Low back pain and lower extremity pain often get put into one category, but the causes, and therefore the treatments, can be different. Lower extremity pain, when it radiates from the low back, is usually the result of pressure on a nerve. The pain is often in the distribution, which the nerve supplies. Low back pain is often related to the mechanics of the spine. Muscle strain, arthritis, trauma, osteoporosis, and fracture are often causes. Often, disease processes which cause lower extremity pain can also cause low back pain, and vice versa. Here is a list of conditions that can cause lower back pain and/or leg pain.
- Compression Fracture
- Degenerative Disc Disease
- Disc Herniation/Bulging Discitis
- Facet Syndrome
- Foraminal Stenosis
- Spinal Stenosis
- Ligament Hypertrophy
- Osteoporosis and Factures
Compression fractures can occur in any vertebra (spinal bones) and is described as a collapse of the vertebra.
Symptoms – The first symptom of a compression fracture may be sudden and severe back pain that remains in one local area. Some persons may experience numbness/tingling, or weakness in the arms or legs if the spinal cord or nerves leading away from the fracture have been compressed. If multiple fractures occur in an area of the back, the person will develop a forward hump-like curvature to the back.
Causes – There are many possible causes of compression fractures. Car accidents, falls, and weakening of the bone due to pathology (i.e. cancer), or Osteoporosis are common.
Diagnosis – The diagnosis is based on observation of the aforementioned symptoms and x-rays of the spine. Additional tests (i.e. bone scan, blood tests) may be needed to diagnose the actual cause of the compression fracture.
Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the fingers, hips, knees and spine.
Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a “shock absorber.” The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).
Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage wears away, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.
Degenerative Disc Disease (DDD) is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address Degenerative Disc Disease in the lumbar spine.
Degenerative Changes to a Disc
Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear aging, even misuse (e.g. smoking).
Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Some of these changes are not unlike those associated with osteoarthritis.
Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc’s inability to handle mechanical stress. Understanding the lumbar spine carries a large portion of the body’s weight; the stress from motion may result in a disc problem (e.g. herniation).
Non-Operative Treatment: Yesterday vs. Today
DDD is a disorder that may cause low back pain. It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery!
In the past some physicians prescribed long courses of bedrest and/or lumbar traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bedrest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan.
Herniation of the nucleus pulposus (HNP) occurs when the nucleus pulposus (gel-like substance) breaks through the anulus fibrosus (tire-like structure) of an intervertebral disc (spinal shock absorber).
A herniated disc occurs most often in the lumbar region of the spine especially at the L4-L5 and L5-S1 levels (L = Lumbar, S = Sacral). This is because the lumbar spine carries most of the body’s weight. People between the ages of 30 and 50 appear to be vulnerable because the elasticity and water content of the nucleus decreases with age.
The progression to an actual HNP varies from slow to sudden onset of symptoms. There are four stages: (1) disc protrusion (2) prolapsed disc (3) disc extrusion (4) sequestered disc. Stages 1 and 2 are referred to as incomplete, where 3 and 4 are complete herniations. Pain resulting from herniation may be combined with a radiculopathy, which means neurological deficit. The deficit may include sensory changes (i.e. tingling, numbness) and/or motor changes (i.e. weakness, reflex loss). These changes are caused by nerve compression created by pressure from interior disc material.
Progression of Herniated Disc
The extremities affected are dependent upon the vertebral level at which the HNP occurred. Consider the following examples:
- Cervical – Pain in the neck, shoulders, and arms
- Thoracic – Pain radiates into the chest
- Lumbar – Pain extends into the buttocks, thighs, legs
Cauda Equina Syndrome occurs from a central disc herniation and is serious requiring immediate surgical intervention. The symptoms include bilateral leg pain, loss of perianal sensation (anus), paralysis of the bladder, and weakness of the anal sphincter.
Diagnosis of a Herniated Disc
The spine is examined with the patient laying down and standing. Due to muscle spasm, a loss of normal spinal curvature may be noted. Radicular pain (inflammation of a spinal nerve) may increase when pressure is applied to the affected spinal level.
A Lasegue test, also known as Straight-leg Raising Test, is performed. The patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.
Other neurological tests are performed to determine loss of sensation and/or motor function. Abnormal reflexes are noted as these changes may indicate the location of the herniation.
Radiographs are helpful, but Computed Axial Tomography (CAT) or Magnetic Resonance Imaging (MRI) provides more detail. The MRI is the best method enabling the physician to see the soft spinal tissues unseen in a conventional x-ray
Discitis, or disc space infection, is an inflammatory lesion of the intervertebral disc that occurs in adults but more commonly in children. Its cause has been the subject of debate, although most authors believe it to be infectious. The infection probably begins in one of the continguous end plates, and the disc is infected secondarily. Severe back pain that begins insidiously is characteristic of the disease.
