The back is a complicated structure that serves many important functions: it provides support to other areas of the body, and allows movement of the legs, head and arms. The back is composed of many types of tissues including bones, muscles, tendons, ligaments, nerves and blood vessels. Back pain may be associated with damage, injury or inflammation to any of these components.
Back pain is common, and there are many different causes and types of back pain. Back pain is not a medical diagnosis, but a symptom of an underlying condition.
The intensity, location and duration of symptoms associated with back pain may vary, but may include:
Certain symptoms that require more urgent medical attention include:
The back is comprised of muscles and the spine (backbone): a structure made up of bones, called vertebrae, which are held together by ligaments. The vertebrae are separated by intervertebral discs that act as rubbery cushions between the vertebrae and prevent the vertebrae from rubbing against each other.
The spinal cord is a bundle of nervous tissue that runs inside the length of the spine (much like electrical wiring inside a cable). The spinal cord connects the brain to the rest of the body: nerves branch off the spinal cord at regular intervals, transmitting signals from the brain to to all parts of the body, and communicating sensations from the body to the brain.
This complicated arrangement of bone, muscle, nerves and connective tissue is particularly prone to experiencing problems, and many (though not all) cases of back pain have something to do with the spine.
Intervertebral discs - layers of cartilaginous material that act as cushions between the vertebrae and the joints in the spine, enabling the spine to bend and twist.
A bundle of nerve tissue that runs from the brain through the spinal column and connects the brain to the body, transmitting sensory and motor signals.
The bones that make up the spinal column.
Back pain can be categorized into many different types depending on:
Sometimes referred to as the lower spine, but is also the abdominal section of the torso, located between the diaphragm and pelvis.
There are several different causes for back pain. Some common causes include:
| Causes | Description |
|---|---|
Non-specific back pain | Most causes of back pain have no clear cause. Fortunately, with appropriate treatment, these cases of back pain tend to improve over time. |
Back strains and sprains | Acute back pain is most often caused by strains and sprains of the back muscles. It generally occurs in the lower back (lumbar muscles). Back strain occurs when the muscles or tendons within the spine are stretched, torn or otherwise injured. When this occurs, there is an initial period of sudden, intense pain in the back, followed by muscular spasms for 1-2 days. The back is usually sore to touch. Resting helps ease the pain. |
Disc prolapse | A disc prolapse (also known as a slipped disc, herniated disc, or ruptured disc) is a common cause of back pain. It happens when one of the discs between two vertebrae tears, and the jelly-like substance inside it leaks out. The tearing causes irritation and sometimes an increase in the pressure to the surrounding nerves. This can lead to pain and numbness or weakness in the neck, arm or shoulder, buttocks, legs or feet. Any disc can potentially rupture, but the ones in the lower back are most at risk. The pain is typically felt only on one side or in one leg and is usually worse after long periods of standing or sitting. |
Degenerative disc disease | The discs of the spine often wear down as we age. In some people, these changes can cause back pain. This is more commonly felt in the lower back, because the lower parts of the spine support the majority of the body's weight. Pain caused by degenerative disc disease is often constant, and mild to moderate. Generally it causes recurrent episodes of back pain that last from a few days to a few months. The pain is made worse by actions that increase pressure on the back such as sitting, coughing, sneezing and flexing. |
Arthritis | Healthy spinal joints experience little friction, as the protective cartilage and fluid within the joint space helps to make movements easy and smooth. However, in arthritis, the protective cartilage becomes worn down and the surfaces rub against each other, leading to pain and stiffness. There are several different causes for arthritis, such as osteoarthritis, rheumatoid arthritis and psoriatic arthritis. |
Fractures | The spine can develop fractures, which can cause back pain. The most common type of spinal fracture is a compression fracture. A compression fracture is when the vertebrae are crushed by the weight of the body. It is generally caused by osteoporosis. Osteoporosis is a condition that causes bones to thin, which makes them less able to support a load. Compression fractures are usually associated with acute back pain that may become persistent and can be associated with a loss of height and/or back deformity, as the spine becomes increasingly compressed and curved. |
