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  • Writer's pictureDr. Harold Pierre

Understanding Chronic Low Back Pain Symptoms and Causes, Diagnosis, and Treatment Options

Updated: Nov 30, 2023

Understanding Chronic Low Back Pain Symptoms and Causes, Diagnosis, and Treatment Options


Chronic low back pain can be very different from person to person. The specific symptoms and severity depend on the underlying cause and individual factors. Some people describe the pain as sharp and stabbing, while others feel an ache or stiffness. The lower back is the most common site, but pain can also radiate into the buttocks and legs.


Many people find their back pain comes and goes, with flare-ups followed by periods of remission. Triggers like certain movements, long periods of sitting, or stress may worsen the pain. Some find relief from changing positions or stretching, while others deal with constant pain that disrupts sleep and daily activities.


What is Acute Low Back Pain?


Acute low back pain is pain, muscle tension, or stiffness localized to the lower back region that lasts for less than 3 months. It comes on suddenly and may arise from muscle strains, fracture, ligament sprains, minor vertebral injuries, bulging or ruptured disks, or other specific back problems.


If the doctors can't figure out the cause, the back pain is called nonspecific pain. Acute back pain should get better in 4-6 weeks. If significant pain lasts beyond 3 months, it is considered chronic. Some acute causes like strains heal fully in time, while degenerative changes like arthritis worsen gradually.


Acute low back pain happens a lot. It can be bad and very debilitating in the short term and could be something more serious underlying spinal condition.


What is Chronic Low Back Pain?

Chronic Lower Back Pain

When the low back pain last more than 3 months, it's now chronic low back pain. In addition to pain itself, chronic lower back conditions often cause frustrating limitations in mobility and flexibility. Simple actions like bending down, getting dressed, reaching overhead, or picking up objects can become difficult. This loss of function can take a toll mentally and emotionally as well as physically.


Back pain is complex because the lower back is responsible for supporting the weight of the upper body while also permitting movement. It withstands significant force and pressure. The lower back contains a complex collection of structures including vertebrae, rubbery disks between the vertebrae, powerful muscles, flexible ligaments, nerve roots exiting the spine, and tendons attaching muscles to bones. Each of these components is important for movement and stability. Unfortunately, with heavy use and daily wear-and-tear, all of these structures can start to develop issues that lead to pain symptoms. A problem with any single part of this intricate network of bones, joints, muscles, and nerves in the lower back region can trigger pain.


Symptoms and Causes of Low Back Pain?


Face it, "father time" is one of the most common risk factors for chronic lower back conditions. As people get older, disks lose elasticity, joints stiffen, bone density decreases, and muscles become less flexible. These changes put more strain on the structures of the lower back and can gradually cause chronic issues. Obesity is another major risk factor. The extra weight strain the muscles that support the spine.


Bulging or herniated disks develop when the soft inner nucleus pushes out through a weakened area of the tougher exterior ring. This puts direct pressure on spinal nerves, resulting in pain, numbness or weakness. Disk problems often start with minor bulges then worsen over time if the disk further deteriorates. They are most common in the lower lumbar region.


Spinal stenosis involves abnormal narrowing of the spinal canal itself. This puts pressure on the spinal cord and nerves traveling through that tight space. Symptoms often include radiating pain in the legs, hips, buttocks or feet, tingling, cramping, and problems with balance or coordination. Moving into certain positions may relieve or worsen the compressed nerve irritation.


Spondylolisthesis means one vertebra sliding forward over the one below it. This misalignment impinges on exiting nerve roots and the spinal canal. There is often a slipping sensation felt along with radiating pain and tightness. In severe cases, this vertebral displacement can put dangerous pressure on the spinal cord.


Sciatica refers tocompression or inflammation of thenerve that starts in the lower spine and runs down the back of each leg. This largest nerve in the body controls muscles and provides sensation. Irritation causes nerve pain radiating along the path it follows through the buttocks and down the legs, sometimes into the feet. Moving the leg in certain ways may trigger or relieve the pain.


Muscle strain results from torn or overstretched muscles and tendons in the back. Poor heavy lifting techniques, lack of strength, repeated heavy exertion, or inadequate rest between activities can cause strains. The muscle fibers tear and become damaged, leading to inflammation, spasms, and localized lower back pain. Rest, ice, medication, and physical therapy help strains heal.


