Low back pain: Nonspecific or Multifactorial?
This is not some objectively written scientific article with empirical measurements, neither is it a review of several research studies. Rather it is an attempt to convey my thoughts and observation as someone handling mostly low back pain patients – at least 7 in 10 visits to my practice are for some type of low back pain.
For privacy reasons, I have refrained from sharing any data or information from my daily practice. However, this post is a product of my experience with people suffering from low back pain, often without a clear consensus among healthcare practitioners on why they have it and how to solve it.
Before highlighting the two most common causes of low back pain I see in daily practice, let me clarify that there are many possible root causes or precipitating factors. These include age-related conditions like facet joint arthritis, sacroiliac joint arthritis, conditions with unknown causes – Scheuermann’s disease, scoliosis, others – sacroiliitis, spondylolysis, spondylolisthesis, fracture of the sacrum etc., among many others. The aim of this post is not to discuss all the possible causes, rather to focus on the most frequently seen conditions, which are acquired (not from birth) and disproportionately affects the majority of adult population around the world.
Data from various studies suggest that 1% of low back complaints may be due to some serious pathology such as tumours or other forms of malignant cancers such as lung cancer, which may have metastasized to the low back. Another 9% of complaints fall into the category of serious mechanical pathology such as herniated disc, spondylosis or vertebral fractures due to, severe degeneration, osteoporosis or accidents. The remaining 90% of complaints are thought to be due to a combination of factors, often times more than one factor, leading to pain and symptoms. These case, while not life threating, may lead to disability and prolonged time out of work.
What we know
For so many reasons, some of which I might touch here, the connective tissue material between the bones of the spinal column may slip out, most times towards the back, touching the nerves emerging from the spinal cord. When this happens in the lowest part of the spine, i.e. lumbar spine, it can produce symptoms such as the following:
- Pain in the spine, on the exact level of the herniation (may or may not be present)
- radiating, burning, or throbbing pain down the leg (sometimes until the foot)
- tightness in the buttock (piriformis syndrome)
- tingling sensation
- numbness or loss of sensation on leg
In extreme cases:
- unbearable pain (>10/10 on VAS scale)
- muscle atrophy and loss of muscle strength (in case of persistent nerve compression)
- loss of bladder control
- loss of control of rectum
Conditions that are known to weaken the intervertebral joints include:
- loss of water content of the intervertebral disc
- weakness of ligaments around the spine
- weakness of deep muscles of the back
- facet joint arthritis
- Structural scoliosis
…..and many other possibilities
Disc herniations are clearly visible in MRI and scans. This may prompt the decision to operate or treat conservatively depending on the symptoms. While surgery has been the standard approach over the years, emerging evidence has prompted health care practitioners to consider conservative approaches such as physical therapy. Studies (see references) have shown that there are degenerative changes in the spine starting as you as 20 years of age and as long as patients remain asymptomatic, these could be considered part of the normal aging process of the spine. A study of MRI findings in asymptomatic adults showed that about 30 to 50% of adults within 20 to 40 year old bracket had disc bulge, while 37 to 68% of participants in the same age cohort shows signs of disc degeneration.
Sacroiliac Joint Dysfunction
This is the misalignment in one or both joints between the sacrum and the pelvic bones (one on each side). There are some practitioners who argue that Sacroiliac Joints (SIJ) do not move but clinical experience and recent studies have shown that they do move, more so multi-directionally and can cause pain, sometimes similar to those coming from the lumbar spine.
This condition is mostly undetected because mechanical changes in the SIJ are not visible in X-ray or MRI images. This results in gross under-diagnoses of sacroiliac joint dysfunction, a condition which accounts for at least half (or more) of low back pain complaints by patients based on patients’ self-reporting and the account of other clinicians I have talked to. Depending on the severity, the symptoms may mimic those of disc herniation, making it difficult to differentiate the two during the subjective evaluation. This calls for a thorough physical examination when a patient presents with low back and radiating pain. Some clinicians who are at the forefront of treating this condition have even argued that all patients with low back pain should be screened for SI Joint dysfunction whether they have a definitive diagnosis or not.
In practice, I have seen patients remain with the same symptoms -pain, numbness, and tingling, even after back surgery for a disc problem. Ideally if the disc bulge was the (only) source of their symptoms, they should be symptom-free post-surgery, but quite often this is not the case. Such a paradox suggests that the initial pain may have been from a different source such as the SIJ or at best multifactorial (herniated disc and some other problems). The referenced studies yield credence to the fact that not all changes in the spine, including disc bulges, will necessarily cause pain or other symptoms.
