It started a few weeks ago---a dull ache in my lower back, more on the right, worse with sitting for prolonged periods of time. I did my usual stretches, although not as much as I should have. The pain waxed and waned, until a few days ago, when the pain escalated suddenly, preventing me from standing up straight, and making even a trip to the bathroom an unwelcome adventure. Two nights ago, I lay in bed awake, pillows wedged at strategic points, hoping to find some comfort, any comfort.
And then all hell broke loose. My back spasms loosened up a bit last night, so I got a few essential things done---and felt sudden burning pain shooting down my right leg, accompanied by numbness, tingling, and weakness. I writhed on the floor in pain, with even more drama than usual. Around 1:00 a.m., Mrs. Pal said, "Hey, I hear there's a pain clinic open now...it's over in the guest room." I rifled through the medicine cabinet and tried various tablets searching for relief.
I ended up laying on the floor of the guest room, legs on a pillow, sleeping fitfully. I was so desperate that I actually saw my doctor.
What is this low back pain stuff anyway?
First of all, it's common. When people come to see their primary care physician for other-than regularly scheduled visits, low back pain is one of the most common complaints (ranking anywhere between first and fifth, depending on the survey). This is a common problem. The good news is that most of the time it gets better spontaneously. The bad news is that while it's healing, there is significant lost work, and significant suffering.
There are many causes for low back pain, but quite often the cause isn't so important. It's useful to divide low back pain into two broad categories: benign causes, and not-so-benign causes. As physicians, we look for "red flags" that point toward the not-so-benign causes, which probably make up less than 5% of all back pain.
In evaluating the patient with low back pain, three questions form a useful framework:
- Is there evidence of systemic disease?
- Is there evidence of neurologic compromise?
- Is there social or psychological distress that may contribute to chronic, disabling pain?
The first two help detect back pain caused by other underlying systemic disease. The last is a prognostic question. People who answer "yes" to the third question are at risk of prolonged back problems and possibly substance abuse if the underlying psychosocial problems are not addressed.
Some of the conditions discovered by the first two questions include infections of the spine, cancers affecting the spine, and other serious neuroanatomical spine problems.
But, as I said, most back problems not due to other serious diseases respond very well to conservative therapy, regardless of the cause.
The picture above is one example. See where the red bit is pushing on the yellow bit? That's probably somewhat like what's happening in my back at this very minute. An intervertebral disk is prolapsed, pushing against a nerve root, causing pain, tingling, numbness, and weakness in my leg. It's possible that surgery could be of some use, but even fairly dramatic injuries such as this one usually heal up with time (and pain control and physical therapy). In fact, imaging is rarely needed (but, at least in the U.S., often obtained).
The evidence would suggest that since I don't have weight loss, fever, incontinence, or other concerning symptoms, I should take some pain medication, go to physical therapy, and try not to do anything stupid.
I've definitely got the first two covered.