Back and spine pain

Understanding the back

The spine is made up of many bones called vertebrae. These are roughly circular and between each vertebra is a disc. The discs are made of strong rubber-like tissue which allows the spine to be fairly flexible. A disc has a stronger fibrous outer part and a softer jelly-like middle part. The middle part is called the nucleus pulposus.

Strong ligaments also attach to nearby (adjacent) vertebrae to give extra support and strength to the spine. There are various muscles that are attached to the spine which enable the spine to bend and move in various ways. Small joints, called facet joints, help to attach the vertebrae to each other. The sacrum is formed from five vertebrae that are joined together (fused) to make one bone. The sacroiliac joints are the large joints that join the sacrum to the main bone of the pelvis (the ilium).

Spinal cord

Close-up diagram lumbar spinal cord

The spinal cord, which contains the nerves that come from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae to relay messages to and from various parts of the body. The lower end of the spinal cord is at the level of the first or second lumbar vertebra. Below this the nerves from the last part of the spinal cord branch to form what is called the cauda equina (from the Latin for a horse's tail).

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Bones, joints and muscles

Spinal stenosis

Spinal stenosis is a term used to describe a narrowing of the spinal canal. The narrowing may not cause any symptoms. However, the narrowing may progress to cause squeezing (compression) of the spinal nerves or compression of the spine. Spinal stenosis causes back pain and leg pain. Most often it occurs when you walk. Weakness of the legs may make you feel unsteady. This may affect both legs or just one leg. Spinal stenosis affecting the cervical spine in your neck may also cause pain and weakness in the shoulders and arms. Spinal stenosis can often be treated by simple measures such as medicines for pain relief, keeping as active as you can and losing weight if you are overweight. Sometimes steroid injections or surgery are needed if simple measures are not successful.

by Dr Colin Tidy, MRCGP

What are the symptoms of back pain?

Back pain is pain that is felt anywhere from the bottom of the neck to your bottom. It can range from mild and fleeting to severe or long-lasting. It can come on for an obvious reason - such as after a fall or lifting something very heavy or awkward - or it can just come on for no reason at all.

Sometimes back pain causes other symptoms:

• Pain in the leg or foot.

• Pain in the buttock or thigh.

• Weakness in one or both legs.

• Pins and needles in one or both legs.

• Other sensations in the legs, such as warmth or a burning feeling.

Who gets back pain?

Everyone can get back pain at some time in their life. The most common type of back pain, low back pain, affects about 8 in 10 people. Back pain even occurs in children: 3 out of every 10 young people have had pain in their back.

What are the causes?

Common causes

• Lower back pain, sometimes also called simple or nonspecific lower back pain:

  • This is the most common type of back pain.

  • It isn't possible to say exactly what the cause is of lower back pain but there is rarely any serious problem with the back.

  • See the separate leaflet called Lower Back Pain.

• Slipped disc, sometimes called prolapsed disc:

  • Often causes severe low back pain.

  • Pain is due to the tissues from a disc pressing on the structures nearby - for example, nerves, when the pain is called nerve root pain.

  • May cause sciatica, which is pain that goes down the leg to the foot.

  • See the separate leaflet called Slipped Disc (Prolapsed Disc).

• Thoracic back the pain:

  • Thoracic back pain is more likely than lower back pain to have a serious cause.

  • It is more common in young people, especially girls, possibly due to carrying heavy school bags, when it is not serious.

  • See the separate leaflet called Back Pain in Children.

Less common causes

• Arthritis of all types can cause back pain:

  • Osteoarthritis is a common type of arthritis that affects people as they get older. It can be a cause of back pain.

  • Spinal stenosis is a common cause of pain in the buttocks and legs, although it doesn't always cause back pain:

    • It mainly affects people aged over 60 years.

    • It is often caused by osteoarthritis of the spine.

    • See the separate leaflet called Spinal Stenosis.

  • Rheumatoid arthritis is a much less common type of arthritis. It can occasionally affect the spine.

