What is back pain?

Back pain is one of the most common types of pain that 80% of us will experience at some point in our lifetime. It is probably as common and naturally occurring in humans as grey hair and wrinkles. You are most likely to suffer from a significant episode of back pain between the ages of 30 and 50, but mechanical back pain is also seen in children and teenagers. To put it into perspective, if you have back pain you are not alone. However severe your pain, you are experiencing something that happens to most people at some point in their life. It is very unlikely that any two people will present with identical back pain symptoms, and usually everyone will require a different management programme, tailored to his or her individual circumstances. Please don't be panicked by stories you hear from people who paint a bleak picture of back pain. For every story of doom and gloom you hear, I can tell you another of someone who has experienced terrible pain and worked hard to get back to fitness, restore their spinal stability and live a full working and sporting life.

Common symptoms

Pain:  is an experience personal to each individual. The Textbook of Pain (ed. P. D. Wall and R. Melzack, Churchill Livingstone, Edinburgh, 1999) describes pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". I have learnt to accept my patients' own descriptions of their pain , so if someone says it's like spiders or knives in their back, so be it! Diagnosing the cause of your back pain is based on characterising pain in various ways, according to its duration, intensity, type (dull, burning or stabbing) and location in your body.

Restricted movement: Being unable to move, or to do basic things like getting dressed, is a common symptom of back pain. Muscle spasm,  which is basically your muscle overworking,  is a major cause of movement restriction because your muscles tighten and become overprotective when you have pain. This can be painful in itself, and it is also important to recognise when fear of moving is part of the problem, since fear will hold you back from recovery as much as anything else.

Altered sensation: This is common and can vary from numbness or pins and needles in your arms or legs to one limb feeling odd or just different from the other one. Some people describe an oversensitivity in the leg (or arm, if the neck is the problem area) rather than numbness. These are all symptoms that should be checked before you are treated.

Weakness: Weakness in your legs can be caused by inflammation or compression of a nerve in your back. It can also be caused by pain, which can prevent you from using your muscles normally. Physiotherapists, osteopaths and chiropractors will all test both your muscle strength and nerve function before you receive any treatment for back and leg pain, to see whether a nerve is being compressed and make sure you get the right treatment.

More serious symptoms

Bladder and bowel problems: Incontinence and/or urine retention are two symptoms that must not be ignored, no matter how embarrassing telling someone may seem. If these symptoms have come on with your back pain, seek medical advice immediately.

Unexplained weight loss: Weight loss can occur for many reasons but if it is unexplained and you haven't been on a diet, it could be a sign that something is wrong. Your GP is the best person to see and will be able to assess you further to find out why you are losing weight.

Night pain: Most pain will settle when you are lying down and you will experience some relief, even if it is only for short periods. However, if your pain becomes more severe when you are in bed at night or lying, down, you should see your doctor.

Sweats: Hot sweats during the day or at night can have many causes but if they are new to you and have come on as you have developed back pain it is important to see your doctor.

What caused my back pain?

The causes of back pain fall under three umbrellas. Within each there are different conditions. The three types of back pain are:

• mechanical problems such as muscular strains and sprains
• nerve irritation from the disc, ligament or facet joint
• serious spinal pathology such as infection or tumours

Before you decide you have a serious spinal pathology, here are a few figures that will reassure you. Your pain may be severe, but the level of pain does not always equate with something serious. The figures for the number of people diagnosed under each of the umbrellas are:

• 93% mechanical low back pain
• 5% nerve root pathology
• 2% serious spinal pathology

Pain caused by the spine is not always felt in the back: many people suffer with associated leg pain, or referred pain, which is also called sciatica. This can sometimes be worse than the pain in your back, and it is important to know what is causing it to ensure it is treated effectively. Causes of leg pain can be:

• nerve root irritation or compression of a nerve in your back
• nerve irritation or compression away from your spine
  
• an injury to your leg unrelated to your back pain
  

Common causes

There are many reasons why you may have back pain. Some are obvious, some creep up on you over time, and some are very easy to prevent. The most common causes of back pain I have treated over the years are:

• poor posture
  
• poor lifting technique
  
• poor ergonomics - in the workplace or at home
  
• stress- everyone is different be aware how stress affects you
  
• poor mattress - how old is your mattress, is it supporting you? 
  
