Ver­te­brae

Parts of the lum­bar spine.

These bones con­nect to cre­ate a canal that pro­tects the spinal cord. The spinal col­umn is made up of three sec­tions that cre­ate three nat­ural curves in your back: the curves of the neck area (cer­vi­cal), chest area (tho­racic), and lower back (lum­bar). The lower sec­tion of your spine (sacrum and coc­cyx) is made up of ver­te­brae that are fused together.

Five lum­bar ver­te­brae con­nect the upper spine to the pelvis.

Spinal Cord and Nerves

These “elec­tri­cal cables” travel through the spinal canal car­ry­ing mes­sages between your brain and mus­cles. Nerves branch out from the spinal cord through open­ings in the vertebrae.

Mus­cles and Ligaments

These pro­vide sup­port and sta­bil­ity for your spine and upper body. Strong lig­a­ments con­nect your ver­te­brae and help keep the spinal col­umn in position.

Facet Joints

Between ver­te­brae are small joints that help your spine move.

Inter­ver­te­bral Disks

Inter­ver­te­bral disks sit in between the vertebrae.

When you walk or run, the disks act as shock absorbers and pre­vent the ver­te­brae from bump­ing against one another. They work with your facet joints to help your spine move, twist, and bend.

Inter­ver­te­bral disks are flat and round, and about a half inch thick. They are made up of two components.

Annu­lus fibro­sus. This is the tough, flex­i­ble outer ring of the disk. It helps con­nect to the vertebrae.

Nucleus pul­po­sus. This is the soft, jelly-like cen­ter of the annu­lus fibro­sus. It gives the disk its shock-absorbing capabilities.

Over-activity

One of the more com­mon causes of low back pain is mus­cle sore­ness from over-activity. Mus­cles and lig­a­ment fibers can be over­stretched or injured.

This is often brought about by that first soft­ball or golf game of the sea­son, or too much yard work or snow shov­el­ing in one day. We are all famil­iar with this “stiff­ness” and sore­ness in the low back — and other areas of the body — that usu­ally goes away within a few days.

Disk Injury

Some peo­ple develop low back pain that does not go away within days. This may mean there is an injury to a disk.

Disk tear. Small tears to the outer part of the disk (annu­lus) some­times occur with aging. Some peo­ple with disk tears have no pain at all. Oth­ers can have pain that lasts for weeks, months, or even longer. A small num­ber of peo­ple may develop con­stant pain that lasts for years and is quite dis­abling. Why some peo­ple have pain and oth­ers do not is not well understood.

Disk her­ni­a­tion. Another com­mon type of disk injury is a “slipped” or her­ni­ated disc.

Her­ni­ated disk.

A disk her­ni­ates when its jelly-like cen­ter (nucleus) pushes against its outer ring (annu­lus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the her­ni­ated disk bulges out toward the spinal canal, it puts pres­sure on the sen­si­tive spinal nerves, caus­ing pain.

Because a her­ni­ated disk in the low back often puts pres­sure on the nerve root lead­ing to the leg and foot, pain often occurs in the but­tock and down the leg. This is sciatica.

A her­ni­ated disk often occurs with lift­ing, pulling, bend­ing, or twist­ing movements.

Disc degen­er­a­tion.

Disk Degen­er­a­tion

With age, intev­er­te­bral disks begin to wear away and shrink. In some cases, they may col­lapse com­pletely and cause the facet joints in the ver­te­brae to rub against one another. Pain and stiff­ness result.

This “wear and tear” on the facet joints is referred to as osteoarthri­tis. It can lead to fur­ther back prob­lems, includ­ing spinal stenosis.

Degen­er­a­tive Spondylolisthesis

(Spon-dee-low-lis-THEE-sis). Changes from aging and gen­eral wear and tear make it hard

for your joints and lig­a­ments to keep your spine in the proper posi­tion. The ver­te­brae move more than they should, and one ver­te­bra can slide for­ward on top of another. If too much slip­page occurs, the bones may begin to press on the spinal nerves.

Spinal Steno­sis

Spinal steno­sis occurs when the space around the spinal cord nar­rows and puts pres­sure on the cord and spinal nerves.

Spinal steno­sis.

When inter­ver­te­bral disks col­lapse and osteoarthri­tis devel­ops, your body may respond by grow­ing new bone in your facet joints to help sup­port the ver­te­brae. Over time, this bone over­growth — called spurs — can lead to a nar­row­ing of the spinal canal. Osteoarthri­tis can also cause the lig­a­ments that con­nect ver­te­brae to thicken, which can nar­row the spinal canal.

Sco­l­io­sis

This is an abnor­mal curve of the spine that may develop in chil­dren, most often dur­ing their teenage years. It also may develop in older patients who have arthri­tis. This spinal defor­mity may cause back pain and pos­si­bly leg symp­toms, if pres­sure on the nerves is involved.

Addi­tional Causes

There are other causes of back pain, some of which can be seri­ous. If you have vas­cu­lar or arte­r­ial dis­ease, a his­tory of can­cer, or pain that is always there despite your activ­ity level or posi­tion, you should con­sult your pri­mary care doctor.

Med­ical His­tory and Phys­i­cal Examination

After dis­cussing your symp­toms and med­ical his­tory, your doc­tor will exam­ine your back. This will include look­ing at your back and push­ing on dif­fer­ent areas to see if it hurts. Your doc­tor may have you bend for­ward, back­ward, and side to side to look for lim­i­ta­tions or pain.

Your doc­tor may mea­sure the nerve func­tion in your legs. This includes check­ing your reflexes at your knees and ankles, as well as strength test­ing and sen­sa­tion test­ing. This might tell your doc­tor if the nerves are seri­ously affected.

