This Really Hurts!

From Chicken Soup for the Soul: Say Goodbye to Back Pain!

This Really Hurts!

I can vividly imagine Laura bouncing on a trampoline, hair blowing in the wind, ocean waves rhythmically keeping time with her youthful energy. Beachgoers are milling all around, scratchy sand between their toes, snow cones dripping, and the sun gently warming their smiling faces.

How does this fun summertime adventure, that most of us can imagine as we recall our own childhood beach memories, suddenly turn into a horrifying event in which “I am flat on my back with a terrible wrench, the worst pain I had experienced in my 10 years?” Laura’s story highlights several important points:

1. Back pain can start at any point during your life.

2. Once you have back pain, it’s likely that there will be flare-ups at different times.

3. Sometimes you can point to a specific injury or way that you move that caused the pain to start (and this can give you clues about how to avoid back pain in the future).

In Laura’s case, her first episode of back pain was when she was around 10 years old. The pain started during forceful movements that included bouncing as well as twisting and turning. The second time she had an episode of pain, it occurred when she was performing bending and twisting motions while doing exercises. The third time this happened she was on a train and her body was again in motion — swaying. Although, Laura can point to specific events that caused her pain, there were undoubtedly many times in between these episodes in which she performed bending, twisting and other motions and these didn’t cause pain. It’s difficult to say exactly what happened that caused these painful episodes, but it was probably a combination of things that occurred simultaneously — like a “perfect storm.”

Your Back Anatomy

The back is a pretty complicated and confusing part of your anatomy. One of the reasons it can be very hard for doctors to pinpoint the precise part of the spine that is causing someone pain is that there are quite a few structures that may be problematic. But, it’s easier to break it down into six parts and to consider each part when trying to diagnose the cause of someone’s back pain.

1. Bones

2. Disks

3. Joints

4. Ligaments

5. Muscles

6. Nerves

The first part of your back is the long line of bones (vertebrae) stacked on top of each other. Each vertebra has a cylindrical shaped body with a bony ring attached to its back. If you put your hand on your spine, you can feel the spinous process of each vertebra. The lumbar vertebrae are in the low back, and they carry most of your body weight and are subjected to the greatest stress when you twist, turn, bend, stand, walk, run and lift objects. There are five lumbar vertebrae, and not surprisingly, they are the biggest and strongest of the bones in your back.

A Closer Look at Your Lumbar Vertebrae

Each vertebra has a cylindrical body with a bony ring attached to its back surface as well as bony processes that project out in different directions from this ring. Intervertebral disks, tucked between each pair of vertebrae, serve as shock absorbers.

Each intervertebral disk has a gelatinous central part, called the nucleus pulposus, and a fibrous covering, called the annulus fibrosus. Each vertebra normally has seven processes (five are shown above; the other two are obscured in this illustration) that help stabilize your spine.

 

Reprinted with permission from the Harvard Health Publications Special Health Report: Low Back Pain (2010)

 

In between the vertebrae are disks. Your disks are spongy and have the same shape as the cylindrical body of the vertebrae (which makes sense, because this means that the disk fits nicely in between the two vertebral bones). Sometimes the disks pop out a bit — sort of like an inflated balloon can change shape when you apply pressure to one end. There are lots of terms to describe discs that become misshapen, and even doctors don’t really agree on which terms to use in every situation. However, when you hear someone say that they have a “bulging disk” or “herniated disk” or “slipped disk” or “ruptured disk” (or something similar), what they are describing is a disk that is misshapen and no longer in the nice cylindrical shape of the vertebrae above and below it. Radiologists often call these disk protrusions or extrusions.

The vertebrae are linked together by ligaments to form joints that allow you to flex, twist and bend to some degree (the joints allow some movement but also restrict movement — if you had too much movement in your spine you’d become very unstable).

The ligaments support your spinal column and allow your back to move, but they don’t cause the movement. What causes movement are your muscles. Muscles shorten (contract) and lengthen (expand) to make your back move.

The final category of “back parts” I want to talk about are your nerves. You can think of your nerves as the electrical cord to your muscles — they supply the power to make the muscles work. If the nerves are injured, your muscles get weak and don’t work well (as if you pulled the plug on the electrical cord). Probably the most concise way to understand the nerves in the back is to recognize that there is a long column of them that are bundled together like a cord — hence the name spinal cord — that goes from the top to the bottom of your spine.

At the end of the spinal cord the nerves become unbundled but still hang together (like the hair on a horse’s tail). These loose nerves at the end of the spinal column are called the cauda equina, which means “horse’s tail.” Along the way, at every level, there are two nerves that branch off called “nerve roots” (one on the right and one on the left). These are the ones that often get pinched when a disk bulges. So, there is the spinal cord that ends in the cauda equina and the nerve roots. Injury to the spinal cord, cauda equina or nerve roots are the most serious problems that doctors worry about.

