Pain in the Lumbar Spine

Problems with the lumbar spine can cause pain for doctors as well as patients because there is not a clear treatment that works for everyone. Diagnostic tests such as X-Rays and MRI can show sources of irritation, yet this information is not consistent with reports of pain.

This article discusses various factors relating to lumbar pain and treatment both from over four years of personal investigation and experience as well as recommendations from a variety of sources.

Most adults, 50-80%, will experience significant back pain some time in their lives. During severe acute episodes, the pain will interfere with normal walking, but most does not.

• See also Emotional Back Pain for relationships between back pain and emotions. Contains tables showing where nerves to various organs insert into the spine.

click on images to enlarge.
Top View of Lumbar Vertebra
source

click on images to enlarge.
Side View of Lumbar Vertebra
source

Degenerative Disc Disease

The spine and in particular the lower spine degenerates over time. This area is a focal point of every step we take, absorbing pressure as it controls and coordinates our movements. This happens to everyone to some extent and these degenerative conditions are at the root of most problems. It can be more severe in people with more flexible joints when they are younger since the bones can get out of alignment more since the tendons connecting them are stretchier. When they are not aligned right, even a little bit, it causes uneven stress on the bones.

• Osteoarthritis The terms osteoarthritis and degenerative joint disease are very general terms for a collection of changes in joints and bones that occur over time and as a result of injury.
• Hip Muscles ¿Hip Muscles

The spine is made of bones with discs between them which act as shock absorbers. When they have difficulty aligning properly, muscles will tighten to protect against misalignment. On one way this helps, but as these muscles pull the bones closer together, making it more likely they will rub. That is why it feels better when the muscles are massaged and relaxed.

All the ends of bones are covered by a thin layer of really smooth material that is "oiled" with synovial fluid (Synovial is greek roots for egg-like since the fluid is like egg white consistency). This allows joints to move without really touching. If the bones are not lined up right, they rub together which starts to rub off this nice smooth layer. The bones react by making the cells in the smooth layer thicker. This is like when you exercise the cells in the muscles enlarge and are firmer when you push on them. This is fine for muscles, but when the connective tissue gets thicker, it also gets stiffer, which means it does not stretch as well when you bend or move. Connective tissue is supposed to be elastic so it can act as a shock absorber.

click on images to enlarge.
Cervical stenosis is the narrowing is caused by bone spurs growing into the spinal canal. This puts pressure on the spinal nerves and the spinal canal.
Source

click on images to enlarge.
Lumbar stenosis the narrowing is caused by thickening of the spinal ligaments.
Source

When the connective tissue is thicker, it is more rigid and tends to get little microscopic tears in it when you lift too much and it can happen just when you move in the course of normal life.

Note: This is why the medical people are always suggesting people do stretching exercises and why they recommend you do them only after you have warmed up so that they muscles stretch so the connective tissues are stretched gently with the muscle. This stretching is essential to keep the entire system flexible with minimal problems. If you don't move much or do stretching, the connective tissue quickly becomes less flexible. This is why the physical therapists recommended the specific exercises to make sure the right things are flexible in the joint and small muscles are strong enough to hold the bones exactly where they belong.

Anyway back to the story... When the connective tissue is thicker, it is more rigid and tends to get little microscopic tears in it when you lift too much or just move in the course of normal life. When you get a microscopic tear, the tiny crack can expose the bone underneath. The bone cells jump into action and try to grow into the crack to fill it. This fills the crack, but the joint is no longer smooth - the bony spot is harder than the connective tissue so it can scratch the the smooth tissue when the joint moves. When these bony growths get bigger, it is called a bone spur.

The spine has a series of bones that are shaped like little snare drums (pa-rum pum pum pum) that alternate with spongy discs that cushion against impact or when you carry weight. These dehydrate as we get older. That article you sent about water shows that drinking water rehydrates (reinflates) the discs.

• When your back hurts, the first thing to do is drink some water.

On one side of the drums is an unique-shaped bone that makes a triangle with a hole in it, called the Spinous Process. The pointy end makes the bumps on the spin you can feel through the skin. In the middle of the triangle, is a safe place for the nerves of the spinal cord with bones on all sides. A pair of major nerves to the lower body extend from the triangle between each of the bones.

As the discs between the bones dehydrate, the bones of the spine get closer together. and can rub. If there is curvature, they will rub unevenly, which over time results in the problems of thickening we just mentioned. When it rubs too much, the thicker tissue starts to extend into the joint making the rubbing worse (this is called osteo arthritis or arthritis of the bones) As this thicker, bumpier layer of tissue to protect the bones can pinch nerves coming out of the spine, or can push on the spinal cord always or just sometimes. Pressure on the spinal fluid affects the entire spine up into your head - making a person short tempered and they don't know why.