Spinal fractures are a serious cause of acute and chronic back pain. Compression fractures most often occur in the upper vertebrae. They occur when bones in the spine become weak or brittle due to osteoporosis weakening the bones. Major trauma from things like car accidents can also fracture vertebrae, usually in the lower back. Broken bone ends rubbing together during movement trigger significant pain.


Noncancerous and cancerous growths in the spinal bones, disks, nerves or soft tissues are uncommon but possible sources of persistent and progressive back symptoms. Benign tumors like osteoid osteomas cause pain due to pressure on nerves. Malignant spinal tumors are serious and need prompt diagnosis and treatment. Metastatic cancer spreading to the spine is most concerning.


Ankylosing spondylitis is a form of inflammatory arthritis affecting the spine that often develops in a person’s 20s. It causes stiffening and fusion of the vertebrae due to excessive bone formation. Spinal inflammation and structural damage contribute to chronic immobility, postural changes, and back pain that tends to worsen with rest. Exercise helps some people.


Cauda equina syndrome is rare but extremely serious nerve compression in the lower spinal canal requiring emergency treatment to prevent permanent damage and paralysis. The bundle of nerve roots resemble a horse’s tail, hence the name cauda equina. Sudden severe back pain, leg weakness, and loss of bowel or bladder control signal a medical emergency.


Previous back surgery can sometimes lead to chronic neuropathic pain if nerves were damaged or tissue healing caused scarring. Failed procedures like discectomies or laminectomies intended to remove pressure on irritated nerves do not always provide lasting relief if degeneration continues. Persistent post-surgical pain is frustrating and depressing for patients.


Nonspecific back pain has no clear structural, anatomical cause found on exam or imaging studies. The majority of chronic back cases fall into this category despite thorough diagnostic workups. The source is believed to be multifactorial – minor disk issues, muscular tightness, joint stiffness, tendon inflammation and deconditioning. There is unlikely to be a quick or obvious fix.


Diagnosing the Cause of Chronic Back Pain


Determining the underlying cause of chronic back pain typically starts with a thorough medical history and physical examination by your doctor. They will ask many questions about your specific symptoms, any previous spinal injuries, and lifestyle factors that could contribute to or worsen back pain.


Your posture while standing and sitting will be assessed. Your doctor will check your spine mobility by having you bend forward, backward and sideways to see the range of motion and if any movements specifically reproduce or worsen the pain. They will test the neurological function in your back and legs to check for any nerve involvement. This often involves assessing reflexes, muscle strength, and sensations in the legs and feet. The information gathered helps guide appropriate treatment.


Medical Imaging Tests


If the cause of the back pain is still unclear after the exam, your doctor may recommend imaging tests such as:

  • X-ray: Looks at the bones and joints of the spine to check for injuries or degeneration.

  • CT scan: Takes cross-sectional X-ray images to get a more detailed look at bone and soft tissues.

  • MRI: Uses radio waves and magnets to produce detailed images of the soft tissues of the back, including nerves and disks.

  • Bone scan: Involves injecting a radioactive tracer then using a special camera to detect areas of increased bone activity that could indicate a fracture.

Keep in mind that findings on imaging tests do not always correlate with the severity of back pain symptoms. Many people have bulging or degenerated disks but no pain, while some with chronic pain have relatively normal imaging results.


Other Diagnostic Tests


Other tests that may help determine the source of chronic back pain include:

  • Simple Blood tests to look for inflammation, infection, or arthritis.

  • Electromyography (EMG) to measure muscle and nerve activity.

  • Nerve conduction studies to assess potential nerve damage.

  • X-ray with dye (myelogram) or CT myelogram to look for spinal cord compression.

  • Bone density scan to check for osteoporosis.

Treating Chronic Lower Back Pain at Home

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For most cases of chronic lower back pain, home treatment and self-care measures should be tried first. This can include:

  • Hot and cold therapy: Use heating pads, hot water bottles, or cold packs on your lower back to help reduce pain and relax muscles.

  • Over-the-counter (OTC) pain medication: Anti-inflammatory drugs like ibuprofen (Advil, Motrin) or naproxen (Aleve) can help relieve back pain. Acetaminophen (Tylenol) may also provide some relief.

  • Exercise and stretching: Low-impact cardio exercise and stretches that target the back, hips, and legs can strengthen muscles and improve flexibility. Walking, swimming, and yoga are good options.