How to Think Like a Doctor

Taking the example of Laura, it’s impossible to go back in time and diagnose the specific structures in the spine that were injured the first time Laura experienced back pain. However, from her reported history in the story, it’s likely that it was either her muscles or ligaments or both. The reason I say this is that I’m thinking about each of the six categories and ruling some of them out. Here’s what I’m thinking: It’s unlikely that Laura broke any bones by jumping on a trampoline (it is possible, but unless she fell off, it’s unlikely). Moreover, she healed pretty quickly (by her account in just a few days), and broken bones don’t heal that fast. So, it wasn’t bone trauma.

Next on my list are disks and nerves. That’s a possibility, but disk problems are more common among middle aged and older people. This is because as we age our disks tend to dry out and their shock absorption capabilities become less effective. When disks bulge, they often touch or push a nerve. This causes nerve symptoms such as numbness, tingling and sharp or “electrical” pain down one leg. Again, Laura didn’t have these symptoms, so I suspect that her problem didn’t involve a disk pressing on a nerve (technically called radiculopathy).

Joint pain is usually due to aging. This is a form of arthritis, and the most common cause in the back is facet arthropathy. It is possible to develop other joint problems, but an injury to a joint is less likely than muscle strains and ligament sprains — what is often called a “soft tissue injury.” Muscle strains and ligament sprains often occur together and may be referred to as a “sprain-strain injury.” These soft tissue injuries are not easily seen on imaging studies such as X-rays that mostly demonstrate bone structure and help to rule out fractures. More likely than not, Laura’s first injury was a lumbar sprain-strain injury, likely involving stretching and minor trauma to some muscles and ligaments in her back. This is the most common type of back pain and can usually be diagnosed by history and physical examination. This type of injury typically resolves fairly quickly — even without treatment. If it doesn’t get better within a couple of weeks, then it’s a good idea to check in with a doctor.

In this chapter, I focused on “how to think like a doctor.” The critical part of thinking like a doctor is to understand the anatomy and then to know what possible problems there can be in the different parts of the body (or back, in this case). By knowing the anatomy of the back, doctors can listen to a patient’s story, examine the patient, and then decide what is the most likely diagnosis. However, there are times when it’s not so easy or when the problem is potentially very serious. In the next chapter, I’ll discuss when to be worried (or not).

Why Does My Back Hurt?

The actual cause of back pain can vary, as there are many structures in this region of the body that may cause symptoms. In fact, there are so many structures, that are so complex, it’s not uncommon that the precise cause of the pain cannot be accurately diagnosed — even with the latest technology and imaging studies. However, if you have neck or low back pain, some of the possible causes include:

• Radiculopathy (due to pressure on a nerve coming from the spine — often caused by a bulging or herniated disk — in the low back this is often called “sciatica”)

• Spinal stenosis (this is a narrowing of the bony spinal canal which causes the nerves to be “squeezed”)

• Facet arthropathy (this is usually due to aging or “arthritis” of the joints in the spine)

• Sprain/strain (a common cause of low back pain that may be due to injury to multiple structures such as muscles and tendons)

• Tumors (not a common cause of back pain but a worrisome one — a “red flag” for this is pain that awakens you at night)

• Bony fractures (these may be due to trauma or sometimes occur without any injury in people with osteoporosis — a specific type of fracture that sometimes occurs in teen athletes as well as other people is called spondylolysis or spondylolisthesis)

• Infection (this is pretty rare but can be serious — people at risk for infection include those with liver failure, diabetes or AIDS)

• Spinal cord compression (this is also unusual but very worrisome and may be associated with weakness, loss of bowel/bladder control and, in men, problems with erections — cauda equina syndrome occurs below the level of the spinal cord where the nerves bundle together in the spine and can cause similar symptoms)

My Neck Thing

When my daughter wrote about having torticollis for this book, she labeled her word document “Neck Thing.” Which is a relatively apt, though not very technical, term for torticollis.

Torticollis has also been called “wryneck” and typically involves the neck twisting with the head tipping to one side while the chin is pointed to the other side. Sometimes this is present at birth (congenital torticollis) and in other people it is acquired later in life. If there is no known reason for it to occur, it is called idiopathic torticollis. Torticollis may be due to a variety of factors including injury to the nervous system or muscles. Spasmodic torticollis is usually classified as a movement disorder and can be quite painful and debilitating.

It is usually easier to treat torticollis in children and before it becomes chronic. Treatment options vary, depending on the cause and duration of symptoms. Usually the treatment includes gentle stretching, heat and massage. Sometimes oral or injected medications are used. For more severe or chronic cases, botulinum toxin injections may be helpful. Rarely surgery is indicated.

 

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