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(Distribution of spinal nerve roots and associated muscles)

This is an overview of back problems collected from books and web sites; It has not been reviewed by medical professionals and is not a substitute for advice from a healthcare professional. Experts tend to have a variety of opinions on causes and solutions for back pain and we have not attempted to rate them on level of agreement. Second opinions are strongly recommended.

About 80 percent of the adults in the U.S. have been bothered by back pain at some point. Lower back pain (LBP) is the fifth most common reason people go to a doctor. Low back pain is second only to the common cold as a cause of lost days at work.
In Dr. Sarno's 1990 best selling book "Healing Back Pain: The Mind-Body Connection" he claims back pain is number 2 and 1 in the above categories.

Symptoms:
Chronic back pain is commonly described as deep, aching, dull or burning pain in one area of the back or traveling down the legs. It tends to last a month or more or be an ongoing problem. Chronic pain tends to last a long time and is not relieved by conservative care.
Acute back pain is commonly described as a very sharp pain or a dull ache, usually felt deep in the lowerpart of the back, and can be more severe in one area, such as the right side, left side, center, or the lower part of the back. it tends to come on suddenly but also improve with time and short-term conservative treatment, such as medication, exercise, physical therapy or rest.
Sciatica - Pain that begins in the hip and buttocks and continues all the way down the leg.
Numbness and Weakness - Paralysis is the extreme manifestation of weakness.

Warning signs that may indicate a problem that needs IMMEDIATE EVALUATION:

  • You experience weakness, numbness or tingling
  • You have pain after a fall or an injury
  • Pain is severe and doesn't improve with medications and rest
  • Your back pain awakens you at night
  • Your have difficulty controlling your bowels or bladder
  • You have a fever, chills, sweats, or other signs of infection
  • Your back pain persists beyond a few days
  • Any other unusual symptoms
Up to 80% of people with back pain even from a herniated disc, will recover without surgery. See treatment below.
Causes:
There are generally two causes Musculoskeletal, which account for 2/3 to 3/4 of back pain, and neurological (pinched nerve). The simplest cause is a muscle sprain or ligament sprain. These can last from six to eight weeks, but usually improves over time.
A combination can occur when nerve irritation causes muscle spasms or swollen muscle tissue pushes against a nerve.

Radiculopathy - A pinched nerve due to a herniated disc.
A herniated disc is sometimes called a bulging disk, Compressed disk, Herniated intervertebral disk, Herniated nucleus pulposus, Prolapsed disk, Ruptured disk, or Slipped disk.
A bulging disk is a weakness in the disk wall (annulus), causing a bulge; a herniate or ruptured disk is a break in the wall allowing the internal fluid (nucleus pulposus) to leak out. In a subligamentous disk herniation the fluid is contained by the posterior longitudinal ligament; In a supraligamentous disk herniation (transligamentous herniation or disc extrusion) the fluid is not contained by the posterior longitudinal ligament.
A separated disc fragment (wandering disc) or disc bulge can also put pressure on the spinal cord or nerves.
Sciatica. (pain running down the leg) can be caused by pinched nerves in L4-S3
 

Normal Vertebrae

See Vertebrae muscles and ligaments on the illustration page.
Herniated Disc

 

Spondylosis a general term for loss of normal spinal structure, is the most common cause of spinal cord disfunction amongst people older than 55.
Also called degenerative disc disease or spinal osteoarthritis it can affect the disk or body of the vertebrae or vertebral facet joints.
Osteoarthritis and degenerative lumbar scoliosis are common forms of spondylosis. Disk Degeneration - Discs dry out and deflate as you age. This sometimes leads to back pain and sometimes not.
Osteoarthritis occurs when the thin layer of cartilage covering vertebrae is broken down by disease, condition or age. The bone overgrows trying to repair itself. This can occur at the edge of vertebrae near the disks or at the facet joints. These abnormal growths are sometimes called bone spurs (osteophytes) .
According to Neck Osteoarthritis - What You Need to Know "Seventy percent of women and 85% of men have x-ray evidence of neck osteoarthritis by age 60."
Osteoarthritis and degenerated discs are commonly found together even though they are separate conditions.

Degenerative lumbar scoliosis or curvature of the spine typically develops in individuals over 50 years and may be caused by asymmetric degeneration of the spine.

Central or spinal stenosis - A narrowing of the spinal canal, which can compress sensory nerve fibers causing loss of sensation. Acquired stenosis usually is related to older age and results from the thickening of the facet joints due to disc degeneration, disc space narrowing, and excess bone deposits.
See:
Questions & Answers about Spinal Stenosis at The National Institute of Arthritis and Musculoskeletal and Skin Disease (NIAMS) in the National Institutes of Health (NIH)
Natural History of Lumbar Spinal Stenosis at SpinalStenosis.org

Cervical spondylotic myelopathy (compression of the spinal cord in the cervical area) from cervical stenosis, caused by degeneration of the disk or vertebrae. It is the most common cause of spinal cord disfunction amongst people older than 55. It usually causes neck, arm and shoulder problems (pain or numbness or pins-and-needles) because those nerves are closer to the surface of the spinal cord in the cervical area, but it may also cause bladder problems and/or cause weakness or jerky movement in the legs.

Foraminal stenosis - Bone spur into neural foramen putting pressure on nerve root.

