How’s Your Back

Man rubbing his lower back.

Roper St. Francis

From aches to strains, back pain is one of the most common maladies to plague American adults. Here, two experts report how to protect your spine and what to do when pain strikes.

How’s Your Back

Human beings are among only a handful of vertebrates who walk the Earth on two legs rather than four. According to anthropologists, standing upright—an evolutionary turn that took place two million years ago and marked the first crucial distinction between hominids and apes—paved the way for humans’ increased cognitive abilities. With the upper appendages free, the top part of the spine could shrink, in turn allowing the brain to grow. The result? Greater intelligence, the invention of primitive tools, the creation of civilization, and the beginning of an epic battle with Earth’s gravitational force.

“Evolutionarily speaking, our spine was meant for an animal on all fours,” explains Dr. George Khoury, a Roper St. Francis affiliated neurosurgeon who’s been operating on the backbone and brain for more than 35 years. “When we stood up, problems with gravity kicked in.” And while our backs can support a significant amount of weight, back injuries have also become the world’s most significant cause of disability. In fact, a whopping 80 percent of adults suffer from lower back pain at some point in their lives, reports the National Institute of Neurological Disorders and Stroke, and an estimated 31 million Americans are currently plagued by the pain.

Anatomy of the Back

The spine is the backbone of everyday mobility, giving structural support to our upright posture while also protecting the spinal cord and nerves that control our muscles and organs. “The spine provides the pathway from our environment—everything we feel, see, and touch—to our brain,” says Dr. Khoury. And to cushion this hard-working column of 33 interlocking bones (called vertebrae), 23 elastic discs made up of connective tissue around a jellylike center act as shock absorbers and allow for flexible motion.

Orthopedists divide the spine into three distinct areas. The cervical spine, what we call the neck, has seven bones that hold up our eight- to 12-pound heads. The middle section, dubbed the thoracic spine, includes a dozen bones that attach to our ribs. The lumbosacral spine encompasses five lower-back, or lumbar, bones as well as the sacrum, a large, triangular bone at the base of the spine that attaches to the tailbone. As they carry the majority of the body’s weight—sometimes hundreds of pounds—the lumbar vertebrae measure five times wider than those in the cervical spine and are most prone to pain.

Ideally, the back should form a slight S shape when viewed from the side—though many of us forsake this natural shape when we slouch, sit, and incorrectly lift, putting undue pressure on the lower lumbar region and causing it to curve in the wrong direction. “The neck and lower back should curve in while the mid back curves out,” explains Hard. “That’s when we are in our strongest position.”

Sources of Pain

Back pain is a broad term that encompasses a wide range of ailments, from pop-up injuries to chronic conditions. In the majority of cases, the pain is a result of overstressed ligaments, muscles, or spinal discs. This can be caused by age-related wear and tear—resulting in disc deterioration—or by low-grade trauma from lifting or twisting. The latter can lead to a sprain (a tear in the ligament), muscle strain, or disc injury like a herniated disc, which occurs when a spinal disc’s jelly-like center pushes out, causing tremendous nerve pain. Less than 10 percent of back injuries involve damage to the actual vertebrae, notes Dr. Khoury, as bones are fairly solid. When vertebral fractures do occur, they are usually caused by trauma, such as a major fall or car accident, or by the bone disease osteoporosis.

Certain lifestyle and genetic factors can increase a person’s odds of experiencing back pain. One of the biggest? “More than half of back injuries occur among patients with a sedentary lifestyle,” says Hard. Slouching in front of a screen all day can contort our spine into unnatural angles; a stationary lifestyle can also lead to weight gain—another risk factor for back pain. “Excess weight puts a chronically heavy load on our frame and can prevent back and abdominal muscles from properly supporting the backbone,” says Dr. Khoury. Ligament sprains may also strike when a person dives too quickly into a physical activity for which they’re not conditioned. Dr. Khoury points to weekend warriors who don’t regularly engage in strength training then hoist a bag of potting soil on Saturday, only to strain a back muscle.

