by Dr. David Borenstein M.D. updated 10/2021
Individuals with back pain want to get it relieved. It would seem straightforward and easily fixed. The problem is that there are over 60 different illnesses that can cause back pain. These disorders involve a number of different organ systems. The following overview will help you determine the best course of action for accurate diagnosis and management.
Low Back Pain: To Begin With - Is It Mechanical or Inflammatory? That is the Question!
In an attempt to get a better answer to the cause of a backache, it is useful to separate back pain problems into two major categories: MECHANICAL and INFLAMMATORY.
Mechanical disorders are the most common causes of low back pain and are related to injury, overuse, or deformity of the low back. Inflammatory disorders on the other hand are usually part of a systemic illness associated with back pain that occurs in addition to a variety of other complaints like fever or weight loss. The characteristics of back pain associated with these two major categories are different and help individuals and their health care providers provide information that results in a corresponding diagnostic and therapeutic approach.
For example, mechanical issues typically start in individuals over 40 years of age, with an acute onset. Symptoms are worse at the end of the day. Morning stiffness is measured in minutes. They may have pain getting into bed but can become comfortable. Activities can make the pain worse with a minority responding to aspirin-like medicines. Mechanical patients with herniated discs may experience sciatica, or pain down a leg.
In contrast, inflammatory symptoms start in individuals less than forty-five years old in an insidious pattern. Symptoms are worse at the beginning of the day. Morning stiffness is measured in hours. Individuals may be awakened from sleep because of low back pain. Exercise and movement make symptoms better with a majority finding benefit from aspirin-like medicines. Inflammatory patients rarely have sciatica.
The number of inflammatory conditions is greater than that of mechanical disorders. However, mechanical problems occur more frequently. The result is the under appreciation of inflammatory conditions, like ankylosing spondylitis, as a cause of low back pain.
Making the correct diagnosis of mechanical and inflammatory spinal conditions has become increasingly important with the advent of a number of new therapies for inflammatory illnesses that can halt progression of the disease.
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Inflammatory Back Pain
A normal immune system fights off infections and kills abnormal cells that can grow into cancers. In people with spondyloarthritis, immune cells localized in different areas of the spine become activated and start damaging your own tissues. These inflamed tissues produce chemical signals released into the blood stream that recruit additional immune cells. The end result is chronic inflammation that can destroy tissues. In the setting of spondyloarthritis, the end result of this inflammatory process is the calcification of spinal structures. The spine can become fused.
Most commonly, four illnesses can cause spondyloarthritis. Ankylosing spondylitis, psoriatic spondylitis, reactive arthritis, and arthritis associated with inflammatory bowel disease can cause characteristic changes in the spine. Each illness has its own distinctive characteristics in regard to initiating the illness and it primary manifestations. Therapies for these illnesses are similar but not identical because of the associated underlying illness causing the spinal disease.
Signs and Symptoms of Ankylosing Spondylitis
Approximately 2% of individuals in the United States will have AS. Similar numbers of individuals are affected in countries around the world. AS tends to run in families. Genetic predisposition is related to the presence of a specific genetic marker, Histocompatibility Leucocyte Antigen (HLA) – B27. Approximately 90% of AS individuals are HLA-B27 positive. This genetic marker is not sufficient to have the disease however, approximately 8% of the population of the USA is B27 positive but do not have disease. Some additional factor is needed to have the illness above and beyond the genetic marker. Both men and women can have AS but it may be milder in women and is under diagnosed.
Symptoms related to inflammation of the musculoskeletal system include
- Prolonged morning stiffness of the spine lasting hours
- Spine stiffness associated with sitting for variable lengths of time
- Back pain improvement with exercise
- Eye inflammation – iritis
- Radiating leg pain – pseudosciatica
General Symptoms of AS
- Disordered sleep
- Mild weight loss
Individuals with AS usually first notice a moderate degree of intermittent aching pain localized to the low back. The muscles on the side of the spine can contribute to pain because of spasms. With progression of AS, the chest and neck develop pain associated with decreasing motion. The low back becomes more difficult to move. Breathing may be affected when moving ribs becomes painful. In a majority of patients, the initial symptoms are low back pain and stiffness. Pain in hips or shoulders is the initial complaint in a minority. Woman may present with neck stiffness prior to low back complaints.