Facet joint problems - When facet joints become worn or torn the cartilage may become thin or disappear and there may be a reaction of the bone of the joint underneath producing osteoarthritis, overgrowth of bone spurs and an enlargement of the joints.

Lumbar spondylolisthesis (LS) - One of the spine bones slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful.

Sacroiliac Joint (SI Joint) Pain is caused by problems in the connection between the sacrum (tailbone) and hip.

Other Causes:
Sciatica can be caused by pressure from the piriformis muscle in the buttocks on the sciatic nerve.
There are many age related causes, arthritus, osteoporosis, ...;
See "Your Aching Back" and "The truth About Back Pain" for others.
Injury (tramua), e.g.Compression Fractures
Tumors, muscle spasms, bone infection, ....

Many intra-abdominal disorders-such as appendicitis, aneurysms, kidney diseases, bladder infections, pelvic infections, and ovarian disorders, among others-can cause pain referred to the back.
Whiplash can cause a muscle injury in the neck which can cause pain or weakness in the arm or hand as nerves are squeezed.

Depression, Stress and other emotional issues are frequently associated with back pain.
John E. Sarno, MD has written several books on Tension Myositis Syndrome (TMS) [Myositis means physiologic alteration of muscles], where he maintains many if not most causes of back pain and other things like Fibromyalgia, colitis and migraines are really muscle pain caused by stress affecting the autonomic nervous system (ANS) and reducing blood flow to the muscles and brain. He states "hardworking, conscientious, responsible, compulsive and perfectionistic people were prone to TMS." See the illustration page for more examples.
 

Distribution of spinal nerve roots and associated muscles The vertebrae are numbered from top to bottom: Cervical - C1-7; Thoracic - T1-12; Lumbar - L1-5, Sacral - S1-5 (fused) and Coccyx (4 fused).

 
Area affected refers to nerve roots below their respective vertebrae. i.e. L5 refers to the roots between L5 and S1.
A spinal cord injury can affect everything below it. Eg. a thoracic cord injury can affect the legs.
Source: Distribution of the spinal nerve roots at instruct.uwo.ca   Spinal Decompression at New York City Chiropractic and Wellness Center *
* See Chiropractors below

The spinal cord fills 95% of the spinal column at the cervical vertebrae, but only 60% in the lumbar.
The spinal cord ends around L1 or L2; The spinal nerves continue as a bundle of nerves called the cauda equina.

The heart, lungs, gastrointestinal tract and most other organs are connected to the vagus nerve which extends through the through the neck near the thorax and not the spinal cord.

Effects of Spinal Injury:
Nerve Injury Effect*
C1 to C5 Paralysis of muscles used for breathing and of all arm and leg muscles; usually fatal.
C5 to C6 Legs paralyzed; slight ability to flex arms.
C5: Weakness - shoulder abduction (raising the arm).
C6: Weakness: elbow flexion, wrist extension.
C6 to C7 Paralysis of legs and part of wrists and hands; shoulder movement and elbow bending are relatively preserved.
Weakness: shoulder abduction.
C7: Weakness in elbow extension, wrist flexion
C8 to T1 Legs and trunk paralyzed; eyelids droop; loss of sweating on the forehead (Horner's syndrome); arms relatively normal; hands paralyzed.
C8: Weakness in thumb extension, wrist ulnar deviation (rotate away from the thumb)
Note C8 refers to nerve root - there are 7 cervical vertebrae and 8 cervical nerve roots.
T2 to T4 Legs and trunk paralyzed; loss of feeling below nipples.
T5 to T8 Legs and lower trunk paralyzed; loss of feeling below the rib cage.
T9 to T11 Legs paralyzed; loss of feeling below umbilicus (belly button).
T12 to L1 Paralysis and loss of feeling below the groin.
L2 to L5 Different patterns of leg weakness and numbness.
S1 to S2 Different patterns of leg weakness and numbness.
S3 to S5 Loss of bladder and bowel control; numbness in the perineum.
* Loss of bladder and bowel control can occur with severe injury anywhere along the spinal column.
Source: The Merck Manual of Medical Information - Home Edition reprinted in: June 1999 Newsletter of the National Centre for Classification in Health at Univ. of Sidney.
and Cervical Radiculopathy at eMedicine Sports Medicine

Cervical radiculopathy is a dysfunction of a nerve root of the cervical spine. Cervical radiculopathy occurs at a much lower frequency than radiculopathy of the lumbar spine. The annual incidence is approximately 85 cases per 100,000 population.