The things we can do to make it better:

• Drink water to keep the discs hydrated.
• Exercise the muscle - especially the small, stabilizer muscles that hold bones exactly in place
• Don't be a couch potato.
• Keep your weight down.
• Massage on tight muscles.
• The vitamins and supplements I mentioned.
• Take over the counter medicine that reduces swelling (acetaminiphin or ibuprofen).
• Tapping Techniques Thought Field Therapy or TFT are methods of tapping a finger on acupressure points. It seems a bit weird but they are easy, self-administered and no cost. There is no harm in trying, many people get great results with Energy Therapies.
• Prescription medications for Back Pain.

Details and Medical Terminology

• The center of the disc is the "nucleus pulposus". This is a mix of proteoglycans, collagen, and water.
  • A proteoglycan is a high molecular weight molecule found in the extracellular matrix of connective tissue. They are made up mostly of carbohydrate consisting of various polysaccharide side chains linked to a protein, and act more like polysaccharides than proteins.
• The nucleus is concentrically surrounded by the 'annulus fibrosis' which has a series of layers like an onion. It can get tears in it. This is composed of strong type I collagen that is attached to the end plates of the vertebral body above and below.
• Biochemical changes occur within the nucleus pulposus primarily with loss of water content and a relative shift of chondroitin sulfate to keratin sulfate which makes up the proteoglycan matrix. The matrix here is the part of the structure that is structural rather than mainly water.
  • Keratan sulfates are large, highly hydrated molecules which in joints can act as a cushion to absorb mechanical shock.
• Asymmetric degenerative changes in the lumbar spine structures can lead to degenerative scoliosis.

As the disc dries out it does not stay as puffy and work as well. The annulus fibrosis (the outer shell of the disc) can become damaged. A disc herniation, is when part of the disc extends beyond the column where it belongs.

Lumbar spinal stenosis means the discs are pushing into the spinal canal, the area reserved for the spinal nerves to pass.

If the disc is unable to control shear forces ( movement side to side), then a degenerative spondylolisthesis can slowly develop.

• Severe back pain will usually cause the patient to lie down for relief since standing or sitting may be difficult.
• Pain waking the patient at night would be more suggestive of neoplastic disease (a new growth of tissue serving no physiological function - such as a benign or malignant tumor).
• Problems visible on an MRI do not necessarily indicate pain.

Common Conditions of the Lumbar Spine

See Reading Lumbar MRI for more information. All the following conditions are generally diagnosed with and MRI report.

Osteoarthritis

• Osteoarthritis The terms osteoarthritis and degenerative joint disease are very general terms for a collection of changes in joints and bones that occur over time and as a result of injury.

Spondylolisthesis

Spondylolisthesis is a condition where one or more of the Vertebrae are out of alignment.

It can occur at other levels but L5-S1 is by far the most common.

Pressure on nerves can cause symptoms to appear in legs and hips, this is called referred pain.

Lumbar Disc Herniation

Lumbar Disc Herniation which means that the disc is not properly place between the vertebrae and can be pushing on the spinal column. The popular term "slipped disc" is misleading, as an intervertebral disc, being tightly sandwiched between two vertebrae to which the disc is attached, cannot actually "slip", "slide", or even get "out of place". The disc is actually grown together with the adjacent vertebrae and can be squeezed, stretched and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated, but it cannot "slip."

Degenerative Spondylolisthesis

Degenerative changes in the lumbar spine leading to lumbar spinal stenosis can also commonly produce a degenerative spondylolisthesis. This is a slipping forward of one vertebrae on another due to degenerative changes of the posterior facet joints (the pointy part of the bones you can feel just under the skin in your back.

The joints become incompetent over time and allow forward subluxation, typically occurring at the L4-5 motion segment.

Because the spinal canal is made up essentially of bony rings stacked on each other, with a degenerative spondylolisthesis one ring slides forward on another and the diameter of the spinal canal will obligatorily be decreased. This will significantly contribute to narrowing of the canal at that level. Degenerative spondylolisthesis and the associated pathoanatomy typically occur very slowly and the degree of narrowing that many patients tolerate without significant symptoms can be surprising.

Ankylosing spondylitis

A chronic, inflammatory arthritis. It affects joints in the spine and the sacroilium in the pelvis, causing eventual fusion of the spine.

