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Back Pain

Axial Lower Back Pain

Back pain comes in many flavors and shapes. It can be caused by a pinched nerve, a herniated disc, an infection, a tumor, a muscle strain, and the list can go one and on for pages. Most commonly, however, lower back pain in adults between age 35 and 65 is caused by degenerating discs. This is also called chronic axial lower back pain to emphasize that the lower extremities (buttocks/legs) are not affected. 

The intervertebral discs are designed to function as 'shock absorbers' in the lower portions of the spine. As shock absorbers, they absorb the wear and tear of carrying the body and distribute those forces and stress over the different discs in the lower back. After a certain amount of degeneration, they can become a source of pain.

As people age, these discs lose their elasticity/ cushion and the discs become stiff and rigid. They no longer function properly and can cause lower back pain. This back pain has a typical pattern. It is usually worse with prolonged sitting (>1-2 hours), leaning forward, and bending/twisting/turning through the lower back. These are actually the reasons why Hollywood tries to make 90 minute movies and domestic airline flights make more allowances for walking about the cabin of the flight is more than 2 hours long.

These discs are moving parts of the lower back, and - like other moving parts - they tend to wear out over time. Unfortunately, there are no perfect treatment options for these degenerative lumbar discs. This is why most people over the age of 35 have some sort of lower back issue/problem. However, an overwhelming majority of people can manage this condition with no impact on their daily activities or their lifestyle. Typically, activity modification and an appropriate lower back exercise program are recommended to prevent flare-ups. Activity modification includes weight loss, proper bending/lifting techniques, and transition to non-impact activities. A exercise program would focus on bending through the hips and knees instead of the lower back.

If a person does aggravate their lower back (which everyone does on occasion), then a course of oral anti-inflammatory medications can be helpful, as can a short course of physical therapy and/or a muscle relaxer. Narcotic medications are not typically recommended as they can be habit-forming, build tolerance, and do not address the underlying problem.

Very rarely is surgery an option for someone with degenerative disc disease of the lumbar spine. Traditionally, surgery for this purpose is reserved for someone who is becoming dependent on narcotic medications and/or cannot work due to their severe pain. The reason why surgery is avoided is 1) it may not reliably relieve the pain, and 2) it increases the need for additional surgery in the future. 

A trained spine surgeon can order/perform a discogram (in conjunction with a battery of other tests) to predict if surgery would be helpful, but even these test are not 100%. The surgery required to remove the pain from a degenerative disc is known as a lumbar fusion. This surgery would remove the movement at the painful disc; if the movement is gone, then - in theory - the pain should be diminished. Lumbar disc replacements are still in their infancy and considered by most spine surgeons to be 'experimental'.

However, lumbar fusion has known long-term risks. If one level of the spine is fused, then that means that there is one less disc available to distribute the stresses/forces of carrying the person's body. This suggests that the other discs have to do more work (carry more stress/force) and will degenerate faster than they would have otherwise. Thus, one can imagine a scenario where a person gets a lumbar fusion and then returns with pain a few years later because the adjacent level disc is now degenerated and causing them pain. This is known as adjacent segment disease and is a known risk of any fusion surgery. Every person who is considering undergoing lumbar fusion surgery should know about adjacent segment degeneration prior to undergoing their fusion surgery.

Until recently, it was considered controversial to perform lumbar fusion surgery for chronic axial lower back pain. One of my teachers, a world famous spine surgeon stated that, "Lumbar fusion surgery for degenerative disc disease is prostitution of one's talents as a surgeon". He meant that a surgeon should not use his talents/skills in a corrupt way, as these surgeries can lead to financial and personal gains for the surgeon, but may not lead to any improvement for the patient. In fact, may patients may end up worse after their surgery for this condition. These surgeons/surgeries are why spine surgery has a poor image in the general population. Spine surgeons tend to perform lower back surgery, but it is more reliable for buttock and leg pain (pinched nerves) than it is for back pain (degenerative discs).

Please discuss any further questions about your specific situation with a fellowship-trained orthopedic spine surgeon.

Managing Chronic Low Back Pain

Whether it's a lumbar strain or lumbar degenerative disc disease, many patients suffer from chronic low back pain. Sometimes physicians refer to this is as chronic axial low back pain. Usually surgery is not recommended for this condition.  A few simple tips may help you manage this condition and minimize the limitation that occurs from your low back pain.

  • Weight management - Keeping your weight at the appropriate level minimizes the stresses and loads on the discs of the lower spine.  It also minimizes the amount of work the back muscles need to do on a daily basis in order to keep your posture straight. Good weight management can also help reduce arthritic pain in other joints such as the hips and knees.  A good diet as well as a well-rounded exercise program can help you maintain or lose weight as appropriate.  This is one of the biggest keys to managing chronic low back pain.
  • Lumbar exercises - A regular set of exercises focused on strengthening the low back muscles and the abdominal muscles can help lessen the amount of stress placed on your spine.  These exercises are usually taught to patients during their physical therapy sessions.  At the end of your course of physical therapy, you should be able to perform most, if not all, of the exercises yourself.  These exercises should be performed on a daily basis to help you recover from your current flare-up of back pain and also to help prevent future episodes of back pain.  These exercises not only help the back muscles heal, but also keep the back in good shape to help you avoid re-aggravating it in the future.
  • Aerobic Exercise - Regular aerobic exercise (defined as 15 to 30 minutes of activity that increases your heart rate to 80% of the maximum recommended heart rate for your age group) can lessen the chronic daily pain in one's back. A healthy exercise that increases your heart rate and makes you sweat releases the body's natural painkillers, such as opiates (morphine, etc.) and endorphins.  Studies have shown that regular aerobic exercise lessens the patients’ need for regular pain medications and lessens the number of days missed from work. It's not going to take all of the pain away, but patients who find benefit from regular aerobic exercise notice their back discomfort more on the days that they have not had a chance to exercise.  It becomes a regular and important part of their daily lives.  Plus, it's good for your heart, lungs, muscles, and weight. Check with your primary care physician prior to starting an aerobic exercise program.

    It's okay if you have not done  regular aerobic exercise in a long-time or never have done it at all.  Start with something simple and achievable.  The most important thing is consistency.  Start with a stationary bike and work your way up to an elliptical, or even a treadmill.  If a stationary bike is too difficult, then start with a hand bike.  The most important thing is to work up a sweat and increase your heart rate.

  • Avoid Re-Aggravation - Hopefully, physical therapy and medicines are successful in helping you overcome your current episode of low back pain.  Once this episode resolves, weight control, lumbar exercises, and aerobic exercise should all help you to  avoid another episode.  Most importantly, it is your awareness of your environment and avoiding activities/movements that can potentially aggravate your back.  There are many instances in our daily lives where our backs are placed in compromising positions, both at home and at work.  During your physical therapy sessions, your therapist has taught you how to lift properly and to properly accomplish most of the tasks of your daily life.  Continue to be mindful of your body posture and bending techniques at home and at work.  Sometimes taking an extra few seconds can help you avoid a few weeks worth of low back aggravation.

If you can remember and apply the tips mentioned above, I am certain that your back will be less of a limitation in your daily life. If you ever have any questions or concerns, please free feel to discuss with an orthopedic spine surgeon.