Discitis in Children:
Although most children will continue to walk in spite of the pain, young children may refuse to ambulate. The characteristic finding is extension of the spine and the child’s complete refusal to flex the spine. Children with discitis usually are not systemically ill. They rarely have an elevated temperature and their white blood cell count is frequently normal. However the erythrocyte sedimentation rate is usually increased. Lateral radiographs of the spine usually will reveal disc space narrowing with erosion of the vertebral end plates of the contiguous vertebrae. bone scanning may be helpful in localizing a lesion that is difficult to diagnose clinically. Some bone scans are falsely negative, so the diagnosis of disc space infection should not be excluded simply because the bone scan is normal. Magnetic resonance imaging (MRI) seems to be helpful in identifying a disc space infection.
Lumbar radiculopathy, which refers to pain in the lower extremities in a dermatomal pattern. A dermatome is a specific area in the lower extremity innervated by a specific lumbar nerve. This pain is caused by compression of the roots of the spinal nerves in the lumbar region of the spine. Diagnosing leg and back pain begins with a detailed patient history and examination.
Is a common cause of pain related to the spine. The facet joints are the articulations or connections between the vertebraes in the spine. They are like any other joint in the body like the knee or elbow that enable the bending or twisting movements of the spine. The facet joints can get inflamed secondary to injury or arthritis and cause pain and stiffness. When the facet joints are affected in the neck or cervical spine it typically causes pain in this area as well headaches and difficulty rotating the head.
People who suffer from this problem usually complain that they have to turn their entire body to look over to the right or left. Pain can be felt in other areas such as the shoulders or midback area. Low back pain is commonly caused by Facet Joint Syndrome. Pain is felt in the lower back and sometimes it can be felt in the buttock as well in the thighs usually not going below the knee.
Sciatica is often just a symptom of another problem.
It starts out as a pain that you can feel in your lower back. Soon the pain begins to travel down one leg and it’s getting more severe. There may be a tingling or burning sensation or your leg may feel numb. At times the pain might be severe, almost overwhelming, but sciatica is really just a symptom of another problem.
The sciatic nerve is the longest nerve in your body. It extends from the lower spine down through the length of both legs. There are a number of conditions that can cause sciatica, including a herniated disc, degenerative disc disease and spinal stenosis – all of which affect the discs that act as “shock absorbers between each pair vertebrae of the spine. These conditions put pressure on the sciatic nerve and it is that pressure or pinching of the sciatic nerve that causes the pain.
Many doctors will prescribe pain medication, anti-inflammatory medication or steroid injections. Worst case scenario? Surgery. What these solutions do, however, is treat the symptoms of sciatica, which is a symptom itself of a nerve disorder, caused by nerve interference, that can be corrected with care in our office.
Because sciatica is most often the result of a spinal misalignment in the lower spine, or compression of the discs Spinal Decompression is often very effective in correcting the compression issues, which eliminates the symptoms of sciatica. Said another way – Spinal Decompression removes the obstruction that is causing the “pinch” in the sciatic nerve, which is causing the pain in the back through the buttocks and down the leg!
The choice is yours. Because most back surgery for sciatica is elective – do you really want to “go under the knife” and risk “failed back surgery syndrome” that can leave you in even greater pain? Or, would you rather come into our practice, where we are trained to locate and correct the cause of the interference in the sciatic nerve, without drugs and surgery. The choice, as always, is yours!
This disease is associated with spinal stenosis, but it differs because it primary affects one or more vertebral foramen. Normally, nerve roots have enough room to easily slip through the foramen. However, with age and disease, the neuroforamen may become clogged with debris. The nerves can become trapped and compressed.
The symptoms of foraminal stenosis may include numbness, weakness, burning sensations, tingling, and pins and needles in the involved extremity, such as the leg. Not every stenosis is critical, but if spinal stenosis is ignored, nerves may die, which could result in a loss of function. The functional loss could involve the ability to feel (sensory) and/or move (motor).
If conservative forms of treatment are unsuccessful, surgery is an option. The procedure is termed a foraminotomy.
Scoliosis seems to mainly affect girls between the ages of 8 to 18.
Scoliosis is an abnormal sideways curvature of the spine. It begins as a postural distortion and may become a permanent deformity. Allowed to advance, it may interfere with the lungs, heart and many other vital organs.