Lower Back Nerves The sensory (cutaneous) nerves leave the spinal cord in the dorsal root (posterior root) and the motor (muscle) leave in the ventral root (anterior root).
The sensory nerves for pain follow a different tract than those for light touch. The nerve roots for the pain tract are on the opposite side of the spinal cord from the area they support. The light touch and motor nerve roots are on the same side as the area they support.
Nerve Segments Muscles Cutaneous (skin)
Genitofemoral Nerve L1-L2 Cremasteric Surface of the anterior labium majus or scrotum (genital branch) and the upper medial thigh (femoral branch)
Ilioinguinal Nerves L1 Muscles of the lower abdominal wall Surface of the lower abdominal wall and the anterior labium majus or scrotum
Iliohypogastric Nerve L1 Muscles of the lower abdominal wall Surface of the lower abdominal wall, upper hip and upper thigh
Obturator Nerve L2-L4 Adductor Longus, Adductor Brevis, Adductor Magnus, Gracilis and Obturator Externus Surface of the lower medial thigh
Femoral Nerve L2-L4 Sartorius, Rectus Femoris, Vastus Lateralis, Vastus Intermedius, Vastus Medialis and Pectineus Surface of the anterior thigh
Nerve to Quadratus Femoris L4-S1 Gemellus Inferior and Guadratus Femoris N/A
Superior Gluteal Nerve L4-S1 Gluteus Medius, Gluteus Minimus and Tensor Fasciae Latae Surface over tensor fasciae and capsule of the hip joint
Common Tibial Nerve (and Sciatic Nerve) L4-S3 Hamstrings, Gastronemius and Intrinsics of the Superior of the Foot medial sural cutaneous nerve posterolateral leg and foot. The sciatic nerve is the largest in the body, 3/4 in in diameter.
Common Fibular Nerve (and Sciatic Nerve) L4-S3 Short Head of the Bicepts, Anterior Tiberalis and Intrinsic of the Inferior of the Foot Lateral sural cutaneous nerve, medial and intermediate dorsal cutaneous nerve anteriolateral leg and foot
Nerve to Obturator Internus L5-S2 Gemellus Superior and Obturator Internus N/A
Inferior Gluteal Nerve L5-S2 Gluteus Maximus Inferior buttocks
Nerve to Piriformis S1-S2 Piriformis N/A
Pudendal Nerve S2-S4 bulbospongiosus, deep transverse perineal, ischiocavernosus, sphincter urethrae, superficial transverse perineal clitoris, penis, bowel and bladder
Coccygeal Nerve S4-Co1 N/A perineum
Source: IOMStudy.com from the Institute of Medicine.

The Femoral Nerve arises from nerve fibers from the the L2-L3-L4 portion of the lumbar spine. The Femoral Nerve then passes down the inside edge of the thigh, past the inside of the knee and towards the ankle and foot.
The Sciatic Nerve is the largest nerve in the body and it is comprised of nerves from the L4-L5-S1-S2-S3 level of the spine. It then descends down the back of the thigh.   Detail of Sciatic nerve root.

It is rare for sciatic nerve roots other than L4 and L5 to be damaged by lumbar disc herniation.
Nerve Root L4 can be squeezed when the disc between lumbar vertebrae L4 and L5 herniates. The symptoms of damage to nerve L4 are:-

  1. Difficulty in lifting the big toe off the ground.
  2. Loss of sensation and/or "pins and needles" in the big toe.
  3. Pain in the back of the thigh and the side of the calf.
Nerve Root L5 can be squeezed when the disc between lumbar vertebra L5 and the first sacral vertebra herniates.
The symptoms of damage to nerve L5 are:-
  1. Weakness when trying to put full weight on the ball of the toe and lift the heal off the ground.
  2. An increased Achilles tendon jerk.
  3. Loss of sensation and/or "pins and needles" in the side of the foot and heel.
  4. Pain in the back of the thigh and calf.
Source: Easy Vigour (www.easyvigour.net.nz)

Leg weakness can be caused by spinal stenosis in a cervical vertebrae (C5-8) putting pressure on a nerve which runs all the way down to the legs, but it is usually associated with arm or shoulder problems because these nerves are closer to the edge of the spinal cord there.


Cervical vertebrae (C1-7)
1. Anterior arch of the atlas (C1)
2. Dens (odontoid peg around which atlas rotates) of axis (C2)
3. Posterior arch of the atlas (C1)
4. Soft palate (roof of the moutn)
5. Root of the tongue
6. Transverse process
7. Intervertebral disc
8. Inferior articular process
9. Superior articular process
10. Zygapophyseal (facet) joint
11. Spinous process of C7
2nd-7th: The bodies of 2nd to 7th cervical vertebrae
Source: University of Szeged, Hungary

Diagnosis:

A computed tomography (CT or CAT) scan or magnetic resonance imaging (MRI) study is usually performed to confirm the associated condition and best procedure.

Studies between 1998 and 2000 and an article in the Journal of the American Medical claim that MRIs resulted in more surgeries with no better outcome.

An Electromyogram (EMG) is often performed when patients have unexplained muscle weakness. The EMG helps to distinguish between muscle conditions in which the problem begins in the muscle and muscle weakness due to nerve disorders. EMGs can also be used to isolate the level of nerve irritation or injury.
It is used to record the electrical activity of muscles by inserting a small needle through the skin into the muscle. The electrical activity is detected by this needle (which serves as an electrode).The patient may be asked to contract the muscle (for example, to bend the leg). The presence, size, and shape of the resulting wave form provide information about the ability of the muscle to respond to nervous stimulation.
See: Electromyogram (EMG) (www.medicinenet.com/electromyogram/article.htm)
EMG Test (www.youtube.com/watch?v=k0uSpYd_Ics)

Nerve conduction studies (NCS) are frequently done at the same time as an EMG. A shock-emitting electrode is placed directly over the nerve and a recording electrode is placed over the muscles under control of that nerve. Several quick electrical pulses are given to the nerve, and the time it takes for the muscle to contract in response to the electrical pulse is recorded.
See: Electromyogram (EMG) and Nerve Conduction Studies at WebMD.

Anesthetic injections can be made at different locations to pinpoint the source of pain. e.g. nerve root blocks or faces blocks.

