discs. Persons with herniated disc
may experience symptoms such as weakening of the lower extremity muscles, severe
back and leg pain that lingers for 6 weeks or more.
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Abnormal sensations may occur, such as electric shock pains, due to nerve pressure. If
it occurs in the cervical region, the electrical shocks go from the neck down the arms. If
it is in the lumbar region, shocks go from the lower back down the legs. Numbness,
tingling and needles may also be experienced in the same regions. Abnormalities in
bowel movement, urinating and numbness around the genitals may also be experienced
as a result of nerve compression in the lowest region of the lumbar spine
(95).
Physical examinations are performed including testing of muscle strength, reflexes and
sensations. The most commonly used aid in diagnosing herniated disc is the magnetic
resonance imaging (MRI).
Prior to the procedure, patients should inform their doctor regarding any medications
they are taking and whether they have allergic reactions to certain drugs. The doctors
should also be informed of the patient’s medical history. Pre-operative testing is done.
This includes chest x-ray, blood test, electrocardiography (ECG) and other tests (95).
Patients who are overweight should talk to their doctor about losing weight. Smoking
should be stopped several days before the surgery. A few hours prior to the operation,
eating or drinking is prohibited.
The determination of the type of surgery to be performed depends on the patient’s age,
diagnosis,
medical
history
and
personal
preference. Patients should be well informed
about the different types of discectomy (95).
The procedure begins with the induction of
anesthesia. An intravenous line (IV) will be
connected to the patient. They may be given
general or regional anesthesia. When general
anesthesia is used, the patient will be unaware
of the procedure and unable to feel pain.
Regional anesthesia, also known as nerve block,
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however, keeps the patient awake but unable to feel pain. Vital signs of the patient need
to be closely monitored throughout the surgery and upon recovery.
There are various types of discectomy, and these are listed below as (95):

Cervical discectomy which is the removal of a disc in the cervical spine (neck
area),

Lumbar discectomy which is the removal of a disc in the lumbar spine,

Sacral discectomy which is the removal of a disc in the sacral spine, between
the pelvic or hip bones), and

Thoracic discectomy, which is the removal of a disc in the thoracic spine.
A discectomy may be performed by a neurosurgeon, (specializing in the treatment of
nerves), or an orthopedic surgeon (specializing in the treatment of bones and muscles);
and, there are three general approaches to discectomy. These are listed below as:
1. Open surgery
2. Microdiscectomy
3. Anterior discectomy
In open surgery, a 2-4 inch incision is made down the middle of the affected spine that
allows the doctor to view the surgical area. This type of surgery is mostly performed for
the treatment of lumbar spine herniated disc, and if additional procedures are needed
such as spinal fusion, foraminotomy or laminectomy.
Microdiscectomy is relatively less invasive than the open surgery. It is considered a
minimally invasive procedure. A small incision (less than 1 inch) is made along the side
of the affected spine and special instruments are inserted through the incision. This
procedure is performed when no other treatment is needed. Unlike open surgery,
microdiscectomy entails lesser pain, infections and faster recovery (95).
In anterior discectomy, an incision is made in the front part of the body. In cervical
discectomy, the incision is made through the neck. In lumbar and sacral discectomy, it
is through the belly or abdomen. In thoracic discectomy, the incision is made in the
chest (95).
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Patients may stay in the hospital for a period for further observations. In most cases,
however, one or two days in the hospital are enough. The recovery stage is gradual. It
depends on the patient’s age, health, anesthesia used and the type of procedure
performed. The doctor may encourage walking and avoid sitting for a long period of
time. It takes about 2 to 6 weeks for full recovery.
After the surgery, patients may experience the disappearance of electrical shock pain,
tingling numbness and weakness. For others, it may take a few weeks. Every surgery
has certain risks and complications. They can develop during or after surgery. The risks
include allergic reactions, breathing and heart problems due to anesthesia. Infections
and bleeding that leads to shock. Blood clot can occur in the leg or pelvis, which can
travel to the brain, heart and lungs and can cause stroke, pulmonary embolism and
heart attack (95).
Complications include nerve damage, which can lead to permanent weakness. Disc
fragments that are not removed may require additional surgery. This case may occur in
microdiscectomy. Recurring pain may also be experienced.
Patients should make sure to inform the medical team members about any allergies.
Restrictions regarding diet, activities and lifestyle should be followed. For pregnant
women, it is necessary to inform the doctor before proceeding with the surgery. The
doctor should be notified immediately in case there is bleeding, swelling, increased pain
and fever. The medicines given by the doctor should be taken exactly as directed
(95).
Foraminotomy
Foraminotomy is a surgery that widens the back opening where nerve roots leave the
canal. It comes from two words, foramen and otomy. Foramen is a hollow passage or a
natural opening through bone. On the other hand, otomy means to incise or cut.
There are 31 pairs of spinal nerve roots that pass through the foramen. These spinal
nerves provide sensations. The nerve opening may narrow, which is called foraminal
stenosis. A nerve root may leave the spinal cord through the openings (neural
foramena) in the spinal column. When the nerve root openings become narrow,
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pressure on the nerve can result. A bone, disc, excessive ligament, scar tissue and
pinched nerves may compress the foramen.
This procedure takes the pressure from the
nerves in the spinal column allowing easy
movement of the spine. Foraminotomy can
often be performed as a minimally invasive
procedure. It may be endoscopically or
microscopically.
In minimally invasive
procedures, only a small cut or incision is
made. The result is less pain, blood loss
and faster recovery time (96).
Symptoms of foraminal stenosis include deep and steady pain in the hands, arms, calf,
shoulder, lower back and thighs. It also includes pain due to a certain movement or
activity. Muscle weakness, numbness and tingling may also be experienced. The
symptoms of foraminal stenosis may become worse gradually. A magnetic resonance
imaging (MRI) is needed to make sure that the symptoms are caused by foraminal
stenosis.
Patients should inform the doctors about any medication they are taking. Smoking
should be stopped because it can result to slower recovery. Taking medicines that
make the blood hard to clot such as aspirin, ibuprofen, naproxen, etc. should be
stopped two weeks before foraminotomy procedure. Patients should at the same time
ask what medications are allowed for them to take
(96).
Patients who have heart disease, diabetes and other medical problems may be asked
by the surgeon to see their regular doctor. They should inform if they have been
drinking a lot of alcohol. The doctors should also be notified if the patient gets a cold,
fever, flu or other illnesses.
Patients may also visit a physical therapist to learn about exercises that can be done
before the surgery.
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Six to twelve hours before the surgery, patients will be asked not to eat or drink
anything. Medicines given by the doctor should be taken with only a small sip of water.
A patient may bring a cane or wheelchair if it is available (96).
Using an x-ray localizes the area of interest. The patient will be given general
anesthesia, so he/she will be asleep and unable to feel pain during the procedure. The
patient will lie down on the operating table facing down. A cut or incision will be made in
the middle of the back of the spine. The incision length varies depending on the part of
the spinal column to be operated. For cervical foraminotomy, the cut or incision is made
in front or back (anterior or posterior) of the neck. For lumbar foraminotomy, it is in the
lower back (96).
Skin, ligaments and muscles will be moved or pushed to the side and the surgeon may
use a surgical microscope, endoscope or arthroscope to view the inside of the back.
The surgeon can now visualize the foramen and remove offending materials. Some of
the bones may be shaved or cut to enable opening of the foramen (nerve opening). Disk
fragments will then be removed. To make more room, other bone at the back of the
vertebrae may also be removed. Aside from that, the surgeon may correct identified
disc issues. To cauterize the disc, a laser is usually used. Spinal fusion may also be
performed to ensure stability of the spinal column (96).
The muscles and ligaments that were moved will be placed back in their position. The
tissue and muscles are closed using absorbable sutures. The skin will also be closed
using the same kind of sutures and sterilized strips. These may be removed if the
wound is already healed.
If the surgery was done on the neck, it is recommended that the patient wear a soft
neck collar. After the surgery, patients can usually get out of bed and sit up for almost 2
hours. Patients can usually go home after the surgery; however, it takes about a week
or two to be able to drive. After 4 weeks, they can perform light activities
(96).
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After foraminotomy, patients may have partial or full relief of the symptoms. However,
there is always a possibility of future spine problems. If a patient had a spinal fusion in
addition to foraminotomy, problems may arise in the spinal column above and below the
fusion in the future. There is a greater chance of future problems if additional
procedures such as laminotomy or laminectomy are needed (96).
The success rate of foraminotomy is between 45% - 90%. There is a large middle
ground for success rates because many factors are to be considered. One of the factors
is the ability, experience, expertise and training of the surgeon. Accurate diagnosis is
also one major factor. Although the surgeon may have the right expertise, it would make
no difference if the diagnosis were not accurate. Accurate diagnosis is the key to finding
out the correct location of the damage. It also helps the surgeon to make the right
approach, whether bilateral, anterior or posterior (96).
Risks associated with anesthesia include allergic reactions and breathing problems.
Bleeding and infections of the wound and vertebral bones may also occur. Spinal nerve
damage may result and cause pain, weakness or loss of sensory perception. After
surgery, partial or lack of pain relief may also be experienced. There are also the risk of
refractory back pain in the future and thrombophlebitis due to blood clot (96).
Nucleoplasty
Nucleoplasty, also known as percutaneous disc decompression, is a minimally invasive,
image-guided procedure that is useful in relieving back pain caused by herniated discs.
As discussed in the previous section, vertebral discs function as shock absorbers
between vertebrae. When discs herniate, they put pressure on the nerve roots, trigger
pain receptors, and cause back pain. Patients with back and leg pain secondary to
herniated discs, especially those demonstrating disc herniation less than 6mm on MRI,
can benefit from nucleoplasty. The procedure removes the offending disc tissues,
relieve the chronic pain and restore functional mobility (117).
Nucleoplasty is generally indicated in patients with chronic (longer than 6 weeks) lower
back pain, usually secondary to herniated discs, who have not benefited from
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conservative treatment approaches. Patients who are severely debilitated and impaired
functionally by the pain are the ones who stand to benefit the most from this procedure.
The ideal candidate for nucleoplasty will have radicular and axial symptoms associated
with a contained herniated disc
(117).
Examples of radicular signs and symptoms include
(117):