  • Massage: Can help relax tight muscle tissues and improve blood flow. Self-massage or seeing a massage therapist may provide relief.

  • Posture correction: Be mindful of posture and use a lumbar support cushion for your office chair and car. Avoid slouching.

  • Good sleep habits: Use a medium-firm mattress, try a lumbar support pillow, and sleep on your side or back.

  • Stress management and relaxation techniques can help reduce muscle tension.

  • Lifestyle modifications: Losing weight, quitting smoking, and limiting activities that aggravate back pain can help.

  • Physical therapy exercises tailored to your condition can strengthen core and back muscles.

If home treatment strategies do not provide sufficient pain relief after a couple of weeks, see your doctor to explore other options. Report any new or worsening symptoms like numbness, weakness, or bowel/bladder changes immediately.


Medical Treatments for Chronic Back Pain


Returning to your normal activities is the goal of self-care and home treatment. But if you do not seem to be adequately improving your ongoing chronic back pain, consult your physician or healthcare provider again. They will reassess the underlying cause of your chronic symptoms, and order tests to diagnose the problem.


Medications

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Prescription NSAIDs like celecoxib or meloxicam can reduce inflammation and pain. They carry risks like ulcers and bleeding.

  • Muscle relaxants: Medications like cyclobenzaprine provide short-term relief by relaxing back muscles. Drowsiness is a common side effect.

  • Nerve pain drugs: Prescription medications for nerve pain like gabapentin or pregabalin may be an option if there is an irritated or compressed nerve causing radiating pain.

  • Topical pain relief creams: Prescription creams containing ingredients like lidocaine and diclofenac can provide local pain relief when applied to the lower back.

  • Corticosteroid injections: Injecting anti-inflammatory corticosteroids into the epidural space of the spine may temporarily relieve pain caused by inflammation or nerve compression.

Physical Therapy


Working with a physical therapist can provide gentle stretching, mobilization, strengthening exercises, and other techniques personalized for your back. The goal is to improve mobility, build muscle support, improve function, and manage pain.


Alternative Therapies


Some people find relief from chronic back pain through alternative therapies like:

  • Acupuncture: Involves inserting thin needles into specific points on the body to reduce pain. Multiple sessions may be needed.

  • Massage therapy: Different massage techniques can help relax muscles, improve blood flow, and reduce chronic lower back pain.

  • Spinal manipulation: Gentle, controlled movements applied to the joints and muscles by chiropractors or other providers to improve mobility and relieve pain.

  • Yoga and Pilates: Can gently stretch and strengthen the back muscles. Specialized classes available.

  • Cognitive behavioral therapy (CBT): Works to modify negative thoughts and behaviors that may worsen pain. Can help with pain coping skills.

Minimally Invasive Procedures


If other treatments fail to adequately relieve chronic back pain, minimally invasive procedures may be considered. These can include:

  • Epidural steroid injections (ESIs): Steroid medication injected into the epidural space of the spine to help reduce inflammation. Provides temporary relief.

  • Radiofrequency ablation (RFA): Use of heat or cold energy to target specific nerves causing chronic back pain. This can numb pain signals from an irritated nerve.

  • Calcitonin injections: For compression fractures, injecting calcitonin can help relieve pain and promote bone healing.

  • Spinal cord stimulation: A small device implanted under the skin sends electrical pulses to the spine to disrupt pain signals.

When Is Surgery Considered for Chronic Back Pain?


Spinal surgery is considered a treatment of last resort when more conservative treatments fail. Remember, surgical results are promised but not guaranteed. You may end up being worse off. Surgery may be indicated for the following situations:

  • Patients with herniated disks, spinal stenosis, or spondylolisthesis causing intractable nerve-related pain or numbness.

  • Pain due to spinal instability from traumatic injury that has not improved with at least 3 months of nonsurgical care.

  • Compression fractures due to osteoporosis or metastasis that have not responded to nonsurgical management.

Surgeries for chronic back pain aim to remove pressure on nerves, stabilize the spine, open space around the spinal cord or strengthen fractured vertebrae. Common procedures include:

  • Discectomy: Removing parts of a herniated disc to take pressure off compressed nerves.

  • Laminectomy: Removing a portion of bone and ligament to relieve nerve compression.

