Lower back pain is one of the most widely reported types of pain in the United States today. It is the most common cause of industrial disability, and the leading cause of physical disability payments taxing our Social Security system.
Studies suggest that the prevalence of lower back pain in the adult population of the United States is at least 60% and its incidence, about 30%. Astonishing as it may sound, 10-12% of the population is seeking health care for low back pain at any given moment.
Because the structures of the lower back are very complicated, and the specific symptoms of lower back pain are highly varied, lower back pain is one of the most difficult to diagnose and treat.
While some forms of back pain are transient—such as simple bruises caused by light trauma, which require at most an analgesic treatment to ease the pain until it heals naturally,—persistent or chronic lower back pain usually develops over an extended period of time, due to interacting causative factors involving the vertebrae and their supporting tissues. Although these two types of “extended pain” are similar in many respects, researchers have distinguished them according to a few basic guidelines.
Generally, pain is described as “persistent” if it does not heal promptly, based on statistical standards; or, if it recurs regularly, in defiance of any treatments provided. “Chronic” is the term usually reserved for pain lasting longer than three months, which, in both cause and effect, often involves psychological as well as physical factors, or combinations of the two.
Degenerative disc disease and ligament injury
As with all types of pain, there are many possible factors causing or contributing to both types of extended lower back pain. The two main causes are spondylosis, or degenerative disc disease, and muscular or ligament injury. In fact, damage to ligaments is estimated to be responsible for up to 70% of all cases of lower back pain. In my clinic, I would estimate these causes to be a high as 95% of back pain. The chronic lower back pain patient typically experiences some type of trauma to the lower back that causes injury to the interspinous and supraspinous ligaments.
This injury mat cause some forward slippage of the fifth lumbar vertebra onto the sacrum, which in turn causes excessive pressure on the vertebra disk. Fissures may occur at the annulus fibrosis, and this begins the degenerative disk problem.
Ligaments are designed to handle a normal amount of stress that will stretch them to their natural limit, and will return to their normal length once the stress is removed. If additional (traumatic) stress is applied— stretching the ligament beyond its natural range of extension—the ligament will not return to its normal length, but will instead remain permanently overstretched, diminishing its power. Such a condition is called Ligament laxity. Ligament laxity in the lower back, as elsewhere in the body, may be caused by a major traumatic injury, repeated minor injuries to the same area, or simple normal aging. Unlike muscle tissue, ligaments have a very limited circulatory system that means a poor supply of blood to replenish them. This is why ligaments do not heal well on their own, and why Prolotherapy is needed in these types of injuries to stimulate circulation and to promote new cell growth.
With its overburdened matrix of ligaments, muscle, nerves, and small, interlocking bones, the spine is an area that benefits greatly from Prolotherapy.
The sacrum at the base of the spine is the “keystone” bone, on which all of the most vital structures of the body rest. Besides the lower vertebrae and the rest of the spinal column that it supports, it bears the weight of the entire torso with all its major organs.
And since the core of the central nervous system is housed in the spinal cord, and the nerves affect not only the legs and other extremities, but also the glands and the organs, the importance of keeping this area healthy and properly aligned becomes readily apparent. It also explains why so much of the pain reported to physicians is rooted in the lower back.
Descriptions and diagnosis of common low back pain include:
- Lumbrosacral strain or sprain indicates a soft tissue injury of the lower back, equivalent to a sprained ankle.
- Discogenic syndrome is used to describe pain originating in the lumbar disk, due to tears in the annulus, release of chemical mediators, or micromotion.
- Disc Herniation indicates a displacement of the nucleus pulposus from the intervertebral space into the spinal canal or foramen, or outside the foramen. This can “pinch” a nerve root and cause sciatica.
- Facet syndrome describes pain originating in the zygapophyseal or “facet” joints between the vertebrae, characteristically localized in the back, aggravated by movement and alleviated by rest.
- Spondylolisthesis is the slipping forward of one vertebral segment onto another. Retrolisthesis describes the inverse: the slipping backward of one vertebra onto another.
- Spondylolysis indicates a defect in the structure of the pars interarticularis, while spondylosis is a catch-all phrase describing the changes that occur as a result of degenerative disk disease, such as desiccation of the disk, narrowing of the interspace, inflammation, spurring or degeneration of the bone, and ligament hypertrophy.
- Spinal stenosis is used to describe the narrowing, in part or in whole, of the spinal canal, either through spondylosis or a congenital defect. More Information on Prolotherapy for treatment of Spinal Stenosis from Dr. Darrow
- Spinal instability is a very general term used when a more precise diagnosis eludes the physician. Specifically, it refers to excess motion of the vertebrae, and can be shown on flexion and extension x-rays. If instability is severe, it can cause spinal cord injury and paralysis.
Perhaps the most distressing is “failed back syndrome” — an official-sounding term to describe the pain of those poor patients whose surgical attempts have failed to correct their problem.
The most common cause of failed back syndrome is poor judgment on the part of the physician. Surgery prescribed as a last resort, with a hope and a prayer that it might alleviate the pain.
Unfortunately, often times surgery does little to help, and in fact can make things worse. Frequently surgery results in post-operative scarring, which often exacerbates the initial problem or causes new pain syndromes.
Subsequent “corrective” surgery can help in some cases, particularly if the damage done by the first operation involves clearly observable physical complications like nerve root compression, massive scarring, bone spurring or foraminal compression.
Unfortunately, the rate of success for second surgical operations in the case of “failed back syndrome” is no greater than it was for the initial operation, and declines with further attempts. In the words of a surgeon involved in such procedures, “In our extensive experience, satisfactory outcome is achieved about 60% of the time. Evidence indicates that many patients suffering from residual pain after multiple operations can benefit from an intensive rehabilitation program.
Please see our article for more information about failed treatments for lumbar disc herniation.
Why did the surgery fail in the first place?
When I was in medical school, I did surgical research and assisted in the operating room more than my classmates. By the time I had finished medical school and internship (where I spent as much time as possible doing orthopedic procedures) I had seen too many surgical failures.