Myelogram: a liquid dye is injected into the spinal column. The dye circulates around the spinal cord and spinal nerves, which appear as white objects against bone on an x-ray film. A myelogram can show pressure on the spinal cord or nerves from herniated disks, bone spurs, or tumors.

See: Diagnosis of Spinal Stenosis at U. Washington


Treatment Procedures:
A wide range of treatment is available for low back pain, depending on what is causing the pain and how long it lasts. Most people find that their low back pain improves within a few weeks. Chances are good that your pain will go away soon with some basic self-care. However if you have one of the symptoms that require immediate attention (see above) you should see a doctor.

Pain medication, anti-inflammatory drugs, rest, heat/cold and eventually exercise to prevent further problems is the first choice.
Over half, up to 80%, of people with back pain even from a herniated disc, will recover without surgery. With time most herniated discs will dehydrate and degenerate, absorbing the protruding cartilage.
Your family physician can help you decide whether to wait and see or visit a neurosurgeon or orthopedist for expert diagnosis. They will keep you under observation for muscle weakness, loss of reflexes, and other symptoms indicating as possible need for surgery.

Physical therapy consists of deep heat (delivered as high-frequency sound waves), deep massage and active exercise. They may also use Transcutaneous Electrical Nerve Stimulation (TENS) is also known as E Stim, which sends a painless electrical current to specific nerves. The current may be delivered intermittently. The mild electrical current generates heat that serves to relieve stiffness, improve mobility, and relieve pain. The treatment is believed to stimulate the body's production of endorphins or natural pain killers.

Extended bed rest is no longer the preferred treatment:
Studies have shown that bed rest of any duration is not an effective therapy for LBP and that it often delays recovery. Sciatica, even when due to nerve-root compression, is not improved with bed rest either. Detrimental results of prolonged bed rest include losses in muscle protein and bone calcium, lumbar muscle atrophy, and undesirable psychologic effects. Several current guidelines advise no more than 2 days of rest for patients with acute LBP.
Source: Sports Medicine Approach to Low Back Pain: Bed Rest or Early Activity?, 2002, at Medscape Today.
See also: Bed rest for acute low-back pain and sciatica. , 2004, National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM) in the National Institutes of Health (NIH).

A 2003 study of the "Journal of Bone and Joint Surgery" 85:975 (2003) compared 278 patients aged 18 to 65 years of age (mean age, 44 years; 53% women) with acute low-back pain or a recent episode (<72 hours) of chronic low-back pain (LBP) with spontaneous lumbar pain. Bed rest and normal daily activity were equivalent for recovery.

Chiropractors:

Chiropractors are another option that have helped many people, but they cannot diagnose or treat problems which require surgery.

In a 2009 article "Relief for your aching back: What worked for our readers" by Consumer Reports they found the percentage of people highly (completely or very) satisfied with their back-pain treatments and advice varied by practitioner visited and type of treatment.

Professional Highly
satisfied
Chiropractor D.C. 59%
Physical therapist 55%
Acupuncturist 53%
Physician (DO or MD), specialist 44%
Physician, primary-care doctor 34%
Treatment Type Beneficial or
Very helpful
Chiropractic treatments 58 %
Spinal injections 51%
Massage 48 %
Physical therapy 46 %
Prescription medications 45 %
Over-the-counter medication 22 %
Source: Relief for your aching back at Consumer Reports Health Ratings Center, 2009

Don't seek chiropractic adjustment if you have osteoporosis or signs or symptoms of nerve damage, such as numbness, tingling or loss of strength in an arm or leg.

Stress Reduction:

If you believe Dr. Sarno's 1990 best selling book "Healing Back Pain: The Mind-Body Connection", the majority of back pain is psychosomatic caused by stress. i.e. the adult version of children's stomach ache. See stress reduction below.

Medication:
Anesthetic injections:

Neurogenic Pain: Can be treated with Epidural Steroid Injections with or without lidocane, narcotics or tranquilizer type substances.
Other injections: Selective nerve root block (SNRB), Facet joint block, Sacroiliac Joint Injections.

See: Guide to spinal injections

Radiofrequency ablation (or RFA) uses radio waves to heat up a small area of nerve tissue, destroying the nerves ability to transmit pain signals. It is frequently used for arthritic or inflames facet joints which can cause chronic pain radiating to the buttocks or back of the leg.

Typically muscle relaxants and pain medication are used for short episodes of acute back pain. See Relief and Prevention below.

Supplements:
I have a friend that was diagnosed with stenosis, who says taking magnesium supplements worked when epidurals, physical therapy and chiropractors did not.
See: Ending Back Pain With the Help of Magnesium from Jigsaw, a manufacturer
and Natural Calm / Magnesium Supplement at HerbsWest.net

There are a variety of medications, supplements for treating osteoporosis

Do it yourself devices:
Inversion Table:
Allows you to hang upside down or partially inverted for 5-10 minutes twice a day or 10-15 minutes before bed to relieve pressure on discs. In addition to relieving back pain they claim improved sleep, mental alertness, flexibility and posture. They cost $200-400.
You can increase the effect and get an additional workout by lifting weights while inverted.

It is based on the principal that when you invert your body, the amount of weight pulling on each level of your spine is directly proportional to the amount of force needed to produce proper alignment.