Recently, I treated a patient with posterolateral herniated disc compressing the nerve root of L5-S1, whom I had previously treated for sacral torsion and shear 10 months prior. What am I trying to say? You can have SIJ dysfunction and disc herniation at the same time. Even after a successful operation, if your SI joint dysfunction remains undiagnosed (which is quite often the case), you will remain in pain, sometimes even for years because though the initially diagnosed problem in the spine has been resolved, a second issue (SI joint dysfunction) which does not show on X-ray and MRI remains untreated. In situations like this, when patients go back to complain, it creates confusion because rightfully so, it is hard to believe for the clinicians that something they believe they had already corrected still causes pain. From there things can spiral out of control with clinicians suggesting it might all be in the patients’ heads and patients feeling they are not heard, thus branding healthcare practitioners unprofessional and unhelpful.
Some of the symptoms of sacroiliac joint dysfunction may include:
- localized low back pain usually on one or both sacroiliac joints
- sometimes, pain across the entire low back, usually difficult to localize
- tightness in the buttock (piriformis syndrome)
- radiating pain down the leg (sometimes until the foot)
- tingling sensation
- numb feeling on leg
- calf muscle tightness
- Shin pain without injury
- Knee pain
- Hip with negative tests for hip pathology
- groin pain
….and many more
These symptoms may vary depending on the type of sacroiliac joint dysfunction a patient presents with.
Causes of sacroiliac joint dysfunction:
- Muscle imbalance/weakness – most common
- Arthritis of sacroiliac joint
- Falls that lead to injury around the pelvis (rare)
Disc herniation has many causes and presentations, but those outlined here appear to be more prevalent in outpatient clinical practice (my personal observation and what I have learned from much more experienced colleagues in the field). The following causes have been identified as factors that cause herniated disc:
- Degenerative joint disease of the spine e.g., facet joint arthritis,
- Scoliosis – both structural and functional
- Many other congenital spinal disorders
It should also be noted that over the course of a lifetime, sometimes starting as early as in the 20s, there are changes in the spine (including disc bulging) which may appear and remain asymptomatic throughout life.
Sacroiliac joint dysfunction is dangerously under-diagnosed, not deliberately, but because frontal plane misalignments that cause low back pain are so minute, they are rarely seen in imaging or considered significant.
While some causes of degenerative spine problems seem to be known, it is plausible that a much less talked-about condition – a pre-existing sacroiliac joint dysfunction, may be another contributing factor. In view of this, I am tempted to argue that weakness of lower extremity and pelvic girdle muscles could trigger the cascade that causes SIJ dysfunction, an instability which may eventually spread upwards to result in herniated disc in the lumbar spine. As counterintuitive as it may sound, there may be a somewhat “egg and chicken” relationship between Lumbar disc herniation and Sacroiliac joint dysfunction, however for now it remains to be determined which one precedes the other.
From clinical experience, I believe it is important for patients to explore conservative treatments such as physical therapy as an option before settling for surgery. It is crucial to find a practitioner who is well experienced in evaluating and treating mechanical low back pain. A proper physical examination is as important, if not more, than the actual treatment. Fortunately there is a growing number of physical therapists who are well versed in dealing with these types of issues. I for one, have helped most of my low back patients make full recovery and return to the activities they love, this includes preventing four needless surgeries in 2022 alone.
Exercises that address the muscle weakness which often lead to the conditions I have described above are very simple and can be done at home. Relieving the pain either on the spine, level of the pelvis (sacroiliac joint) or radiating down the leg (or arm) is a common practice among clinicians who understand how to integrate highly effective alternative methods into their practice. It is rarely necessary to touch the affected parts of the body because pain can be relieved completely by using other remote parts of the body. Ancient practices like Acupuncture/Acupressure, modern and cutting-edge practices like Pulsed electromagnetic field (PEMF) and myofascial treatments, when combined can work wonders in totally relieving or drastically reducing pain instantly. These never failed me when the diagnosis was correct.
I live in a world where I touch people’s legs to relieve their shoulder pain, move people’s arms to relieve their hip pain etc., so I am writing this from practical of experience.
Low back pain is a silent pandemic which has been under the radar for decades. My little contribution would be to treat as many people as I can and to give them the tools needed to keep it under control, making sure it never comes back again.
About the author
The author is a Physical Therapist with a passion for helping people come out pain, heal themselves and go back to engaging in the activities they love. He specializes in treating orthopaedic conditions, with particular interest in mechanical low back pain, especially in patients who have tried and failed with other forms of treatment. He is also an avid follower of traditional Chinese medicine and an aspiring acupuncturist.
- Sacroiliac Joint Dysfunction: An Exercise Treatment Protocol (practicalpainmanagement.com)
- Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period – PubMed (nih.gov)