  • Spinal fusion: Permanently joining two or more vertebrae together for stability.

  • Kyphoplasty: Injecting bone cement to repair compression fractures.

Surgery risks include infection, bleeding, pain, nerve damage and the possibility of little to no pain relief. Most experts recommend trying at least 6 months of nonsurgical treatments before considering surgery for chronic lower back pain.


Postlaminectomy Syndrome (When Surgery Fails)


Postlaminectomy syndrome, also known as failed back surgery syndrome (FBSS), is a back and leg pain that does not go way after spine surgery intended to relieve pain. This frustrating condition is characterized by intractable neuropathic radicular pain that disrupts sleep, daily function, work, and quality of life.


Diagnosing Postlaminectomy Syndrome


Diagnosis starts with a history of prior back surgery like laminectomy or discectomy to address herniated disks or spinal stenosis. Post-surgical pain continuing longer than 3 months either without any improvement or following a pain-free period is the hallmark.


On exam, the doctor checks for limited mobility, tenderness, muscle tightness, and nerve symptoms suggesting radicular pain or neuropathy. Your medical professional may order imaging studies like X-rays or MRIs to look for causes of persistent pain like scar tissue compressing nerves, further disk degeneration, abnormal curvature, instability, or other spinal abnormalities.


Selective nerve root blocks can help pinpoint still-compressed or damaged nerve roots. Psychological factors may also contribute to postsurgical pain sensitivity. No single test confirms the diagnosis - it requires combining history, exam findings, imaging results, and response to treatments.


Long Term Impacts of Postlaminectomy Syndrome


Living with constant back and leg pain after surgery intended to correct these problems leads to significant frustration, anger, and depression. Relationship, work, activity, and lifestyle disruptions frequently occur. Daily function is limited and quality of life diminished. Pain intensity fluctuates but often remains stubbornly moderate to high.


Each additional failed surgery further decreases the chances of eventual pain relief yet patients desperately cling to hope. Positive outcomes decline while costs, risks, and complexities rise with repeat operations. Patients struggle to accept that the pain may never resolve completely. Learning to make lifestyle adaptations and manage expectations is important.


Treatment Options

Doctor with human spine anatomy model. Spinal cord disorder and disease, back pain, lumbar, sacral pelvis, cervical neck, thoracic, Coccyx, orthopedist, chiropractic, office syndrome and health

Treatment focuses on relieving neuropathic nerve pain and improving function. Strategies aim to avoid further unnecessary surgery and risks. Options include:

  • Prescription medications like NSAIDs, muscle relaxants, nerve pain and antidepressant drugs

  • Physical therapy to improve mobility and strengthen core muscles

  • Psychological counseling to help cope with pain

  • Alternative therapies like massage, acupuncture, spinal manipulation

  • Minimally invasive injections for targeted pain relief

  • Spinal cord stimulation implants to interrupt pain signal transmission

  • As a last resort, corrective surgery to address a specific anatomical cause

Treatment plans are customized to each patient’s needs and response. Most utilize multiple approaches for the best pain relief. Lifestyle changes to lose excess weight, improve posture, modify activities, and manage stress play a key role.


The Role of Spinal Cord Stimulators


If medications, physical therapy, injections, and other treatments prove ineffective for chronic post-surgical pain, spinal cord stimulation may provide relief. This minimally invasive, reversible technique uses a small implanted device to deliver electrical impulses near the spine to interrupt pain signal transmission.


Patients initially trial externally-worn stimulator units to assess if stimulation relieves enough pain before deciding on permanent surgical implantation. The implantable pulse generator is similar to a pacemaker for the spine. Electrodes deliver impulses near targeted nerves involved in pain.


Multiple studies found spinal cord stimulation reduced leg and back pain by over 50% in the majority of failed back surgery patients compared to continued drug treatment alone. It improved function, quality of life, and patient satisfaction. Risks include infection, electrode migration, and loss of pain relief over time requiring adjustments or additional surgery.


For suitable candidates who respond well to the trial, spinal cord stimulation is considered an effective option to help manage severe, chronic postlaminectomy pain. It does not correct the anatomical problem but can greatly reduce debilitating pain and medication needs.


What About Opioids for Chronic Back Pain?


Due to concerns about side effects and addiction, opioids are not routinely prescribed for chronic back pain. They may be considered as a very short-term last resort if other pain medications are ineffective and the pain severely limits daily activities. When I say short-term, I mean less than 2 weeks.