We also carry the burden of time on our backs. As we age, the elastic discs in our spine slowly lose their cushioning capabilities. “Spine strength peaks when we’re young adults,” notes Dr. Khoury. Even for active, healthy adults, the risk of injury increases as the spine wears down over time. Lower back pain is most common among the 40 and older set, as is the condition spinal stenosis—a narrowing of the spinal canal that can cause nerves to become pinched, resulting in pain, numbness, or tingling in the legs, and sometimes loss of bladder or bowel control.

Additional risk factors for back pain include lifestyle choices like a high-calorie, high-fat diet and smoking, as well as inherent traits such as sex, race, and genetics. Scoliosis, a spine curvature that can cause pain in middle age, progresses seven to eight times faster among adolescent girls than boys, reports the Baylor Scoliosis Center. African-American women are three times more likely than their Caucasian peers to develop spondylolisthesis, a condition in which a lumbar vertebrae slips out of place, causing other vertebrae to enlarge and squeeze nerves. And anklosing spondylitis, a spinal arthritis, can be hereditary, says the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

man lifting a bag of dirt

Types of Treatment

The good news? Though back pain is widespread, it’s typically short-lived. According to Hard, roughly 90 percent of people who suffer from a back injury recover within two to four weeks, and only about five percent require surgery for chronic pain. (Acute pain, the more common of the two, lasts no longer than six weeks, while chronic pain is defined as pain lasting for longer than three months.)

Acute back injuries typically heal on their own without treatment; however, there are some steps you can take to ease the initial discomfort. “At the onset of pain, immediately apply ice to the area, which will help calm muscle spasms and reduce inflammation, then gently stretch the problem area,” Hard advises. While intense exercise should be avoided until the injury heals, going about your daily activities might reduce stiffness and aches. “Acute pain may also call for an anti-inflammatory or muscle relaxer,” adds Dr. Khoury. Over-the-counter options like acetaminophen, aspirin, ibuprofen, and topical analgesics like Icy Hot can help ease discomfort. (Seek medical help immediately if you experience numbness, tingling, weakness, paralysis, incontinence, or severe groin pain, as those may be signs of nerve involvement.)

If severe acute pain persists or worsens over the course of a week or two—or if you experience chronic back pain—visit your primary care doctor. He or she may offer a steroid injection at the problem site to help manage pain, and/or refer you to a neurosurgeon or orthopedic spine surgeon for further evaluation. The specialist will examine range of motion in your neck and back as well as your reflexes, gait, and sensation (using a dull pinprick). He or she will likely also conduct a manual test of motor strength, such as squeezing a hand or pulling against an arm, and may order an X-ray, MRI, or CT scan to view your bones and soft tissues.

Treatment will vary based on diagnosis. For severe sprains and disc injuries, the first course of action is typically physical therapy, which uses manual therapy (hands on adjustments to the spine), heat treatment, stretching, and exercise to relieve pain and strengthen the back. “With a good regimen of physical therapy, the majority of cases can be resolved,” says Dr. Khoury. “We’ve had patients try alternative treatments such as acupuncture, dry needling, cupping, and chiropractic treatment with some success, as well.”

Should non-invasive treatments fail, surgery—followed by physical therapy—may be required. The most common operation is a laminectomy to correct a herniated disc, which involves removing part of the vertebral bone, ligament, and the ruptured disc. The patient may lose up to a third of the damaged disc, which the body replaces with scar tissue. “The result is good, but won’t be a 100 percent return to normal,” warns Dr. Khoury. “Patients will be given a lifelong ‘be careful’ prescription.”

Diagnoses such as degenerative disc disease and spondylolisthesis may call for a more-involved surgery known as a spinal fusion. The procedure relies on bone grafts, screws, and rods to join two or more vertebrae together, thereby immobilizing the fused region of the spine. For those with rare bone fractures, whether due to osteoporosis or trauma, a procedure known as vertobroplasty injects polymethylacrylate, a fancy word for a sort-of cement, to stabilize the spine and relieve pain.