  • Ankylosing spondylitis is a form of arthritis that mainly affects the spine:

    • It can affect other joints and other parts of the body.

    • See the separate leaflet called Ankylosing Spondylitis.

• Fracture of a vertebra:

  • Road traffic accidents, falls, sports injuries and violent attacks can all lead to fractures of the spine causing back pain.

  • Osteoporosis:

    • Causes bones to be more likely to break with a minor injury.

    • May cause thoracic back pain, as well as low back pain.

    • Is more common in the elderly, particularly women.

    • Is more common in people on steroid medication.

• Shingles:

  • Shingles is a common infection, which can cause pain before any sign of the typical rash.

• Scoliosis of the spine:

  • Scoliosis causes the spine to curve to the left or right side.

  • It is often painless.

  • See the separate leaflet called Scoliosis and Kyphosis (Curvature of the Spine).

Rare causes

• Tumours.

• Infection - for example, tuberculosis.

• Cauda equina syndrome:

  • This is a rare but serious type of nerve root problem.

  • The nerves at the bottom end of the spine are squashed causing:

    • Low back pain.

    • Problems with the bowel and bladder (usually not being able to pass urine).

    • Numbness in the 'saddle' area, which is around the back passage (anus).

    • Weakness in one or both legs.

  • See the separate leaflet called Cauda Equina Syndrome.

Do I need any tests?

This depends on what is thought to be the cause of your back pain. Your doctor will usually be able to tell what the likeliest cause is of your pain, simply by talking to you and examining you. If you haven't had your back pain for very long and your doctor doesn't think it is serious, you are unlikely to need any tests.

The pain is more likely to have a serious cause if it is constant and becoming worse or if you are unwell in other ways, such as having a temperature or losing weight. In this case you may need further tests, such as:

• Blood tests.

• X-rays.

• Magnetic resonance imaging (MRI) scan.

• Bone scan.

What should I do if I have back pain?

Usually back pain settles down quickly, within a week or so. You should try to keep as active as you can and do your normal activities, if possible. If the pain is stopping you from being able to keep moving then you should take painkillers regularly so that you can. The old advice of resting until the pain eases has been proven to be wrong.

When should I seek medical advice?

Generally if your pain lasts longer than 4-6 weeks or if your symptoms change, you should see a doctor.

Other reasons for seeking medical advice are:

• You suspect cauda equina syndrome (see above):

  • Seek immediate medical advice.

• Your pain is constant and is not eased by lying down or resting.

• Your pain is gradually becoming worse and worse.

• You are experiencing weakness in any of your muscles in your leg or foot or you are tripping up (which can be a symptom of weak ankle muscles).

• You have a lack of feeling (numbness) in any part of your bottom or leg.

• Your pain started after a road accident or a fall.

• You have been diagnosed with osteoporosis.

• You have recently taken or are still taking steroid medication.

• Your pain is worst in the early hours of the morning and on waking and is eased by activity.

What treatments may be offered?

Aside from keeping active and taking painkillers if necessary, there are many other possible treatments. Which treatment is suitable for you may depend on the cause of your pain.

• Structured exercise programme.

• Manual therapy, including massage and spinal manipulation may help symptoms in some people.

• Cognitive behavioural therapy (CBT) may be useful in some people with long-standing (chronic) back pain.

• Spinal injections.

• Surgery:

  • This is rarely needed.

  • About one person in every ten with a slipped disc (prolapsed disc) may benefit from surgery.

  • May be needed urgently for cauda equina syndrome.

See separate leaflets on the different causes of back pain for more details of other possible treatments.

How can I avoid back pain?

In general, you should try to keep fit and active and exercise regularly - swimming, walking, running and cycling are all excellent forms of exercise. However not all forms of back pain can be avoided. Also it isn't known why some people develop back pain and some people never do.

What is the outlook (prognosis)?

Most people with back pain that doesn't have a serious cause, get better fairly quickly, often within a week or so. If you have low back pain (including pain caused by a disc problem), you will recover quicker if you can get moving again quickly and get back to work as soon as you are able.

It is common to have further bouts (recurrences).