Most people will experience back pain at sometime in their life. Fortunately most back pain is myofascial or due to muscle or ligament strain. This type of back pain will resolve in a few weeks with conservation therapy. Treatment includes anti-inflammatory medications such as ibuprofen and physical therapy. More serous back pain radiates into the lower extremities. Pain that persists for more than three months is considered chronic back pain.

Pain that radiates into the leg is secondary to nerve root inflammation and usually from a disk herniation or narrowing of the spinal cord. The narrowing can be of the central canal or where the nerve roots exit the canal, and is referred to as spinal stenosis.

Back pain that does not go into the leg is generally from degeneration of the disc or arthritis of the small joints of the back called facet joints.

An acute disc hernation often occurs after a lifting injury. The injury usually happens the day prior to the onset of pain and results from lifting off balance or lifting and twisting. One may feel a pop or “something let go” and may experience immediate pain. Since pain is carried on smaller nerves, symptoms of weakness or numbness are much more serious because they involve larger nerves. Pain from the back into the leg combined with numbness and weakness requires immediate medical attention. Compromise of large nerves may require a magnetic resonance imaging (MRI) and surgical evaluation.

A disc herniation with only back and leg pain is treated more conservatively. In fact recent studies show that for simple disc herniations the outcomes from conservative therapy versus surgery are similar after two years.

Conservation therapy includes physical therapy, anti-inflammatory medications, and epidural steroid injections plus or minus pain medications. Physical therapy should include stretching, particularly the hamstring muscles; strengthening of the longitudinal back and abdominal muscles; and range of motion exercise both in the morning and night. Anti-inflammatories such as ibuprofen, Aleve or Advil will help with pain and nerve root inflammation. Epidural steroid injections are similar to a spinal injection or the injections women get for pain relief during labor and delivery. The steroids reduce inflammatory of nerve roots and eliminate leg pain more than 60% of the time. Steroids taken by mouth may be effective but generally less so than injected steroids. If pain is not controlled with above therapy a stronger pain reliever may be required. Most important of all, continued activity is recommended. Bed rest results in increased pain and stiffness. Chiropractic or Osteopathic therapy may be helpful for pain that does not radiate into the leg but “cracking the back” is not recommended for a disc herniation. Traction can be effective but is usually not long lasting.

Back and leg pain from spinal stenosis usually occurs in older individuals as a result of disc degeneration and arthritis of the spine. Less commonly it may be caused by slippage of one vertebral body over the one below it, called spondylolisthesis. Both of these conditions result in nerve root inflammation and the treatment is similar to that for a disc herniation, including physical therapy, anti-inflammatories, epidural steroid injections and pain medications. Failure of conservation therapy may require surgical decompression and/or spine stabilization.

Back pain that does not radiate into the leg is usually from degenerated disc or arthritis. Everyone will experience disc degeneration to some degree and it is commonly related to age. Occupations that cause vertical stress on the spine, however, can cause early degenerative disease. Vertebral discs are fibrous on the outside and liquid in the center. Degeneration of discs results in desiccation or drying out of disc centers. Irritation to nerves in the fibrous capsules cause pain. In extreme cases loss of disc height can result in nerve root compression. Pain from degenerated disc is treated with physical therapy, anti-inflammatoies, and pain medications. Ablating (destroying) the nerves in the disc with interdiscal electrothermal therapy (IDET) can be effective therapy. Rarely is degenerative disc pain treated with surgery.

Another source of back pain that does not go into the leg below the knee is spinal arthritis. This arthritis affects the small joints (facet joints) along the posterior of the spine. This occurs most commonly as one ages but may be a result of a hyperextension injury. Such an injury can result from a rear-end motor vehicle collision or a fall onto ones back. Pain is in the lower back and may radiate into the buttock or hip. The pain is worse with extension of the spine from prolonged standing, sitting in a straight back chair, or going up stairs. Initial therapy is the same as for other arthritic joints; physical therapy, and anti-inflammatories. If pain persists it can be successfully treated with anesthetic injections to the nerves that go to these joints. If the pain returns following the anesthetic injections the nerve can be ablated with radiofrequency generated wave through an insulated needle.

These are the most common causes and treatments for low back pain. There are many others less common causes including vertebral compression fracture, sacroiliac joint pain and coccyx pain.
Also although not mentioned Complementary Alternative Medical (CAM) therapies should be considered including massage, heat, and acupuncture. CAM therapies that are mildly effective or produce very short-term results should be balanced with their expense.

To review back pain that radiates into the leg with numbness and weakness requires immediate medical attention. Back pain that may or may not go into the leg that persists more than three months is termed chronic pain. Chronic pain results in changes in the spinal cord that magnifies symptoms and may result in psychological conditions such as depression.

A certified pain specialist should evaluate chronic back pain. An evaluation by a pain specialist will result in a diagnosis and treatment plan. Medical management, and if necessary, invasive (injection) therapy can be done by a qualified pain management specialist. He or she can recommend appropriate physical therapy and behavioral coping therapy if necessary. The pain specialist will know if and when to have a surgical evaluation or intervention. Your primary care provider can recommend a qualified pain specialist.