Back Pain: Everything You Need to Know

Back pain is one of the most common reasons people self-treat and seek medical care. It will affect approximately three in four adults during their lifetime.

It’s caused, directly or incidentally, by a huge number of health conditions, which may make teasing out the root cause of back pain exceedingly difficult. Sometimes the cause is obvious and sometimes not even a team of doctors can figure out why your back hurts. Many cases go away on their own, but some stick around for months or even years.

Yes, uncertainty abounds when dealing with back pain, but we're here to help. Below is your guide to everything back pain: Its causes, its complications, how it’s diagnosed, how it’s treated, how to live with it, mitigate it and prevent it. Read on.

Learning about spine anatomy can help you understand your back pain on a deeper level.

Reginald Q. Knight, M.D., an orthopedic surgeon and Director of the Bassett Spine Care Institute in Cooperstown, NY, breaks down the regions of the spine.

“The cervical spine is a highly mobile segment of the spine prone to degenerative changes,” says Dr. Knight. As you age, pain is more likely to take place in what’s called the “transitional zone” between the flexible cervical vertebrae and the more rigid thoracic portion of the spine.

The thoracic spine is associated with the chest and connects to your ribs. Dr. Knight says that particularly, the elderly can experience compression fractures in this region, a result of losing bone mass.

The lumbar spine is generally known as the lower back. “This is the most common region for back pain,” Dr. Knight says. “Younger patients are more prone to discogenic back pain, whereas older patients are more prone to facet joint issues.”

Discogenic pain means one or more intervertebral discs cause pain while facet joint issues originate from the top and bottom of each vertebra.

Finally, the sacral region is the very bottom of the spine. It consists of the flat, triangle-shaped sacrum bone that connects to the hips, and the coccyx, also known as the tailbone, an evolutionary leftover.

Dr. Knight mentions that degeneration of this area tends to occur in older patients. You can also fracture your sacrum or tailbone by falling hard on your rear.

Back pain is a big topic. Between the upper back and tailbone, there are 17 vertebral bodies, many joints, the sacrum and tailbone, plus fibrous and muscular supporting structures, intervertebral discs, spinal cord and nerve roots, and blood vessels. The spine is more than the sum of its parts, but here’s what you need to know about those parts.

Before discussing the muscles, we need to talk about vertebrae. Vertebrae are a series of small bones that make up the backbone to which the muscles attach. An adult spine typically consists of 24 vertebrae, each separated by an intervertebral disc.

Every vertebra is made up of two parts: an anterior vertebral body that protects the spinal cord and nerve roots and a posterior vertebral arch which accommodates the canal and also safeguards the spinal cord.

Back muscles fall into three groups:

• Intermediate muscles make up something called the erector spinae, which includes the longissimus, iliocostalis, and spinalis muscles. These muscles help to flex/extend and laterally bend the spinal column.

• Intrinsic muscles stabilize the vertebral column and are located underneath the erector spinae; also known as the “deep” muscles of the back and control the movement and posture of the vertebral column.

• Superficial muscles are directly underneath the skin and attach to the bones of the shoulder, aiding in neck and shoulder movements along with controlling upper limb movements.

Muscles that support the spine are structured in layers, says Dr. Knight. Some muscles extend from the base of a person’s skull to their pelvis. Other muscle groups cover shorter distances depending on the segment of the spine: cervical, thoracic, or lumbar.

Dr. Knight adds, “These muscle groups function as primary stabilizers of the bony and ligamentous structures. Strains of these muscles affect all age groups.”

There are several other parts of the spine worth considering when you are identifying your back pain. These include:

• Ligaments and tendons. While tendons are part of the muscular structure attaching a muscle to bone, ligaments attach bone to bone with no intervening muscle. Both ligaments and tendons contain elastic fibers.

• Intervertebral discs, which actas miniature shock absorbers that sit between vertebrae and prevent bone-on-bone friction. Discs can naturally degenerate over time.

• Hinge-like facet joints, which connect each of the vertebra to the one above it and the one below it. They provide the optimal combo of mobility and stability: Each vertebra can move independently, but since they’re all connected the spine can act as a whole. There are four facet joints per vertebra—two on top and two on the bottom.