The typical patient is young, aged 18-30, with chronic pain and stiffness in the lower part of the spine, often with pain referred to one or other buttock or back of thigh from the sacroiliac joint early on. Pain is often severe on rest, and improves with physical activity.

No cure is known for AS, although treatments and medications are available to reduce symptoms and pain.

Physical therapy and exercise, along with medication, are at the heart of therapy for ankylosing spondylitis. Physiotherapy and physical exercises are clearly to be preceded by medical treatment in order to reduce the inflammation and pain and are commonly followed by a physician. This way the movements will help in diminishing pain and stiffness, while exercise in an active inflammatory state will just make the pain worse.

Medical professionals and experts in AS have widely speculated that maintaining good posture can reduce the likelihood of a fused or curved spine which occurs in a significant percentage of diagnosed persons.

Degenerative Scoliosis

Some patients with lumbar degenerative disease will develop a deformity of the lumbar spine in the coronal plane or front view. This is called degenerative scoliosis. The wear and tear on the disc and facet joints is more on one side than the other. If the slippage is for more than 20% that could indicate a need for intervention when other conditions warrant back surgery.

• Scoliosis means the spine column is curved rather than straight. The asymmetry causes abnormal wear and tear on the bones and connective tissue.

Mechanical Pain

Leg Pain

The leg pain component of a low lumbar disc herniation is commonly termed sciatica. The more proper term for leg symptoms involved with nerve root compression manifesting as pain, numbness, or weakness is 'radiculopathy'. By definition, this term means symptoms are originating from a nerve root source. The mechanical squeeze on the root is believed to be the main problem in symptomatic disc herniations; however, it has been well established there is a chemical component to radiculopathy.

Referred pain associated with a disc herniation is a deep pain that is felt in the buttocks, sacroiliac joint area, or posterior thigh. It will not radiate below the knee, as this would imply a radicular or nerve root pattern. Referred pain is believed to arise from mechanical or cytokine induced irritation of soft tissue structures such as ligaments, joint capsule, and annulus.

Patients with a lumbar disc herniation and radiculopathy may have difficulty walking secondary to pain. Young patients may present with a list to one side or the other, which suggests they are trying to find a position that minimizes the root compression. Tenderness to palpation in the paraspinal muscles as well as the sciatic notch on the symptomatic side is common. Limitation in lumbar range of motion is also typical.

Because lumbar disc herniations are most common at the two lowest levels, weakness would usually be present in an L4, L5, or S1 motor group. Similarly, dermatomal sensory findings would most commonly be present for these three root levels. The knee jerk reflex is mediated mostly by L4 and the Achilles reflex is modulated by the S1 level.

Sitting on a stationary bike may not be well tolerated by a patient with a lumbar disc herniation as sitting generally makes the symptoms worse. A treadmill, stair stepper, or aquatic program may be more appropriate for this patient group.

Chronic compression of the cauda equina classically produces symptoms termed neurogenic claudication. This symptom complex is pain in the low back and buttocks, aggravated by standing or walking distances, with or without pain radiating distally into the legs that may be accompanied by numbness or tingling in the legs and feet. As degenerative changes slowly accrue in the low lumbar spine, patients with stenosis will typically cut back on their walking until they can only walk a block or two.

They will sit down for relief or even lean over, as these maneuvers flex the lumbar spine and slightly expand the canal.

Whereas standing in place will relieve vascular claudication, relief of neurogenic claudication will require the patient to sit or bend forward.

Although the classic presentation of lumbar stenosis is that of neurogenic claudication, it is not uncommon to have a radicular component in any given patient. One or more nerve roots can be pinched enough to produce radicular pain all the way down the leg with or without neurologic deficit

Treatment

As the patient can tolerate, active core strengthening combined with stretching and aerobic conditioning has the best chance of providing sustained relief or at least minimizing recurrent episodes.

Exercise bike may be better tolerated by those with Lumbar Stenosis (narrowing of spinal canal).

• Homeopathy recommends: Arnica montana along with Hypericum

• See also Osteoarthritis
• How bad is the pain? A guide to several tests assessing level of back pain.

Walking

• Walking Styles
• Shoes This is our guide to footwear from history to modern times. As always, we are always looking for more information to fill in the gaps. Areas of interest: Boot Covers, Famous Boots and more.
• Brain Reeducation Techniques to educate your brain on ways to walk without pain.

Sources

• Osteoarthritis fourth Edition: Diagnosis and Medical/Surgical Management, 2007

---