An enthesis is the anatomic structure that attaches tendons and ligaments to bones. Enthesitis is inflammation of this structure and is a characteristic finding in spondyloarthritis. A common location for this inflammation is the Achilles tendon and plantar fascia on the bottom of the foot.
Ankylosing spondylitis is more than a skeletal disease. Current therapy has limited the appearance of these extra-articular manifestations of disease but is present in individuals who have extensive disease. Iritis is a form of eye inflammation where looking into a light is painful. Iritis occurs in about 25% of AS patients. Individuals with uncontrolled disease for 30 years or longer may have inflammation of the heart particularly involving the aortic valve. Aortic valve disease can cause heart failure and abnormal heart beats. Involvement of the thoracic spine can affect lung function because of decreased movement of the chest wall. Scarring of the upper most portion of the lung occurs.
A variety of common symptoms are related to dysfunction in the different parts of the spine and surrounding structures.
The spine is a beautifully engineered structure that supports and facilitates movement of other body parts such as the head, ribs, and legs. At the same time, the spine protects the entire length of the spinal cord and cauda equina (tail of the horse) at the upper portion of the lumbar spine. The spinal cord is the cable allowing the flow of the electrical impulses to and from the brain. The spine is supported by muscles that supply the force that moves the spine in different directions.
A number of physicians and other health care professionals care for people with spine pain. Primary care physicians, internists or family physicians, evaluate the greatest number of individuals with spine pain. Additional expertise will often be required to determine the correct cause of the symptoms and their management.
Rheumatologists are sub-specialists who care for people who have disorders that affect the musculoskeletal system. Other physician groups include other internal medicine sub-specialists as well as interventional radiologists, anesthesiologists, and spine surgeons. Allied health professionals, such as physical therapists, chiropractors, massage therapists, occupational therapists, are also important parts of an overall treatment plan.
Neck pain is located from the ridge on the back of the skull to the top of the shoulders. Muscles that support the neck also travel to an area below the shoulder blades. The most common cause of neck pain is injuries to these muscles like sitting in front of computers for long periods of time. Another cause of local neck pain is disc degeneration and osteoarthritis of the cervical facet joints.
Low Back Pain
Low back pain occurs from the lowest rib to the crease of the buttocks. The most common cause of low back pain is injuries to muscles alongside of the lumbar spine. Muscle injuries occur when lifting heavy objects or from sitting for long periods of time. Another cause of low back pain is disc degeneration and osteoarthritis of the lumbar facet joints.
Fever and Weight Loss
Persistent fever and/or weight loss is most frequently associated with infections or cancer. Infections occur in the vertebral bodies (osteomyelitis), intervertebral discs (discitis), or facet/sacroiliac joints (septic arthritis). Sources for infection are most commonly found, not in the spine, but in other areas of the body like the urinary tract or the lungs. Between 1 and 2 percent of people undergoing spine surgery will develop an infection at the surgical site. Individuals at increased risk are those with decreased immunity like diabetics and human immunodeficiency virus (HIV) infected individuals.
Metastases from tumors in other organs frequently travel to the spine. These lesions may be noted only after weight loss has occurred. These metastatic lesions may cause back pain when erosion of skeletal bone results in a fracture. Breast cancer is a common cause in women, and prostate cancer in men.
Pain at night or when lying down – Most individuals with mechanical causes of back pain are able to find a comfortable position in bed. Cancer patients may find that their pain is increased when lying down. They prefer to sleep in a chair. Expanding cancerous tumors compress spinal nerves. Being flat stretches these nerves, increasing pain. Also, benign tumors that are expanding also seem to increase pain at night
Prolonged Morning Stiffness
Many individuals will have some stiffness in the spine when they first get up in the morning. The duration of this stiffness is measured in minutes. This duration of stiffness is most commonly associated with mechanical problems like muscle strains. Inflammatory disorders of the spine cause morning stiffness measured in hours. Inflammatory arthritis of the spine (spondyloarthritis and rheumatoid arthritis) causes white cells and proteins that fight infection to invade spinal structures. The lining of the joints (synovium) or the attachment of ligaments and tendons to bones (enthesis). These tissues swell, impeding motion. In rheumatoid arthritis, which affects the cervical spine, the end result of the inflammation is erosion and instability of the neck. In spondyloarthritis, which affects the entire spine), calcification of spinal structures results in marked stiffness and loss of motion.