Pretty much anyone, it depends on where it hurts.

Upper Back

Chronic upper back pain affects 15% to 19% of people globally. Those suffering tend to fall into certain age groups. For instance, one study found that postmenopausal women are at greater risk, likely due to the risk of osteoporosis and vertebral compression fractures.

Your career choice may also lead to upper back pain. Those who have to hunch for long periods, such as dentists and eye doctors, report higher incidences of upper back pain. Office workers frequently have upper back pain due to poor ergonomics.

Mid-Back

So, what about pain in the mid-back—low in the thoracic spine and even the top of the lumbar? Adolescents get it a lot. According to a 2016 study, between 13% and 45% of children and adolescents will have mid-back pain in a given four-year period.”

A Danish report, which studied overall spinal pain in 11- and 13-year-olds, reported increased mid-back pain if the kids were more physically active than most. Mid-back pain is also a common result of car accidents.

Lower Back

You’ll often get mid-back pain from pushing your body too hard, but lower back pain can come from not pushing it hard enough. A sedentary lifestyle is a big contributor to low back pain.

One study says that reporting of chronic low back pain has gone from 3.9% in 1992 to 10.2% in 2006. Reasons are unclear for this increase.

The first thing you should probably know about back pain is that it can last anywhere from a few days to years, and that timeline makes a big difference in how your pain is diagnosed and treated.

• Acute back pain is defined as severe but lasting a short time, usually seven to 10 days.

• Subacute pain can last from two to six weeks.

• Chronic back pain usually occurs every day and sticks around for longer than six to eight weeks. It can be severe and last months or even years, but may be characterized as mild, deep, achy, burning, or electric-like.

Beyond the when, there’s also the where. Mechanical pain means that the source of your pain may lie in the facet joints, discs, soft tissues, or vertebrae.

Back pain that travels into another part of the body, such as the leg, may be consider radicular pain (because it radiates; get it?), particularly when it radiates below the knee. This scenario is commonly called a lumbar radiculopathy (e.g., sciatica). Fortunately, not all occurrences of back pain include leg pain.

Perhaps you’ve heard of inflammatory pain. While it sounds like it could be a separate type of pain from mechanical and radicular pain, it’s actually an element of both. Dr. Knight explains, “Symptoms of pain, whether mechanical or radicular, share a component of inflammation.”

Simply put, inflammation is when your body knows something isn’t right and “flares up” as a result.

There are myriad health conditions that can lead to back pain. Dr. Knight points out that other than these specific conditions, there are overarching factors as well. The two main factors, says Dr. Knight, are:

• Obesity

• Smoking

He says, “The impact of excessive weight and its effect on spinal anatomy is significant. Smoking and the adverse impact on the vascular system—macro and micro—is associated with increased severity and frequency of back pain.”

Smoking impairs the delivery of nutrients to structures in the back, and can also make healing from back injuries or surgery more difficult and less effective.

Other risk factors include:

• Age

• Fitness level

• Genetics

• Jobs or activities

• Sedentary lifestyle

Among all the different areas of back pain—neck pain, upper back pain, lower back pain, and tailbone pain—there’s a host of conditions that can bring it on.

There are several diseases, disorders, and illnesses that can cause back pain. They fall into a few broad categories.

Structural Issues

Structural issues are, collectively, a top cause of back pain. We can define structural issues as any condition that affects the spinal column itself or any part. This includes a pretty diverse array of structures and tissues, including:

• The vertebrae

• The intervertebral discs

• The spinal canal

Conditions that can be considered structural issues include:

• Spinal Stenosis: When the spinal canal narrows, usually due to a herniated disc but sometimes caused by bone spurs from osteoarthritis or by injury; the structure causing the narrowing frequently compresses a nerve root or the spinal cord itself (myelopathy)

• Herniated Disc: When the pads between vertebrae move out of position and press on the nerves. Herniated discs are more common in the lumbar and cervical spine, but can sometimes occur in the thoracic spine as well.

• Arthritis: Characterized by swelling and tenderness, back pain can be caused by different types of arthritis, including ankylosing spondylitis, spondylosis (spinal osteoarthritis and the most common form of arthritis by far), and rheumatoid arthritis.

