Medical Causes of Back Pain
Most back pain is related to aging or degeneration but many other conditions can be associated with back pain.
Low back pain is not commonly due to generalized arthritis.
Osteoarthritis occurs more commonly in the fingers, hips and knees but can involve the spine.
Rheumatoid arthritis commonly involves the neck but usually presents in other joints first. Rheumatoid arthritis never begins in the lumbar spine.
Reiter’s disease, ankylosing spondylitis and other seronegative arthropathies can present with back pain – see glossary. These can be associated with other symptoms such as iritis, oral ulceration, bowel disturbance, urethritis, heel pain and large joint arthritis. Blood tests are often abnormal. Review by a Rheumatologist may be indicated.
Dilatation of the aorta (aortic aneurysm) can press on the thoracic or lumbar spine causing back pain while disease of the lower limb arteries can cause limping (claudication) due to loss of blood flow. This can be confused with a similar condition due to spinal narrowing (stenosis).
Cancers arising in the spine (primary cancers) are not common but include cancers of the bone and bone marrow such as myeloma, lymphoma, osteosarcoma, chondrosarcoma as well as cancers of the nerves, such as neurofibrosarcoma. In some cases surgery can be curative or may be required to prevent or reverse paralysis.
Cancers arising in the thorax or abdomen, behind the abdomen (retroperitoneal) or in the pelvis can spread directly into the spine causing pain.
Secondary cancers which spread to the bone (metastases) are more common, especially such cancers as breast, colon, lung, cervical, prostate, thyroid, melanoma and kidney. Where the likely survival is more than a few months spinal surgery can stabilize the situation, reduce pain and prevent paralysis.
Any patient with a history of cancer who develops new spinal pain must have metastasis excluded.
Pain in the spine, which is worse at night and steadily getting worse, may be due to cancer especially in patients over fifty years old.
Structural abnormalities of the spine present at birth include failure to appear and failure to develop. These abnormalities due not usually cause pain by themselves but may cause secondary changes at adjacent levels. Common conditions in the lumbar spine are having one less vertebra – common (or one more – rare), having a disc fused and having the lowest lumbar vertebra joined to the sacrum (sacralization). Sometimes the sacrum is higher than usual in relation to the pelvis which is associated with a higher risk of degeneration at the lowest two discs.
D.I.S.H (Diffuse Idiopathic Skeletal Hyperostosis), also called Forrestier’s Disease. More common in males in the middle ages or older, associated with extensive osteophyte formation around discs, causes stiffening and pain. There is no surgical solution.
Not a common cause of spinal pain. Other crystal deposition can occur, e.g., CPPD (Calcium pyrophosphate deposition disease – pseudogout). Disc calcification is often an incidental finding.
Certain conditions such as diabetes mellitus, bacterial endocarditis, AIDs and immunosuppressive drugs including steroids (prednisone) as well as intravenous drug abuse are associated with an increased risk of infection in the spine, often beginning in the disc as a discitis before spreading to the bone as an osteomyelitis. The patient may become quite sick with fever and chills (shakes), increasingly severe back pain and spasm yet ordinary radiographs (X-rays) may be normal. Blood tests are usually abnormal (increased White Cell Count and raised ESR). Imaging with bone scan or MRI is indicated. Treatment usually involves prolonged antibiotics (after biopsy to identify the cause) and sometimes surgery.
Tuberculosis has become more common, especially in patients from overseas.
Rare infections of the spine include brucellosis and hydatids.
Being overweight is not a primary cause of back pain but it makes treatment more difficult – it’s hard to tighten abdominal muscles with a paunch, and surgery is made even more difficult. Lack of exercise due to back pain is a frequent excuse. Dietary readjustment is difficult and a change in lifestyle is required. Drugs may be required.
Osteoporosis is common in women over forty. Assessment of bone density is helpful to assess the severity of the disease and the effect of treatment. I do not treat osteoporosis itself (referral to another specialist may be indicated – endocrinologist) but may treat the consequences, e.g., fracture by use of a brace. Surgery is usually contraindicated. It is frequently associated with steroid use.
Vertebroplasty (injection of the collapsed bone by injection of bone cement) may be helpful. This is performed by a radiologist.
Loss of bone density due to other causes (metabolic bone disease, eg, rickets, Vitamin D deficiency, kidney disease) requires further assessment by a physician such as endocrinologist or rheumatologist. A full blood and urine screen is indicated.
A chronic disorder of bone with localized areas of hyperactivity bone replacing the normal bone matrix with softer enlarged bone. Commonly involves the skull, spine and pelvis. May cause spinal stenosis. Incidence increases with age > 55 years. Occasionally becomes malignant. Associated with a raised alkaline phosphatase (blood test). Can be treated with Biphosphanate drugs or calcitonin. Patients are often referred to Endocrinologists.
Slouching and prolonged sitting (like me as I sit writing this) can be associated with back pain. Regular changes in position help along with abdominal exercises. The precise positioning of computer keyboard, screen and seat can be adjusted to suit you with benefit.
SCHEUERMANN’S DISEASE – see below under adolescents
SPONDYLOLISTHESIS – see below under adolescents