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Contents

Who develops back problems?

Age

Gender

Family history

Work and play

Physical characteristics and posture

Psychological factors

Other factors

The anatomy of your back

Disks: Your back’s shock absorbers

A flexible, protective column

Ligaments and muscles

Nerves

Why does your back hurt?

Sprains and strains

Nerve-compression syndromes

“Red flag” situations

Other causes of back problems

Diagnosing back pain

Your medical history and exam

Imaging studies and other testing

Assessing your treatment options

Factors to consider

SPECIAL BONUS SECTION: Healing your back

Medications for back pain

Over-the-counter pain relievers

Prescription pain relievers

When surgery is an option

Surgery for disk disease

Surgery for spinal stenosis

Surgery for compression fractures

Surgeries for other back problems

Guidelines for recovery

Five rules for a safe comeback

Resources

Glossary

Dear Reader,

Back pain is one of the most common, non-life-threatening, painful conditions, affecting four in five Americans at some point in their lives. And many of us—myself included—have to be wary of return bouts. But the good news is that back pain need not govern how you live your life.

Thanks to the pioneering work of back pain researchers, low back pain treatment has undergone a sea change. We now appreciate the central role of exercise in treating back problems and maintaining a healthy back. We also know that the best strategy for preventing back pain recurrence is to reduce the factors that raise your risk, like excess weight and sedentary living. This is good news both for people suffering with back pain and for society at large, because the overall costs of this common condition are staggering, with some estimates of economic impact running from $84.1 billion to $624.8 billion in the United States alone.

If you already suffer from low back pain, a program of medication, exercise, and lifestyle modification is likely to offer the most relief. Surgery is useful in select situations for patients whose conditions meet certain criteria. And if you are a candidate for surgery, you may find that you have options for minimally invasive procedures that can reduce surgical risk and have you back on your feet and getting on with your life quickly, sometimes within hours.

This report describes common types of back problems and the treatments that are likely to relieve them. Our Special Section is devoted to self-help information on exercises, healthy back habits, and strategies like choosing the right mattress or chair. The evidence for complementary therapies such as chiropractic care, acupuncture, and massage is also included.

Most back pain isn’t dangerous, but it’s important to learn the “red flag” situations that require immediate medical attention. Then, you and your health care team can choose the right treatment for your condition and your particular lifestyle. An athlete, for example, might need to undergo surgery to get back on the playing field as soon as possible, while someone with a desk job may have more freedom to try out different nonsurgical strategies. Be aware that a mismatch of condition and treatment can do more harm than good. Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115

One thing is clear: a patient’s engagement in and determination to stick with a treatment program is vital, especially when it comes to exercise. So please work closely with your health care team as you evaluate the information in this report in light of your particular circumstances and find an approach that feels right for you.

Sincerely,

Jeffrey N. Katz, M.D.

Medical Editor

Who develops back problems?

If you’re like most adults, you’ll probably suffer from low back pain at some point in your life. Although anyone can develop backache regardless of their health or circumstances, research has found that some conditions or activities put you at greater risk for such problems. Key factors include the following.

Age

People are most likely to suffer from low back pain in midlife. During the middle years, even in the absence of any injury, the bones and joints in your lower back (the lumbar spine) begin to change (see Figure 1). Disks (the structures that serve as cushions between the bones in the spine) tend to wear out and sometimes become fragmented (see “Disk abnormalities,”). These structural alterations sometimes cause pain. While back pain problems may be more common in people in their middle years, in older individuals back pain attacks are more severe and last longer.

Gender

Studies suggest that back pain plagues men and women equally. However, in Western industrialized societies, men are more apt to have disk problems, and they are more likely to be treated surgically. These differences most likely reflect the fact that a greater number of men than women work in jobs that involve heavy lifting, pushing, and pulling, and that men in such jobs often feel the need to return to work as soon as possible following an absence due to back pain.

On the other hand, osteoporosis (loss of bone density and strength) occurs in women much more often than men. This disorder can cause severe weakening of vertebrae and may eventually lead to vertebral fractures. Vertebral fractures can cause a loss of height and a rounding of the back. They can also be very painful. Women are also especially susceptible to degenerative arthritis of the lower spine (a condition that generally involves the vertebral joints). They are also more likely to develop spondylolisthesis (an abnormal forward displacement of a vertebra relative to the one below it).

Family history

Heredity appears to play a role in certain types of back pain. Defects of the disks seem more common in some families; a hereditary difference in the chemical makeup of disks may render them more prone to fragmentation or herniation, conditions that can trigger back pain. Ankylosing spondylitis (see “Arthritis”) and spondylolisthesis likewise seem to run in families.

Work and play

Certain jobs and activities put a greater strain on your back. Riding in motor vehicles is notoriously hard on your back, for instance, because it involves prolonged periods of sitting and exposure to vibration. The sitting positions necessary for office work—from typing to computer programming—can also eventually take a toll on your back regardless of your age.

Several other job-related activities increase the likelihood of future back problems:

• lifting or forceful movements such as pulling and pushing

• frequent bending or twisting of the back

• heavy physical exertion

• maintaining the same position for long periods

• repetitive motion patterns

• prolonged exposure to vibration.

Physical characteristics and posture

Your build, weight, and height seem to have little to do with your likelihood of developing back pain, although being overweight puts you at increased risk of having your symptoms return. Even a moderate difference in leg length (up to three-quarters of an inch) has no proven adverse effect on the lower back.

And despite your mother’s admonition to “sit up straight,” experts now agree that, in most cases, posture alone—whether bad or good—Building muscles