• Degenerative Disc Disease (DDD): A condition tied to aging that causes discs to break down

• Sciatica: Compressed-nerve pain in the buttocks, usually from a herniated disc

• Compression and Wedge Fractures: A vertebral body, almost always due to weak bones from osteoporosis, collapses under the weight of the spinal column

• Pregnancy: 50% to 80% of pregnant women experience back pain

• Scoliosis: An abnormal curvature of the spine that is also frequently diagnosed in childhood

• Kyphosis: Abnormal curvature that causes a hunchback or slouching posture

• Flatback Syndrome: When the lower spine doesn’t reflect normal curvature

• Lordosis: Abnormal curvature that causes swayback

• Spondylolisthesis: When one vertebra slips forward over the vertebra below it

• Osteoporosis and its precursor, osteopenia: These conditions, largely age-related, don’t cause back pain per se, but they do put you at a much greater risk of vertebral compression fractures

• Discogenic Low Back Pain: One or more intervertebral discs of the low back cause pain

• Pinched Nerves: When too much pressure is applied to a nerve

• Lumbar Radiculopathy: Pain in the lower extremities stemming from nerve compression in the lower back

• Cauda Equina Syndrome: A consequence of long-term nerve condition in the lumbar spine that can affect bowel and bladder function and even lead to paralysis. Cauda equina syndrome is a medical emergency.

Sprains and Strains

Many experts believe that sprains and strains are the most common cause of back pain, especially acute episodes that resolve by themselves. Strains are injuries to the muscle or the tendon that connects it to bone, while sprains are injuries to ligaments, which connect bones to each other.

Other conditions in this category can include:

• Cervical Sports Injuries: Also called a “stinger,” these injuries occur when the head or neck is hit to one side

• Whiplash: Neck sprain or strain from hyperextension and hyperflexion

Movement and Posture

People in modern Western society sit a lot. A sedentary and inactive lifestyle can cause a whole host of problems, not least of which is back pain. Because of its potentially devastating effects on your overall health, it is often said that “Sitting is the new smoking.”

Movement (or lack thereof) and posture problems such as text neck (or tech neck) may cause one or more structure problems, muscle strains, or other back-pain-causing condition. Other incorrect movement and posture patterns can include:

• Lifting incorrectly (with the back instead of the legs)

• Excessive or awkward bending and twisting

• Sleeping on a mattress or pillow that is too soft and puts your spine out of alignment

• Long periods of sitting, standing, or driving

• Poor office work habits

Pregnancy and Back Pain

Between 50% and 80% of pregnant women experience back pain. This greater susceptibility to back pain is the result of a number of factors, including:

• Weight gain

• A shift in the center of gravity

• Hormonal changes

• Increased stress

Pregnancy back pain usually manifests in the lower back: the lumbar spine, the sacrum and coccyx, and the hips and pelvis.

Other Causes

Less common causes of back pain can include:

• Acute Flaccid Myelitis (AFM): A polio-like illness of the spinal cord

• Arachnoiditis: Inflammation of one of the central nervous system’s protective linings. Arachnoiditis causes a combination of neurologic difficulties along with stinging, burning pain

• Avascular Necrosis: A loss of blood supply in a bone

• Spinal Cancer: When primary and/or metastatic tumors form in the vertebrae

• Chiari Malformation: A congenital (present at birth) condition that causes brain tissue to settle into the spinal canal

• Fibromyalgia: A chronic pain disorder characterized by widespread muscle pain, including back pain

• Paget’s Disease: A bone disorder centering on improperly functioning bone cells

• Synovial Cysts: Benign, fluid-filled sacs of the facet joints of the lumbar spine

• Syringomyelia: A fluid-filled cyst forms within the spinal cord

• Tarlov Cysts: A fluid-filled sac on the spine that can affect nerve roots

• Adjacent Segment Disease: A disorder that can develop after a spinal fusion

• Failed Back Surgery Syndrome: When a back surgery causes more or new pain afterwards

• Spinal Infections, including vertebral osteomyelitis (an infection of vertebral bone tissue), discitis (an infection of an intervertebral disc), and spinal epidural abscess (an infection in the spinal canal)