• deconditioning - after illness, back pain can be a side-effect 
  
• a busy life
  
• pregnancy - this can affect your posture 
  
• arthritis - not always painful, but can flare up
  
• trauma - a fall or a car accident can result in pain
  

Less common causes

Disc herniation: This occurs when a disc between the vertebrae bulges and can push against nerves and ligaments in the spine. There are three types of disc herniation/prolapse, all of which produce different symptoms. The normal ageing of a disc includes dehydration and a reduction in its height. The nucleus should sit centrally in the disc and most people's nucleus will stay central as they age. The different stresses and strains that your spine goes through in a lifetime will influence how the position of the nucleus may change and how it may bulge or become herniated. 

A protruded/bulging disc: the most common type of disc herniation, is when the soft inner centre of the disc moves towards the edge of the disc and pushes against the outer shell. The bulging disc can push against ligaments and nerves, and cause inflammation which can cause back pain. Many factors can contribute to causing a disc to bulge including lifestyle, posture, poor lifting technique and lack of general fitness. It is rarely the result of just one thing or event. Manual therapy, acupuncture, physiotherapy, rehabilitation and exercise will help manage this kind of pain.

An extruded disc: is the next stage, in which the nucleus bulges through a tear in the disc wall and pushes on the adjacent spinal nerve roots and ligaments. This process can create a lot of inflammation and subsequent pain. Extruded discs create a greater risk of nerve root irritation and compression which can cause leg pain (sciatica). Manual therapy, acupuncture, physiotherapy and specific exercises will help manage this kind of pain. If the symptoms indicate serious compression on the nerve root, further treatment may be needed and it may take longer to recover. In most cases surgery will not be required.

A sequestrated disc: occurs when the extruded part of the disc breaks off. This can give many symptoms which can be severe and changeable as the piece of floating disc moves. This sometimes, though not always, requires surgery.

Myths about discs

The term 'slipped disc' is a misnomer, as discs themselves don't slip. However, once the central part of a disc (the nucleus) leaks through the outer layer (annulus), it can't go back in. Similarly, discs don't crumble, but small tears occur around the annulus as part of the normal ageing process. Annular tears are also a common cause of back pain.

Spinal stenosis

This is caused when the spinal canal narrows, usually as a result of arthritis. The condition develops over many years and can cause pain as it reduces the space available for the spinal cord. If your doctor or physiotherapist suspects you may have spinal stenosis, X-rays and an MRI scan will confirm the diagnosis and allow it to be monitored and managed effectively. Spondylolisthesis This is a rare problem and affects under 5% of people with back pain. It is diagnosed by an X-ray showing that a lumbar vertebra has moved forward or backwards slightly from its normal alignment.

Cauda equina syndrome

The cauda equina is the collective name given to the spinal nerves as they come out of the bottom of the spinal cord. If the nerves are compressed at this level by a disc herniating backwards towards your spinal cord, cauda equina syndrome is possible. It is more common for the disc to herniate to one side or the other rather than backwards or forwards, but all directions are possible. If the cauda equina does become compressed, you may not be able to empty your bladder or may lose control of your bowels. You may also experience numbness in your genital area.

Cauda equina syndrome is uncommon, but if you have these symptoms they need immediate medical attention. This is the only time you should go to A&E with back pain. The earlier you are assessed and treated, the better chance your nerve has of recovering.

Back pain in children

Back pain in children is usually mild and a result of poor posture or growth spurts (growing pains) which are caused when bone and muscle development are not happening at the same rate. In very sporty children who repetitively put their spine through stress and strain, for example fast bowling in cricket, there may be a risk of stress fracture to the bony arch called the pars interarticularis, which is a part of the vertebrae. This will be diagnosed by an MRI scan. Rest with physiotherapy and rehabilitation over three to six months may be needed but surgery is rarely required.

Scoliosis and curvatures

Scoliosis is a side-to-side curve in the spine rather than the normal front to back curves. This may or may not cause any more trouble than normal spinal anatomy. It doesn't cause pain. If you think you or your child has a scoliosis it's a good idea to have it checked out. It doesn't mean you or they will have any more episodes of back pain than anyone else, but you still need to watch your posture both standing and sitting and keep fit to ensure good spinal health.