Low back pain is the second most-common reason for a doctor's visit and it is the most common cause of disability in young Americans.  More than 80% of Americans will suffer at least one episode of severe back pain during our lifetime, but only a small percentage of people will develop recurrent or chronic back pain that may require surgery.

Causes:

There are many causes of low back pain, which include degenerative, trauma, infection, musculoskeletal, or tumor.  The most common cause of recurrent or chronic back pain is degenerative (wear and tear) disease of the lumbar spine (aka. lumbar spondylosis) or musculoskeletal. The following table is a list of potential causes of low back pain.

• Congenital: developmental anomalies, congenital scoliosis, myelomeningocele
• Degenerative: annular tear, degenerative disc disease, degenerative facet arthropathy, disc bulge/herniation, spinal stenosis
• Infection: discitis, osteomyelitis, tuberculosis, fungus
• Inflammatory: ankylosing spondylitis, rheumatoid arthritis, lupus
• Musculoskeletal: muscle strain or sprain
• Oncologic: metastatic tumors, primary bone tumors: chordoma, chondrosarcoma, giant cell tumor, osteosarcoma,
• Ewing's tumor.
• Psychogenic: depression, other psychiatric disorders
• Unknown

Symptoms:

Typical complaint from patients with acute back injury or muscle strain is lower back pain associated with back muscle spasms.  The pain is self-limiting in majority of the cases and resolves in several days.  On the other hand, patients with recurrent or chronic back pain from degenerative spine disease will report pain that is located at the lower aspect of spine just above the pelvis, pain that is worse with sitting, standing, or performing activities, and pain that is improved with rest or laying down.  It is also not uncommon for patients to complain of pain that is daily, constant, and not improved with rest or lying down.  
Patients with traumatic injury, infection, or tumor to the spine will also complain of similar symptoms listed above.  However, they typically have an acute onset of symptoms and the symptoms will progress and worsen in a shorter period of time.   In addition, patients with traumatic injury, infection, or tumor to the spine are more likely to develop neurological complaints, such as weakness, sensory loss, or bladder/bowel problems.

Diagnostic test:

Clinical history and physical examination are the most important diagnostic tools for low back pain.  Patient with isolated low back pain will generally have a normal neurological examination associated with some localized tenderness to palpation and decreased range of motion in the lower back.  Patients with nerve or spinal cord compression can have radiating pain down their buttocks and legs, weakness, sensory loss, depressed or loss of reflex, or decreased bladder and rectal tone.  Plain x-ray is generally obtained as the initial radiographic study.  However, plain x-rays have a low sensitivity and specificity to detect spinal pathology, compared to CAT scan and MRI.  MRI of the spine should be obtained in patients with chronic low back pain, neurological symptoms, or acute and progressive symptoms.  For those with degenerative disc diseases detected on MRI, diskograms can be obtained to help to localize the pain generator level(s).

Treatment Options:

Most low back pain and spine conditions are self-limiting.  The initial treatment is often conservative treatment with rest, icing, anti-inflammatory medications, exercises, physical therapy, and pain medications.  Epidural and facet injections can be performed as the second line of therapy prior to surgical treatment.  When patients fail an adequate length of conservative therapies, surgical treatment may be beneficial.   A wide variety of surgical treatments are available for treatment of low back pain.  Treatment goals are targeted to relieve spinal cord or nerve root compression and stabilization of the painful segment(s).  Traditionally, spinal fusion is the mainstay surgical therapy for patients with severe degenerative spine disease and chronic low back pain.  Spinal fusion results in permanent immobilization of a painful segment and prevent movement that can illicit pain.  Recent advances in technology and surgical techniques have provided other treatment options for patients.  Spinal fusion and decompression can now be performed minimally invasively through small incisions and keyhole approaches.  Advantages of minimally invasive spine surgeries include decreased blood loss, decreased muscle and soft tissue injury, shorter hospital stay, decreased recovery time, and decreased time away from work.   In additional to minimally invasive spine surgery, new surgical approaches include artificial disc replacement and dynamic stabilization procedures.  These are relatively new procedures with unknown long-term results, but early experiences and clinical studies have shown favorable results.

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