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Lower back pain affects millions of patients in the United States. 84% of adults have lower back pain at some time in their lives. Most of these are self-limited however after 12 weeks the back pain is defined as chronic. It is rare that back pain indicates a serious medical illness.
Back pain can affect various age groups and patients from all walks of life. Because of the wide prevalence of disease, particularly in working age individuals, lower back pain severely impacts income, quality of life, and personal relationships. The prevalence of back pain in the general population varies from 20-30%. People at risk for pain includes all ages but a significant number occurs at 45-65 years of age. It is the fifth most common reason most Americans seek medical care in the United States and costs our nation approximately $40 billion annually to treat this condition.
The spinal column is a large and complex structure containing an interconnected network of bones, nerves, ligaments, and tendons making it extremely susceptible to pain if a part of the structure is damaged. Most back pain can be rooted in problems related to repetitive motion of the parts of the spine, typically caused by improper lifting or from a muscle strain. Back pain can have more serious causes, however, and it can also be a symptom of a larger medical problem. These symptoms can present as lower left back pain, lower right back pain, lower back pain right side, lower back pain left side.
Important factors to rule out in lower back pain such as tumors, infections, nerve damage must be treated immediately. Outside of these conditions, degenerative disc disease and spondylosis are very common, as is herniated disc (disc herniation). Spinal stenosis is also very common. These conditions however are not very clearly defined and how they cause pain is not clearly understood. Certain individuals have risk factors for lower back pain such as obesity, sedentary lifestyle, or repetitive injury. Factors such as age, sex, genetic, family history, occupation, smoking, posture have been implicated but studying these factors have proven very difficult.
Many times, patient’s experience back pain with daily activity at home or in recreational sites. Previous studies have shown males are more likely to sustain lower back pain in athletic activities and females. When looking at age risk factors, individuals 20-40 years old are more likely to be injured.
With respect to gender, one study showed males 10 to 49 years and females 65 to 84 years had significantly higher risk for developing lower back pain then their opposite gender counterparts published in The Spine Journal by Dr. Waterman B in 2012.
Activities of daily living account for the majority of patients with lower back pain. In other words, many cases of lower back pain do not have a specific identifiable cause. Of usual daily activities, lifting is commonly reported as a mechanism of injury.
When lifting, all of the muscles from the cervical to lumbar spine are engaged. This may not necessarily correlate to the weight of the object lifted because posture and ergonomics are also very important. Uneven force will cause a herniated disc (disc herniation) in some cases. For example, lifting a moderately large object can still cause pain and if done in an awkward position (such as reaching for something far as trying to lift while bending at the same time). Other times a slip or fall can cause acute trauma to the discs, joints, and muscles. Many patients also experience back pain from twisting because torsional forces can distribute weight unevenly. In younger patients a Pars defect can result with excessive force which may ultimately cause spondylolisthesis.
Sports related lower back pain can arise from many different activities. Aerobic exercise, such as extensive running, weight lifting, baseball and bicycling have been reported. The majority of patients with lower back pain do not require hospitalizations. Some studies report less than 2%. Typically, patients older than 80 years old are hospitalized compared to younger counterparts.
Once lower back pain occurs, it severely impacts one’s ability to work and function. For example, with lower back pain many patients are unable to sit for prolonged periods of time and that would limit their ability to drive or sit in front of a computer. Frequently patients are frustrated because the pain impacts their ability to work which in turn will inhibit their income. Sometimes coworkers and family will notice a patient is irritable and moody. Production at work slows down because of the pain.
On a personal level patient become withdrawn because they are not able to engage with social activities. Sitting in a car can become unbearable, especially with prolonged traffic or travel time. Patients are unable to exercise, such as running, which usually leads to weight gain. This leads to a sedentary lifestyle which can cause weight gain and a host of other problems related to obesity, diabetes, and cardiovascular conditions.
Some common conditions that may cause back pain include sciatica, herniated disc, facet disease, facet arthritis, sacroiliitis, spinal stenosis, degenerative disc disease, muscle strain, ligament injury.
Degenerative disc disease
The disc serves to cushion forces along the vertebral canal. The disc starts from the cervical spine in the neck all the way down to the lower back. It is composed of a thick rubbery ring with a soft gel the middle. The outside reading is called annulus fibrosis, the inside is called a nucleus. There is not much blood supply to the disc and therefore it is prone to degeneration and poor healing. As the disc undergoes trauma or wear and tear, usually the outer fiber ring begins to tear and weaken. Once the outer fibrillar ring is weak, the nucleus may begin to push outwards and bulge into the spinal canal. When the nucleus separates out from the disc, it is referred to as a disc extrusion. Frequently a disc extrusion will cause chemical as well as physical injury to a spinal nerve root. This injury will show as radiating pain into the arm or leg.