Here's how it works: The weight of your head exerts just the right amount of pull for your cervical spine. The weight of your head, neck, chest, shoulders and arms is exactly the right amount of combined weight needed for the thoracic spine. The same goes for the lumbar spine: See: Do Inversion Tables Really Work? at LoseTheBackPain.com
Spinal Decompression Treatment for Lower Back Pain and Sciatica
and www.inversion-table-direct.com/

Other Home Remedies:

See: Ice, heat and medication in Relief below
and Home Remedies for Back Pain

Other conservative treatments are listed under Relief and Prevention below.

Surgery:
Surgery should only be used when a specific problem is identified which cannot be remedied by any other means.
Surgery can offer an 80% to 85% chance of improvement, but sometimes surgery can make things worse.
It's important to get a second opinion before undertaking surgery.

Orthopedic surgeons specializing in spine surgery and neurosurgeons can treat disc herniations, disc degenerations, spinal stenosis and fractures of the spine, slippage of the spine (spondylolisthesis), scoliosis, bone tumors of the spine. Only neurosurgeons are trained to perform procedures inside the lining of the spinal canal. Scoliosis and other spinal deformities are still primarily treated surgically by orthopedic spine specialists.
See: Neurosurgeon or Orthopedic Surgeon? Does it Matter?

Fusion:
There are many different specific techniques to try to fuse vertebrae together.

The goal of the lumbar fusion is to have the two vertebrae fuse (grow solidly together) so that there is no longer any motion between them after a Discectomy.

     
(eOrthopod.com) fusion

The most common type is a posterior lumbar interbody fusion (PLIF) .
Small strips of bone are removed from the top rim of the pelvis. This is called a bone graft. The surgeon lays the bone strips over the back of the spinal column.

During an interbody fusion, the surgeon removes the intervertebral disc (discectomy) and places either a piece of bone or a metal or plastic cage in its place.

Posterior lumbar interbody fusion (PLIF) is a type of spinal fusion procedure that utilize a posterior (back area incision) approach to fuse (mend) the lumbar spine bones together (using an interbody fusion technique). Interbody fusion means the intervertebral disc is removed and replaced with a bone spacer (metal or plastic may also be used), in this case using a posterior approach. The posterior technique is often favored when one or two spinal levels are being fused in conjunction with a posterior decompression (laminectomy) and instrumentation (use of metal screws/rods).
A newer technique, called a TLIF (transforaminal lumbar interbody fusion), involves placing only one bone graft spacer in the middle of the interbody space, without retraction of the spinal nerves.
See: PLIF and TLIF at the USC Center for Spinal Surgery

In many cases metal frames are attached to the bones or rods are screwed into vertebrae to hold them steady while the fusion occurs.
A new development is the use of PEEK (polyetheretherketone) rods which provide some flexibility.

Spinal Fusion - Minimally invasive lumbar spinal fusion is an operation that is less invasive to the traditional lumbar spinal fusion to treat degenerative disc disease and other vertebral problems. There are advantages and disadvantages to the procedure.
Fusion of 2 or 3 vertebrae doesn't cause much loss of mobility according to the literature, but my neighbor who had two lumbar vertebrae now has difficulty bending forward. See: minimally invasive Surgery / Interbody Fusion

The Swedish Lumbar Spine Study Group compared 3 methods of fusion in 222 patients with physical therapy in 72 patients. It showed, that pain was reduced by 33% in the surgical group compared to 7% in the controls and disability was reduced by 25% compared to 6% in controls.
Swedish National Register for Lumbar Spine Surgery, Stromquist et al, 2001

Lumbar Interspinous Process Decompression (IPD) , also known as interspinous distraction or posterior spinal distraction, has been proposed as a minimally invasive alternative to laminectomy and fusion. In IPD an interspinous distraction implant, also called a spacer, is inserted between the spinous processes through a small (4-8 cm) incision. The supraspinous ligament is maintained and assists in holding the implant in place. No laminotomy, laminectomy or foraminotomy is performed. The device is intended to restrict painful motion while enabling otherwise normal motion. The device theoretically enlarges the neural foramen, decompresses the cauda equina and acts as a spacer between the spinous processes to maintain the flexion of the spinal interspace.

Discectomy
Disk removal without fusion or other treatment can cause several problems. Pieces of the disk may be left. You end up with bone on bone which can cause pain.

Spinal fusion may or may not be done in conjunction with a discectomy.
Active people may well be able to return to physically demanding work more quickly, maintain it better, and avoid lumbar fatigue (when muscles of your back get tired) if they have the fusion with their discectomy.

Partial Discectomy
Sometimes just part of the disc that is protruding is removed, most of the internal disk material near the herniation will have dried out so there will be no more leakage, however there is about a 5% recurrence rate as more of the internal disc material is squeezed out thru the weakened outer material sometime later.

Lumbar Laminectomy
A laminectomy involves removing a section of the bony covering over the back of the spinal canal. This takes pressure off the spinal nerves caused by stenosis or a herniated disc.
Sometimes a laminectomy is performed to provide access to the spinal canal to remove part of a herniated disc. The space left after removal of the disc should gradually fill with connective tissue. See: Lumbar Laminectomy (eOrthopod.com)

Spine surgery - back pain treatment options for lower back pain at back.com

Laminoplasty
Instead of removing the lamina, it is cut on one side and hinged to widen the opening for the nerve root. The cut side is held open with wedges or metal plates.


