Causes back pain
Referred back pain
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Peptic ulcer or tumor of the posterior stomach or duodenum typically produces epigastric pain (Chaps. 285 and 90), but midline back or paraspinal pain may occur if retroperitoneal extension is present. Back pain due to peptic ulcer may be precipitated by ingestion of an orange, alcohol, or coffee and relieved by food or antacids. Fatty foods are more likely to induce back pain associated with biliary disease. Diseases of the pancreas may produce back pain to the right of the spine (head of the pancreas involved) or to the left (body or tail involved). Pathology in retroperitoneal structures (hemorrhage, tumors, pyelonephritis) may produce paraspinal pain with radiation to the lower abdomen, groin, or anterior thighs. A mass in the iliopsoas region often produces unilateral lumbar pain with radiation toward the groin, labia, or testicle. The sudden appearance of lumbar pain in a patient receiving anticoagulants suggests retroperitoneal hemorrhage.
Isolated low back pain occurs in 15 to 20% of patients with a contained rupture of an abdominal aortic aneurysm (AAA). The classic clinical triad of abdominal pain, shock, and back pain in an elderly man occurs in fewer than 20% of patients. Two of these three features are present in two-thirds of patients, and hypotension is present in half. Ruptured AAA has a high mortality rate; the typical patient is an elderly male smoker with back pain. The diagnosis is initially missed in at least one-third of patients because the symptoms and signs can be nonspecific. Common misdiagnoses include nonspecific back pain, diverticulitis, renal colic, sepsis, and myocardial infarction. A careful abdominal examination revealing a pulsatile mass (present in 50 to 75% of patients) is an important physical finding.
Lumbar Pain with Lower Abdominal Diseases
Inflammatory bowel disorders (colitis, diverticulitis) or colonic neoplasms may produce lower abdominal pain, midlumbar back pain, or both. The pain may have a beltlike distribution around the body. A lesion in the transverse or initial descending colon may refer pain to the middle or left back at the L2-L3 level. Sigmoid colon disease may refer pain to the upper sacral or midline suprapubic regions or left lower quadrant of the abdomen.
Sacral Pain in Gynecologic and Urologic Disease
Pelvic organs rarely cause low back pain, except for gynecologic disorders involving the uterosacral ligaments. The pain is referred to the sacral region. Endometriosis or uterine carcinoma may invade the uterosacral ligaments; malposition of the uterus may cause uterosacral ligament traction. The pain associated with endometriosis begins during the premenstrual phase and often continues until it merges with menstrual pain. Malposition of the uterus (retroversion, descensus, and prolapse) may lead to sacral pain after standing for several hours.
Menstrual pain may be felt in the sacral region. The poorly localized, cramping pain can radiate down the legs. Other pelvic sources of low back pain include neoplastic invasion of pelvic nerves, radiation necrosis, and pregnancy. Pain due to neoplastic infiltration of nerves is typically continuous, progressive in severity, and unrelieved by rest at night. Radiation therapy of pelvic tumors may produce sacral pain from late radiation necrosis of tissue or nerves. Low back pain with radiation into one or both thighs is common in the last weeks of pregnancy.
Urologic sources of lumbosacral back pain include chronic prostatitis, prostate carcinoma with spinal metastasis, and diseases of the kidney and ureter. Lesions of the bladder and testes do not usually produce back pain. The diagnosis of metastatic prostate carcinoma is established by rectal examination, spine imaging studies (MRI or CT), and measurement of prostate-specific antigen (PSA) (Chap. 95). Infectious, inflammatory, or neoplastic renal diseases may result in ipsilateral lumbosacral pain, as can renal artery or vein thrombosis. Ureteral obstruction due to renal stones may produce paraspinal lumbar pain.
Postural Back Pain
There is a group of patients with chronic, nonspecific low back pain in whom no anatomic or pathologic lesion can be found despite exhaustive investigation. These individuals complain of vague, diffuse back pain with prolonged sitting or standing that is relieved by rest. The physical examination is unrevealing except for "poor posture." Imaging studies and laboratory evaluations are normal. Exercises to strengthen the paraspinal and abdominal muscles are sometimes therapeutic.
Chronic low back pain (CLBP) may be encountered in patients with compensation hysteria, malingering, substance abuse, chronic anxiety states, or depression. Many patients with CLBP have a history of psychiatric illness (depression, anxiety, substance abuse) or childhood trauma (physical or sexual abuse) that antedates the onset of back pain. Preoperative psychological assessment has been used to exclude patients with marked psychological impairment who are at high risk for a poor surgical outcome. It is important to be certain that the back pain in these patients does not represent serious spine or visceral pathology in addition to the impaired psychological state.
The cause of low back pain occasionally remains unclear. Some patients have had multiple operations for disk disease but have persistent pain and disability. The original indications for surgery may have been questionable with back pain only, no definite neurologic signs, or a minor disk bulge noted on CT or MRI. Scoring systems based upon neurologic signs, psychological factors, physiologic studies, and imaging studies have been devised to minimize the likelihood of unsuccessful surgical explorations and to avoid selection of patients with psychological profiles that predict poor functional outcomes.
Acute Low Back Pain
A practical approach to the management of low back pain is to consider acute and chronic presentations separately. The best treatment is take vitamin-C powder four times a day for three months along with a magnesium supplement daily and Vitamin D through a supplement or sun exposure for one hour a day.