Ideally, opioids should only be used for acute flare-ups and stopped as soon as possible to prevent dependence. Additional treatments should be used along with opioids to help manage the chronic back pain. Non-opioid medications and nondrug therapies are preferred in most cases.


Long-term high dose opioids are notorious for causing allodynia and hyperalgesia. Allodynia is when mere touch brings pain, like skin that stings when clothes brush against it. It's pain caused by things that normally don't hurt at all. Hyperalgesia is when minor pain turns into major ones. What should feel like a pinch feels like a punch. Things that ought to be mildly painful end up feeling excruciating.


When allodynia or hyperalgesia is suspected, the best treatment is to slowly taper the opioids down or covert to another opioid like buprenorphine. This is a very difficult thing to do because patients may be extremely resistant. It's understandable. All they have experienced is that increasing their opioids lead to more pain relief. It sounds counterintuitive that decreasing the opioids will relieve their pain. But for allodynia and hyperalgesia, it is a technique that can work well.


When to See Your Doctor


You should consult your doctor or a back specialist if:

  • Your back pain does not start to improve within 2 weeks of home treatment

  • The pain gets significantly worse or spreads down your leg

  • You experience numbness, tingling, or weakness in your legs

  • You have a history of cancer, osteoporosis, steroid use or trauma

  • You have difficultly with bowel or bladder control

  • Your back pain is so severe you cannot do normal daily activities

  • Over-the-counter medications provide little to no pain relief

Do not hesitate to seek medical attention if your back pain suddenly worsens or you develop concerning neurological symptoms. Call 911 if you experience loss of bladder or bowel control.


Conclusion: Key Takeaways on Chronic Back Pain

  • Chronic back pain that lasts more than 3 months is common, affecting up to 20% of adults at some point.

  • Underlying causes range from muscular strains and herniated disks to spinal conditions like stenosis, spondylolisthesis, and fractures.

  • Most chronic lower back pain can be managed at home initially with rest, OTC medication, hot/cold therapy, exercise, and lifestyle modifications.

  • See a doctor if pain worsens or persists after 2 weeks of home treatment.

  • Imaging like X-rays or MRIs may be needed to determine the cause of lingering back pain.

  • Treatment options for chronic back pain include physical therapy, prescription medication, injections, complementary therapies, minimally invasive procedures, and surgery in rare cases.

  • Opioid pain medication is discouraged for long-term use due to addiction risks.

  • Surgery may be considered after at least 6 months of unsuccessful nonsurgical management.

  • Report any bowel or bladder changes, weakness, or worsening pain to your doctor immediately.

Frequently Asked Questions About Chronic Back Pain


What is a ruptured disk?

A ruptured disk refers to a herniated disk in the spine where the inner gel-like nucleus pushes through a tear in the outer wall and puts pressure on nerves. This can cause sciatica.


What helps ease lower back pain at home?

Applying ice or heat, OTC pain medication, massage, gentle stretches, and modifying activity levels can help ease acute lower back pain at home. Chronic back pain often requires other treatments prescribed by a doctor.


Can a chiropractor help with back pain?

Some patients find relief through chiropractic manipulation and adjustments combined with exercises to improve spinal mobility and strengthen the back. Results vary.


What does a steroid injection for back pain involve?

An injection into the epidural space of the spine delivers anti-inflammatory corticosteroid medication near inflamed nerves or tissue to try to reduce swelling and pain.


When should you go to the ER for back pain?

Seek emergency care if you experience sudden severe back pain after an injury or accident along with numbness, loss of bowel or bladder control, or lower body weakness indicating potential nerve damage.


Can stress and mental health issues cause back pain?

There is a complex interaction between chronic stress, mental health, muscle tension, inflammation, and back pain. Treatments like therapy and stress management can complement medical care.


How long does it take for a bulging disk to heal?

Many mild disk bulges heal on their own over 4-6 weeks. Some persist longer, even years, and require treatment. Severe bulges pressing on nerves may need epidural injections or surgery.


Can you prevent back pain?

Basic prevention tips include maintaining a healthy weight, proper lifting technique, good posture, regular low-impact exercise, and addressing mobility problems. But back pain still often occurs despite precautions.


About the author:

Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.


This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.




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