Low Back Pain

What is Low Back Pain? How is it diagnosed?

What is Low Back Pain?

Low back pain is one of the most common problems resulting in more disability than any other condition. Almost everyone will experience some type of low back pain at some point in their lives as it affects approximately every two out of three adults. While some forms of low back pain are short-lasting and recover quickly, others take much longer to heal and may require more extensive treatment.

Broadly speaking, the two types of low back pain are:

• Acute Low Back Pain: pain that is short in duration, often lasting 4 weeks or less
• Chronic Low Back Pain: long lasting pain that has been going on for 3 months or more

Low back pain can result from a variety of different conditions that cause damage or irritation to the structures of the lumbar spine of the low back, including the muscles, discs, spinal cord, nerves, or vertebrae bones. Conditions that cause low back pain include injuries, overuse, or age-related wear and tear changes that affect the strength and stability of your spine to support your body.

Common causes of low back pain include:

• Muscle strain from heavy lifting, twisting, or motor vehicle accidents
• Poor posture with sitting, standing, exercising, and sleeping
• Arthritis of the spine
• Bulging or herniated discs
• Spinal stenosis (narrowing of the openings of the vertebrae due to age related changes in the spine)
• Spinal fracture

Because the spine of your lower back and surrounding structures support your entire body with everything you do, low back pain can significantly impact all of your daily activities. Injury to your low back can also cause symptoms to travel into your legs if your spinal cord and/or nerve roots are affected.

How is it diagnosed?

History & Physical Exam

A thorough history and physical examination by your healthcare provider can help determine the underlying cause of your low back pain. Your healthcare provider will ask you questions about your symptoms and how and when your symptoms began to get a clearer picture of how your condition occurred. 

Risk factors that increase your risk of developing low back pain include:

• Older age
• Being overweight
• Abdominal (core) muscle weakness
• Repeated stress through bending, twisting, and heavy lifting
• Poor posture
• Smoking

In addition to discussing your medical history, your healthcare provider will perform a physical examination to assess your low back for pain, swelling, and mobility. Your healthcare provider will feel the bones and soft tissues around your low back to see if anything is tender to the touch, and ask you to move your body in different positions to see if your range of motion is affected or if certain motions are painful.

If you complain of symptoms like pain, numbness, tingling, or weakness in your legs, your healthcare provider will also test the strength of your leg muscles and assess the sciatic nerves of your legs for signs of compression.. 

Imaging 

Certain causes of low back pain, such as bulging or herniated discs or spinal stenosis, cause increased pain with certain motions, like forward or backward bending of the spine, or different positions, like sitting, bending, standing, or laying flat. Other causes of low back pain, or a combination of more than one condition that causes low back pain, present with more vague symptoms and cause pain that is difficult to link to specific motions and positions. 

Because symptoms of many low back conditions cause similar symptoms and occur together, imaging studies are often performed to determine a diagnosis and the underlying reason causing your low back pain. Different imaging methods can be used to examine the tissues and structures of your lumbar spine, which include:

• X-Ray: An x-ray is a 2-dimensional image that examines the structure of your bones. Your healthcare provider will order an x-ray to make sure that you do not have a broken vertebra in your lumbar spine and to check for signs of spinal osteoarthritis or a spinal deformity like scoliosis.
• MRI: An MRI, or magnetic resonance imaging, is a 3-dimensional imaging scan that illustrates soft tissues of the body and can be used to assess the integrity of structures within your spine like ligaments, discs, and cartilage. 

Common conditions that result from aging of the spine, cause low back pain, and occur together include spinal osteoarthritis, bulging or herniated discs, spinal stenosis, and nerve compression.

Low Back Pain Treatment Options (Surgical vs Non-Surgical)

Surgery for low back pain is only recommended after all other non-surgical treatment methods have been exhausted with little improvement in your symptoms. For cases of low back pain that require surgery where the vertebrae bones are relatively sturdy and intact, a minimally invasive spine operation may be performed to increase the openings of the vertebrae or remove a portion of a bulging or herniated disc to reduce nerve compression.

In cases where the structure of the vertebrae is significantly degenerated and/or a disc is significantly damaged, a more involved procedure called a lumbar spinal fusion may be performed to provide added stability to the spine. Because a lumbar spinal fusion is a very involved procedure, it is only performed as a last resort treatment option for severe and disabling low back pain and instability. 

Whether you have surgery or not, physical therapy is extremely important for managing your low back pain to strengthen and support your spine to help alleviate some of your symptoms.

Surgery – Lumbar Spinal Fusion

When low back pain is severe and other treatment methods fail to yield a lasting improvement in your symptoms, a lumbar spinal fusion may be performed if a minimally invasive spine surgery cannot be used to effectively treat your condition. The three main types of minimally invasive spine surgeries include:

• Discectomy: a surgical procedure to remove a portion of a damaged disc between vertebrae
• Foraminotomy: a surgical procedure to widen the foramina, the openings at the sides between vertebrae where nerve roots exit from the spinal cord
• Laminectomy: a surgical procedure to remove a portion of bone called the lamina from the vertebrae to widen the opening for the spinal cord and nerve roots

When a significant bulging or herniated disc is present and/or significant instability of your spine is causing low back pain and nerve compression, a lumbar spinal fusion may be performed to fuse two or more vertebrae together to provide added stability to support your low back.