Posterior Dynamic Stabilization System is a dynamic stabilized device with the emphasis on motion preservation of vertebrae; it's a flexible frame with metal screws and rods placed from the back into the bonesframe simulating a healthy spine to support the body physically.

Fixed (non flexible) rods may also be used to stabilize the back after fusion or to straighten a curvature of the spine. They may be attached with screws into the vertebral body or hooks over the lamina.

Osteophytes (bone spurs) can be ground off.

Other Minimally invasive procedures:
Vertebroplasty. A minimally invasive procedure in which a bone cement is injected into the spine in order to relieve the pain from certain spine fractures.

Nucleoplasty - Use of hot wires or lasers to evaporate disk material.
See: DISC Nucleoplasty Percutaneous Discectomy

IDET (Intradiscal Electro-Thermal Annuloplasty/Coagulation) - A probe inserted into the disc to heat the tissues. Pain reduction may occur through the thermal coagulation of nociceptors in the outer annulus.

PIRFT (percutaneous intradiscal radiofrequency thermocoagulation) - Similar to IDET, but uses radiofrequency energy. It is thought to reduce the nocioceptive pain input from the free nerve ending in the outer anulus fibrosis.


Relief - Prevention

Relief:

  • Take over-the-counter pain medicine if needed, such as acetaminophen (Tylenol, for example) or an anti-inflammatory drug such as aspirin or ibuprofen (Advil or Motrin, for example). I take it before I start an activity which may stress my back.
  • Some people get relief from pain by using treatments such as massage, spinal manipulation (chiropractic or osteopathic manipulation), or acupuncture.
  • Ice or Heat:
    Many recommend (and it works best for me) ice as often as you can for the first 2-5 days. 20 min on and 20 min off. There are a variety of ways to do this; Crushed ice in a zip-loc bag with a little water, a bag of frozen peas, ... Always protect skin from tissue damage by using a cover (some use a wet paper towel) over the ice pack.
    See: Should You Use Ice or Heat to Treat Back Pain?
    After 2-3 days, choosing ice or heat is really up to you. Try using a heating pad on a low or medium setting, or a warm shower, for 15 to 20 minutes every 2 or 3 hours. You can also buy single-use heat wraps that last up to 8 hours.
  • Stay Hydrated - Drink plenty of water to help flush away acidic waste products from the muscles especially if you are having muscle spasms. High levels of acidic waste products (byproducts of muscular activity) in the muscles can cause muscle irritation and pain.
  • Furniture - There are a variety of furniture, back rests, lumbar supports for your car to help relieve back pain.
    See Furniture, Beds, Back Rests for Back Pain.
  • Mattresses - Traditional wisdom was that a firm mattress was best for your back. What you want is a mattress which allows you back to rest in a normal position. You want it to avoid sag but to be soft enough for your shoulders and hips to sink in when on your side. A medium firm mattress is usually best.
    See Mattress Firmness
  • Sleep on your side with your knees bent or on your back with pillows under your knees.
Prevention:
  • Exercise to strengthen core muscles
  • Practice good posture when you sit, stand, and walk. Put one foot up on a stool when standing for a long time. (That was the purpose of bar rails.)
  • Don't depend on a "back belt" to protect your back. Studies have not shown these belts to be effective in reducing back injuries. The most they can do is to help remind you to use good techniques for lifting.
  • Lifting:
    • place your feet apart for good balance
    • bend your knees
    • keep the load close to the centre of your body
    • lift gradually, smoothly, and without jerking
    • do not twist your back while lifting, pivot with your feet
  • Driving
    • get out of the car every hour and walk around for a few minutes
    • position the seat forward so that knees are bent
    • place a cushion at the small of the back
    • if the tilt of a car's seats can be adjusted, change the angle slightly every so
    often.
  • Links:
    Medicine: Some Dos and Don'ts for Back Care
    Low Back Care
    Back Injury Prevention at DocsToc.com
    Ergonomic Guidelines for Labs - Lawrence Berkeley National Laboratory
    backcare-ergonomics.com - Comfort Solutions for Everybody
See: Yahoo! Health

Stress Reduction:
According to an article in the January 2007 issue of Health Psychology. Biofeedback or cognitive-behavioral therapy (CBT) can actually reduce feelings of pain by about 30 percent, in patients with chronic back pain.
"That approach teaches patients to divert their attention from pain and to think about it in a less alarming manner. For instance, pain often triggers waves of fear because we associate a sudden twinge with damage to bone, muscle, or skin."
The senior author of the study, Robert Kerns, a psychologist at the Veterans Administration Connecticut Healthcare System and a professor at Yale University says. "Now it's clear these therapies affect the intensity of the pain itself."
See: U.S.News article "Psychological Treatments Are a Balm for Back Pain"


