Back pain is nearly universal, being the second most common cause for doctors visits overall, and increases in likelihood as we age. One of the most insightful and hilarious commentaries I have encountered recently regarding back pain was on comedian Louis CK’s eponymous show “Louie”. Louis throws his back out while reaching for a vibrator on a shelf at a sex shop. It’s super awkward and cringe-worthy. He hobbles home, complete with the emasculating experience of being helped into a cab by a tiny, elderly woman, and stops in the doctor’s office in the lobby of his New York apartment building. Here’s a short clip of the beginning of this exchange:
The cranky doctor’s point is that back pain is simply part of life, the result of our evolution from four-legged to two-legged ambulation. “We were given a clothesline,” he says, referring to our spine, “and we use it as a flagpole”. Something designed to be horizontal has now become vertical due to our upright stance – of course the mechanics are going to be off! And the doctor’s advice to Louis? “Use your back as it was intended, walk around on your hands and feet, or accept the fact that your back is going to hurt sometimes.”
The first step to understanding back pain is accepting that it’s going to happen at some point. It’s going to be miserable. But it will most likely get better if you take care of yourself. The most important thing is to recognize when back pain is a sign of something more serious and evaluation by a medical professional is required.
There are several different types of back pain, usually all merging into one amalgam of misery for the sufferer. The most common form of back pain would be muscular strain and tension. Overexertion, lifting heavy objects incorrectly, holding abnormal postures (i.e. hunching over a keyboard), and stress can all lead to this type of injury. When muscles are strained, they go into spasm – tightening, cramping and pulling our back out of alignment. This pain is usually described as deep, aching and throbbing, though there can also be sharp twinges of pain superimposed. This type of pain can occur anywhere along the back, from the neck, to between the shoulder blades to the low back.
Muscular strain and spasm can be easily differentiated from a neurological cause of back pain. Nerve pain, or neuropathic pain, is often described as electrical and shooting. This occurs when something is pressing on a nerve root as it exits the spinal cord, on its way to supplying a part of the body with motor and sensory function. This is called a radiculopathy. The most common structure that causes this compression is an intervertebral disc, which is the squishy shock absorber between the bones of our spine. With aging or trauma, the gelatinous material of the disc can squeeze out from between the vertebra (called a herniated or bulging disc) and press on the nerve roots, causing radiating pain down an extremity. This most commonly occurs in the low back, or lumbar spine, leading to what’s commonly known as sciatica, but it can also happen in the neck, or cervical spine. Sciatica is pain that shoots from the low back, down the buttock and the back of the leg like an electrical shock. This nerve pain will often induce the muscular spasm and tension as well, causing a miserable combination of both pains.
The best treatment for both types of pain is gentle stretching, NSAIDs like ibuprofen, and heat and/or ice (whatever feels good, there is no benefit to one temperature over the other). DO NOT lay in bed all day feeling sorry for yourself. This will allow the muscles to continue spasming. Gentle activity is better than rest. Physical therapy is the first line of prescribed treatment if needed. Prescription medications, such as opioids, should be avoided at all costs, though low doses of muscle relaxants can be used if needed. Massage, acupuncture and chiropractic manipulation can also help. Prevention is the best treatment, however, with regular physical exercise (with a combination of cardio, weight lifting and stretching) and maintaining a healthy weight. Excess abdominal weight throws our low back out of alignment by changing our center of gravity.
Most of the time, the disc will get sucked back into its rightful place on its own and stop pressing on the nerve roots over time with the above conservative treatments. Sometimes, this doesn’t happen and that shooting pain doesn’t go away. Or maybe other “red flag” symptoms develop, like weakness or numbness of the extremity, or bowel or bladder issues, like incontinence or retention. This is the point at which you need to see a doctor about it ASAP. Red flag symptoms = emergency room immediately.
Should all radicular pain be treated with steroid injections into the space around the nerve roots, or surgery to remove the offending disc? No, definitely not. But if conservative measures like those mentioned above don’t help, then it should be considered. As a neurologist, I am biased by seeing the complicated cases where back surgery caused more problems than it helped, which makes me wary of surgery overall. But for every one patient I see with intractable back pain, I’m sure there are many more who had an uncomplicated surgery and were cured of their pain.
So, bottom line, your back is going to hurt at some point in your lifetime. You have less of a risk of your back hurting if you take care of yourself by exercising regularly, maintaining a healthy weight and not using your back muscles incorrectly (sit up straight and lift with your legs!). Back pain that stays in your back and doesn’t shoot down your arms/legs is usually due to muscle strain and spasm and can be treated conservatively. Back pain that does shoot down an extremity should be evaluated by a doctor if it is persistent or excruciating. Back pain that is associated with weakness, numbness or bowel/bladder issues, needs to be evaluated by a doctor ASAP, most likely in the ER.
Let me know if you have any specific back pain questions in the comments and I will try to answer them for you! Otherwise, everyone should do at least 5 cat-cow yoga poses right now, and repeat them every night before bed, for back health!