A lumbar spinal fusion is performed through an open surgery where an incision is made down the length of your lumbar spine of your low back to access the affected vertebrae. During your lumbar spinal fusion, the spinal disc between the affected vertebrae will be removed and replaced with a bone graft to fill in the missing space to preserve the height of your spine. The two vertebrae and the bone graft between them will then be fixated together with metals rods, plates, and screws. As your spine heals from the operation, the two vertebrae and bone graft will fuse together, forming one solid unit.

A lumbar spinal fusion is used to treat conditions such as:

• Spinal fractures
• Spondylolisthesis
• Scoliosis
• Severe arthritis
• Multiple bulging or herniated discs
• Spinal instability

A lumbar spinal fusion can either be performed in the outpatient surgical setting where you will be able to go home the same day of your surgery, or might require you to stay overnight in the hospital for 1-4 nights to make sure that your pain levels are under control and that you are able to get out of bed and walk before going home.

Non-Surgical Management of Low Back Pain

Non-surgical management for low back pain includes a variety of different treatment options to address your symptoms. Resting, applying ice to your low back, and use of nonsteroidal antiinflammatory drugs (NSAIDs) like Tylenol or Advil are recommended to help decrease low back pain and inflammation. Your healthcare provider may also recommend taking a muscle relaxer or using topical pain-relieving options like creams, gels, or patches to help manage your symptoms. 

Physical therapy is also always recommended for patients with low back pain to improve spinal mobility and the strength and flexibility of surrounding muscles. Without proper strength in your abdominal (core) muscles to support your low back, your vertebrae and discs are subjected to increased stress and pressure with all movements, especially repeated bending, twisting, and heavy lifting. 

When you strengthen your core muscles, they activate to stabilize, protect, and hold your spine in place to prevent repeated stress and wear and tear over time with aging. A physical therapist can work with you to provide you with low back stretches and core strengthening exercises to decrease your pain, restore normal low back range of motion, and improve the strength of your core muscles to stabilize your spine in different positions. If you are overweight, weight loss will also significantly help decrease your low back pain by reducing pressure within your spine.

For ongoing chronic low back pain, more invasive procedures may be considered, such as steroid injections into the spine or radiofrequency ablation, the use of a heated needle to destroy nerve fibers to decrease pain signals sent to the brain.

Lumbar Spinal Fusion FAQs

General

How common is a Lumbar Spinal Fusion?

A spinal fusion is the most commonly performed spinal surgery with between 400,000 and 500,000 spinal fusions performed each year in the United States. More than half of these procedures are performed on the lumbar spine. 

How long does a Lumbar Spinal Fusion last?

The metal hardware used for a lumbar spinal fusion surgery is intended to be permanent without the need for removal or replacement. If the metal hardware loosens, becomes infected, or causes pain, it may have to be removed through another operation. Metal hardware is typically removed in cases where the vertebrae bones do not heal and fuse together properly, causing the metal hardware to break or shift out of place. 

Treatment Decision

Who is not a good candidate for surgery?

People with significant comorbidities such as heart and lung problems and bleeding disorders may not be healthy enough to undergo any type of surgery and are usually not good candidates for a lumbar spinal fusion. People with significant osteoporosis, or low bone mineral density causing brittle bones, may not have strong enough bones to support the placement of plates, rods, and screws, and will likely have to improve their bone mineral density first before undergoing surgery. 

Can I wait to have surgery?

A lumbar spinal fusion is performed as the last resort treatment option for low back pain. Waiting to have surgery while trying other treatment methods like pain medications, physical therapy, and cortisone injections is recommended for at least 3-6 months. 

After Surgery

Can I shower or take a bath?

You should avoid taking a bath or submerging your body in water during the first month after surgery to decrease the risk of your incision reopening or becoming infected. While you will be allowed to shower, you should avoid direct water pressure on your incision for at least two weeks.

Will I be able to walk after surgery?

You will be able to walk after lumbar spinal fusion and will be encouraged to do so as soon as possible by your healthcare providers. If your back pain and other symptoms significantly affect your leg strength, balance, and ability to walk, you may need to use an assistive device like a cane or a walker to help you walk after surgery until you build up more overall strength.

Will I have limitations after surgery?

After lumbar spinal fusion surgery, you will need to avoid certain motions and positions to allow your spine proper time to heal so that the metal hardware does not break or loosen. Remember BLT – no bending, lifting, or twisting. Pushing and pulling movements should be avoided as well. Vigorous activities like yard work, household chores, and exercises, other than those approved by your physical therapist, should be avoided until you are given clearance from your surgeon. 

How can I minimize scarring?

You can minimize scarring by avoiding picking at your surgical incision and leaving your stitches, staples, or steri-strips in place until they naturally come off or are removed by your healthcare provider. Keeping your incision clean and dry will also help avoid infection which can delay healing and worsen scarring.