The importance of back and neck pain in our society is underscored by the following:
- The cost of back pain in the United States exceeds $ 100 billion annually; approximately one-third of these costs are direct health care expenses, and two-thirds are indirect costs resulting from loss of wages and productivity;
- Back symptoms are the most common cause of disability in those <45 years; (3) low back pain is the second most common reason for visiting a physician in the United States; and (4) 70% of persons will have back pain at some point in their lives.
|Causes of Back Pain
Lumbar Disk Disease
|• Degenerative Spine Disease
• Lumbar spinal stenosis without or with neurogenic claudication
• Intervertebral foraminal or lateral recess narrowing
• Disk-osteophyte complex
• Facet or uncovertebral joint hypertrophy
• Lateral disk protrusion
• Spondylosis (osteoa rthritis) and spondylolisthesis
|• Vertebral osteomyelitis
• Spinal epidural abscess
• Septic disk (diskitis)
• Lumbar arachnoiditis
|Neoplasms-Metastatic, Hematologic, Primary Bone Tumors Fractures|
|• Trauma/fal ls, motor vehicle accidents
• Atraumatic fractures: osteoporosis, neoplastic infiltration, osteomyelitis
• Strain or sprain
• Whiplash injury
• Metabolic Spine Disease
• Osteoporosis-hyperparathyroidism, immobility
• Osteosclerosis (e.g., Paget's disease)
• Spina bifida Occulta
• Tethered spinal cord
Autoimmune Inflammatory Arthritis Other Causes of Back Pain
• Referred pain from visceral disease (e.g., abdominal aortic aneurysm) Postural
• Psychiatric, malingering, chronic pain syndromes
LUMBAR DISK DISEASE
Lumbar Disk Disease is a common cause of acute, chronic, or recurrent low back and leg pain. Disk disease is most likely to occur at the L4-L5 or L5-S1 level, but upper lumbar levels are involved occasion ally. The cause is often unknown, but the risk is increased in overweight individuals.
Disk herniation is unusual prior to age 20 years and is rare in the fibrotic disks of the elderly. Complex genetic factors may play a role in predisposing some patients to disk disease. The pain may be located in the low back only or referred to a leg, but tock, or hip. A sneeze, cough, or trivial movement may cause the nucleus pulposus to prolapsed, pushing the frayed and weakened annulus posteriorly. With severe disk disease, the nucleus may protrude through the annulus (her niation) or become extruded to lie as a free fragment in the spinal canal.
The mechanism by which intervertebral disk injury causes back pain is controversial. The inner annulus fibrosus and nucleus pulposus are normally devoid of innervation. Inflammation and production of proinflammatory cytokines within a ruptured nucleus pulposus may trigger or perpetuate back pain. Ingrowth of nociceptive (pain) nerve fibers into inner portions of a diseased disk may be responsible for some chronic “diskogenic” pain.
Nerve root injury (radiculopathy) from disk herniation is usually due to inflammation, but lateral herniation may produce compression in the lateral recess or at the intervertebral foramen.
A ruptured disk may be asymptomatic or cause back pain, abnormal posture, limitation of spine motion (particularly flexion), a focal neurologic deficit, or radicular pain. A dermatomal pattern of sensory loss or a reduιed or absent deep tendon reflex is more suggestive of a specific root lesion than is e pattern of pain. Motor findings (focal weakness, muscle atrophy, or fasciculations) occur less frequently than focal sensory or reflex changes. Symptoms and signs are usually unilateral, but bilateral involvement does occur with large central disk herniations that compress multiple roots or cause inflammation of nerve roots within the spinal canal.