Lower Back Pain (Lumbar Back Pain)

What is the anatomy of the low back?

The Important structures of the low back that can be related to symptoms include the bony lumbar
spine (vertebrae, singular = vertebra), discs between the vertebrae, ligaments around the spine and
discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and
the skin covering the lumbar area.
The bony lumbar spine is designed so that vertebrae "stacked" together can provide a movable support
structure while also protecting the spinal cord from injury. The spinal cord is composed of nervous
tissue that extends down the spinal column from the brain. Each vertebra has a spinous process, a bony
prominence behind the spinal cord, which shields the cord's nervous tissue from impact trauma.
Vertebrae also have a strong bony "body" (vertebral body) in front of the spinal cord to provide a
platform suitable for weight bearing of all tissues above the buttocks. The lumbar vertebrae stack
immediately atop the sacrum bone that is situated in between the buttocks. On each side, the sacrum
meets the iliac bone of the pelvis to form the sacroiliac joint of the buttocks.
The discs are pads that serve as "cushions" between the individual vertebral bodies. They help to
minimize the impact of stress forces on the spinal column. Each disc is designed like a jelly donut with
a central softer component (nucleus pulposus) and a surrounding outer ring (annulus fibroses). The
central portion of the disc is capable of rupturing (herniating) through the outer ring, causing irritation
of adjacent nervous tissue and sciatica as described below.
Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of
the vertebrae to each other and surround each of the discs. The nerves that provide sensation and
stimulate the muscles of the low back as well as the lower extremities (the thighs, legs, feet, and toes)
exit the lumbar spinal column through bony portals, each of which is called a "foramen."
Many muscle groups that are responsible for flexing, extending, and rotating the waist, as well as
moving the lower extremities, attach to the lumbar spine through tendon insertions. The aorta and
blood vessels pass in front of the lumbar spine in the abdomen and pelvis. Surrounding these blood
vessels are lymph nodes (lymph glands) and tissues of the involuntary nervous system that are
important in maintaining bladder and bowel control.
The uterus and ovaries are important pelvic structures in front of the pelvic area of women. The
prostate gland is a significant pelvic structure in men. The kidneys are on either side of the back of the
lower abdomen, in front of the lumbar spine.
The skin over the lumbar area is supplied by nerves that come from nerve roots that exit from the
lumbar spine.
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What is the function of the low back?

The low back, or lumbar area, serves a number of important functions for the human body. These
functions include structural support, movement, and protection of certain body tissues. When we stand,
the lower back is functioning to support the weight of the upper body. When we bend, extend, or rotate
at the waist, the lower back is involved in the movement. Therefore, injury to the structures important
for weight bearing, such as the bony spine, muscles, tendons, and ligaments, often can be detected
when the body is standing erect or used in various movements.
Protecting the soft tissues of the nervous system and spinal cord as well as nearby organs of the pelvis
and abdomen is a critical function the lumbar spine and its adjacent muscles.
What are common causes of lower back pain?
Common causes of low back pain (lumbar backache) include lumbar strain, nerve irritation, lumbar
radiculopathy, bony encroachment, and conditions of the bone and joints. Each of these is reviewed
below.
Lumbar strain (acute, chronic)
A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The
stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is
considered one of the most common causes of low back pain. The injury can occur because of overuse,
improper use, or trauma. Soft-tissue injury is commonly classified as "acute" if it has been present for
days to weeks. If the strain lasts longer than three months, it is referred to as "chronic."
Lumbar strain most often occurs in people in their 40s, but it can happen at any age. The condition is
characterized by localized discomfort in the low back area with onset after an event that mechanically
stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the
degree of strain and resulting spasm of the muscles of the low back.
The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion
of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities.
The treatment of lumbar strain consists of resting the back (to avoid re-injury), medications to relieve
pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode
resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Initial treatment
at home might include heat application, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), and
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avoidingreinjury and heavy lifting. Long periods of inactivity in bed are no longer recommended, as
this treatment may actually slow recovery. Spinal manipulation for periods of up to one month has
been found to be helpful in some patients who do not have signs of nerve irritation. Future injury is
avoided by using back-protection techniques during activities and support devices as needed at home
or work.
Nerve irritation
The nerves of the lumbar spine can be irritated by mechanical pressure (impingement) by bone or other
tissues, or from disease, anywhere along their paths -- from their roots at the spinal cord to the skin
surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and
inflammation of the nerves caused by a viral infection (shingles). See discussions of these conditions
below.
Picture of herniated disc between L4 and L5

Cross-section picture of herniated disc between L4 and L5

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What are the points to be noted in the patient with backache?

Age of the patient.