Imag­ing Tests

Other tests which may help your doc­tor con­firm your diag­no­sis include:

X-rays. Although they only visu­al­ize bones, sim­ple X-rays can help deter­mine if you have the most obvi­ous causes of back pain. It will show bro­ken bones, aging changes, curves, or defor­mi­ties. X-rays do not show disks, mus­cles, or nerves.

Mag­netic res­o­nance imag­ing (MRI). This study can cre­ate bet­ter images of soft tis­sues, such as mus­cles, nerves, and spinal disks. Con­di­tions such as a her­ni­ated disk or an infec­tion are more vis­i­ble in an MRI scan.

Com­put­er­ized axial tomog­ra­phy (CAT) scans. If your doc­tor sus­pects a bone prob­lem, he or she may sug­gest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.

Bone scan. A bone scan may be sug­gested if your doc­tor needs more infor­ma­tion to eval­u­ate your pain and to make sure that the pain is not from a rare prob­lem like can­cer or infection.

Bone den­sity test. If osteo­poro­sis is a con­cern, your doc­tor may order a bone den­sity test. Osteo­poro­sis weak­ens bone and makes it more likely to break. Osteo­poro­sis by itself should not cause back pain, but spinal frac­tures due to osteo­poro­sis can.

Non­sur­gi­cal Treatment

Med­ica­tions. Sev­eral med­ica­tions may be used to help relieve your pain.

• Aspirin or aceta­minophen can relieve pain with few side effects.
• Non-steroidal anti-inflammatory med­i­cines like ibupro­fen and naproxen reduce pain and swelling.
• Nar­cotic pain med­ica­tions, such as codeine or mor­phine, may help.
• Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.

Phys­i­cal med­i­cine. Low back pain can be dis­abling. Med­ica­tions and ther­a­peu­tic treat­ments com­bined often relieve pain enough for you to do all the things you want to do.

• Phys­i­cal ther­apy can include pas­sive modal­i­ties such as heat, ice, mas­sage, ultra­sound, and elec­tri­cal stim­u­la­tion. Active ther­apy con­sists of stretch­ing, weight lift­ing, and car­dio­vas­cu­lar exer­cises. Exer­cis­ing to restore motion and strength to your lower back can be very help­ful in reliev­ing pain.
• Braces are often used. The most com­mon brace is a corset-type that can be wrapped around the back and stom­ach. Braces are not always help­ful, but some peo­ple report feel­ing more com­fort­able and sta­ble while wear­ing them.
• Chi­ro­prac­tic or manip­u­la­tion ther­apy is pro­vided in many dif­fer­ent forms. Some patients have relief from low back pain with these treatments.
• Trac­tion is often used, but with­out sci­en­tific evi­dence for effectiveness.
• Other exercise-based pro­grams, such as Pilates or yoga are help­ful for some patients.

Sur­gi­cal Treatment

Surgery for low back pain should only be con­sid­ered when non­sur­gi­cal treat­ment options have been tried and have failed. It is best to try non­sur­gi­cal options for 6 months to a year before con­sid­er­ing surgery.

In addi­tion, surgery should only be con­sid­ered if you doc­tor can pin­point the source of your pain.

Surgery is not a last resort treat­ment option “when all else fails.” Some patients are not can­di­dates for surgery, even though they have sig­nif­i­cant pain and other treat­ments have not worked. Some types of chronic low back pain sim­ply can not be treated with surgery.

Spinal Fusion. This is essen­tially a “weld­ing” process. The basic idea is to fuse together the painful ver­te­brae so that they heal into a sin­gle, solid bone.

Spinal fusion elim­i­nates motion between ver­te­bral seg­ments. It is an option when motion is the source of pain. For exam­ple, your doc­tor may rec­om­mend spinal fusion if you have spinal insta­bil­ity, a bad cur­va­ture (sco­l­io­sis), or severe degen­er­a­tion of one or more of your disks. The the­ory is if the painful spine seg­ments do not move, they should not hurt.

Fusion of the ver­te­brae in the lower back has been per­formed for decades. A vari­ety of sur­gi­cal tech­niques have evolved. In most cases, a bone graft is used to fuse the ver­te­brae. Screws, rods, or a “cage” are used to keep your spine sta­ble while the bone graft heals.

The surgery can be done through your abdomen, your side, your back, or a com­bi­na­tion of these. There is even a pro­ce­dure that is done through a small open­ing next to your tail­bone. No one pro­ce­dure has been proven bet­ter than another.

The results of spinal fusion for low back pain vary. It can be very effec­tive at elim­i­nat­ing pain, not work at all, and every­thing in between. Full recov­ery can take more than a year.

Disc Replace­ment. This pro­ce­dure involves remov­ing the disk and replac­ing it with arti­fi­cial parts, sim­i­lar to replace­ments of the hip or knee.

The goal of disk replace­ment is to allow the spinal seg­ment to keep some flex­i­bil­ity and main­tain more nor­mal motion.

The surgery is done through your abdomen, usu­ally on the lower two disks of the spine.

Exer­cise

Com­bine aer­o­bic exer­cise, like walk­ing or swim­ming, with spe­cific exer­cises to keep the mus­cles in your back and abdomen strong and flexible.

Proper Lift­ing

Be sure to lift heavy items with your legs, not your back. Do not bend over to pick some­thing up. Keep your back straight and bend at your knees.

Weight

Main­tain a healthy weight. Being over­weight puts added stress on your lower back.

Avoid Smok­ing

Both the smoke and the nico­tine cause your spine to age faster than normal.

Proper Pos­ture

Good pos­ture is impor­tant for avoid­ing future prob­lems. A ther­a­pist can teach you how to safely stand, sit, and lift.