To understand various causes of low back pain, it is important to appreciate the normal design
(anatomy) of the tissues of this area of the body. Important structures of the low back that can be
related to symptoms in this region include the bony lumbar spine (vertebrae, singular = vertebra),
discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves,
muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the
lumbar area.
The bony lumbar spine is designed so that vertebrae "stacked" together can provide a movable
support structure while also protecting the spinal cord from injury. The spinal cord is composed
of nervous tissue that extends down the spinal column from the brain. Each vertebra has a
spinous process, a bony prominence behind the spinal cord, which shields the cord's nervous
tissue from impact trauma. Vertebrae also have a strong bony "body" (vertebral body) in front of
the spinal cord to provide a platform suitable for weight bearing of all tissues above the buttocks.
What is the anatomy of the low back? (Continued)
The discs are pads that serve as "cushions" between the individual vertebral bodies. They help to
minimize the impact of stress forces on the spinal column. Each disc is designed like a jelly
donut with a central, softer component (nucleus pulposus) and a surrounding, firm outer ring
(annulus fibrosus). The central portion of the disc is capable of rupturing (herniating as in a
herniated disc) through the outer ring, causing irritation of adjacent nervous tissue and sciatica as
described below. Ligaments are strong fibrous soft tissues that firmly attach bones to bones.
Ligaments attach each of the vertebrae to each other and surround each of the discs.
The nerves that provide sensation and stimulate the muscles of the low back as well as the lower
extremities (the thighs, legs, feet, and toes) all exit the lumbar spinal column through bony
portals, each of which is called a "foramen."
Many muscle groups that are responsible for flexing, extending, and rotating the waist, as well as
moving the lower extremities, attach to the lumbar spine through tendon insertions.
Nerve irritation and lumbar radiculopathy causes lower back pain
Nerve irritation: The nerves of the lumbar spine can be irritated by mechanical pressure
(impingement) by bone or other tissues, or from disease, anywhere along their paths -- from their
roots at the spinal cord to the skin surface. These conditions include lumbar disc disease
(radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection
(shingles). See descriptions of these conditions below.
Lumbar radiculopathy: Lumbar radiculopathy is nerve irritation that is caused by damage to
the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and
tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion
of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its
nerves as they exit the bony spinal column. This rupture is what causes the commonly
recognized "sciatica" pain of a herniated disc that shoots from the low back and buttock down
the leg. A history of localized low-back aching can precede sciatica, or it can follow a "popping"
sensation and be accompanied by numbness and tingling. The back pain commonly increases
with movements at the waist and can increase with coughing or sneezing. In more severe
instances, sciatica can be accompanied by incontinence of the bladder and/or bowels. The
sciatica of lumbar radiculopathy typically affects only one side of the body, such as the left side
or right side, and not both. Lumbar radiculopathy is suspected based on the above symptoms.
Increased radiating back pain when the lower extremity is lifted supports the diagnosis. Nerve
testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can
be used to detect nerve irritation. The actual disc herniation can be detected with imaging tests,
such as CAT or MRI scanning. Treatment of lumbar radiculopathy ranges from medical
management to surgery. Medical management includes patient education, medications to relieve
pain and muscle spasms, cortisone injection around the spinal cord (epidural injection), physical
therapy (heat, massage by a therapist, ultrasound, exercises, electrical stimulation), and rest (not
strict bed rest but avoiding reinjury). With unrelenting pain, severe impairment of function, or
incontinence (which can indicate spinal cord irritation), surgery may be necessary. The operation
performed depends on the overall status of the spine and the age and health of the patient.
Procedures include removal of the herniated disc with laminotomy (a small hole in the bone of
the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by
needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and
others.