• Ehlers-Danlos Syndrome: An inherited disorder that affects connective tissue, including tendons and ligaments in the back

• Baastrup’s Sign (Kissing Spine): The spinous processes of two adjacent vertebrae touch one another

• Slipping Rib Syndrome: When ribs move abnormally

• Spina Bifida: A neural tube defect caused by incomplete brain development

• Depression: Depression can bring about back pain, or, depression can come about as a result of chronic pain

• Stress: Daily pressures can exacerbate back pain

The hallmark symptom of back pain is pain anywhere in the back—either along the spine or off to the sides, and in the lumbar, thoracic, or neck regions.

Other Symptoms

Sometimes, back pain doesn’t show up alone. Other symptoms can appear along with it, and there are some that can be concerning. While pain radiating in the legs is a fairly common symptom that accompanies back pain, others can be concerning, including:

• Bowel or bladder issues

• Fever

• A recent injury

• Sudden and unexplained weight loss

• Weakness, numbness, or tingling in legs

When to See Your Doctor

The symptoms listed above may indicate a medical emergency. At the very least, call your doctor right away, but be prepared to head to the ER.

Additionally, if you’re experiencing pain for longer than a few weeks, or pain that doesn’t go away even though you’re treating it, you should speak with your doctor to find out what’s causing your back pain.

Whether you back pain falls into the “seek urgent medical care” list above, or you are following your gut reaction that says, “Go see your doctor,” below is what you can expect.

• A review of your medical history, including immediate family members who have back problems. Some back problems (e.g., scoliosis, osteoporosis) have a genetic potential.

• Discuss when back pain started, what you were doing when pain began, current pain severity and characteristics (e.g., stabbing, burning), how pain may have changed since it began, and other questions. Your doctor wants to learn as much about your pain and symptoms before he examines you—while the exam may provoke pain, your doctor doesn’t want to make the process intolerable!

• Physical examination evaluates your vital signs (eg, heart rate). It is not unusual for your blood pressure to be elevated as a result of pain. The doctor examines your spine, feeling for abnormalities and areas of tenderness.

• Neurological examination involves assessing sensation and function. The doctor may employ the pin prick test to determine if feeling is the same on both sides of particular parts of the body (eg, legs). Function, flexibility and range of motion are assessed while you walk, bend forward and backward (if able to), and during other movements. The doctor tests your reflexes too.

After a thorough review, your doctor probably has come to one or two conclusions as to what is causing your back pain and other symptoms. To obtain more information about your back problem, and to help confirm the diagnosis, the doctor may order an X-ray, CT scan, or MRI.

Sometimes lab tests are ordered too. Keep in mind that an accurate diagnosis is essential to a well-developed treatment plan.

It can be comforting to know that you don’t always—or even usually—have to go the surgery route when addressing back pain. Every case of—and person with—back pain is different, and what works for one instance may not work for another. Luckily there are a wide array of treatments you can try, both on your own or with a treatment team.

Medication

Since most cases of back pain resolve without the need for surgery, medication is usually one of the front-line treatments. Although many over-the-counter drugs work well for many cases of back pain, prescription drugs of a number of types are available if you need something more heavy-duty.

Common medications for back pain include:

• NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Motrin, Advil) and aspirin

• Acetaminophen (Tylenol)

• Muscle relaxants

• Opioids

• Antidepressants

• Topical rubs and ointments

Corticosteroid Injections

Also known as a cortisone shot, corticosteroid injections are sort of a middle ground. As they involve getting an injection of medication in the spinal epidural space, they’re more invasive than oral or topical medications, but less invasive than surgery.

Dr. Knight says he uses corticosteroid injections for radiculopathy (radiating pain in the arms or legs such as sciatica) when oral or topical medications haven’t worked.

Physical Therapy

This type of therapy is effective in helping people return to a normal, active range of motion. Dr. Knight also notes that since physical therapy can lessen pain, it may reduce or eliminate the need to take opioids.

Home Remedies

Although back pain is incredibly common, the vast majority of cases can be managed quite well without seeing a doctor. Here are a few treatments you can try at home when you feel those first twinges of back pain.

