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Axial Low Back Pain

Back pain comes in many flavors and shapes. It can be caused by a pinched nerve, a herniated disc, an infection, a tumor, a muscle strain, and the list can go one and on for pages. Most commonly, however, lower back pain in adults between age 35 and 65 is caused by degenerating discs. This is also called chronic axial lower back pain to emphasize that the lower extremities (buttocks/legs) are not affected.

The intervertebral discs are designed to function as 'shock absorbers' in the lower portions of the spine. As shock absorbers, they absorb the wear and tear of carrying the body and distribute those forces and stress over the different discs in the lower back. After a certain amount of degeneration, they can become a source of pain.

As people age, these discs lose their elasticity/ cushion and the discs become stiff and rigid. They no longer function properly and can cause lower back pain. This back pain has a typical pattern. It is usually worse with prolonged sitting (>1-2 hours), leaning forward, and bending/twisting/turning through the lower back. These are actually the reasons why Hollywood tries to make 90 minute movies and domestic airline flights make more allowances for walking about the cabin of the flight is more than 2 hours long.

These discs are moving parts of the lower back, and - like other moving parts - they tend to wear out over time. Unfortunately, there are no perfect treatment options for these degenerative lumbar discs. This is why most people over the age of 35 have some sort of lower back issue/problem. However, an overwhelming majority of people can manage this condition with no impact on their daily activities or their lifestyle. Typically, activity modification and an appropriate lower back exercise program are recommended to prevent flare-ups. Activity modification includes weight loss, proper bending/lifting techniques, and transition to non-impact activities. A exercise program would focus on bending through the hips and knees instead of the lower back.

If a person does aggravate their lower back (which everyone does on occasion), then a course of oral anti-inflammatory medications can be helpful, as can a short course of physical therapy and/or a muscle relaxer. Narcotic medications are not typically recommended as they can be habit-forming, build tolerance, and do not address the underlying problem.

Very rarely is surgery an option for someone with degenerative disc disease of the lumbar spine. Traditionally, surgery for this purpose is reserved for someone who is becoming dependent on narcotic medications and/or cannot work due to their severe pain. The reason why surgery is avoided is 1) it may not reliably relieve the pain, and 2) it increases the need for additional surgery in the future.

A trained spine surgeon can order/perform a discogram (in conjunction with a battery of other tests) to predict if surgery would be helpful, but even these test are not 100%. The surgery required to remove the pain from a degenerative disc is known as a lumbar fusion. This surgery would remove the movement at the painful disc; if the movement is gone, then - in theory - the pain should be diminished. Lumbar disc replacements are still in their infancy and considered by most spine surgeons to be 'experimental'.

However, lumbar fusion has known long-term risks. If one level of the spine is fused, then that means that there is one less disc available to distribute the stresses/forces of carrying the person's body. This suggests that the other discs have to do more work (carry more stress/force) and will degenerate faster than they would have otherwise. Thus, one can imagine a scenario where a person gets a lumbar fusion and then returns with pain a few years later because the adjacent level disc is now degenerated and causing them pain. This is known as adjacent segment disease and is a known risk of any fusion surgery. Every person who is considering undergoing lumbar fusion surgery should know about adjacent segment degeneration prior to undergoing their fusion surgery.

Until recently, it was considered controversial to perform lumbar fusion surgery for chronic axial lower back pain. One of my teachers, a world famous spine surgeon stated that, "Lumbar fusion surgery for degenerative disc disease is prostitution of one's talents as a surgeon". He meant that a surgeon should not use his talents/skills in a corrupt way, as these surgeries can lead to financial and personal gains for the surgeon, but may not lead to any improvement for the patient. In fact, may patients may end up worse after their surgery for this condition. These surgeons/surgeries are why spine surgery has a poor image in the general population. Spine surgeons tend to perform lower back surgery, but it is more reliable for buttock and leg pain (pinched nerves) than it is for back pain (degenerative discs).

Please discuss any further questions about your specific situation with a fellowship-trained orthopedic spine surgeon.