Spinal stenosis | Spinal stenosis is a narrowing of the spinal canal. It may be caused by a birth defect, or from degenerative changes associated with arthritis. It occurs more commonly in the ageing population. Stenosis can produce symptoms related to spinal cord and nerve root compression ('pinched nerve'). People with spinal stenosis that causes nerve compression may experience leg pain when walking, and may feel numbness and tingling that radiates from their lower back into the buttocks and legs (this symptom is known as sciatica). The pain associated with spinal stenosis is usually made worse by activity, and relieved by rest. |
Spondylolisthesis | Spondylolisthesis is a spinal condition in which one vertebral body (the main weight-bearing region of a vertebra) slips forward onto the one below. Spondylolisthesis can be either degenerative (caused by repeated wear over time), or it may be caused by fractures within the spine. |
Spondylolysis | Spondylolysis refers to a condition where there is a weakness in an area of the vertebrae of the lower spine. Excessive strain in the back, particularly in teenagers, results in a fracture through this area of weakness, which results in back pain. |
Cancer | In rare cases, back pain may be associated with a spinal cancer. The symptoms of a spinal cancer may vary, depending on its location. They can either originate from the spine or, more commonly, spread from another part of the body. Some of the more typical symptoms that may be associated with a spinal cancer may include:
|
Infection | In rare cases, an infection can develop in the spine. The resulting back pain is not always associated with a fever. Urgent treatment is required before the infection damages the spine and spreads throughout the body. |
Referred pain | Back pain can also arise from causes outside the spine, particularly the abdomen and pelvis. Examples of referred back pain include:
|
A tough, flexible connective tissue found in various parts of the body including the joints and larynx.
Intervertebral discs - layers of cartilaginous material that act as cushions between the vertebrae and the joints in the spine, enabling the spine to bend and twist.
A connecting surface or tissue between two bones.
Sometimes referred to as the lower spine, but is also the abdominal section of the torso, located between the diaphragm and pelvis.
Degeneration of or injury to a disc in the spine, which causes the jelly-like core to push against or leak outside the disc. This results in back pain. Also known as 'slipped' disc.
A bundle of nerve tissue that runs from the brain through the spinal column and connects the brain to the body, transmitting sensory and motor signals.
Abnormal narrowing of the spinal cord which compresses the spinal cord and nerves.
The bones that make up the spinal column.
Relating to the pelvis, which is the bony structure in the lower part of the trunk. The pelvis connects the base of the spine to the legs, anchors the thigh and abdominal muscles and protects important organs such as the bladder and bowel (and in women, the uterus).
The cavity running through the middle of each vertebrae of the spine that contains the spinal cord.
You can be at greater risk of experiencing back pain due to factors such as:
Back pain can be a result of long-term sedentary work.
The word ‘stress’ can have a variety of meanings, but generally describes the physical and mental responses of the body to a demand placed upon it. Often used to describe conditions where the demand is high or unable to be resolved and creates anxiety and tension.
A thorough medical history and physical examination will help your doctor diagnose the cause of your back pain.
Your doctor will take a thorough medical history. Your doctor may also ask you about things such as:
During a physical examination, your doctor may ask you to perform a series of movements while you stand, sit and lie down. Your doctor may then be able to determine what may be causing your back pain. Your doctor may also feel for tenderness and carry out a general examination of your trunk and legs.
In most people with acute back pain, imaging is generally not necessary, especially if the symptoms improve within 6-8 weeks with simple pain-relief medications (see "Types of treatments" below). If the treatment has failed to resolve the symptoms, or you have unexplained chronic back pain, X-rays may be obtained to help make a definitive diagnosis. If there are signs of serious disease such as significant nerve compression, fractures or a cancer, scans such as computerized tomography (CT) or magnetic resonance imaging (MRI) may be needed.