• Over-the-counter NSAIDs

• Alternating heat and ice for about 20 minutes at a time

• Essential oils

• Salt baths

• Stretching and gentle exercise, especially no- or low-impact activities such as walking, swimming, and biking

Complementary and Alternative Therapies

Scientific evidence for the effectiveness of complementary and alternative therapies is somewhat limited, mostly due to a lack of high-quality research. That doesn’t mean that these treatments don’t work, though; it just means they need to be studied more.

Other types, such as cognitive behavioral therapy, work best when combined with other forms of treatment (which is why they are known as “complementary”).

Anecdotally, many people with back pain have great success with some of these therapies, such as:

• Yoga

• Chiropractic care

• Acupuncture

• Massage

• Tai chi

• Body movement therapies

• Posture correction programs

• Mindfulness-based stress reduction and cognitive behavioral therapy

• Transcutaneous Electric Nerve Stimulation (TENS)

If you’ve tried everything or you have a condition that requires surgical attention, these are some of the main back surgery options currently available.

• Microdiscectomy: Discectomy is the removal of portions of a herniated disc that are compressing nerve roots. It’s the main surgical method of addressing herniated discs. It can be accomplished via traditional open (just called a discectomy).

  However, it’s much more likely you’ll have a microdiscectomy. In a microdiscectomy, the surgeon uses minimally invasive techniques and special magnifying glasses called loupes. The loupes act as microscopes, hence the term ‘microdiscectomy.’

A surgery like this is recommended if a person is experiencing radicular symptoms, has a visually-confirmed disc herniation, and has failed to experience symptom improvement following a therapy program.

• Laminectomy: This is a procedure that removes a portion of the vertebral bone, also called the lamina. It’s advised when back or neck pain persists after treatment or there are symptoms of nerve damage—these can include numbness in the arms or legs.

  Recovery time has a wide range, from a few days with a mild laminectomy to a few months when it’s coupled with a spinal fusion. A laminectomy can also occur during a discectomy. Dr. Knight says, “A partial laminotomy is typically part of the discectomy procedure.”

• Vertebroplasty and kyphoplasty: These surgeries are performed when the spine has a compression fracture, which can result from trauma or osteoporosis. They use bone cement injected into the vertebral body to restore its height and shape. “Both procedures are typically used to treat osteoporotic compression fractures,” Dr. Knight says. “The difference between these procedures relates to the consistency of cement used and preparation of the vertebra. "In vertebroplasty, the cement is injected under higher pressures, thinner consistency, and without coring out or other preparation of the vertebral body. In kyphoplasty, the cement is injected under lower pressures, thicker consistency, and following preparation of the vertebral body to accept the cement.”

  Most patients report a reduction of pain either immediately or within 24 to 48 hours.

• Spinal Fusion: A spinal fusion is the use of a bone graft to bring two opposing bony surfaces together, usually in the case of a spinal deformity like scoliosis. A full recovery requires physical therapy and a time period of three to six months.

When experiencing back pain, whether it’s acute, subacute, or chronic, you’ll be glad to know that several professionals can help you.

• Orthopedic Surgeon: a surgeon who specializes in bone, joint, tendon, ligament, muscle, and nerve disorders

• Neurosurgeon: a surgeon who specializes in the central and peripheral nervous system

• Neurologist: a medical professional who specializes in disorders of the brain and nervous system; “Neurologists often evaluate patients with radicular symptoms or more unusual complaints,” Dr. Knight adds.

• Physical Therapist: a movement expert who specializes in specific exercises and provides “the mainstay of care for most patients presenting with mechanical symptoms,” Dr. Knight says.

• Chiropractor: a professional who specializes in spinal manipulation and alternative therapies; Dr. Knight states, “Chiropractors have a longstanding role in evaluation and treatment of mechanical symptoms.”

• Acupuncturist: Dr. Knight notes that an acupuncturist, a professional who specializes in inserting thin needles into specific points of the body, is “another modality in managing difficult mechanical symptoms.”

With the number of sources of back pain, you might think it’s inevitable. It is not.

There are steps you can take to reduce your risk of developing back pain, mitigating the symptoms, or lessening the severity. Much of back pain prevention involves making healthy life choices and taking care of your body.

