Common Conditions

Low back pain

Low back pain is one of the most common reasons people seek medical care, affecting individuals of all ages. It refers to discomfort or pain in the lumbar region of the spine, which supports much of the body’s weight. Low back pain can range from a mild ache to sharp, severe pain that interferes with daily activities. Most low back pain results from specific conditions, typically disc, facet joint or sacroiliac joint pathology. All these conditions can also produce referred pain – which may be either nerve related or due to somatic pain referral. There is always an underlying cause for back pain but finding it and treating it can prove challenging. The diagnosis of “non-specific low back pain” is a misnomer as there is always a cause. Most cases do improve after several months with avoidance of aggravating activity, gentle stretches and simple analgesia. Diagnosing the underlying cause may be difficult, costly, risky, involve radiation or may not alter clinical management. However, in some cases of persisting low back pain specific treatment can be offered.

What causes low back pain?

The main causes of low back pain include:

Discogenic pain, 40% of cases: This includes disc degeneration, annular tears and Modic changes.
Facet Joint Pain, 15-25% of cases: This increases with age and is often reported on imaging. The gold standard in the diagnosis is response to injection.
Sacroiliac Joint Pain, 15-25% of cases: This increases with age due to arthritis but can occur in young hypermobile athletes such as gymnasts. SIJ disease is commonly reported on radiology imaging, but the best assessment test of clinical relevance is response to injection (cortisone or lateral branch block).
Unknown or undiagnosable, 20-30% of cases.
Referred Pain: Some structures, particularly in the abdomen or pelvis can refer to the lumbar spine and cause low back pain, e.g. gynaecological, renal, bowel or vascular causes.
Combination of above: Typically, any combination of the above causes may be found in the same individual and this can be the diagnostic challenge.

Common symptoms of low back pain

The symptoms of low back pain can vary based on the underlying cause but may include:

Localized pain: An ache or sharp pain in the lower back.
Radiating pain: Pain that travels into the buttock and down the leg, often due to nerve involvement (sciatica), but some back conditions may cause somatic pain referral which does not follow spinal nerves
Stiffness: Difficulty moving or bending the lower back.
Worsening pain with activity: Pain may intensify during lifting, twisting, sitting, standing, or walking.
Improvement with rest: Many people find relief by lying down or avoiding certain activities. However, a subset of people can experience more low back pain at night.

Diagnosing the cause of low back pain

Low back pain is extremely common, and most cases will resolve with time, rehabilitation exercises with avoidance of provoking activity. Some clinicians describe this as Non-Specific Low Back Pain – and providing it improves, there is no requirement to undergo investigations or to make a diagnosis. However, in certain cases making a diagnosis is important. This includes persisting or severe pain, possible nerve involvement, disabling pain or when any ‘Red Flags’ are present. The ‘Red Flags’ of low back pain include: a history of cancer, unexplained weight loss, significant trauma, intravenous drug abuse, recent bacterial infection or fever, and/or neurological deficits. Other red flags include bladder or bowel dysfunction, saddle anaesthesia, and age <18 or >50 years.

It is important to be aware that often finding a cause will not alter treatment and investigations should only be used when appropriate or if indicated.

Management of low back pain

Treatment for low back pain focuses on relieving symptoms and improving function. Options include:

Physical therapy: Tailored exercises to strengthen the back and core muscles, improve flexibility, and correct posture.
General exercise: Keeping fit and active is important in all patients with low back pain. Some people require a tailored gym program. Regular cardio exercises including walking, cycling and swimming are generally encouraged.
Medications: Over-the-counter analgesics or anti-inflammatories (e.g. ibuprofen or paracetamol) and, in some cases, prescription medications.
Lifestyle adjustments: Maintaining a healthy body weight, practicing good posture, and avoiding activities that strain the lower back can help. These may include avoiding gym activities such as dead lifts, kettle bell swings, rowing machine and Olympic weights.
Injections: Spinal corticosteroid injections can target inflammation and reduce pain. This may help in making a diagnosis and may reduce pain with exercise rehabilitation by creating a ‘therapeutic window’.
Surgery: In cases of severe or persistent pain, surgery may be considered to address issues including herniated discs, degenerate discs or spinal stenosis.