Back pain: Pathology review

At the urgent care clinic, three people came in with lower back pain. The first is Jeff, a 26-year-old, who says his pain began 5 hours ago after trying to lift a 300-pound weight off of the floor at his local gym. He describes the pain as sharp and severe and says the pain goes down the back of his right leg and into his foot. Physical examination reveals a positive straight leg raise test on the right, and a diminished right Achilles tendon reflex. Second is Beth, a 68-year-old, who says she slipped and fell while walking in her kitchen yesterday. Her history includes a wrist fracture from a little over a year ago. Physical examination shows midline spinal tenderness to palpation. Finally, we have Harry, a 71-year-old male, who says his back pain has progressively worsened over the past month, keeping him up at night. He also reports increased urinary frequency.

Back pain is a very common complaint and one for which there are many potential causes. It can originate from the spinal cord, nerve roots, the vertebral column, the surrounding muscles, and ligaments, or even extra-spinal structures, such as abdominal organs. Therefore, the causes of back pain can be subdivided into mechanical causes, such as muscle strain, spinal osteoarthritis, disc herniation, spinal stenosis, vertebral fractures and osteoporosis; and non-mechanical causes, such as bone metastasis, seronegative spondyloarthritis, and vertebral osteomyelitis.

First, let’s start with musculoskeletal causes. The vast majority of cases of back pain are considered non-specific musculoskeletal pain due to strained muscles or ligaments. These individuals have no sensory or motor deficits, and they typically complain about tenderness over the affected muscle or ligament. The treatment for these individuals is prescribing activity as tolerated and NSAIDs for pain management. The next one is spinal osteoarthritis, which can be due to the natural aging process where the cartilage at the tips of bones wear down over their lifetime. It is associated with joint degeneration, ligamentous changes, disc degeneration, and finally, deformity of the spine.