Terms/Glossary:
ACDF - Anterior cervical discectomy and fusion.
EMG - Electromyogram - Test of muscle reaction
CAT scan - computed tomography - Produced by a special x-ray machine connected
  to a computer to produce cross-sectional images. 
Cauda Equina Syndrome - A serious neurological problem due to pressure
   from a disc on the lower portion of the spinal cord and spinal nerve roots.
CBT - Cognitive-behavioral therapy 
CBLP - chronic back and leg pain
Cervical spondylotic myelopathy - compression of the spinal cord in the cervical area
CSF - Cerebrospinal fluid 
CT scan - same as CAT scan
Discectomy - Removal of all or a portion of the disc material.
   A partial Discectomy removes a fragment of a disc that is causing the pressure on the nerve.
  Sometimes all of the nucleus pulposus  is removed to prevent risk of further prolapse,
Discogram/Discography - A radio-opaque dye is injected into the disk; an X-Ray
    is then taken to view the disc anatomy and to see if the dye leaks out of the disc.
Epidural - An injection of Steroid or Anesthetic in epidural space between
  the bony ring of the spine and the covering of the spine called the dura. See image.
DC - Doctor of Chiropractic - 2-4 years of college plus 4 years of a chiropractic college course,
   and a 1 year internship. Chiropractic colleges are accredited by the
    Council on Chiropractic Education. recognized by the U.S. Department  Education.
D.O. - Osteopathic physician - 4 years of college plus 4 years of curriculum  as well as internship
   and residency training similar to a M.D.
    They are licensed to practice medicine, perform surgery, and prescribe 
    medication. D.O.s receive extra training in the musculoskeletal system.
E Stim - (also E Stem) Electronic Muscle Stimulation
ESI Epidural steroid injections
Fusion Surgery causing two vertebrae to fuse (grow solidly together)
  so that there is no longer any motion between them.
Herniated Disk -  A disk that slips out of place or ruptures.
  Also called a Bulging disk, Compressed disk, Herniated intervertebral disk,
  Herniated nucleus pulposus, Prolapsed disk, Ruptured disk, or Slipped disk.
   These terms are all are used differently by doctors.
FAAP - Fellow in the American Academy of Pediatrics
IDET (Intradiscal Electro-Thermal  Annuloplasty/Coagulation) - A probe inserted into the disc to heat the tissues.
  Pain reduction may occur through the thermal coagulation of nociceptors in the outer annulus.
Laminectomy - Removal of a section of the bony covering over the back of the spinal .
Laminotomy - Only a portion of the lamina is cut and extracted.
LS - Lumbar spondylolisthesis - Caused when one vertebrae slips forward.
MRI - magnetic resonance imaging 
MIS - minimally invasive spine surgery
Myelopathy - The gradual loss of nerve function caused by disorders of the spine.
Neurologist - Treats problems like seizures, Parkinson's disease, headaches,
   tremor, and peripheral nerve problems like numbness and burning.
Neurosurgeon - Treats brain and spine problems. Those specializing in spine surgery
  can perform procedures inside the lining of the spinal canal.
NCS - Nerve conduction studies
NCV - nerve conduction velocity
NSAID - Nonsteroidal anti-inflammatory medications (e.g. aspirin, ibuprofen, Naproxen)
nucleus pulposus - jelly-like substance in the center of a disc.
OMT (osteopathic manipulation) - Manipulation performed by an Osteopath (DO)
Orthopedic surgeons perform bone and joint surgery, however some specialize in spine surgery 
  and treat  disc herniations, disc degenerations, spinal stenosis and fractures of the spine.
osteopathic manipulative medicine (OMM)
Osteoarthritis - The cartilage around a joint wears out and causes the joint
    to rub against each other, creating inflammation and pain. Can be any joint
    not just vertebra. The most common form of arthritis.
Osteomyelitis - Vertebral osteomyelitis is the infection of the bones of the vertebral column.
  It may be caused by either a bacteria or a fungus. 
  Bacterial or pyogenic vertebral osteomyelitis is the most common form.
Osteophytes  - Bone Spurs
Osteoporosis - Reduced bone density
OT - Occupational Therapist
PCEA- patient controlled epidural analgesia, see epidural
Physiatrists -  rehabilitation physicians
P.T. - Physical Therapist
PIRFT (percutaneous intradiscal radiofrequency thermocoagulation) - Similar to IDET,
  but uses radiofrequency energy.  It is thought to reduce the nocioceptive pain
  input from the free nerve ending in the outer anulus fibrosis.
PLIF - Posterior lumbar interbody fusion - A graft placed between the vertebral bodies
PNT (Percutaneous neuromodulation therapy) - Treatment for pain by electrical stimulation
  directly to the deeper tissues (muscles, ligaments, tendons) near the spine 
  through several needle electrodes.
Prolapsed Disc - See Herniated disc
Prolotherapy - Injection  (often containing a sugar solution, which is an irritant)
  into the  ligaments or tendons, which causes irritation,
  but stimulates repair and the growth.
Radiculopathy - A pinched nerve due to a herniated disc.
Sciatica - Pain running down the leg from pressure on the Sciatic nerve
SCS - Spinal cord stimulation
SNRB - Selective nerve root block
Spondylosis - Osteoarthritis
Spondylolisthesis is a condition in which a bone (vertebra) in the lower part
   of the spine slips forward and onto a bone below it.
Stim - See E Stim
Subluxation - Misalignment of the spinal column.
  Chiropractic subluxation is usually too minor to see on an x-ray.  
    Traditional chiropractic subluxation theory claims that spinal adjustments
    can solve problems such asthma, digestive problems, etc in addition to 
    back pain.
  Orthopedic subluxation is a partial dislocation of a bone in a joint causing
  pain and limiting range of motion. 
Subligamentous disk herniations are contained by the posterior longitudinal ligament.
Supraligamentous disk herniations not contained by the posterior longitudinal
ligament.
  This is also called transligamentous herniation or disc extrusion.
TENS - Transcutaneous electrical nerve stimulation 
TLIF - Transforaminal lumbar interbody fusion
TMS - Tension Myositis Syndrome - Psychosomatic causes of backpain
   Made popular by Dr. Sarno's bestseller
  "Healing Back Pain: The Mind-Body Connection" 

