Stroke & Vascular Disorders
Spontaneous carotid and vertebral artery dissection
Oct. 26, 2023
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If you have had lower back pain, you are not alone. Back pain is one of most common reasons people see a doctor or miss days at work. Even school-age children can have back pain.
Back pain can range in intensity from a dull, constant ache to a sudden, sharp or shooting pain. It can begin suddenly as a result of an accident or by lifting something heavy, or it can develop over time as we age. Getting too little exercise followed by a strenuous workout also can cause back pain.
There are two types of back pain:
What structures make up the back?
The lower back—where most back pain occurs—includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. The spaces between the vertebrae are maintained by round, rubbery pads called intervertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain.
Other regions of vertebrate are cervical (in the neck), thoracic (upper back), and sacral and coccygeal (below the lumbar area) segments.
What can cause lower back pain?
Most acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Some examples of mechanical causes of low back pain include:
Nerve and spinal cord problems
What are the risk factors for developing low back pain?
Anyone can have back pain. Factors that can increase the risk for low back pain include:
Age: The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes more common with advancing age. Loss of bone strength from osteoporosis can lead to fractures, and at the same time, muscle elasticity and tone decrease. The intervertebral discs begin to lose fluid and flexibility with age, which decreases their ability to cushion the vertebrae. The risk of spinal stenosis also increases with age.
Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine. “Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise can help maintain the integrity of intervertebral discs.
Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the back and lead to low back pain.
Genetics: Some causes of back pain, such as ankylosing spondylitis (a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine), have a genetic component.
Job-related factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when it involves twisting or vibrating the spine, can lead to injury and back pain. Working at a desk all day can contribute to pain, especially from poor posture or sitting in a chair with not enough back support.
Mental health: Anxiety and depression can influence how closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can contribute to the development of such psychological factors. Stress can affect the body in numerous ways, including causing muscle tension.
Smoking: It can restrict blood flow and oxygen to the discs, causing them to degenerate faster.
Backpack overload in children: A backpack overloaded with schoolbooks and supplies can strain the back and cause muscle fatigue.
Psychological factors: Mood and depression, stress, and psychological well-being also can influence the likelihood of experiencing back pain.
How is low back pain diagnosed?
A complete medical history and physical exam can usually identify any serious conditions that may be causing the pain. Neurologic tests can help determine the cause of pain and appropriate treatment. Imaging tests are not needed in most cases but may be ordered to rule out specific causes of pain, including tumors and spinal stenosis. Occasionally the cause of chronic lower back pain is difficult to determine even after a thorough examination.
Blood tests are not routinely used to diagnose the cause of back pain but might be ordered to look for signs of inflammation, infection, cancer, and/or arthritis.
Bone scans can detect and monitor an infection, fracture, or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones, particularly in areas with some abnormality. Scanner-generated images can identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
Discography involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection.
Electrodiagnostics can identify problems related to the nerves in the back and legs. The procedures include:
Diagnostic imaging tests allow specialists to see into the body without having to perform exploratory surgery. Imaging includes:
Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray or CT scans.
How is back pain treated?
Acute back pain usually gets better on its own. Acute back pain is usually treated with:
Exercising, bed rest, and surgery are typically not recommended for acute back pain.
Chronic back pain is most often treated with a stepped care approach, moving from simple low-cost treatments to more aggressive approaches. Specific treatments may depend on the identified cause of the back pain.
Step 1 Early treatments
Medications may include:
Step 2 Complementary and alternative techniques include:
Spinal injections include:
Trigger point injections can relax knotted muscles (trigger points) that may contribute to back pain. An injection or series of injections of a local anesthetic and often a corticosteroid drug into the trigger point(s) can lessen or relieve pain.
Epidural steroid injections into the lumbar area of the back are given to treat low back pain and sciatica associated with inflammation. Pain relief associated with the injections tends to be temporary and the injections are not advised for long-term use.
Radiofrequency ablation involves inserting a fine needle into the area causing the pain through which an electrode is passed and heated to destroy nerve fibers that carry pain signals to the brain. Also called a rhizotomy, the procedure can relieve pain for several months.