Standard X-rays can be used to assess bones, but are very limited when attempting to look at discs, muscles, ligaments or nerves. CT scans are more useful for a closer look at bone-related causes. MRI scans are particularly useful when looking at discs, nerves, ligaments and muscles.
A scan that uses X-rays to create a 3D image of the body. This can detect abnormalities more effectively than a simple X-ray can.
Intervertebral discs - layers of cartilaginous material that act as cushions between the vertebrae and the joints in the spine, enabling the spine to bend and twist.
A type of imaging that uses a magnetic field and low-energy radio waves, instead of X-rays, to obtain images of organs.
For an acute case of back pain, your doctor may initially suggest rest or reduced activities for a few days. Medication may be used to treat the pain and swelling.
The use of heat packs or ice packs may provide some degree of short-term reduction in pain and stiffness.
Pain relief may include acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can also help reduce swelling. Typical medications may include ibuprofen, naproxen and celecoxib. There are some risks associated with using NSAIDs; their usage may depend on whether there is an underlying stomach, kidney, heart or lung condition. NSAID creams, such as Voltaren ointment, have fewer side-effects and are a potential option. However, topical NSAIDs are less effective than oral forms of NSAIDs.
In severe cases of acute back pain, other treatments may be needed. These may include:
People experiencing severe and disabling pain that cannot be controlled with acetaminophen or NSAIDs may be treated with opioid analgesics, such as tramadol or oxycodone (commonly known as Endone®). However, these medications should only be used for a few days as there are associated side-effects such as drowsiness, constipation and itch.
Rarely, a muscle relaxant, such as diazepam, may be given to treat severe back spasms. These are not always effective and have severe side-effects, such as drowsiness.
Occasionally, prednisolone may be used for a few days to treat back pain caused by acute disc prolapse. Prednisolone is a corticosteroid that works to reduce inflammation and swelling that may contribute to the pain. There is no conclusive evidence that its use is beneficial for back pain. If it is used, especially in high doses, it is important to be aware of potential side effects such as difficulty sleeping, mood changes and unstable blood sugar levels in patients with diabetes. Also, its use should be restricted to only a few days, to limit potential long-term complications.
As the back pain eases and mobility is restored, the goal of treatment changes to restoring proper function, strengthening your back, and preventing recurrence of the injury. You may be given an exercise plan.
Treatment for chronic back pain will vary depending on the cause, frequency and severity of the pain. It is generally more difficult to manage than acute back pain. Treatment focuses on controlling the pain and improving your quality of life. Often, more than one treatment is needed to help manage symptoms. It follows the same principles as managing other causes of chronic pain. More information on chronic pain can be found here.
Known causes of chronic back pain should be avoided. This includes avoiding heavy lifting and sitting for long periods of time.
There is benefit in physical training programs that stretch the back, strengthen core muscles and improve spine flexibility. Exercise can also help with the maintenance of a healthy body weight, which may reduce the risk of further episodes of back pain.
Behavioral therapy teaches techniques to help relax muscle tension, deal with thoughts or feelings that may trigger pain, and/or change behaviors that may increase pain. It is found to help in short-term treatment of chronic back pain. [1]
Some people may find relief from pain and swelling with acupuncture. There is inconclusive evidence to support the use of acupuncture in acute back pain. However, for chronic back pain, acupuncture is more effective for pain relief and functional improvement than no treatment, but this is only a short-term effect (three months).
Spinal manipulation by a chiropractor or osteopath is a form of manual movement of spinal joints beyond their usual range of motion. It has been shown to have some short-term benefit in reducing pain and improving movement. [2]
Either of these treatments can provide some relief in chronic back pain; however, they are best combined with other treatments, particularly physical therapy.
Transcutaneous electrical nerve stimulation (TENS) uses a battery-powered device to delivery electrical stimulation to areas of the back to provide pain relief. There is little evidence for TENS in the treatment of chronic back pain.