Radicular symptoms greater than Axial symptoms

Radiologic evidence of contained disc protrusion

Discography concordant, if indicated

Failed conservative treatment

Disc height greater than 50%
Examples of axial Symptoms (due to a contained disc herniation) include

Discography positive for concordant pain

Disc height greater than 75%

Failed conservative treatment
(117):
Since the procedure involves minimal invasive techniques, it is performed on an
outpatient basis instead of the overnight stay required from many invasive procedures.
To begin with, a fine needle is inserted into the herniated disc with the aid of x-ray
guided imaging. It is followed by the insertion of the ‘spine wand’ into the nucleus of the
disc using the needle. This device uses coblation to ablate and remove tissues in the
nucleus pulposus of the disc. Because tissue removal is achieved at temperatures of
approximately 40-70ºC, thermal damage to surrounding tissue is minimized.
After coblation, the annulus ring shrinks in size, which substantially relieves the
pressure on the adjacent nerves. Although the time scales vary from physician to
physician, the whole procedure usually lasts less than an hour and patients are
discharged from the hospital within a couple of hours following surgery. Disc infection is
a rare complication (117).
Nucleoplasty is usually not recommended in individuals over 60 years of age and those
with spondylolisthesis and segmental instability. Moreover, it is not usually performed on
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patients with disc herniation measuring more than 6 mm on MRI. Additionally,
nucleoplasty is contraindicated in patients with severe disc degeneration, who appear to
have complete annular disruption, and whose painful disc measures half or less than
half the size of the adjacent disc.
Although generally safe and well tolerated, nucleoplasty can result in a few
complications, namely (117):

Soreness at the site of the injection within 24 hours following the procedure;

Numbness and tingling sensations which can last for a long time; and

Greater pain intensity that may persist for a long time.
Nucleoplasty is a fairly recent development in diagnostic medicine. Although it is a
popular alternative treatment for discogenic back pain, some critics have called its longterm clinical benefits into question.
A study conducted in Romania in 2013 compared the clinical usefulness of nucleoplasty
against open discectomy as a treatment for back pain. Long-term post-operative pain
scores in both groups were found to be similar. Additionally, no major complications
were reported with nucleoplasty, with patients exhibiting rapid recovery and returning to
their daily routine 3 days following the procedure (115).
A systematic review published in Pain Physician in 2011 recommends nucleoplasty to
be a category 1C procedure which means that strong evidence exists supporting its
therapeutic effectiveness in treating lower back pain
[116].
However, prospective
randomized controlled trials with higher quality of evidence are necessary to confirm
these findings, and to determine ideal patient selection for this procedure.
Intradiscal electrothermal therapy (IDET)
Intradiscal electrothermal therapy (IDET), also known as intradiscal electrothermal
annulopasty, is a relatively new procedure that was introduced in 1997 as an alternative
treatment for discogenic low back pain. It is a minimally invasive procedure and
successful treatment with IDET helps patients achieve pain relief without having to go
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through major back surgery. This is the kind of treatment that can very well help patients
avoid surgical disc removal, disc replacement, and even spinal fusion (118).
Discogenic low back pain is thought to arise from nerve fibers that have outgrown their
limitations and reached into the interior of the disc. This process is related to the
destruction of the tough annulus layer of the disc. Another mechanism by which
discogenic pain is triggered is injury to the disc. An injury may cause tissue materials
from the nucleus pulposus to dislocate to the outer layer of the disc where pain
receptors are present (118).
Prior to the procedure, clinicians use discography techniques to visualize the nature and
extent of the disc herniation. Once identified, patients are advised to prepare for surgery
(118).
At the start of the procedure, patients are given
sedatives and local anesthetics to minimize the pain.
Under fluoroscopic guidance, a catheter and a heating
element are inserted into the annulus of the disc. The
catheter, upon reaching its optimum position, is heated to
90°C for 15 to 20 minutes. The heat delivered destroys
the nerve fibers, toughens the disc tissues and also heals
any small disc tears. Antibiotics may be administered
locally or intravenously to prevent the onset of infection on the disc (118).
IDET does not provide immediate relief from lower back pain. In fact, the pain
symptoms may initially seem to increase for a short time immediately following the
procedure. During this time, clinicians usually advise patients to incorporate mild
exercises such as walking and short stretches into their daily routine. However,
strenuous exercises are best avoided until 5-6 months after the procedure. During the
initial months following procedure, clinicians also advise patients to avoid prolonged
periods of sitting, lifting, and bending (118).
IDET therapy is an effective method of treating lower back pain associated with a select
group of spinal disc diseases. It is not recommended in patients with severe disc
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degeneration and conditions that undermine spinal instability such as spondylolisthesis
and spinal stenosis. It is also not recommended in patients who have three or more
symptomatic discs, large disc herniation, significant narrowing of discs, and diffused
disc degeneration. Moreover, patients are obese or strongly dependent on pain
medications may not show an optimum response to the procedure (118).
Like other invasive spinal procedures, IDET also carries a few risks of complication
such as:

Disc infection

Nerve root injury

Disc herniation

Post-treatment disc degeneration

Paradoxical increase in pain intensity
A single arm prospective clinical trial conducted in the US and published in 2008 studied
the effects of IDET in patients with lower back pain. The results of the study showed
improvement in pain scales as well as mean tolerance scores for sitting, standing and
walking. Seventy-five percent of the patients who underwent the procedure were
classified as successfully treated; having exhibited improved pain scales and/or overall
physical functioning. The study concluded that IDET therapy in select subset of patients
with mild disc degeneration, confirmatory imaging evidence of annular disruption, and
concordant pain provocation by low pressure discography are those who stand to
benefit the most from this novel procedure [119].
In 2008, the Connecticut Pain Care in the US published a set of guidelines for IDET
therapy. They identified five compulsory indications, all of which are enumerated below
[120]:
1) persistent axial low back pain +/- leg pain and non-responsive to > or = 6
weeks of conservative care;
2) history consistent with discogenic low back pain without marked lower
extremity neurological deficit;
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3) one to 3 desiccated discs with or without small, contained herniated nucleus
pulposus by T2-weighted magnetic resonance imaging, with at least 50%
remaining disc height;
4) concordant pain provocation by low pressure (< 50 psi above opening
pressure) discography; and
5) posterior annular disruption by post-discography computed tomography.
IDET is an effective and safe method of treatment in lower back pain that is refractory to
conservative treatment. However, it is only beneficial in select subset of populations and
should only normally be offered to those whose outcomes are favorable and outweigh
the risks outlined above.
Radiofrequency nerve lesioning
Radiofrequency nerve lesioning, also known as facet rhizotomy, is a treatment modality
that involves the use of a special machine to help interrupt nerve conduction
temporarily. The interruption of nerve conduction is responsible for the cessation of pain
signal transmission. Its mechanism of action is primarily based on the heat generated
by radio waves or electrical impulses to damage specific nerves to halt their
transmission of pain temporarily. Nerve conduction can be blocked typically for up to of
6-9 months using this procedure. It is especially beneficial in the treatment of chronic
spinal pain conditions such as spinal arthritis (spondylosis), pain due to whip lash injury,
chronic regional pain syndrome, and sometimes even pain secondary to nerve
entrapments (128).
Radiofrequency lesioning is performed under the guidance of fluoroscopy. Since nerves
cannot be visualized, bony landmarks are identified to gauge nerve pathways. It
proceeds in the following steps (128):
1. The area of needle insertion is numbed by local anesthetics.
2. The radiofrequency needle is inserted.
3. Once the needle tip is in place, another special needle is inserted. The correct
positioning of the needle is achieved by visualizing its placement on the x-ray.
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4. Electrical stimulation follows which results in tingling sensations or sometimes,
numbness. The electric current is passed for about 90-120s using the radio
frequency machine, which heats the surrounding tissue. This local heat action
renders the nerve numb temporarily.
Radiofrequency lesioning is not done under general anesthesia since patients may be
required to be awake to give appropriate
feedback
during
the
procedure.
Again,
depending on the expertise of the surgeon, the
procedure can last anywhere from 30 minutes to
an hour. Patients may experience soreness after
the procedure, which resolves in the next couple
of days, even without medication. Because of the
minimal tissue invasion, tissue and wound
healing is fast, allowing patients to return to work
within 1-2 days following the procedure (128).
When done correctly, the procedure can provide prolonged pain relief that may last
years after the procedure. The long lasting pain-relief it provides makes it a good
palliative treatment option in patients with chronic lower back pain.
Although radiofrequency is a minimally invasive procedure, it does carry the risk of
infection to the spinal structures. Patients taking anticoagulants may experience
excessive bleeding, despite the minimal wound created by the procedure. It should not
be performed on patients as an alternative to corrective surgery. Lastly, patients who
experience widespread and non-localized pain are not likely to benefit from
radiofrequency of a single nerve because of the multifocal nature of the pain.
A retrospective study published in 2013 and conducted in Australia investigated the
effects of radiofrequency lateral branch neurotomy in patients with from sacro-iliac joint
mediated low back pain. Some of the parameters assessed were visual analog scale
(VAS) pain scores, quality of life, medication usage, and also patient satisfaction. The
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study found a significant reduction in pain scales during follow up assessments.
Patients also reported an improved quality of life along with decreased need for opioid
medications. Additionally, some patients reported long-term pain relief lasting as much
as up to 20 months after treatment [129].
A study conducted in 2008 in the US provided retrospective data regarding pain relief
and changes in functionality in patients who underwent radiofrequency lesioning
treatment. Data from 27 individuals was analyzed and found to suggest that a significant
number of the participants with chronic sacroiliac joint pain benefited the most from the
procedure. Specifically, this group experienced marked improvement in their pain
scores and also in their functional status [130].
Another American study published in 2001 was the first of its kind to review the use of
radiofrequency lesioning in patients with sacroiliac syndrome. Thirty-three patients who
underwent a series of 51 consecutive radiofrequency lesioning were identified and
assessed pre- and post- operatively in terms of pain scores, opioid use, and physical
examination. The study concluded that radiofrequency lesioning might prove to be of
substantial benefit in certain subset of patients. Additionally, the study suggested the
delivery of effective analgesia using this treatment in patients with sacroiliac syndrome
[131].
Acupuncture
Acupuncture is a form of ancient Chinese medicine that is based on the belief that an
energy or life force flows through the body channels called meridians. This energy or
force is referred to as Qi (pronounced as ‘chee’). The practitioners of acupuncture
believe that when Qi is not able to flow freely throughout the body, an illness ensues.
Acupuncture practitioners believe there to be approximately 2000 points in the human
body, all of which when stimulated corrects the life force imbalance in the body.
Scientists and some modern acupuncture practitioners believe that acupuncture helps
stimulate certain nerves and muscles, and attribute its beneficial effects to this very
reason. The traditional form of the treatment, trigger point acupuncture, involves the use
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of fine needles inserted into the skin at specific points. Its use has become very popular
in recent years, with majority of the results of studies done on it pointing to positive
outcomes in terms of pain reduction, cementing its effectiveness in the management
and treatment of pain.
Currently, acupuncture for treating lower back pain is recommended by the National
institute of Health and Clinical Excellence (NICE). The NICE guideline published in 2009
suggest that acupuncture may be offered for 10 sessions lasting up to 12 weeks for
nonspecific lower back pain
[88].
Another guideline published by the American Pain
Society (APS) and American College of Physicians (ACP) also recommend acupuncture
as an alternative form of pain treatment to patients with lower back pain who have not
benefited from conventional forms of therapy [89].
Acupuncture provides pain relief by stimulating various nerves and muscles, which help
reduce the intensity and frequency of pain
symptoms. Moreover, it is also associated
with the release of endorphins and other
kinds of neuro-hormonal factors, which are
the body’s natural substances that generate
feelings of well-being. It is also effective in
reducing inflammation through the release
of immunomodulatory and vascular factors
that play a role in the body’s inflammatory responses. Since acupuncture also
stimulates muscles, it is also believed to improve muscle stiffness and joint mobility by
stimulating the microcirculation locally, which ultimately helps in reducing the swelling
associated with tissue injury [97].
Numerous research findings have proven acupuncture to be significantly better than no
treatment at all in cases of chronic back pain. Some studies have even suggested it to
be equally effective if not more, than other forms of conventional treatment. It is
certainly useful in patients who wish to avoid the use of analgesic medications or wish
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to augment their existing conventional therapy with another form of treatment that is
relatively safe and noninvasive to alleviate severe symptom episodes (97).
A study was conducted in 2005 by the University of Sheffield, UK to determine the cost
effectiveness, safety of acupuncture, and clinical benefits, i.e. long-term pain relief of
acupuncture. Patients aged between 18-65 years with nonspecific back pain for 4-52
weeks were enrolled into the study.
The results showed that individuals receiving
acupuncture did not report any serious or life threatening adverse effects. They also
reported lesser worry and anxiety symptoms associated with back pain at 12 and 24
months compared to the conventional care group. Another significant finding was that at
24 month, the patients treated with acupuncture reported significant decrease in the use
of pain medications. The same group was also found to be more likely to report a pain
free interval of 12 months. However, no additional benefits regarding function and
disability were reported. The study also suggested that acupuncture therapy referred by
GPs could prove to be cost effective in the long run
(98).
A systematic review undertaken by the University of Ulster in Northern Ireland on 2008
also advocated the use of acupuncture versus no treatment for nonspecific lower back
pain. The study concluded that moderate evidence existed to support the use of
acupuncture therapy when compared to no treatment at all; however, no difference in
short term pain relief was identified between acupuncture versus sham acupuncture
treatment. Another significant finding of the report was that acupuncture was shown to
provide significant clinical benefits when used as a supplement to conventional therapy.
However, the effectiveness of the treatment alone when compared to conventional
therapy requires more thorough research. Conclusively, the review advocated the use
of acupuncture than no treatment at all and its use as an adjunct to conventional
therapy in individuals with nonspecific back pain [99].
A specific acupuncture technique that has become popular in the recent years is motion
style acupuncture. This technique is new and differs from the conventional trigger point
acupuncture in that it involves mobilizing the patient (e.g. doing exercises) while the
needles are being placed into specific meridian points. In the treatment of lower back
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pain, the needles are usually positioned onto back of the neck, elbows, and extremities,
i.e. hands and feet. The patient is then mobilized with the help of the practitioners.
Motion style acupuncture may prove to be an effective alternative and adjunctive
treatment in patients with lower back pain. A study conducted in Korea and published in
2013 recruited 58 patients and compared the effectiveness of motion style acupuncture
versus non-steroidal anti-inflammatory drug (NSAID) injection. The results showed that
the pain intensity in patients receiving acupuncture was reduced significantly. The
disability levels of these patients also declined significantly. The clinical effects lasted up
to a month following the treatments [97,100].
Other studies have also advocated the use of trigger point acupuncture for back pain. A
study conducted in Japan in 2009 suggested it to be a fairly effective method in treating
back pain in elderly patients compared to sham acupuncture
[101].
Trigger point
acupuncture essentially differs from conventional acupuncture in that specific trigger
points are targeted. Trigger points, also known as trigger sites or muscle knots, are
actually hyperirritable parts of skeletal muscles which may also be associated with
palpable nodules found on the taut bands of muscle fibers. Acupuncture practitioners
believe these to be the source of many unexplained pain symptoms, even in cases of
referred pain. Compression of any trigger point elicits three kinds of responses, namely:
1. Local pain
2. Referred pain, and
3. Local twitch response
Trigger points are usually classified into various types depending on their specific
characteristics, namely:
1. Active trigger points which refer to either local or distal pain,
2. Latent trigger points, which refer to points that exist but only actively elicit pain
when compressed.
3. Key trigger points which refer to a pain referral pattern along a nerve pathway.
4. Satellite trigger points, which refer to those that elicit pain only upon activation
by key trigger points.
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The above trigger points can arise from of a number of diseases or dysfunctions
including inflammation, muscle overload, trauma, homeostatic imbalances, infection,
and smoking. A study conducted in Japan in 2006 found that deep needling these
trigger points via acupuncture is a superior method of treating lower back pain than
superficial needling of the same trigger points [102].
Like other alternative forms of treatment for lower back pain, acupuncture has shown
effectiveness and safety in both acute and chronic lower back pain. It is undoubtedly
useful in treating back pain that is irresponsive to conventional therapy and those who
need an additional treatment to augment the benefits of their existing primary pain
treatment.
Traction
Traction refers to a treatment modality that primarily involves the use of pulleys, ropes
and/or weights to apply mechanical forces on tissues that usually surround broken
bones. The purpose of traction is to apply a force that is strong to draw apart two
adjoining bones, increasing their shared joint space, and providing pain relief (121).
The mechanical forces may be applied manually or with the aid of devices such as
ropes and pulley. Although traction has been largely replaced by modern orthopedic
techniques, some of its techniques are used in a variety of clinical scenarios today. It is
especially useful in aligning different bony structures following a fracture as well as to
promote its healing, decrease the pain, and provide stability before being operated on. It
is also used to treat bony deformities such as scoliosis of the spine and correct
musculoskeletal problems such as muscle contractures
(121).
Generally speaking, there
are two different types of traction, namely (121):
1. Skin traction, and
2. Skeletal traction
Skin traction
Skin involves the application of a mild pulling force on the soft tissues of the body such
as the skin, tendons, and muscles. Skin traction does not necessarily facilitate fracture
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healing but it helps in aligning the fractured part of the bones and prevents bone
shortening during the healing process. It is usually carried out during the hospital stay of
the patient (121).
It is performed while the patient lies in a supine position on the bed. A pulley system
attached to the bed and equipment such as adhesive tapes, special gloves, boots, and
splints are attached to the weights are used to apply the necessary mechanical force.
Skeletal traction
Skeletal traction is usually indicated
when greater mechanical force is
required to facilitate fracture healing.
This method differs from skin traction
in that the force applied directly to the
skeleton. Skeletal traction involves the
surgical implantation of pins, wires,
and screws into the bones. This is
usually
done
under
general
anesthesia. The weights are then
applied after implantation. The duration of weight application largely depends on the
patient’s clinical needs (extent of injury, presence of positive healing factors, etc.) (121).
Spinal decompression traction therapy
Spinal decompression traction therapy is another treatment modality for back pain. Its
aim is to create greater space between the injured spinal structures by pulling apart the
vertebrae. This action allows decompression of structures in the spinal cord and
improves circulation.
One unproven theory suggests pulling apart the discs to improve their water absorbing
ability, thus affording them greater shock absorption abilities. Spinal traction is
performed either mechanically or manually. Sometimes, the force is applied
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intermittently through manual and mechanical traction. A sustained traction, lasting no
more than 30 minutes, is usually done using mechanical devices.
Although in theory traction appears to provide a good rationale for the treatment of back
pain, there is little evidence to suggest its actual clinical benefit in the treatment of lower
back pain. A recent systematic review published in 2013 analyzed 32 randomized
control trials that involved a total of 2762 patients with lower back pain. These control
trials were conducted to establish the role of traction in patients with acute, subacute
and chronic non- specific lower back pain (with or without sciatica). The results of the
review found low to moderate quality evidence of traction being more beneficial than
placebo in reducing pain intensity, and improving functional status of the patient and
recovery speed. In the same review, traction exhibited very little substantial benefit
compared to physiotherapy [122].
TENS [transcutaneous electrical nerve stimulation] therapy
Transcutaneous electrical nerve stimulation or TENS therapy involves the use of a small
low- voltage electric current to provide relief in patients with lower back pain. A small
battery-operated device containing two electrodes connected to the skin generates the
electric current. The device can be attached to a belt and carried close to the body.
Like traction therapy, transcutaneous electrical nerve stimulation has greater theoretical
value than practical application. In theory, the electrical nerve stimulation closes the
‘voltage-gate mechanism’ of the spinal cord, which eliminates the sensory signal
conduction of pain. However, this is still just a theory and has not been proven yet to be
the case [123].
Some patients report a reduction in pain perception when electrical impulses are being
delivered. However, this may be due to the fact that simulation of the nerves temporarily
blocks the pain sensory pathways, providing a false sense of relief. Proponents of
TENS therapy believe that the induction of electrical signals in the body produces
endorphins, the body’s natural opioid substances, which trigger pain relief [123].
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TENS treatment is generally started after a thorough evaluation of the patient’s medical
history and need for treatment. The following are important points to remember when
using a TENS device [123]:

It is best avoided during the initial stages of pregnancy and patients who have
pacemaker implants.

As with every other device, it is recommended that individuals who wish to use
this treatment modality to read and follow the instructions carefully.

Patients should clean the skin before putting on the electrodes.

Patients need to check the integrity of their skin prior to application of electrodes,
as these should not be placed on broken or burnt skin.

It should not be used while sleeping or showering.

It should not be used in conjunction with other heating or electrical pads.

It should not be used while driving.

Patients should contact their doctor in case any adverse reaction occurs.

It should only be used for the purpose it was prescribed for by the healthcare
professional to avoid unnecessary harm.
Although a study conducted in Turkey and published in 2012 favors the use of TENS
therapy during the third trimester of pregnancy, this is generally not the consensus
regarding this treatment modality. This particular
study showed that pregnant patients who underwent
TENS treatment at 32 weeks gestation experienced
a significant pain reduction compared to treatments
with acetaminophen and exercise [123].
A small-scale recent study conducted in Italy and
published in 2013 emphasized the importance of
appropriate
selection
of
electrode
placement
location in TENS therapy in obtaining the strongest pain relief. It reported frequent
peripheral nerve trunk stimulation to provide the greatest pain relief. The study
consisted of 10 volunteers who underwent three different sessions of TENS therapy.
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The study also suggested the negative implications of continuous stimulation such as
the development of tolerance [124].
Another type of transcutaneous electrical nerve stimulation is high frequency electrical
stimulation via the peripheral nerve. A study conducted in January 2007 in Italy enrolled
18 volunteers and studied the effects of high frequency transcutaneous peripheral nerve
stimulation (HF-TPNS) on improving heat pain threshold during and after delivery. The
heat pain threshold was initially measured under basal conditions, then during and after
the application of HF-TPNS. The results showed that this type of treatment has the
potential to induce hypoalgesia or decreased sensitivity to pain stimuli [125].
Ultrasound
As discussed in the previous section, ultrasound or sonography is a common diagnostic
imaging tool. However, ultrasound is also used as a treatment modality in lower back
pain. Ultrasound therapy has been used for several decades now and found effective in
treating spinal conditions such as osteoarthritis, herniated discs, and pinched nerves
[126].
It may be used as an adjunct to other treatments to provide optimum pain relief.
The basic mechanism of action of ultrasound treatments is based on the action of sonic
waves that pass from the ultrasound wand over the skin to the tissue beneath it.
Specifically, they cause vibrations and increase heat generation by the tissues. Warmer
temperatures promote improved circulation to the area, thereby reducing inflammation
and pain, and also relaxing the muscles in the area. There are two main types of
ultrasound therapies, namely:

Mechanical, and

Thermal
Both therapies involve the delivery of sound waves into the affected area with the help
of a transducer. Each type differs in their sound wave delivery rates. Thermal ultrasound
therapy involves the delivery/transmission of sound waves at a continuous rate. The
sound waves reach the deep tissue molecules, causing microscopic vibrations that
produce friction and heat in the area they are delivered to. Tissue metabolism
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increases, with the warming effect promoting tissue healing. Mechanical ultrasound
therapy, on the other hand, delivers sound
waves in a pulsatile manner. It produces a
much lower heat than the thermal therapy.
It promotes continuous contraction and
expansion of the molecules of soft tissues,
which helps in reducing inflammation and
pain
perceptions.
The
therapy
recommended to patients depends on the
underlying condition and their causes.
Patients with muscle sprains, strains, or
myofascial pain stand to benefit the most from thermal ultrasound therapy. On the other
hand, patients with pain associated with swelling and carpal tunnel syndrome will
benefit the most from mechanical ultrasound therapy.
Although ultrasound therapy is generally considered safe, it is contraindicated in cases
after immediate injury. Some of its other limitations and drawbacks are:

It may possibly speed up the spread of diseases via the blood, and is therefore
not safe in patients diagnosed with or are suspected of cancer.