- Congenital genetic predisposition
- Habitual behavioral routines
- Idiopathic unknown cause
Regardless of cause, early detection can be helpful.
An alert parent may notice that a high shoulder or low hip make clothing fit poorly. Or uneven shoe wear offers a clue. Back and leg pains may develop but are often dismissed as “growing pains.”
Wait and See?
Allowed to run its course, scoliosis may often worsen. Severe cases may involve unsightly bracing or surgery that attaches steel rods, forcing the spine to straighten. We believe and have the training to help slow or stop the progression of this condition if caught early enough.
A schedule of specific chiropractic adjustments may help improve the function and structure of the spine. As muscles are retrained and strengthened, posture may improve. Bring your child in so we can discuss your concerns and explore the possibilities.
Frequently Asked Questions:
Isn’t a certain amount of sideways curvature normal?
Any type of sideways curvature is abnormal. From the back, the spine should appear straight. When scoliosis is present, there are usually two curves. A primary curve in one direction and a compensatory curve in the opposite direction.
Isn’t scoliosis caused by a lack of calcium?
No. However, there are a growing number of people who believe uncorrected spinal damage from the birth process may be involved. Some theorize that “walkers” may prematurely interrupt the crawling stage so essential for proper spinal development.
Do heavy back-packs cause scoliosis?
Not necessarily, however this is a growing concern. Make sure your son or daughter use both shoulder straps on their back-packs so the weight is evenly distributed. Weigh their bag. Make sure it doesn’t exceed 10% -15% of their body weight.
Fibromyalgia syndrome (or fibromyalgia) is a chronic disorder associated with widespread muscle and soft tissue pain, tenderness, and fatigue. A person with fibromyalgia will experience pain when up to 18 specific areas called tender points are pressed. Pushing carefully on these specific trigger points during an examination causes discomfort or sharp pain.
The cause of fibromyalgia is not known. Fibromyalgia has been recognized as a medical disorder only since the 1980s, although there is evidence it may have existed for centuries.1
The pain of fibromyalgia is more than normal muscle aches common after physical exertion. Fibromyalgia often can be severe enough to disrupt a person’s daily work and activities.
Other symptoms that commonly occur with fibromyalgia include:
- Unrestful sleep.
- Morning stiffness.
Less common symptoms or conditions that can accompany fibromyalgia include:
- Raynaud’s syndrome.
- Irritable bowel syndrome (present in about one-half of those with fibromyalgia).2
Fibromyalgia can be difficult to diagnose because its symptoms are similar to many other disorders and diseases. There are no lab tests to diagnose fibromyalgia. It is often diagnosed after other conditions have been ruled out. Fibromyalgia is diagnosed when:3
A person has had widespread pain for at least 3 months. To be considered “widespread,” the pain must be both above and below the waist and on both sides of the body.
At least 11 of 18 specific tender points are painful when pressed. (Because symptoms vary widely from person to person, some people with fibromyalgia may have fewer painful tender points.)
Fibromyalgia is not a psychological condition, although it has some psychological components. As with many conditions that cause chronic pain, anxiety and depression are common in people with fibromyalgia and may make symptoms worse.
While there is no specific cure for fibromyalgia, symptoms of this syndrome can be treated. If you have fibromyalgia, taking an active role in your treatment is very important to managing your condition.
Treatment may be different for each individual. It can include:
- Medications to help you sleep better and to relieve pain.
- Exercise therapy to help with muscle aches and stiffness.
- Counseling to help you manage chronic pain.
- Research is ongoing to understand the cause of fibromyalgia and its cure.
This refers to a narrowing of the spinal canal. Certain individuals may have a narrow canal from birth, but the majority of individuals develop narrowing with age. With age, wear and tear arthritic spurs build up on the facet joints in the posterior part of the spine. These arthritic spurs then encroach on the spinal canal and pinch the lumbar nerve roots. This condition can be worsened as well by narrowing and degeneration of the disc at that level as the space for exit of the nerve root (called the foramen) is narrowed further by a degenerated disc. Spinal stenosis is most common in the last three levels of the lumbar spine namely L3-4, L4-5 and L5-S1. It is diagnosed and confirmed by an MRI or CAT scan/myelogram. There are various signs and symptoms of spinal stenosis. A common one is referred to as spinal claudication. This refers to pain in the legs, the calves or the buttocks. This pain is associated with activity. The pain is often relieved by sitting and resting. It will then often times start up again with activity. A common complaint is that an individual will be able to walk several blocks then develops leg pain, is able to get rid of the leg pain by sitting and resting for five to ten minutes and then, upon trying to walk another several blocks the pain will return. The pain may be a radiating pain like a sciatica or it may be a cramping pain. At times though, the stenosis may be severe enough that the leg pain is constant and unremitting. It may at times be indistinguishable from the kind of pain that occurs with a herniated disc. Spinal stenosis is uncommon in younger people. It usually occurs at age 50 or older. Leg pains from spinal pathology are more common from herniated discs in people under 50. Over 50 it is more common that spinal stenosis will be the problem. In addition to developmental degenerative spinal stenosis, entrapped nerve roots may be caused as well by spondylolisthesis and scotiosis. There is really no conservative treatment for a spinal stenosis. It will rarely cause paralysis. The condition will tend to gradually worsen with time and cause increasing pain however. Patients with congenital spinal stenosis (such as achondroplastic dwarfs) may develop symptomatic stenosis as early as age 15 or 20.