Step 3 More advanced care options
Surgery. When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. However, surgery is not always successful. It may be months following surgery before the person is fully healed and there may be permanent loss of flexibility. Surgical options include:
Implanted nerve stimulators
Rehabilitation programs. Rehabilitation teams use a mix of healthcare professionals from different specialties and disciplines to develop programs of care that help people live with chronic pain. The programs are designed to help the individual reduce pain and reliance on opioid pain medicines. Programs last usually two to three weeks and can be done on an in-patient or out-patient basis.
Can back pain be prevented?
Recurring back pain resulting from improper body mechanics may be prevented by avoiding movements that jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture.
Recommendations for keeping one’s back healthy
What research is being done?
The mission of the National Institute of Neurological Disorders and Stroke (NINDS) is to seek fundamental knowledge of the brain and nervous system and to use that knowledge to reduce the burden of neurological disease. NINDS is a component of the National Institutes of Health (NIH), the leading supporter of biomedical research in the world.
As a primary supporter of research on pain and pain mechanisms, NINDS is a member of the NIH Pain Consortium, which was established to promote collaboration among the many NIH Institutes and Centers with research programs and activities addressing pain. On an even broader scale, NIH participates in the Interagency Pain Research Coordinating Committee, a federal advisory committee that coordinates research across other U.S. Department of Health and Human Services agencies as well as the Departments of Defense and Veterans Affairs.
The NIH HEAL (Helping to End Addiction Long-term) Initiative, launched in April 2018, is a trans-NIH effort (which NINDS co-leads) that aims to prevent opioid addiction and provide more non-drug treatment options for chronic pain. Back pain is one of the most common pain conditions worldwide and is a major contributor to the prescribing and use of opioids in America. The treatment of low back pain is a specific area of focus of the Initiative. The Back Pain Consortium established through HEAL will conduct studies to better understand the mechanisms of common pain conditions such as chronic low back pain, develop improved diagnostic and treatment tools, and identify, prioritize, and test therapies that reduce the need for opioid use for millions of Americans. For more about the HEAL Initiative, see https://www.nih.gov/heal-initiative.
NINDS-funded studies are contributing to a better understanding of why some people with acute low back pain recover fully while others go on to develop chronic low back pain. Brain imaging studies suggest that people with chronic low back pain have changes in the structure and function of certain brain regions. Other research seeks to determine the role of brain circuits important for emotional and motivational learning, and memory in this transition, in order to identify new preventive interventions. Furthermore, several studies are being conducted to identify and characterize bidirectional neural circuits that communicate between the spinal cord to brain, which are aimed at discovering and validating new interventional targets for low back pain.
Different studies are looking at the response to placebos in individuals with acute and chronic back pain. For example, one study is designed to examine brain properties for placebo response and critically assess the neurobiology of placebo pain relief for individuals with chronic pain. Another study is assessing ibuprofen plus acetaminophen compared to ibuprofen plus placebo in treating acute low back pain.
In addition to NINDS, other NIH Institutes— including the National Institute on Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Drug Abuse, and the National Center on Complementary and Integrative Health—fund research on low back pain. More information on NIH efforts on back pain research and on other disorders can be found using NIH RePORTER (http://projectreporter.nih.gov), a searchable database of current and past research projects supported by NIH and other federal agencies. RePORTER also includes links to publications and patents citing support from these projects.
Where can I get more information?
For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at:
P.O. Box 5801
Bethesda, MD 20824
Information also is available from the following organizations:
American Academy of Family Physicians
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2680
913-906-6000 or 800-274-2237
American Academy of Orthopaedic Surgeons
9400 West Higgins Road
Rosemont, IL 60018
American Academy of Physical Medicine & Rehabilitation
9700 West Bryn Mawr Avenue
Rosemont, IL 60018
American Association of Neurological Surgeons
5550 Meadowbrook Drive
Rolling Meadows, IL 60008-3852
847-378-0500 or 888-566-2267
American Chronic Pain Association (ACPA)
P.O. Box 850
Rocklin, CA 95677-0850
National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
1 AMS Circle
Bethesda, MD 20892-3675
301-495-4484 or 877-226-4267; 301-565-2966 (TTY)
"Back Pain Fact Sheet", NINDS, Publication date March 2020. NIH Publication No. 20-NS-5161.
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
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