Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
The low back, or lumbar area, serves a number of important functions for the
human body. These functions include structural support, movement, and protection
of certain body tissues.
When we stand, the lower back is functioning to support the weight of
the upper body. When we bend, extend, or rotate at the waist, the lower back is
involved in the movement. Therefore, injury to the
for weight bearing, such as the bony spine, muscles, tendons, and ligaments,
often can be detected when the body is standing erect or used in various
Protecting the soft tissues of the nervous system and spinal cord as well as nearby organs of the pelvis and abdomen is a critical function the lumbar spine and adjacent muscles of the low back.
Common causes of low back pain (lumbar backache) include lumbar strain, nerve irritation, lumbar radiculopathy, bony encroachment, and conditions of the bone and joints. Each of these is reviewed below.
Lumbar strain (acute, chronic)
A lumbar strain is a stretch injury to the ligaments,
tendons, and/or muscles of the low back. The stretching incident results in
microscopic tears of varying degrees in these tissues. Lumbar strain is
considered one of the most common causes of low back pain. The injury can occur
because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as
"acute" if it has been present for days to weeks. If the strain lasts
longer than three months, it is referred to as "chronic."
Lumbar strain most often occurs in people in their
40s, but it can happen at any age. The condition is characterized by localized
discomfort in the low back area with onset after an event that mechanically
stressed the lumbar tissues. The severity of the injury ranges from mild to
severe, depending on the degree of strain and resulting spasm of the muscles of the low back.
The diagnosis of lumbar strain is based on the history of injury, the
location of the pain, and exclusion of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities.
The treatment of lumbar strain consists of resting the
back (to avoid reinjury), medications to relieve pain and muscle spasm, local
heat applications, massage, and eventual (after the acute episode resolves)
reconditioning exercises to strengthen the low back and abdominal muscles. Initial treatment at home might include heat application, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), and avoiding reinjury and heavy lifting. Long periods of inactivity in bed are no longer recommended, as this treatment may actually slow recovery. Spinal manipulation for periods of up to one month has been found to be helpful in some patients who do not have signs of nerve irritation. Future injury is avoided by using back-protection techniques during activities and support devices as needed at home or work.
The nerves of the lumbar spine can be irritated by mechanical pressure (impingement) by bone or other tissues, or from disease, anywhere along their paths -- from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment,
and inflammation of the nerves caused by a viral infection (shingles). See descriptions of these conditions
Lumbar radiculopathy is nerve irritation that is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognized "sciatica" pain of a herniated disc that shoots from the low back and buttock down the leg. Sciatica can be preceded by a history of localized low-back aching or it can follow a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels. The sciatica of lumbar radiculopathy typically affects only one side of the body, such as the left side or right side, and not both.
Lumbar radiculopathy is suspected based on the above
symptoms. Increased radiating pain when the lower extremity is lifted supports
the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction
velocity) of the lower extremities can be used to detect nerve irritation. The
actual disc herniation can be detected with imaging tests, such as CAT or MRI scanning.
Treatment of lumbar radiculopathy ranges from medical
management to surgery. Medical management includes patient education,
medications to relieve pain and muscle spasms, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage
by a therapist, ultrasound,
exercises, electrical stimulation),
and rest (not strict bed rest but avoiding reinjury). With unrelenting pain,
severe impairment of function, or incontinence (which can indicate spinal cord
irritation), surgery may be necessary. The operation performed depends on the
overall status of the spine and the age and health of the patient. Procedures
include removal of the herniated disc with laminotomy (a
small hole in the bone of the lumbar spine surrounding the spinal cord),
laminectomy (removal of the bony wall), by needle technique (percutaneous
procedures (chemonucleolysis), and others.
Picture of herniated disc between L4 and L5
Cross-section picture of herniated disc between L4 and L5
Any condition that results in
movement or growth of the vertebrae of the lumbar spine can limit the space
(encroachment) for the adjacent spinal cord and nerves. Causes of bony
encroachment of the spinal nerves include foraminal narrowing (narrowing of the
portal through which the spinal nerve passes from the spinal column, out of the
spinal canal to the body, commonly as a result of arthritis), spondylolisthesis (slippage of one vertebra relative
to another), and spinal stenosis (compression of the nerve roots or spinal cord
by bony spurs or other soft tissues in the spinal canal). Spinal-nerve
compression in these
conditions can lead to sciatica pain that radiates down the lower extremities.
