Why does low back pain occur?

Lumbago or low back pain is pain located in the lower back, buttocks or hip. It is important to distinguish between acute and chronic low back pain. And, most importantly, the physician must take into account the risks of acute pain becoming chronic and persistent.

Acute low back pain is that which lasts a few weeks (2-4) and subsides with time. Chronic low back pain is that which lasts more than three months.

It may appear for the following reasons:

  • Muscular: syndromes of the pyramidal muscle, quadratus lumborum, psoas iliacus….
  • Nervous: sciatica (radiculopathy L5).
  • Bone: facet syndrome, discopathies, sacroiliitis…

There are a series of risk factors that make it easier to develop low back pain:

  • Patient factors: age, weight, height.
  • Environmental factors: poorly designed furniture.
  • Physical behavior: lack of exercise. Sedentary life.
  • Physical condition: muscle weakness, poor posture.
  • Psychological factors: stress, depression.

Most of the time, the origin of low back pain is non-specific, without a clear cause, and the pain is usually limited to a region of the spine (functional disorder). In a low percentage of cases, the pain is specific and its cause can be determined; it usually radiates to the leg and is associated with radiculopathy and spinal stenosis.

The two tables below show the types of low back pain and their characteristics and the structures of the lumbar spine susceptible to cause an ailment.

Can it be prevented?

It can be prevented, especially low back pain crises in patients with chronic low back pain, but in general it is recommended:

  • Exercise regularly (walking, cycling, swimming). Aerobic exercises.
  • Losing weight if overweight.
  • Do not carry heavy objects.

And in those patients with associated risk factors, such as those who have frequent episodes of low back pain or patients who have undergone back surgery, it is recommended in addition to the above:

  • Targeted physiotherapy
  • Periodic abdominal wall strengthening exercises. Postural hygiene and back care programs with the objective of stretching and relaxing the muscles that tend to shorten and toning those muscles that are key to the stability and protection of the spine.
  • Avoid certain types of postures and maintain others correctly.
  • Avoid abrupt physical exercises
  • As a curiosity, certain postures can be adopted in bed to facilitate rest and avoid lumbar pain: a good posture is the “fetal position”. Another good posture is “supine decubitus” (face up), with knees bent and a cushion underneath. Sleeping in “prone position” (face down) is not recommended, since it modifies the curvature of the lumbar spine and forces the neck to be turned in order to breathe. Sleeping in the same position and in small beds should be avoided.
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What is the treatment for this pathology?

The treatment of low back pain is very broad and ranges from a simple analgesic or anti-inflammatory to more aggressive interventional techniques.

In general, acute low back pain remits in a few weeks and is usually treated with drugs such as paracetamol, anti-inflammatory drugs, tramadol and sometimes systemic corticoids. However, chronic low back pain is usually treated with a multidisciplinary approach consisting of rehabilitation (physiotherapy), pharmacological treatment and interventional treatment.

For acute low back pain, treatment is centered on physical therapy, stimulating the patient to move as soon as possible. The options are as follows:

  • Physical aspect: mobility as soon as possible, brief bed rest and sick leave, application of heat/cold and physical therapy.
  • Pharmacological aspect: analgesics, anti-inflammatory drugs.
  • Stimulation: TENS, acupuncture.
  • Interventional and surgical treatment.

The treatment of chronic low back pain is more complex and complicated. Perhaps the most important thing is to help patients self-manage their disease with the aim of reducing pain and its impact on quality of life.

Unlike acute pain and in general, the treatment of chronic low back pain should begin with interventional treatment, followed by medication and then non-pharmacological treatment.

The following options are available:

  • Interventional treatment
  • Treatment with medication
  • Non-pharmacological treatment: uncontrolled exercise, relaxation measures, behavioral therapy.

Or to put it another way:

  • Long-term multimodal treatment consisting of: physical therapy, stimulation therapy (TENS, spinal cord stimulation), psychological treatment, pharmacotherapy and interventional treatment.

We will focus on pharmacological and interventional treatment.

Since low back pain is usually mixed, that is, it has several pain-producing mechanisms, pharmacological treatment should be directed at these mechanisms. On the one hand, analgesics and anti-inflammatory drugs are prescribed, but it is not unusual for a patient with low back pain to receive other “rare” drugs, such as pregabalin, gabapentin…. The latter are prescribed because of the chronicity of low back pain.

As for interventional treatment, the spectrum of techniques to treat low back pain is very broad, but in broad terms, we could highlight the application of thermal or pulsed radiofrequency in nerve structures and the administration of epidural steroids. Sometimes it is necessary to complement these techniques with blocks or infiltrations in myofascial structures (pyramidal muscle, iliolumbar ligament…).