Exercise and Stretch Regularly

Strong, stable muscles are like armor for your spine and its structures. A strong core is one of the most protective things you can do for your back. Just keep in mind that “core” is more than your six-pack abs. You’ve got deeper muscles, plus the obliques on your side body and, of course, the muscles in the lower back. Strengthen them all to ward off back pain. The plank is a safe, effective core exercise that’s a great starting point for almost everyone.

Just as weak muscles can contribute to back pain, so can tight muscles. Tight hamstrings are a big contributor to lower back pain, and tight muscles in general can throw off your body mechanics and cause back muscles to spasm. Start with these five stretches to loosen up.

Lift Properly

Lifting heavy objects wrong is one of the most common ways to injury your back, and it’s one of the easiest to avoid. Before getting into proper lifting mechanics, our top tip is to know yourself and know your limits. It’s one thing to go for a deadlift personal record in the gym under the watchful eye of an experienced trainer. It’s quite another to try to get that couch into your truck by yourself.

Your leg muscles are some of the biggest and strongest muscles in your body, so employ them when you’re lifting something. Keep your spine straight and bend and extend with your legs. You don’t want to rely on the small stabilizer muscles around your spine, which are not designed to move heavy loads.

Just as you’re not supposed to bend your spine when you're lifting, you’re also not supposed to twist your spine. The spine is weaker in a twisting position, and you risk doing real damage to spine structures such as discs, spinal joints, and ligaments.

Improve Your Posture

Although poor posture and body mechanics may not wreck your back as quickly as improperly lifting something heavy, they’ll take their toll sooner or later. Be mindful of your posture to reduce or eliminate this sneaky cause of back pain.

Whether standing or sitting, you want your joints stacked—that is, your shoulders over your hips. This keeps your spine in its most natural alignment, where it can most easily and comfortably provide structure to the rest of the body. Deviation from that optimal position means the little stabilizer muscles in the back have to work overtime to keep you stable, something for which they were not designed, and that can lead to muscle spasms or worse.

When you’re sitting, the idea position is with your feet flat on the floor and 90-degree bends in your hips and your knees. Keep your head centered over your neck. Moving it forward even a little bit multiplies the force on your cervical spine, which can lead to neck problems if you’re not careful.

Change Your Shoes

You may feel comfy in flip flops and look stunning in high heels, but these two forms of footwear are the toughest on your back. Flip flops don’t offer enough support, and wearing high heels changes your movement mechanics in ways that could hurt your back. Instead, opt for supportive, low-heeled shoes.

Clean Up Your Diet

If you eat a typical Western diet that’s high in saturated fat and processed foods, adding more fruits and veggies, switching out your meats for leaner cuts, and cutting out processed foods can pack a one-two punch in your bout against back pain.

First, switching to low-calorie foods from higher calorie foods makes it much easier to control your weight, and excess weight, as Dr. Knight already mentioned, is one of the top modifiable causes of back pain. A 180-pound person would have to walk about an hour to burn off a 300-calorie doughnut … or you could just not eat the doughnut. Ever heard the expression, “You can’t outrun your fork?” That’s what that means.

The other way eating better can help with your back pain is that high fat, high sugar foods can cause inflammation which, as you now know, can contribute to back pain in a number of ways, from rheumatoid arthritis flares to intervertebral disc trouble. Changing your diet to more closely mimic the classic Mediterranean Diet will get you most of the way to where you want to be.

Quit Smoking

As Dr. Knight has already pointed out, smoking is bad news for your back because it impairs the delivery of nutrients to spinal structures. This can put you at risk for new back pain, make existing back pain worse, and sabotage your recovery from spine surgery. We understand that quitting smoking is easier said than done, but the US Department of Health and Human Services has resources to help at smokefree.gov.

We know that’s a lot of information to take in—the back is a complex structure. That’s why we’ve created an entire website dedicated to the spine! But, knowledge really is power, and this information can aid you as you seek out a diagnosis for your back pain or wish to learn more about a condition you already know you have.

To learn even more about back pain and its accompanying disorders and conditions, we recommend visiting a spine specialist near you who can help.