Spinal stenosis can cause lower-extremity pains that worsen with walking
and are relieved by resting (mimicking the pains of poor circulation). Treatment
of these afflictions varies, depending on their severity, and ranges from rest,
and exercises to epidural cortisone injections and surgical decompression by
removing the bone that is compressing the nervous tissue.
Bone and joint conditions
Bone and joint conditions that lead to low
back pain include those existing from birth (congenital), those that result from
wear and tear (degenerative) or injury, and those that are due to inflammation of
the joints (arthritis).
Congenital bone conditions -- Congenital causes (existing from birth) of low
back pain include scoliosis and spina bifida. Scoliosis is a
curvature of the spine that can be caused when one lower extremity is shorter
than the other (functional scoliosis) or because of an abnormal
architecture of the
spine (structural scoliosis). Children who are significantly affected by
structural scoliosis may require treatment with bracing and/or surgery to the
spine. Adults infrequently are treated surgically but often benefit by support
Spina bifida is a birth defect
in the bony vertebral arch over the spinal canal, often with absence of the
spinous process. This birth defect most commonly affects the lowest lumbar
vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of
hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can
also be accompanied by serious nervous abnormalities of the lower extremities.
Degenerative bone and joint conditions -- As we age, the
water and protein content of the body's cartilage changes. This change results
in weaker, thinner, and more fragile cartilage. Because both the discs and the
joints that stack the vertebrae (facet joints) are partly composed of cartilage,
these areas are subject to wear and tear over time (degenerative changes).
Degeneration of the disc is called spondylosis. Spondylosis can be noted on X-rays of the spine
as a narrowing of the normal "disc space" between the vertebrae. It is
the deterioration of the disc tissue that predisposes the disc to herniation and
localized lumbar pain ("lumbago") in older patients. Degenerative
arthritis (osteoarthritis) of the facet joints is also a cause of localized
lumbar pain that can be detected with plain X-ray testing. These causes of
degenerative back pain are usually treated conservatively with intermittent
heat, rest, rehabilitative exercises, and medications to relieve pain, muscle
spasm, and inflammation.
Injury to the bones and joints -- Fractures (breakage of bone) of the lumbar
spine and sacrum bone most commonly affect elderly people
with osteoporosis, especially
those who have taken long-term cortisone medication. For these individuals,
occasionally even minimal stresses on the spine (such as bending to tie shoes)
can lead to bone fracture. In this setting, the vertebra can collapse (vertebral
compression fracture). The fracture causes an immediate onset of severe
localized pain that can radiate around the waist in a band-like fashion and is
made intensely worse with body motions. This pain generally does not radiate
down the lower extremities. Vertebral fractures in younger patients occur only
after severe trauma, such as from motor-vehicle accidents or a convulsive seizure.
In both younger and older patients, vertebral fractures take weeks to heal with rest and pain relievers. Compression fractures of vertebrae associated with osteoporosis can also be treated with a procedure called vertebroplasty or kyphoplasty, which can help to reduce pain. In this procedure, a balloon is inflated in the compressed vertebra, often returning some of its lost height. Subsequently, a "cement" (methymethacrylate) is injected into the balloon and remains to retain the structure and height of the body of the vertebra. Pain is relieved as the height of the vertebra is restored.
Arthritis -- The spondyloarthropathies are inflammatory
types of arthritis that can affect the lower back and sacroiliac joints.
Examples of spondyloarthropathies include reactive arthritis (Reiter's disease), ankylosing spondylitis,
psoriatic arthritis, and the arthritis of inflammatory bowel disease.
Each of these diseases can lead to low back pain and stiffness, which is
typically worse in the morning. These conditions usually begin in the second and
third decades of life. They are treated with medications directed toward
decreasing the inflammation. Newer biologic medications have been greatly
successful in both quieting the disease and stopping its progression.