Any history of cancer (like prostate or breast carcinoma).
Unexplained weight loss.
Long term use any steroidal drugs or drugs for AIDS.
Duration of back pain.
Any pain or worsening of pain at rest.
Drug abuse
Numbness or weakness of legs
History of injury to the back.
Urinary disturbance(difficulty in passing urine)
Work status.
Educational level of the patient.
Any pending cases in court against the patient.
Worker's compensation issues.
Previous failed treatment for backache.
Depression.

What are the 'Red flags' or warning signals in a patient with backache?
These conditions tell that patient is not having a simple back pain, but has a serious underlying back
problem.
1. Age of the patient if greater than 50 or less than 20 years.
2. If the patient suffers from cancer.
3. Unexplained weight loss.
4. Drug abuse.
5. History of significant trauma to the back.
6. Prolonged intake of steroids.
7. Acute difficulty in passing urine.
8. Numbness over the buttocks and groin.
9. Weakness of the legs.
What are the investigations to do for low backache?
For over 90% of the patients with back pain, no further testing is necessary except for the physician
consultation, if the pain subsides in first 4 weeks. Otherwise one must proceed with investigations like
X-rays, CT scan and MRI scan for the back (lumbosacral region). It will reveal bony abnormalities,
lumbar disc prolapse or spinal tumour, if present.
What are the treatments available?
Initially all cases of backache can be managed conservatively (non-surgical) except under special
situations, where patient should be taken up for emergency surgery. If there is lumbar disc prolapse,
patient can be taken up for surgery after a trial of conservative management. Spinal tumours should be
operated immediately.
Non-surgical treatment includes:
Bed rest:This will reduce the intra discal pressure and pressure on the nerve roots. Bed rest up to
4days is allowed. Prolonged bed rest does more harm to the patient, producing weakness, stiffness and
pain.
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Activity modification: For some period of time, patients are advised not to lift heavy objects, not tosit
in the chair for a long time and not to bend or twist the back.
Exercise: Low stress aerobic exercise is advised. Walking, cycling and swimming are allowed in
thefirst two weeks. Physiotherapist should be included in the programme for the benefit of patient.
Analgesics: For acute pain, paracetamol, or other drugs like diclofenac sodium can be used.
Patient education: Patient should be educated how to modify the daily activities, how to lift
weightetc., by charts and diagrams.
Steroids: In some cases, epidural steroid injections may be helpful.
Physical treatment: Lumbar traction is of no use. Spa therapy has proven effective in some
studies.Relaxing techniques and ultrasound therapy to the back may be helpful to some extent.

Three Simple Exercises for Your Back Pain

Exercise While Working at Your Desk
Hours and hours of sitting and working at your desk will surely lead to back pain. Back ache or back
pain can be caused due to strain on any of the over 200 muscles in your back. Proper posture while
working at your desk can help in reducing and preventing back pain. There are also some exercises
which can easily be done while sitting on your chair. Here are three very simple exercises for back
pain which can help you:
* Shoulder blade exercise for back pain
The shoulder blade exercise for back pain basically requires you to squeeze the blades of your
shoulder. Shoulder blades are bones which attach your arm bone to your collar bone and are roughly
triangular in shape. They are located on your upper back. To do this exercise, just sit upright in your
chair. Your shoulders should be relaxed and your back should be straight. Slowly push your shoulder
blades back towards each other. Your chest will be held high in this position. Now hold it for about
five to six seconds. Relax. Repeat this exercise about four to five times. This exercise helps in easing
and preventing back pain by strengthening the muscles of your shoulders and upper back.
* The twisting exercise for back pain
This exercise for back pain can also be done while you are sitting at your desk. Sit upright with your
back straight. Your feet should be firmly planted on the floor. Your thighs should be parallel to the
floor. Now slowly turn your neck and back towards your right and turn as much as possible. Your legs
should not move while doing this exercise. You can either let your hands lie in your lap or use your
arms to help you do the exercise. You can use your hands to support yourself by placing them on the
back of your chair. Hold the position for about five to six seconds and then come back to your original
position. Repeat the exercise by turning your back to the left side. You can repeat this exercise two or
three times on both the sides. This exercise will help stretch and strengthen your lower back and hip
muscles and prevent back pain.

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* The sideways bending exercise for back pain

This is another exercise for back pain which can easily be done while working at your desk. Sit upright
in your chair with your back straight. Hold your left hand with your right hand and place them in your
lap. Now slowly bend towards your right side. You will feel a stretch in the muscles on the left side
and on your lower back. Don't overdo this exercise. You might just hurt your back. Bend as much as is
comfortable and then hold for four to five seconds. Come back to your original position and then
repeat on the left side. This exercise for back pain strengthens the muscles on the sides, on your lower
back and your hips.
These exercises for back pain are easy to do and can be done while you are working. If you have a
back injury or have had surgery of any kind, it is advisable to consult with your physician before
attempting these exercises. Otherwise, if these exercises are practiced slowly and regularly, they will
strengthen the muscles of your back and prevent back strain.

DrPuttaRaju
MrsSabitha
MrsSowjanya

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