Wearing a posture brace or support may help address poor posture that may be contributing to recurrent back pain. However, it should not be a long-term solution. It is important to strengthen the back with physical therapy. As your posture improves with posture exercises, will gradually use the brace or support less and less, until you no longer need it.
For persistent back pain that is not responding well to treatment, there may be benefit in attending a pain clinic. A pain clinic is a multidisciplinary clinic that typically has a pain specialist, specialist nurses, physiotherapists, psychologists and pharmacists. The aim of the clinic is to streamline medication, deal with psychological issues and help with improving function and quality of life.
Chronic back pain can have periods where the pain suddenly worsens. The treatments described above for acute back pain can also be used to help treat these periods of pain in those with chronic back pain. It is best to start with acetaminophen and/or NSAIDs. Opioid medications should be reserved for severe episodes of pain. Overall, limiting the duration of medications in chronic back pain is recommended.
Anticonvulsant medications, such as gabapentin, and certain antidepressants, such as amitriptyline, may be used regularly to treat chronic back pain. Muscle relaxants, such as diazepam, are not effective for chronic back pain.
Occasionally, injections of local anesthetic and/or anti-inflammatory corticosteroids around an irritated nerve, inflamed joint in the back and/or into the epidural space (the space around the spinal cord) may provide temporary or occasionally permanent relief.
Most back pain will not require surgical management. Surgery is generally reserved for the more severe cases. There are many surgical procedures for treating various types of back pain; two of the more common procedures are spinal fusion and discectomy.
Spinal fusion surgery - which joins (fuses) two or more vertebrae together that are causing the pain - may be used in people who:
Discectomy may be required when a prolapsed disc causes severe nerve root or spinal cord compression. There are various techniques for this type of surgery, whose goal is to remove the pressure from the affected nerve. The trend has been to perform microdiscectomy: a small portion of bone or disc material, which is impinging on a nerve, is removed. This allows enough room for the nerve to then heal.
Complications of surgery may include blood loss, nerve damage, infection and anesthetic complications.
A form of complementary therapy that involves fine sterilized needles being inserted into the skin at specific points to treat medical conditions.
Any drug that relieves pain.
A medication that resembles the cortisol hormone produced in the brain. It is used as an anti-inflammatory medication.
A metabolic disorder that is caused by problems with insulin secretion and regulation and which is characterized by high blood sugar levels. Also known as diabetes mellitus.
A connecting surface or tissue between two bones.
Degeneration of or injury to a disc in the spine, which causes the jelly-like core to push against or leak outside the disc. This results in back pain. Also known as 'slipped' disc.
A type of imaging that uses a magnetic field and low-energy radio waves, instead of X-rays, to obtain images of organs.
Non-steroidal anti-inflammatory drugs are commonly used to manage arthritis-related pain and inflammation and other musculoskeletal disorders. NSAIDs include aspirin and ibuprofen.
A class of drugs that contain opium, derivatives of opium, or have similar effects to opium. They are powerful painkillers that act on the central nervous system and cause drowsiness and include drugs such as morphine and pethidine.
A bundle of nerve tissue that runs from the brain through the spinal column and connects the brain to the body, transmitting sensory and motor signals.
The bones that make up the spinal column.
A professional specializing in mental development, diagnoses and management of mental health conditions.
Henschke, N. et al (2010) Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. Accessed on 5 February 2016 from
Rubinstein, SM. et al (2011) Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011
Back pain can lead to various complications, such as:
Most people with back pain make a full recovery by making lifestyle changes that may include:
The long-term outlook for most cases of back pain is generally good.
Some cases of back pain are the result of underlying medical conditions. In those cases, back pain cannot be prevented. However, most cases of back pain can be avoided, or the severity of symptoms reduced, by making some lifestyle changes such as:
The word ‘stress’ can have a variety of meanings, but generally describes the physical and mental responses of the body to a demand placed upon it. Often used to describe conditions where the demand is high or unable to be resolved and creates anxiety and tension.