It is contraindicated in patients with active infection, bone fractures, and also
during pregnancy.

It is contraindicated on sensitive body parts such as eyes and sex organs

It should not be used in children since the sound waves can adversely affect the
growth plates.

It should be avoided in patients with pacemakers.

It should not be used over broken skin, lesions, and healing fractures.
A study conducted in Iran in 2012 recruited 50 patients suffering from non-specific
chronic lower back pain. The patients were randomized into two groups and underwent
combination therapies consisting of ultrasound with exercise, and placebo ultrasound
with exercise. The treatments were given alternatively, switching treatments between
days, three times a week for four weeks for a total of ten sessions. Although beneficial
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effects were seen in both groups, it was found that patients receiving ultrasound therapy
in addition to exercise showed a significant improvement in terms of functionality,
lumbar flexion, extension ROM, and endurance time
[127].
PHARMACOLOGY TREATMENTS
Over the counter (OTC) drugs for low back pain
Over the counter (OTC) pain medications are used to provide symptomatic pain relief.
Examples include NSAIDs such as ibuprofen, acetaminophen, mefenamic acid,
diclofenac, and aspirin.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Clinical trials have found that non-selective NSAIDs show superior efficacy in the
treatment of acute lower back pain treatment without the need for additional analgesics
(137).
Ibuprofen was found to be especially effective in the treatment of chronic lower
back pain
(132).
Other studies claim effectiveness of NSAIDs in the treatment of back
pain with sciatica (137).
Mechanism of action:
NSAIDs relieve nociceptive pain due to tissue
damage and inflammatory mechanisms. These
drugs inhibit the enzyme, cyclooxygenase (COX)
resulting
in
decreased
synthesis
of
pro-
inflammatory prostaglandins from arachidonic
acid in the central nervous system and the
peripheral sites in the body. Non-selective
NSAIDs inhibit both the COX-1 or COX-2
enzymes. COX-1 is involved in pain mechanisms
as well as the normal functioning of the
gastrointestinal tract, platelets, and kidneys while COX-2 does not. Cox-2 is particularly
active in reducing inflammatory responses (134).
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Side effects of NSAIDs:
NSAIDs are associated with various risk factors. The toxicity associated with the use of
both selective COX-2 inhibitors and non-selective inhibitors are similar. Their most
common adverse effects known are listed below (134):

Cardiovascular system:
Rise in blood pressure, fluid retention, myocardial infarction

Neurological system:
Headaches, confusion, hallucinations, depression, tremor, meningitis, tinnitus,
vertigo, neuropathy

Gastrointestinal system:
Nausea, vomiting, dyspepsia, diarrhea, constipation, gastric mucosal irritation,
peptic ulcers, esophagitis, gastrointestinal hemorrhage

Hematological system:
anemia, bone marrow depression, reduced platelet aggregation

Hepatic system:
hepatotoxicity

Renal system:
nephritis, changes in renal blood flow, edema, inhibition of renin release

Others:
precipitation of asthma, skin rashes
Selection of NSAIDs:
The selection of the most appropriate NSAID is an important step in successfully
treating pain symptoms. Clinicians agree that some patients respond to some drugs
better than others. Whichever is the NSAID of choice the drug must only be used for the
shortest time possible. With chronic conditions, the drug can be used for up to 2 to 4
weeks since their maximum effect may be delayed. Before prescribing any NSAID,
clinicians need to consider non-drug treatment as well as the risk-benefit profile (134).
Topical NSAID formulations:
NSAIDs in topical and transdermal formulations are widely used in the treatment of local
musculoskeletal disorders. Examples include diclofenac, ibuprofen, ketoprofen, and
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piroxicam. NSAID gels are frequently used for muscular aches and pains. They are
considered to be great alternative to oral NSAIDs, especially when rapid and local pain
relief is required. They are also advantageous because they do not cause gastric
irritation, unlike many of its oral NSAID counterparts (134).
Examples of NSAIDs:
Aspirin
Aspirin acts by irreversibly blocking the enzyme cyclooxygenase-1, thereby reducing the
production of inflammatory substances, prostanoids (134).
Patients with history of hypersensitivity to any NSAID should not take aspirin. Likewise,
those suffering from peptic ulcer should avoid it because of its adverse effects on the
gastric mucosa. It should not be used in children under the age of 12 because of its
propensity to cause Reye’s syndrome. Patients who are taking Ginkgo biloba along with
aspirin may sometimes exhibit spontaneous bleeding.
Aspirin is used as an anti-platelet, analgesic, antipyretic, and anti-inflammatory drug at
various doses. It can cause gastrointestinal and cerebral hemorrhage. Its dosage for
anti-platelet therapy, though minimal, can also cause minimal adverse reactions.
Diclofenac
Diclofenac sodium is an analgesic-antipyretic and anti-inflammatory drug. Like other
NSAIDs, it inhibits prostaglandin synthesis. It reduces neutrophil chemotaxis and
superoxide production at the site of inflammation. It is well absorbed after oral
administration and eliminated from the body via urine and bile. It has high tissue
perfusion and thus, able to achieve high concentration in the synovial fluid
(136).
Diclofenac is indicated in the pain management of rheumatoid arthritis, osteoarthritis,
bursitis, ankylosing spondylitis, dysmenorrhea, post traumatic and post inflammatory
conditions. It exhibits immediate pain relief after oral administration.
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Diclofenac sodium is generally associated with mild epigastric pain, nausea, headache,
dizziness, and rashes. It is also associated with gastric ulceration and bleeding. It can
rarely cause kidney damage and reversible increase in serum aminotransferase.
Ibuprofen
One of the safest drugs, ibuprofen, also blocks the synthesis of prostaglandin, inhibit
platelet aggregation, and prolong bleeding time. It is well-absorbed following oral
absorption and is highly bound to plasma proteins. It is used as an OTC analgesic in
rheumatoid arthritis, osteoarthritis, and other musculoskeletal disorders where pain is
more pronounced than inflammation. It is also useful in soft tissue injuries, fractures,
and vasectomy in alleviating pain, swelling, and inflammation
(136).
Ibuprofen is associated with mild side effects such as gastric discomfort, nausea,
vomiting, headache, dizziness, blurred vision, tinnitus, and depression.
Piroxicam
Piroxicam is a long-acting NSAID, and a reversible inhibitor of COX. It lowers
prostaglandin concentration in the synovial fluid, and also inhibits platelet aggregation. It
is very well absorbed after oral administration and almost 99% of it is bound to plasma
proteins. Its metabolites are eliminated from the body via urine and bile
(136).
It is associated with common side effects such as heartburn, nausea, and anorexia.
Rashes and pruritus are also seen in rare cases.
It is indicated in both short and long term pain relief in rheumatoid arthritis,
osteoarthritis, ankylosing spondylitis, acute gout, musculoskeletal injuries, dentistry,
episiotomy, and dysmenorrhea.
Acetaminophen/paracetamol
Research evidence is strong on the efficacy of acetaminophen in short-term pain relief
of a variety of pain conditions such as joint pain
(133).
Unlike other NSAIDs, it lacks anti-
inflammatory effects. Popularly known as paracetamol, it has both analgesic and
antipyretic actions in the central nervous system
(135).
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Mechanism of action:
Acetaminophen inhibits the enzyme prostaglandin synthetase in the hypothalamus as
well as the synthesis of spinal prostaglandin. Additionally, it also inhibits the synthesis of
nitric oxide in macrophages.
As mentioned previously, it shows negligible anti-inflammatory action in normal
therapeutic doses because of its insignificant inhibition of prostaglandin
(135).
Alternatively in conditions where arachidonic acid concentration is low, acetaminophen
weakly inhibits the isozymes COX-1 and COX-2 as well as prostaglandin synthesis,
accounting for its very low and negligible anti-inflammatory effects (135).
Properties:
Acetaminophen is rapidly absorbed, reaching its peak plasma concentration within 10 to
60 minutes following oral absorption. Its analgesic effect is exhibited within 30 minutes
of oral administration and 15 minutes of Intra venous administration. It does not bind to
the plasma proteins, highly lipid soluble, and thus, easily enters the brain by crossing
the blood brain barrier. The analgesic effect is primarily exhibited in the brain. It
undergoes extensive first pass metabolism in the liver and is converted to its
metabolites. Its elimination occurs via the kidneys (135).
Acetaminophen should be used with caution in individuals with hepatic and renal
disorders to avoid toxicity (133).
Indication:
It is comparably less effective than the nonsteroidal anti-inflammatory drugs in providing
relief from moderate to severe pain. It is the first line of analgesic in the treatment of
mild to moderate pain especially if it is of soft tissue and musculoskeletal origin. It is
also helpful in reducing the daily doses of NSAIDs or opioids, allowing a significant
reduction in their doses and subsequent adverse effects
(135).
Other indications of acetaminophen are (135):