Localized Bone Pain
Bones in the spinal column can fracture like any in the skeletal system. Most commonly, fractures are the result of direct trauma to bones that occur with falls. Other fractures occur spontaneously when the lattice (scaffold) of the bone is weakened. Osteoporosis the disorder associated with decreased bone mineral density resulting in fractures. Loss of bone density occurs in older individuals. Younger individuals lose bone related to diseases that affect the bone marrow that resides inside vertebral bones or hormonal disorders (hyperparathyroidism) associated with disordered calcium metabolism. Osteoporotic fractures can cause acute, localized pain, chronic aching, or no pain at all. The lumbar and thoracic spine are more common locations for osteoporotic fractures. Osteoporotic fractures are rare causes of neck pain.
Abnormalities in organs that share nerve with part of the spine can cause referred spine pain. The sequence, character, and duration of spine pain takes on the characteristics of the diseased organ. Referred pain can arise from the gastrointestinal system. Colicky pain is characterized by repeated spasms of intense pain followed by pain-free periods. Hollow structures containing small muscles cause colicky pain. Organs that cause colicky spinal pain include gall bladder, colon, and ureter.
The Importance of the ICD-10 Code for Non-Radiographic Axial Spondyloarthritis
Most patients have minimal interest in the International Classification of Disease (!CD-10) coding manual.
Kidney stones cause severe back pain that may occur without any prior event. Gallbladder pain may also cause colicky back pain but usually after fatty meal. Kidney and gall bladder pain occur in the upper portion of the lumbar spine just below the ribs. Colonic pain occurs in the lower lumbar spine near the sacrum and may occur in conjunction with diverticulitis in the sigmoid colon. Diverticulitis is an inflammation of an out pouching of the colon.
Tearing and throbbing pain may occur in the lumbar spine with an aneurysm of the abdominal aorta. The aorta is the major arterial blood vessel that supplies blood from the heart to the rest of the body and runs in front of the lumbar spine. An aneurysm is a weakening in the wall of the vessel. If pressure grows too high, the weakening will rupture. Aneurysms occur in individuals with arterial disease associated with a family history, smoking, high blood pressure, and elevated cholesterol levels. There may be no complaints when the aneurysm grows slowly. Pain frequently increases as the aneurysm grows.
Patients with episodic pain have discomfort on a regular basis. The frequency may be daily, associated with eating (gastrointestinal - pancreatitis, peptic ulcer disease), or monthly, associated with menstrual cycles (endometriosis). Pain is not modified by change in position. Movement of the spine has little effect on the intensity of pain.
Pain that radiates from the neck to the shoulder and lower arm is associated with nerve compression by structures in the cervical spine. The pain, radiculopathy, is generated by inflammation of nerve roots that originate from the spinal cord. The most common compressed cervical nerve roots are between C6-C7 (C7 nerve root) and C5-C6(C6 nerve root). Pain, numbness, and tingling can travel down the arm along the course of the involved nerve. The cause of the nerve pressure can be from soft tissues (herniated disc), bone, or a combination of the two.
Peripheral nerve compression can mimic findings of radiculopathy. Individual nerves further along the arm can be compressed. The symptoms of numbness or weakness are in the specific distribution of the peripheral nerve in the upper or lower arm without neck pain. Carpal tunnel syndrome (compression of the median nerve) can cause pain and numbness in the hand radiating to the level of the shoulder, but not the neck, for example.
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Pain that radiates from the back to the anterior thigh or the lower leg to the foot is associated with nerve compression by structures in the lumbar spine. The pain, radiculopathy, is generated by inflammation of nerve roots that originate from the spinal cord. The most common nerve roots in the lumbar spine originate between L4-L5 (L5 nerve root) and L5-S1 (S1 nerve root). Pain, numbness, and tingling can travel down the leg along the course of the involved nerve. The cause of the nerve pressure can be from soft tissues (herniated disc), bone, or a combination of the two.