Sciatica is a nonspecific phrase people were used to describe pain shooting down the leg. Back pain can present in all shapes and sizes. Aching, burning, sharp, dull, radiating, electrical, throbbing has all been used to describe symptoms of lower back pain. Many times, these are nonspecific and could be caused by many factors in the spine or muscles of the lower back. With conditions such as sciatica which may be related to nerve compression, patients will typically state radiating or shooting pain occurs from the spine down to their leg or foot. If the nerve damage is severe, patients may even describe “hot coals” or “ants crawling” on their skin. This condition has come really diagnosed as radiculopathy. It is related to damage at the spinal nerve root which may result from degenerative changes at the disc. Other causes could be arthritis or vertebral hypertrophy causing pressure on the nerve root. Over 90% of radiculopathies involve the L5 and S1 nerve roots. Patient can have pain, weakness, reflex changes, sensory changes. In many acute pain episodes related to radiculopathy improvement gradually occurs with conservative care.
Spinal stenosis refers to narrowing in the spinal canal. At times this is associated with other conditions such as spondylosis, spondylolisthesis, ligamentum flavum hypertrophy. The underlying problem is a narrowing of the spinal canal which causes pressure in the nerves. These nerves that travel down the leg began to feel pain and usually improve with resting or bending forward. Bending forward opens up the spinal canal and therefore patient feel better. Unfortunately, the pain returns with walking or standing straight. Spinal stenosis evaluation should be considered when activities are limited. The evaluation should also rule out other causes of pain such as blood vessel narrowing (vascular claudication).
The sacroiliac joint is located in the pelvis and connects the sacrum to the iliac bones. It describes pain in the lower back related to his alignment of the joint. Diagnosing this condition is through a combination of physical exam, history, and diagnostic injection performed by a board-certified physician under fluoroscopic guidance. The joint has various treatment options such as physical therapy, steroid injection, or nerve ablation.
Piriformis syndrome typically causes pain in the lower buttock and radiates down the lower extremity to the foot. It is due to the piriformis muscle causing pressure along the sciatic nerve. Usually physical therapy maneuvers are needed to help alleviate pressure off of the sciatic nerve. Diagnostic and therapeutic injections under fluoroscopic guidance may be utilized to help aid in recovery period
Imaging for diagnosis and treatment of back pain
Fluoroscopy. Fluoroscopy is used in most spine procedures because it helps insure accuracy and safety. The fluoroscope is an x-ray machine that projects and x-ray picture on the television screen. A physician will place the needle and used imaging to guide the needle into an exact target. Once located at the target the picture gives live confirmation of direct medication spread.
MRI. Magnetic resonance imaging utilizes energy from a magnetic field that is placed into the body. The energy comes out of the body and is captured by a sensor which then creates an image. An MRI is very useful in helping to diagnose a condition and the cause of pain. Disc herniations are seen from 20-70% of adults even though there is no pain. Spinal stenosis occurs in about 20% of patients over 60 years old. Many times, seemingly abnormal findings on MRI exam does not mean the patient requires treatment, in other words they are asymptomatic.
Treatment for lower back pain depends on identifying the source of the pain and the severity. There are a number of different options for treating back pain. Most commonly rest, stretching, lifestyle changes, warm compress may help improve the symptoms. Even occasional over-the-counter medications can take away the pain. However, if it does not improve, a physician will need to reevaluate the back to identify the source. Various treatment options can be instituted after seeing a physician for example cortisone injection, trigger point injection, sacroiliac joint injection, facet joint injection, epidural steroid injection, radiofrequency ablation is successful in many cases. These treatments usually can help patients improve so they can slowly recover and get back to restoring their quality of life.
Back pain can last for weeks or months. Usually after treatment a patient would be followed up in the physician’s office to assess progress and determine a specific rehabilitative program. The rehabilitative program would involve physical therapy, exercise, or specialized physical therapy tapes. It may also include increased functional exercises in order for a patient to return to sport or work. Treatment options for back pain is best achieved through a combination of injection in conjunction with graded rehabilitative exercise. Individual programs may include cortisone shot, regenerative medicine, PRP injection, PRP treatment or stem cell therapy which boosts the body’s natural ability to heal.
If your pain does not resolve after a brief period, contact us so that we may help diagnose the problem and treat the underlying cause. Do not let pain persist or else it may become chronic.