Vertebral subluxation - See subluxation.
Vertebroplasty: A minimally invasive procedure in which a bone cement is injected
   into the spine in order to relieve the pain from certain spine fractures. 
Whiplash - A  injury to  the soft tissues that hold the cervical vertebrae together
(ligaments, facet capsules, muscles), typically from a rear-end car accident.
It can cause pain or weakness in the arm or hand as nerves are squeezed.
Zygapophyseal - Facet joint on the back of the vertebrae.
See:
Glossary at spine-health.com
Spinal Surgery Glossary by Stanton Schiffer M.D. at the Western Neurosurgical Clinic
Back and Leg Pain - Definition List at NYU

Chiropractors
For many years, chiropractors were labeled as quacks by the established medical community. Only in recent years have medical doctors started to work with chiropractors.
In the Consumer Reports reader survey above chiropractic had the best patient satisfaction.
According to Chiropractic Versus The AMA in EZineArticles.com: "There is no scientific evidence that supports chiropractic theories; All the studies made in support of chiropractic are basically testimonials from patients."

See: The Chiropractic page for more information.


Books:
"Do your really need back surgery", by Aaron Filler, 2004
Your Aching Back: A Doctor's Guide to Relief, by Augustus A. White III, MD, 1990
The Truth About Back Pain: A Revolutionary, Individualized Approach to Diagnosing and Healing Back Pain by Todd Sinett, DC & Sheldon Sinett, DC, 2008   (DC - Doctor of Chiropractic)
Back Pain: How to Relieve Low Back Pain and Sciatica by Carol Ardman, Loren Fishman MD, 1997
Do You Really Need Back Surgery?: A Surgeon's Guide to Back and Neck Pain and How to Choose Your Treatment, by Aaron G. Filler M.D., 2004
The Mindbody Prescription: Healing the Body, Healing the Pain, by John E. Sarno M.D., 1998
  A followup to his 1990 best selling book "Healing Back Pain: The Mind-Body Connection"
Straight-talk, No-nonsense Guide to Back Care, 1984, The AMA, Consumers Union

Articles:
Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain? N Engl J Med 1986; 315:1064-1070
Rozenberg S; Delval C and Rezvani Y: Bed Rest and Normal Daily Activity Were Equivalent for Acute Low-Back Pain, "Journal of Bone and Joint Surgery" 85:975 (2003)
Hadler, Nortin M., MD: "MRI for Regional Back Pain: Need for Less Imaging, Better Understanding", JAMA.2003; 289: 2863-2865.
"Relief for your aching back: What worked for our readers" by Consumer Reports, April 2009
Hoffman B.M., Papas R.K., Chatkoff D.K., Kerns R.D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26(1), 1-9.
Hagen KB, Hilde G, Jamtvedt G, Winnem M: Bed rest for acute low-back pain and sciatica. , 2004, Nadtional Resource Centre for Rehabilitation in Rheumatology, Oslo, Norway.
Selye, Hans: "Stress and disease". Science, Oct.7, 1955; 122: 625-631.

Links:
Neuroanatomy in Science
The Spine Center at Columbia U.
Back Pain and Disk Disease at The Dana Guide to Brain Health
Spine Conditions at LSU (UniversityNeurosurgery.com)
Back pain and low back pain - have questions? Back.com has answers
WebMD Back Pain Health Center - Information and News About Back Pain
Back Pain Treatment (non-surgical) at BigBackPain.com
Glossary at spine-health.com
backpain-guide.com
Injuries of the Spinal Cord and Vertebrae Merck Manual Home Edition
Einstein - Orthopaedics - Back/Spine - Common Problems
The Nerves of the Lower Extremity at FootDoc.ca
Other Illustrations and Pictures
Back Pain Causes, Symptoms, and Treatment on eMedicineHealth.com
Spine General, Cervical, Thoracic, Lumbar at (eOrthopod.com)
Guide to spinal injections at SpinalNeurosurgery.com, Reno, NV
www.spine-health.com
Back pain, leg pain, neurosurgeon at lowback-pain.com
Electromyogram (EMG) (www.medicinenet.com/electromyogram/article.htm)
EMG Test (www.youtube.com/watch?v=k0uSpYd_Ics)
Minimally InvasiveLumbar Spinal Fusion (www.medicinenet.com/minimally_invasive_lumbar_spinal_fusion/article.htm)
eOrthopod.TV
BackCare101
Posterolateral fusion using laminectomy bone chips in the treatment of lumbar spondylolisthesis
Mind Body Connection Links
Lower back pain and sciatica
What are the Problems with Fusions?
The Back Story, AARP, July & August 2009
Low Back Pain: Causes, prognosis, diagnosis, and treatment
Neurosurgeon or Orthopedic Surgeon? Does it Matter?
Birth of the Disc Herniation


This website also contains material copyrighted © by 3rd parties.
Medical Multimedia Group (MMG), LLC (incl. eOrthopod.com);   Consumers Union;   Medscape.

last updated 15 Dec 2010