Alternative to aspirin
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
Treatment of mild procedural pain

Management of fever
Paracetamol is safe for use in children. The recommended dose of acetaminophen in
adults is 0.5 to 1 g given every 4 to 6 hours (135).
Adverse effects / toxicity of acetaminophen:
Acetaminophen is very safe to use in therapeutic doses. There is very low risk of side
effects, which includes an increased risk of upper gastrointestinal complications in
increased doses.
Acetaminophen is known to increase the risk of hypertension in women. In very rare
instances, patients may also experience urticarial or erythematous rashes, fever, and
blood dyscrasias as adverse effects (135).
Overdose of paracetamol is associated with potentially life threatening toxicity. The
toxicity can manifest as either hepatotoxicity, hypoglycemia, or acute renal tubular
necrosis.
Formulations:
Acetaminophen is available as immediate release tablets and capsules, oral solutions
and suspensions, chewable tablets, soluble/effervescent tablets and, modified release
tablets. It is available in rectal and injectable formulations
(135).
Acetaminophen is also available in several oral preparations in combination with other
medications such as other analgesics, decongestants, antihistamines, and antiemetics.
Anticonvulsant and antidepressant medications for lower back pain
The development of newer classes of antidepressants and anticonvulsant drugs in the
recent years expanded their clinical indications, including their off-label use in the
management and treatment of chronic pain. This is achieved by their actions on specific
neurotransmitters and ion channels. These classes of drugs exhibit varying efficacy in
the treatment of different types of pain. They are widely prescribed off label in the
management of neuropathic and non-neuropathic pain (138).
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The antidepressants that are used in pain management are the classic tricyclic
antidepressants
like
amitriptyline,
nortriptyline,
and
desipramine;
and
novel
antidepressants like bupropion, venlafaxine, and duloxetine. These drugs have been
found to be especially effective in the treatment of neuropathic pain
(138).
First generation antiepileptic drugs like carbamazepine, phenytoin, and secondgeneration antiepileptic drugs like gabapentin and pregabalin have been effectively
used in the treatment of neuropathic pain
(138).
Antidepressant drugs
Antidepressant medications are used in the treatment of pain for the following common
reasons (139):

Psychiatric disorders are common among those suffering from chronic pain

Sleep disturbances are also consistently found among those in chronic pain

Certain antidepressant classes provide pain relief as an independent feature
from relief of depression and other psychiatric symptoms.
Mechanism of action:
Tricyclic antidepressants inhibit the transmission of pain in the spinal cord by blocking
the
reuptake
of
neurotransmitters,
serotonin
and
norepinephrine.
These
neurotransmitters are instrumental in several pain pathways. Additionally, tricyclic
antidepressants have high affinity for histamine H1 receptor that may be helpful in
producing pain relief. As such, tricyclic antidepressants are also used in the
management of acute pain (138).
The newer antidepressant drugs like venlafaxine and duloxetine block the reuptake of
serotonin and norepinephrine but do not block other neuroreceptors, which may result in
side effects related with tricyclic antidepressants. Bupropion is thought to exert its
mechanism of action by blocking the uptake of dopamine (138).
Use:
Tricyclic antidepressants are particularly useful in treating symptoms of chronic back
pain. Serotonin norepinephrine reuptake inhibitors (e.g. duloxetine and milnacipran) are
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used to treat pain of both neuropathic and non-neuropathic origins. Of the two,
duloxetine is the only one that is FDA-approved for use in musculoskeletal pain
(145).
Antidepressants with mixed–receptor and noradrenergic activity exhibits greater efficacy
in the treatment of patients with neuropathic pain (138).
Adverse reactions:
The most common side effects associated with tricyclic antidepressant are dry mouth,
constipation, urinary retention, sedation, and weight gain. The novel antidepressants
bupropion, venlafaxine and duloxetine exhibit side effects such as anxiety, insomnia,
sedation, loss of weight, seizures, head ache, nausea, sweating, hypertension, dry
mouth, constipation, and dizziness (138).
Drug interaction:
There are many clinically significant interactions involving antidepressants. These
include the interaction between fluvoxamine and benzodiazepines, clozapine,
theophylline, and warfarin, wherein it increases their respective plasma concentrations.
Sertraline and fluoxetine can also increase the concentration of benzodiazepines,
clozapine and warfarin (142).
Some antidepressants are substrates of the CYP enzymes and also inhibit the
metabolic clearance of other drugs resulting in significant drug–drug interaction (142).
Examples of antidepressants:
Amitriptyline and trimipramine
Amitriptyline and trimipramine are tricyclic antidepressants and nonselective uptake
inhibitor of noradrenaline and serotonin. Following oral administration, they show a high
level of absorption. They are metabolized in the liver into active metabolites. Generally,
amitriptyline or trimipramine are given once daily with definite changes in steady state
plasma concentration. They are known to cause many adverse effects including dry
mouth, blurred vision, constipation, urinary retention, sedation, postural hypotension,
sexual dysfunction, and weight gain. Amitriptyline is one of the most sedating
compounds of the tricyclic antidepressant class. Alcohol has been studied to exacerbate
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the effects of amitriptyline. They should be used with caution in children as they can
impair cardiac conduction and even result in fatal arrhythmias. They show interactions
with serotonergic medications leading to serotonin syndrome (140).
Venlafaxine
Venlafaxine is a serotonin reuptake inhibitor. At higher doses it also acts as a
noradrenaline reuptake inhibitor. It is a weak dopamine reuptake inhibitor. Venlafaxine
and its metabolite have both short half-lives, which makes the recommended dose to be
given twice daily. It shows several side effects including nausea, vomiting, anorexia,
headache, increased sweating, rashes, agitation, periodic limb movements of sleep,
sexual dysfunction, hypotension, and hyponatremia. Withdrawal symptoms may also
appear if the drug is stopped suddenly without tapering the dose gradually. It should not
be used in children or adolescents since it has been reported to instigate hostility and
thoughts of suicide (140).
Antiepileptic/anticonvulsant drugs
Anticonvulsant drugs are also used in the treatment of neuropathic pain. They exert
analgesic effects through multiple neuronal mechanisms such as blockade of voltage
gated sodium channels, enhancement of GABAergic neurotransmission, and inhibition
of glutamatergic neurotransmission. These mechanisms of inhibition of neuronal hyper
excitability are also present in neuropathic pain. Modulation of this mechanism is the
target of neuropathic pain therapy with anticonvulsants
(139).
Mechanism of action:
Antiepileptic drugs act at several sites, which may be relevant to the perception of pain.
They trigger the inhibition of neuronal excitation, thereby providing pain relief. The major
sites of action of antiepileptic agents in pain relief are voltage gated ion channels
(sodium and calcium), ligand gated ion channels, excitatory receptors for glutamate and
N-methyl-D-aspartate, and inhibitory receptors of GABA and glycine
(138).
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Use:
Both first generation and second-generation antiepileptic medications are used in the
treatment of pain. However, it is the second-generation medications that exhibit greater
tolerance since they cause lesser sedation and have lower central nervous system
activity.
Antiepileptic drugs are used in the management of neuropathic pain. Carbamazepine is
extensively used in the treatment of trigeminal neuralgia. Occasionally these agents are
also used in the treatment of other types of pain such as lower back pain
is frequently used in the treatment of chronic pain
(145).
Phenytoin
(138).
Second generation antiepileptic drugs have documented efficacy in patients with painful
diabetic nephropathy, and post-herpetic neuralgia (Maizels & McCarberg, 2005). There
is not much evidence to prove their efficacy in the management of lower back pain
which makes them better suited as adjunctive therapy in cases when the first lines of
drugs are ineffective (145).
Adverse reactions:
First generation antiepileptic drugs like carbamazepine and phenytoin are associated
with side effects like dizziness, diplopia, nausea, ataxia, slurred speech, confusion and
rashes (138).
Second generation antiepileptic agents are known to be more tolerated but exhibit
certain side effects such as drowsiness, dizziness, fatigue, nausea, sedation, and
weight gain (138).
Drug interaction:
The plasma concentration of hydantoins is increased in the presence of any drug
metabolized by CYP2C9 or CYP2C10. Carbamazepine is known to enhance the
metabolism of phenytoin and hence their concomitant use results in reduced
concentration of phenytoin. The reverse is also true, i.e. phenytoin may reduce the
concentration of carbamazepine (151).
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Examples of anticonvulsants:
Carbamazepine
Carbamazepine is an anticonvulsant, which works by blocking the sodium channels. It is
used in epileptiform conditions of neurological origins. Studies have found strong
evidence of its clinical efficacy in the management of trigeminal neuralgia, and other
neuropathic pain conditions (141).
It is remarkable in its ability to induce its own metabolism, which is started within 3 to 5
days of initiation of therapy and completed in 3 to 4 weeks. It also interacts with other
drugs like corticosteroids, cyclosporine, oral contraceptives, other antiepileptic drugs,
and warfarin.
It shows many dose-related side effects, namely:

Sedation

Headache

Ataxia

Dizziness

Nausea

Visual symptoms like diplopia

Skin rash

Diarrhea and,

Hepatitis
Gabapentin
Gabapentin is structurally similar to GABA. Its mechanism of action is rooted in its ability
to inhibit glutamate synthesis and increase GABA concentration in the brain. It acts
upon the calcium-gated ion channels to bring about its effects (141).
It is widely prescribed to treat neuropathic pain. It acts on the spinal cord to interact with
neuronal calcium channels to decrease neurotransmitter release and increase the
synthesis of GABA. It has been documented to reduce neuropathic pain by almost 50%.
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It is absorbed via the amino acid uptake system in the gastrointestinal tract, with its
bioavailability decreasing with a corresponding increase in dose. It interacts with
antacids. It remains unchanged in the urine when eliminated. Among its most common
adverse effects are somnolence, dizziness, and ataxia.
Phenytoin
Phenytoin inhibits the voltage-gated sodium channels. It is highly bound to albumin, with
its unbound portion exhibting pharmacological activity. Phenytoin is associated with a
plethora of adverse effects, which may be dose-related or idiosyncratic in nature.
Examples include neurotoxic symptoms such as drowsiness, dysarthria, tremor, ataxia,
diplopia, and cognitive difficulties. It may also result in gum hypertrophy, acne,
hirsutism, and facial coarsening. Phenytoin shows a wide range of interactions with
major drug classes. It has very poor water solubility. Its intra muscular injection should
be completely avoided (141).
Pregabalin
Pregabalin is an analogue of gamma–aminobutyric acid, with both anticonvulsant and
analgesic properties. It blocks calcium channels and reduces the release of
neurotransmitters such as glutamate, noradrenaline and substance P (141).
It is well absorbed orally and eliminated from the body via urine. It has not shown any
clinically significant drug interactions. The side effects related to its use are
somnolence, dizziness, blurred vision, weight gain, peripheral edemas, and increased
creatine kinase levels (141).
Comparative account of anticonvulsant and antidepressant drugs
The antidepressant and anticonvulsant drugs have shown comparable efficacy in the
management of pain of neuropathic origin, but there are profound differences in the
safety profiles, drug tolerance, and side effect associated with specific drug classes.
According to certain clinical trials, SSRI’s are found to be most effective in treating
neuropathic pain when compared to tricyclic antidepressants, sodium channel blocking
antiepileptic drugs, and gabapentin. In the treatment of non-neuropathic pain, tricyclic
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antidepressants are the only class of drugs that has well documented efficacy in the
treatment of pain.
A research meta-analysis in patients with chronic back pain has shown that
antidepressants exhibit significant, albeit small, decrease in pain. But the improvement
in pain has not been associated with an improvement in day-to-day quality of life.
Antidepressants that showed serotonergic activity showed even lesser efficacy in
reducing pain (152).
Opioid Analgesics
Opioid analgesics are still the mainstay in pain management and treatment since the
first discovery of their parent compound, opium, hundreds of years ago. The opioid
analgesics are drugs used especially in the treatment of moderate to severe pain in
post-operative and cancer patients. Their analgesic effects are attributed to their ability
to reduce the pain sensation. The most significant feature of this class of drugs is its
sensory role in inhibiting responses to painful stimuli, regulating the gastrointestinal,
endocrine and anatomic functions. These drugs are also addictive and play an
important role in cognition and memory (155,154).
Endogenous opioid peptides
Peptides can be classified in three different families:
All

Enkephalins

Endorphins

Dynorphins
three
families
of
opioids
are
derived
from
natural
precursors;
prepro-
opiomelanocortin (POMC), preproenkephalin, and dynorphins, respectively. The main
opioid peptide, which has been derived from POMC is β-endorphins (155).
Opioid receptors
There are three classical opioid receptors classified as μ, δ and κ. The opioids, which
are used for clinical purpose are selective for and activate μ receptors. Some drugs also
change their receptor selectivity at high doses while others act on more than one
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receptor; being an agonist for one receptor while being an antagonist for another.
Morphine and most of the clinical opioid drugs exert their action by acting on the μ
receptors (155).
Effects of clinically used opioids
The opioid analgesics have been known to exert their effects on a wide range of
physiological systems. Their actions include production of analgesia, affect mood and
change the respiratory, cardiovascular, gastrointestinal and neuroendocrine function.
Delta (Δ) opioids have also been useful in some cases to alleviate pain. Studies on
animals have also shown that κ-opioid receptors are most effective in the spinal region
(155).
Morphine like drugs produces analgesia, drowsiness, mood changes and mental
clouding. Another significant feature is that pain is relieved without causing
unconsciousness (155).
Mechanism of action:
Opioid analgesics interact with one or more opioid receptors (including μ, δ, κ) at the
supraspinal, spinal and peripheral regions to result in analgesia. The opioid analgesics,
which are currently in use, are μ agonists but some δ and κ agonists also produce
analgesia. The opioid receptors exist as heterodimers and respond in more a complex
and elaborate manner to different combination of drugs (155).
Opioids inhibit the presynaptic release of neurotransmitters from the C-fiber terminals,
promote postsynaptic activity in the nociceptive pathways, and trigger the disintegration
of other pathways involved in nociceptive regulation. Opioid analgesics classified as
pure agonists of opioid receptors or mixed agonist-antagonist drugs act at specific
receptors (154).
Use of opioids for treatment of acute pain:
Morphine and fentanyl are clinically used to relieve severe acute pain. Since opioid
overdose is associated with increasing risk of toxic effects such as respiratory
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depression, rapid dosage increments are not advisable. Essentially, rapid dosage
increments disrupt the balance between analgesia and safety. Its administration usually
starts with a low dose with repeat doses given at approximately 5-minute intervals to
achieve the required analgesic effects (155).
Adverse effects of opioids:
Opioids are associated with many adverse or side effects on various body systems
including cardiovascular, neurological, dermatological, gastrointestinal, musculoskeletal,
neuroendocrine, respiratory, and urinary systems. The withdrawal symptoms of opioids
are manifested as body aches, diarrhea, loss of appetite, ‘goose flesh’, loss of appetite,
restlessness or nervousness, runny nose, squeezing, tremors, stomach cramps,
nausea, and loss of sleep, diaphoresis, asthenia, tachycardia or fever
(154).
The adverse effects of opioids are listed below (154):

Cardiovascular system:
Bradycardia, release of histamine resulting in vasodilation and hypotension;

Neurological system:
Mental clouding dependent on dose, delirium, sedation, nausea and vomiting,
apnoea, spinal and epidural morphine may also reactivate herpes simplex, but
the central adverse effects are much delayed following an intraspinal
administration of morphine;

Dermatological system:
sweating, flushing, urticarial and pruritus;

Gastrointestinal system:
Vomiting, anorexia, reduction in gastric motility, delayed gastric emptying, biliary
colic, slowed digestion, increased time for intestinal transit, increased anal
sphincter tone, constipation;

Musculoskeletal system:
myoclonus, chest wall rigidity;

Neuroendocrine system:
hypothalamia
resulting
in
reduced
gonadotrophins,
adrenocorticotrophic
hormones, beta endorphin, testosterone and cortisol and increased prolactin;
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
Respiratory system:
respiratory depression which is directly related to the dose, bronchospasm;

Urinary system:
Urinary retention, difficulty with micturition, increased tone of external sphincter,
decreased muscle tone of detrusor muscle, antidiuretic effect.
It should be noted here that most of the adverse effects could be reversed with the use
of naloxone, which is an opioid antagonist. Its use will also reduce the analgesic effects.
Interactions and precautions with opioids:
Opioids may interact with other medicines, which is why they should be used with
caution and only under medical advice and supervision. The health care practitioner
should always confirm with the patient if he is using any other prescription medications,
OTC medications, complementary and alternative medicines, and illicit compounds (154).
Opioids should not be used within 14 days of the use of monoamine oxidase inhibitors
(MAO) such as pethidine or tramadol since serious adverse reactions may occur.