Peripheral nerve compression can mimic findings of radiculopathy. Individual nerves further along the leg can be compressed. The symptoms of numbness or weakness are in the specific distribution of the peripheral nerve in the thigh, or lower leg without back pain. Tarsal tunnel syndrome (compression of the tibial nerve) can cause pain and numbness in the sole of the foot radiating to the knee but not the low back.
Healthcare Professionals Who Treat Back Pain
Internist/Family practitioner: An allopathic (M.D.) or osteopathic (D.O.) physician who is a primary care professional offering general health care needs, including general back therapy.
Rheumatologist: Rheumatology is a subspecialty of internal medicine dealing with the treatment of patients with arthritis or any disorders in the bones, joints, or muscles. They are not surgeons and prescribe non-steroidal anti-inflammatory drugs (NSAIDs—aspirin-like drugs), muscle relaxants, and physical therapy.
Neurologist: M.D. or D.O. specializing in the diagnosis and treatment of nerve disorders; this doctor has special skills in the diagnosis of nerve abnormalities, including electro-diagnostic tests.
Physiatrist: M.D. or D.O. specializing in rehabilitation of the musculoskeletal and nervous systems, who offers special skills in electro-diagnostic tests, exercise methods, and body supports.
Orthopedic surgeon: M.D. or D.O. who is a specialist in the surgery of the skeletal system, including the spine
Neurosurgeon: M.D. or D.O. specializing in the surgery of the nervous system, including the spine.
Physical Therapist: P.T., R.P.T. (Registered), or M.P.T. (Masters) specializing in the use of exercise and physical methods to relieve pain and restore function
Chiropractor: D.C. (Doctor of Chiropractic) who uses physical adjustments and mobilization to treat spinal disorders.
Acupuncturist: A health professional who places needles at various points of the body to unblock energy to treat spinal disorders.
Massage therapist: L.M.T. (Licensed massage therapist) who uses therapeutic muscle massage to improve musculoskeletal disorders.
Chose your health care provider depending on your specific back problem, but always start with your primary care physician or rheumatologist. See a surgeon if you have muscle weakness or have failed medical therapy.
- The most important part of the back evaluation is your own complete medical and lifestyle history.
- The specific character of back pain helps define its source.
- The physical examination identifies abnormalities of normal movement, sensation, muscle strength, and reflexes.
- Most back evaluations do not require additional X ray or blood tests.
- Your primary care physician or rheumatologist can start your back evaluation and offer appropriate referrals if additional therapy is needed.
Choosing a Surgeon
Back or spine surgery is typically performed by and orthopedic or neurosurgeon and these specialists gain experience as they perform more operations. Orthopedists with an interest in spine surgery usually take extra training to gain greater expertise with spinal procedures. Neurosurgeons may not learn about spinal instrumentation or fusion, but they have expertise in procedures that preserve spinal cord function. Either type of experienced spinal surgeon can perform the typical discectomy, laminectomy, or decompression operation. If a fusion or instrumentation is required, an orthopedic surgeon should be part of the surgical team.
If you want the best chance for a good surgical outcome, then choose your spine surgeon carefully. This sounds logical, but the process may not be so obvious. Surgery is subspecialized into different parts of the body. In order to gain experience, spine surgeons have extra years of training in the techniques used to fix fractures, straighten curves, remove pieces, and fuse them together. Here are some characteristics of good spine surgeons.
- Board-certified in a surgical specialty
- Recommended by your primary care physician or internist
- Recommended by a person you trust who had spine surgery
- Able to communicate with you about your surgery
- Extensively experienced with the procedure you require
Ask questions. You need confidence in your surgeon, and you should understand the surgical procedure being performed:
- How (and why) will it improve my condition?
- How long will it take to heal from my surgery?
- What are the potential surgical complications?
- Do my other medical conditions affect the success of the procedure?
You may not like the answers to these questions, but your surgeon should answer them before you have the surgery. If the surgeon doesn’t want to speak with you before the procedure, it won’t be any easier after the surgery. Always consider a second opinion, even if you are satisfied with your initial surgeon.
If your car needs bodywork you get two estimates before you would proceed. Surely your body is worth two “estimates.” If both physicians agree on the need for surgery and the operative procedure, you can feel reassured. If they don’t agree, at least you will be educated about differences of opinion. If you go to a neurosurgeon for the first opinion, try an orthopedic surgeon for the second. You can then decide which procedure makes the most sense to you.