Kyphosis is the abnormal forward bending of the spine. In kyphosis, the curve of the spine is abnormal, forming a hump.
What is going on in the body?
The normal spine rounds slightly in the chest area, with arching in the lower back and neck regions. Excessive kyphosis can occur mainly in the chest area of the spine, causing the roundness of the back to appear exaggerated.
What are the signs and symptoms of the condition?
Symptoms are usually minimal, unless the deformity is severe. In that case, the back may ache or, rarely, nerve problems may arise. The hamstrings, or muscles at the back of the thigh, may also be tight.
What are the causes and risks of the condition?
Kyphosis is generally caused by an abnormal posture. Other possible causes include: · a significant fracture of the vertebra, which can cause the back to angle forward · spinal surgery · Scheuermann’s disease, which results in wedging of the vertebrae. This disease is usually seen in teenage boys, and its cause is unknown. · Pott’s disease, which refers to kyphosis due to collapse of the vertebra when tuberculosis infects the spine · osteoporosis in elderly women, which causes a type of kyphosis known as dowager’s hump · spinal tumors, or surgery to remove them · nerve disorders
Spondylolisthesis occurs when one lumbar vertebra slips forward in relationship to the adjacent vertebra. In the Greek language, the term spondylolisthesis means slipped vertebra. The neural arch (lamina) and the paired facet joints are anatomical structures that prevent vertebrae from slipping (Fig 1). A vertebra may slip following the development of a stress fracture through the neural arch. The defect in the lamina separates the back part of the vertebra from the remaining part; the vertebral body and disc. The stabilizing role of the paired facet joints is lost and the vertebral body slips forward. The laminar stress fracture (in Greek called spondylolysis) occurs in a specific region of the lamina called the pars interarticularis or isthmus. Hence the condition is called isthmic spondylolisthesis.
Lordosis is a disorder defined by an excessive inward curve of the spine. It differs from the spine’s normal curves at the cervical, thoracic, and lumbar regions, which are, to a degree, either kyphotic or lordotic. The spine’s natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.
Lordosis can be found in all age groups. It primarily affects the lumbar spine, but does occur in the neck (cervical). When found in the lumbar spine, the patient may appear swayback, the buttocks more prominent, and in general an exaggerated posture. A lumbar lordosis can be painful sometimes affecting movement.
Certain disease processes can adversely affect the structural integrity of the spine and contribute to lordosis. Some common causes include achondroplasia, discitis, kyphosis, obesity, osteoporosis, and spondylolisthesis.
Ligaments run up and down the spinal column. Hypertrophy of the ligaments in the vertebral canal (the posterior longitudinal ligament — runs up and down along the back side of the vertebral bodies, and the ligamentum flavum — runs up and down under the posterior bone ring made up of the lamina and spinous process) can increase their mass enough that they narrow the canal (stenosis) sometimes to the point that the spinal cord and/or nerve roots running through the canal are compressed. When the posterior longitudinal ligament in front and ligamentum flavum behind the spinal cord hypertrophy the cord is almost “circumferentially” surrounded and compressed).
Hypertrophy of the ligamentum flavum laterally near the facet joint can also contribute to foraminal narrowing (stenosis) with potential nerve compression (pinching).
There is a reason why osteoporosis is commonly called the “fragile bone disease.” It is due to loss of bone density caused by a deficiency in such bone-building nutrients as calcium, vitamin D, magnesium and other vitamins and minerals.
One of the most common results of fragile bones is vertebral compression fractures. While these types of fractures can be the result of trauma or tumors, they are seen most often in people with osteoporosis. In fact, they are the most common complication of osteoporosis. In people with advanced osteoporosis, compression fractures can occur as the result of simple daily activities such as bending, carrying heavy loads, or a minor fall. See Compression Fractures.