Opioids should be used with caution when given with other central nervous
system depressant drugs such as sedatives, hypnotics, antipsychotics,
antidepressants, anesthetics or alcohol as the sedative and antidepressant
effects of opioids may be exacerbated.

When given with anticholinergic drugs, the patient should be made aware of an
increased chance of developing constipation or urinary retention.

Partial opioid agonist such as buprenorphine may decrease the analgesic effects
produced by morphine and may even initiate the withdrawal symptoms.

Drugs affecting the hepatic cytochrome system may also alter the blood level of
opioids, which may either result in toxicity or decreased effectiveness.

There is a risk of arrhythmia when opioid are given with drugs like methadone.
Opioid use in the elderly:
Older adults are more sensitive to the analgesic and other effects of opioids, which is
why lower doses are generally more appropriate for this particular subset of population
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group. Lower doses produce an equivalent analgesia in the elderly when compared to
higher doses in adults. Additionally, due to the elderly’s greater likelihood of reduced
renal function, the risk of accumulation of active opioid metabolites is also greater along
with increased brain sensitivity leading to respiratory depression or nausea (156).
Opioid drugs:
Morphine
The prototype of this group, morphine, is an agonist for all opioid receptors, specially
the μ receptor. Morphine is well absorbed following oral use but almost 30% of it is
metabolized during first pass hepatic metabolism. The metabolites of morphine are
morphine-3-glucuronide and morphine-6-glucuronide. Morphine is eliminated via renal
excretion in the form of its metabolites (156).
The duration of morphine action is 3 to 6 hours. It is administered via oral,
subcutaneous,
intramuscular,
intravenous,
epidural,
intrathecal
and
intracerebroventricular routes with the preferred mode of administration being oral.
Morphine is used in the treatment of chronic pain, cancer pain, and also non-cancer
pain. It is also used for pain management in palliative care such as terminally ill
patients. Tolerance to morphine develops rapidly.
Oxycodone
Oxycodone has greater bioavailability compared to its other opioid counterpart,
morphine, which makes it twice more potent. It undergoes metabolism to form the
metabolite, oxymorphone, through the action of the hepatic enzyme, CYP2D6. The
efficacy profile of oxycodone is similar to morphine. It is also available in an oral
modified release formulation, which brings about early onset of analgesia lasting almost
12 hours.
Buprenorphine
Buprenorphine is a partial opioid agonist at μ receptors and an antagonist at κ
receptors. It has a prolonged duration of action. It is available as sublingual, parenteral,
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and transdermal preparations of which the sublingual preparation is indicated for use in
acute and chronic pain, cancer pain, and opioid detoxification (153).
It is metabolized by the cytochrome P450 3A4. It is worth mentioning that
buprenorphine can lead to respiratory depression, which is unresponsive to the reversal
effects of naloxone. It is not recommended for use in palliative care. The transdermal
patches are not effective for acute pain or in cases where the need for analgesic effects
varies constantly.
It is used in the treatment of opioid overdose.
Fentanyl
Fentanyl is a very potent opioid, which is synthesized in the lab. It has a short duration
of action. It has been indicated for use in both management of acute and chronic pain. It
is administered orally, parenterally as intramuscular, intra venous, sub cutaneous,
intrathecal or epidural, and transdermal patch (154).
It is metabolized in the liver to form inactive metabolites. It is suitable for patients with
compromised renal system and those who are hemodynamically compromised. Its
adverse effects are similar to that of morphine but with lesser frequency of constipation
and confusion.
COGNITIVE BEHAVIORAL THERAPY
Cognitive Behavior therapy or CBT is a type of psychological therapy that involves
engaging the patient in dialogue to change existing thoughts and behavior. It helps
patient tackle a number of problems in a more positive way.
Cognitive behavior therapy is routinely done by psychiatrists, psychologists and other
professionals trained in the treatment of mental illnesses such as anxiety, depression,
post-traumatic stress disorder, and personality disorders, to name a few. Evidencebased studies suggest its role in the management of chronic painful conditions such as
lower back pain, irritable bowel syndrome (IBS) and arthritis.
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Cognitive behavior therapy tends to focus on changing the patient’s way of dealing with
problems. It focuses on changing the way a patient thinks and behaves, allowing and
welcoming a completely different response to difficult situations than previously
exhibited. It helps improve the patient’s state of mind. It does not provide a solution to
the problems; however, it equips the patient with new behavior and thoughts to
overcome negative thinking and manage existing problems.
A recent systematic review conducted in Belgium assessed the use of cognitive
behavior therapy in patients with acute and sub-acute chronic back pain. The review
suggested the incorporation of operant conditioning, a CBT-based strategy, into
ambulatory physiotherapy practice to manage chronic back pain symptoms [161].
Biofeedback
Biofeedback is a technique that enables patients to control their sympathetic responses
to various injuries and trauma. It can help patients control various body functions and
responses such as heart rate and pain perception. As such, it is often advocated as an
important relaxation technique.
During the treatment process, patients are connected to an external sensor device,
which provides the feedback used to control sympathetic responses. It brings about
subtle changes such as relaxation of specifically targeted muscles and subsequent pain
relief.
Biofeedback is a noninvasive treatment modality and carries very minimal and
insignificant risks, if any. It may be used in a number of conditions especially in cases
where pain relief is an immediate need. It is also a treatment option in patients who are
not keen to take medications (possibly due to side effects and allergies) and exhibited
refractory pain following conventional treatments.
The use of biofeedback in the treatment of chronic back pain is intensely being studied
worldwide. There are multiple trials that advocate the use of Biofeedback in patients
with no specific chronic lower back pain. For example, a study conducted at the
University of Limerick, Ireland in 2013 involving 24 participants concluded that postural
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biofeedback that is appropriately matched to specific clinical presentations of patients
could significantly help in reducing lower back discomfort even with a single session
[162].
Another fairly recent scientific paper published in June 2013 reviewed the available
existing literature regarding biofeedback techniques and their clinical effectiveness in
physical rehabilitation. The review suggested that EMG (electromyogram) biofeedback
could be beneficial in relieving pain associated with musculoskeletal conditions and
cardiovascular accident. Additionally, the review also highlighted the fact that real time
ultra sonography (RTUS) biofeedback could potentially prove to be effective in treating
patients with chronic low back pain [163].
Aside from alleviating chronic back pain, biofeedback is also most useful in conditions
such as constipation, incontinence, and irritable bowel disease.
SUMMARY
The spine is a complex region of the body whose major function is to provide skeletal
support and structure. It is made up of bones, tough cartilages and ligaments, joints,
and highly sensitive nerve roots that supply sensations to all parts of the body. Trauma,
deformities, degeneration, metastases, and infections can all undermine the spine’s
major function. A case of lower back pain is usually an indication of a disease process
in any of the spinal structures that warrants an immediate medical assessment.
Lower back pain is a general symptom that is associated with various medical
conditions; some of which are benign and easy to treat (e.g. overexertion, minor sports
injuries) and some, which have high morbidity and life-threatening implications (e.g.
spinal stenosis, cauda equine syndrome).
The diagnosis of lower back pain, both acute and chronic, require careful review of
medical history, physical examination, and results of diagnostic imaging and specialized
techniques. The most commonly ordered imaging modality in spinal disorders involving
lower back pain is spinal x-ray of the lumbar and sacro-iliac regions. It is cheap,
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universally available and delivers quick images. On the other hand, it is limited to the
visualization of bones since it does not capture clinically useful images of soft tissues
such as muscles and nerves, making it useless in identifying conditions such as nerve
impingement, muscle sprains, and strains. Other imaging modalities provide superior
visibility of soft tissue structures such as the CT and MRI scans. As such, they are more
expensive and not as universally available and accessible as x-ray machines. Other
diagnostic tools such as ultrasound and bone scan are also useful in diagnosing causes
of back pain.
The treatment approaches to back pain, both acute and chronic, depends largely on the
symptoms, patient history, physical health, and suspected underlying causes. Because
the causes of back pain are generally difficult to pinpoint, the clinician usually starts with
common OTC pain-relievers until further tests and evaluation have provided sufficient
evidence to suggest interventional therapies such as surgery and steroid injections.
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