Dr. Arranz Duran has a degree in Medicine and Surgery from the Faculty of Medicine of Zaragoza. He is also an expert in Bioethics and holds a Diploma awarded by the European Society Regional and Pain Practice. He is currently Coordinator of the Acute Pain Unit at the Nuestra Señora de la Candelaria University Hospital and of the Pain Unit at the Vithas Santa Cruz Hospital.
What is low back pain and what does it consist of?
Low back pain consists of pain in the lumbar region. As defined by the word pain, pain is an emotional, sensory experience that may have a structural or non-structural cause that may be the referent and origin of the pain. Low back pain, as the word says, comes from pain in this area, lumbar region, which normally encompasses the anatomical structure corresponding to the lumbar vertebrae, and then part of what is the structural phase with the iliac crests, sacroiliac, referred pain in this area, we normally refer to it as low back pain.
What causes low back pain, why is it so frequent?
Human beings, in their evolution, began to walk with the lower extremities; all previous species, all of them, walk with all four extremities. This transition from walking with four to two limbs forced the generation of a series of changes at the level of the body anatomy. Among them, the whole structure and all the weight is unloaded on the lumbar area, that is to say, the weight of the whole body. And then the transition that exists with the lower extremities. That is to say, mainly between L4, L5, S1 is the hinge zone for pain and where the causes of low back pain mainly originate. It is the price we have paid in evolution; it is one of the consequences that we have, which is low back pain.
The origin of pain is multiple. These causes can be originated either by affectation at the level of the lumbar region itself, transition zones, between the last lumbar vertebrae, then the great tendinous structure that joins the iliac crests with the transverse processes to stabilize that transition zone. And then, apart from that, the nexus that joins, which is the whole iliac bone with the lower extremities, as you can see here. So, all this forces to have a great tendon structure, osteomuscular, to be able, let’s say, to make work and stabilize all that is the body, and all the loads that we bear. Causes that can originate pain, can be derived from multiple structures, either joints, which are between each area. Then disc areas, which are the discs that join between the transitions between the vertebral bodies, and is what makes that serves as a cushion, so that the forces do not fracture the bones, and we can cushion in the steps. And then between both vertebral bodies there are facets which are the nerve roots, and those nerve roots are the ones that will stimulate us and receive both sensory and motor information. So we have multiple causes that can originate pain at the level of the lumbar structures.
What types of low back pain are there and what are their symptoms?
The types of low back pain, as they are derived from all the structures that I have previously mentioned, whether bony, radicular or ligamentous, and depending on the area of pain, they can be more intense or less intense. It is very important what we were commenting before, the discs are like cushions that allow to cushion what is the weight between the vertebral bodies. If there is an injury of the vertebral bodies, or an injury of the discs, it will produce a degeneration. This degeneration is what is called discogenic pain. Pain can also be produced by an affectation of the lumbar bodies, which can produce an affectation of what are called fissures, vertebral crushing, which can be another cause of pain. It is also important because of the degeneration at other levels, there will be a degeneration mainly at the level of the vertebral bodies and involvement of the joints that produces what is called facet hypertrophy, which is a cause of pain. And then this facet hypertrophy, by increasing the volume of the joints can compress what is the medullary canal, the radicular canal.
Then it can produce what is called a decrease of the space or foraminal stenosis, or an affectation inside the spinal canal itself and produce a stenosis of the spinal canal. This is called lumbar canal stenosis. There are multiple causes that can be defined, bodies, joints, discs, radicular involvement or global degeneration, which is what is defined as lumbar axial ospondyloarthrosis. Depending on the causes and intensity, there may be different treatments. But normally in a patient, depending on age and evolution, low back pain tends to have more of an osteomuscular or ligamentous cause, and is usually benign. Normally, treatment is conservative at first, until 60-80% of cases disappear with minimal treatment and a series of basic physical measures.
How is low back pain treated, and can its appearance be prevented?
The main thing for the treatment and evolution of low back pain is prevention. Prevention includes hygienic-physical and hygienic-dietary measures, that is, maintaining a position, a posture, keeping the body straight, trying to maintain a normal position in your work habits, how you sleep, how you do sports, to try to avoid injuries that will mainly affect the joints or the discs. This prevention, maintained over the years, will prevent us from eventually developing lumbago or degeneration due to poor support of the vertebral bodies, which will lead to degeneration. Once it has already been triggered and this type of injury has already occurred, we would have to see what type of treatment.
Normally a high percentage with anti-inflammatory treatments, minor analgesics, which are the second step, usually control these acute phases of pain. Depending on the degree of injury that occurs and if there is no improvement in the following 5 to 6 months, other types of techniques can be considered with higher complementary studies, with resonance imaging, radiological studies that can confirm some type of injury that requires another type of treatment. Treatment that can be, if there are no red flags, that is to say, important lesions in nervous structures or motor deficits, what can be proposed in these cases is conservative treatments based on techniques with selective blockades at different levels, mainly at joint level, at the level inside the spinal canal, or at peripheral level in muscular or tendon wall, or sacroiliac joint. Let’s say if a next level occurs. If neuroaxis injuries occur or are suspected, a spinal expert should be contacted.