No matter the procedure, if surgery is required, discharge instructions will include a prescription for physical therapy as well as an examination of the factors that may have caused the problem. “Back surgery marks a big life change, and, while not always avoidable, it should spur the patient to take better care of his or her body,” stresses Dr. Khoury.

spine model

Supporting the Spine

Though some back conditions are unavoidable, there are ways to strengthen and protect the spine to help ward off future injuries. “As a physical therapist, I spend a lot of time with clients discussing the best ways to sit, stand, and sleep,” says Hard. For those in sedentary jobs, opt for a standing workstation, if possible. When sitting is unavoidable—like on long summer road trips—use lumbar support to help maintain the spine’s shape. Roll up a thin towel about the thickness of your elbow, she suggests, then tuck it behind you, just above your tailbone. Also, stand and walk around as often as possible to stretch out the spine.

Those who stand all day long need to pay attention to posture, as well, says Hard. “Remember when your mother said slouching isn’t pretty? She was right. Holding your shoulders back not only looks better, it pulls your chest up and puts a natural curve in the back, automatically placing the spine in its best position.” If your profession requires extensive standing, try regularly shifting your weight between feet. Another trick the therapist recommends: place a book on the floor and alternate putting the left and right foot on it to minimize pressure on your lumbosacral spine.

Back your good posture up with a healthy diet that includes calcium (which helps build bones and strengthen muscles) and a regular fitness routine. “Be sure to include core and lower back exercises like planks and leg lifts; isometric strength training for the abs, back, hips, and glutes; and stretching,” notes Dr. Khoury. Hard stresses that core exercises should not just work the abdominals; rather, they should strengthen the spine extensor muscles (those that are attached to the back of the spine) and oblique muscles, too. And to reduce your risk of falling, consider weight-bearing and balance exercises like tai chi and yoga.

Finally, at the end of the day, enjoy a good night’s sleep. That horizontal position gives your spine a reprieve from the constant pressures of our upright lives and recharges the body for tomorrow’s gravity grudge match.

Tips for a Healthy Back

Flex Your Muscles

Regularly stretching the back and core muscles can help ease tension, making them more limber and less prone to injury, says Hard, who recommends working these mild stretches into your fitness regime. However, she cautions, “while strengthening and stretching the back is healthy, don’t do any back exercises that hurt. ‘No pain, no gain’ is a myth,” says the physical therapist.

woman stretching her back

The 123s of Catching ZZZs

Gravity places constant pressure on our upright spine during waking hours, so sleep provides the back with much-needed relief. However, some positions are more restorative than others. To prevent waking with aching, you need to maintain a neutral position. Here, Hard gives tips for proper form:

Lift Wisely

When lifting incorrectly, a load becomes 10 times heavier. So when you lean straight over to pick up a 10-pound object, the weight feels like 100 pounds at the base of your spine. For proper form, be sure to:

Beware of Pain Killers

According to the CDC, in 2012, healthcare providers wrote 259 million prescriptions for opioid pain medications like morphine, hydrocodone, and oxycodone—enough for every adult in the United States to have a bottle. However, “these opioids only mask back pain, rather than actually treating the problem,” explains Dr. Khoury. “And once you get started on these medications, it can be hard to stop.” Over time, patients can develop a tolerance to opioids, requiring more and more of the drugs to achieve the same results. Such increased dosing can then lead to side effects such as sedation, nausea, dizziness, and constipation and result in high risks for addiction and overdose. So in recent years, doctors have increasingly turned to prescribing safer alternatives, such as steroid shots, physical therapy, and even yoga. “Steroid shots work to reduce inflammation while physical therapy helps to build strength and flexibility,” says Dr. Khoury. And studies show that restorative yoga can significantly relieve chronic pain.

By Lauren Johnson

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