If a miracle cure for back pain was rolled out tomorrow, I’m convinced that the workload facing my GP colleagues and I would fall by at least a quarter. On a typical day, I’ll see three or four patients with back pain. For some, it’s the reason they’ve booked an appointment; for others, it’s an incidental but nonetheless irritating complaint that’s just come on, or stubbornly refuses to go away.
It’s astonishing to think that the estimated lifetime prevalence of back pain is nearly 60 per cent, but I’d wager that it has to be higher than that – surely closer to 100 per cent. Undoubtedly, each and every one of us has experienced back pain at some point, which has forced us to call in sick at work, or go limping into the GP surgery.
An entirely unscientific poll I’ve taken of my family and friends over the weekend has suggested as much – even my young daughter, who once fell off the jungle gym and needed a few days off school with bad bruising.
Acute low back pain (and that’s what we’re referring to here – the lower portions of your spine, not the neck) is defined as being a new episode lasting less than six weeks. Chronic back pain is diagnosed when symptoms are present for longer: three months or more.
Knowing how the pain came on and how it has developed over time can also provide useful clues about what the underlying cause might be. That is, of course, if you make it to see us in the first place. For every patient I see with back pain on each surgery day, there will be as many, if not more, who are putting up with it at home, or at work.
I’m sometimes equally astonished by how long it’s taken some patients to make an appointment to see a doctor. Some have adopted a “grin and bear it” approach, whilst others have put a sticking plaster of paracetamol or ibuprofen over the top for months on end – or haven’t been able to get away from busy life or work. It’s understandable. Back pain is so commonplace that it’s so tempting to dismiss it as a nuisance that will eventually sort itself out.
Not every back pain needs a trip to the doctors – many improve with time and with self-care. But there are times when I wish patients had come to see me sooner. For back pain is a symptom, not a diagnosis, and has so many different causes, ranging considerably in their severity. And some are a genuine emergency.
The common causes
“Trapped a nerve.” “Pulled a muscle.” “Something’s gone!”
These are the descriptions I often hear from patients presenting with back pain. And they’re not that far off the mark.
What they’re referring to is what we call mechanical back pain – a generic term for pain arising from the tissues that move or support the back. It could be a strained muscle, an inflamed joint, a pulled ligament or damage to the cushioning discs that join up the vertebrae to make the spine. These diagnoses are estimated to account for a stonking 97 per cent of back pain diagnoses.
It’s often difficult to identify precisely what’s caused the issue – but in many cases, we don’t really need to. Reassuringly, with simple painkillers and gentle movement, things will usually improve within a couple of weeks. Rest appropriately, but not extensively – long, inactive periods lying down in bed will not do you any favours in the long run.
Postural back pain also counts for a good number of cases. “Stop slouching!” I was often told as a child (in fact, it often happens now), but over time, sustained poor posture like hunched shoulders over a desk, bending awkwardly from the waist, or prolonged lack of movement can generate symptoms, too.
For these patients, I usually suggest changing position regularly during the day, making sure their workstation is well setup, and building strength through exercise – simple changes which can really make a significant difference.
It’s not always about the spine
The alternative list of other diagnoses that can cause back pain doesn’t always relate to the spine. Kidney disorders are one common example. Kidney stones or pyelonephritis (a kidney infection) can cause severe pain felt higher in the back, or in the flanks.
Certain gynaecological disorders can also be the problem – and not in the same way that period pain can be experienced as backache. I can still remember a patient many years ago with longstanding back pain who led an extremely active lifestyle – she exercised each day rigorously, practised yoga and had an excellent posture. There was little to suggest any mechanical cause for her pain.
Further investigation revealed the problem was endometriosis: a condition where tissue similar to the inner lining of the uterus grows in deposits elsewhere – including upon the pelvic ligaments, which can generate low back pain. This tissue can sometimes respond to the hormonal changes of the menstrual cycle, causing backache to fluctuate, and sometimes worsen around menstruation.
It’s a useful reminder that sometimes you have to look to these alternative causes, and beyond the commonplace labels of pulled muscles and irritated joints. Other conditions causing back pain can include inflammation of the gallbladder or pancreas (often caused by gallstones) – or even shingles, a painful skin condition caused by reactivation of the chickenpox virus in nerves.
The danger signs
Despite there being many minor and short-lived causes of back pain, some caution is still advised. Certain warning signs – also known as red flags – are important to recognise. And it’s recommended that patients seek help with more urgency if they notice them.
The first mention goes to any sudden, severe back pain, especially without an obvious cause, or getting progressively worse. There are several possible explanations, including a slipped disc, spinal fractures, or even a problem with the aorta – the largest artery in the body. Any sudden back pain, associated with faintness, dizziness or collapse, should prompt a call to 999 immediately. It could signal something life-threatening, like a rupturing aortic aneurysm.
Cancer is a possible explanation for more longstanding pain that isn’t getting better. Unfortunately, several cancers are able to spread to bone – particularly lung, breast, kidney, thyroid and prostate tumours. So, anyone who notices new pain with a current or prior history of cancer should take it seriously, and see a doctor.
There are other clues here, too; back pain whilst lying down, at night, or occurring in the thoracic spine – the segment associated with the chest – is more suspicious. And if you’ve also been unwell with weight loss, or have noticed neurological signs (like pins and needles, or muscle weakness), get checked too. Not all of these mean something sinister, but they’re good reasons to seek medical advice sooner rather than later.
Other individuals who should also exercise caution include those who have a suppressed immune system (including HIV); those using intravenous drugs or who take long-term steroid medications – which might increase the risk of spinal infections, or indeed fractures.
Some symptoms should never be ignored: any patient who notices new weakness in their legs, has lost control of their bowels or bladder, or experiences numbness around their genitals and between their thighs (a sign we call saddle anaesthesia – referring to the areas that would touch the saddle if horse riding). Any one of these warrants an emergency trip to A&E.
These are signs of a rare but serious condition, known as cauda equina syndrome, which arises when the nerves at the end of the spinal cord become compressed – such as from a slipped disc or spinal injury. Without prompt diagnosis and treatment, symptoms can become permanent, with lasting paralysis or incontinence. It’s one example of back pain where timing is really crucial. Don’t delay.
The causes for back pain are vast, and varied, but every case deserves some attention – even if that attention is taking appropriate steps to look after yourself. A conversation with your GP is warranted when it’s severe enough, or been around long enough to be disrupting your life. As important as knowing to how to look after your back, is knowing when to seek help when things feel wrong.