If you are an American adult between, say, 30 and 50, chances are you belong to a highly inclusive, fast growing club. You, and millions like you, have had a bout with back pain. Perhaps you’re lucky and pain free at the moment, but you've been there, or you know someone who has. Back pain follows close behind headaches and colds as the most frequent reason that people visit their doctors and stay home from work. The question we might well ask is: Why all this back pain?

When asked to describe a common cause of back pain, Mark Rosenthal, M.D., co-director of Sinai’s Spine Center and an orthopedic surgeon, allows himself a small chuckle. “Life,” he replies. “When you realize that probably 80 percent of people will have back pain, it appears living is a cause of back pain.

Risk factors are really at issue here. A sedentary American lifestyle is a leading cause of back pain. At the other end of the spectrum is heavy labor. People who work lifting heavy objects suffer from back pain. Interestingly, it’s been shown that vibration is also a risk factor for back pain.

In addition, heredity, your occupation, accidents, sports, even an innocent twisting move in search of a stray sock can precipitate back pain.

The need for safe, effective treatment is great as evidenced by the following: 35 million Americans will suffer from low back pain this year, according to the National Center for Health Statistics. Cost estimates in terms of treatment and lost productivity run from $50 to $100 million annually in the United States. Back pain is the most common cause of job-related disability.

In addressing the problem, the Spine Centers at Sinai and Northwest hospitals have developed an advanced, comprehensive treatment program using new technologies, along with a network of specially trained care providers, designed to treat the full scope of back problems that afflict us. By adopting newly improved CT scans for diagnosis, better MRI scans for surgical planning and new pain management techniques, the Centers' diagnostic, treatment and rehabilitation programs are delivering the best possible care to patients. Although surgery is needed in very few cases, Sinai and Northwest orthopedic surgeons and neurosurgeons perform a full range of surgical remedies including a new, revolutionary approach to spinal fusion surgery.

Sinai Spine Center’s approach, says Rosenthal, is multidisciplinary. A team of specialists—physiatrists, dedicated nursing staff, neurosurgeons, orthopedic surgeons and physical therapists—along with psychologists who help patients adjust when permanent physical disabilities have occurred, has been formed to attack the problem at different points. New patients are evaluated and quickly assigned both surgical and nonsurgical physicians to minimize lag time between referrals. Rosenthal emphasizes that the Sinai Spine Center is committed to “giving the absolute best care possible, quickly, easily and inexpensively.”

Naturally, people with back pain wonder: “Can’t someone just turn back the clock and make all this go away?” In fact, many people with episodic back pain will find exactly that—the pain does go away in a few days, or weeks.

Neurosurgeons caution that there are many, many different things that can cause back pain, but a majority of back pain is caused by strains. There may be small tears in the tissue and these heal, just like in other parts of the body.

But not everyone is so lucky. A trucker with back pain may have disc degeneration stemming from years in a vibrating, bouncing truck. Improvement is unlikely without a significant change in occupation, lifestyle or treatment, preferably all three. Spinal stenosis is a narrowing of the spinal canal often seen in the elderly, and resulting pain is unlikely to abate without therapy. Much depends on the nature of the problem. But ultimately, a lot depends on us. We need tolook at employment, risk factors and family history. We must act accordingly and, as the need arises, choose a physician who can help guide us back to good health.

Certain risk factors are better known for other problems. Rosenthal cites as a major risk factor a “usual suspect” involved in all manner of health problems—smoking. “Smokers have a higher incidence of disc disease,” he says. “The nicotine in cigarette smoke will cause the fluid that surrounds your disc to become more acidic. We know that discs are made of protein and if you put protein in acid, protein breaks down.” Adding insult to injury, smokers recover less quickly owing to poor blood vessel formation necessary for healing.

Because the discs in your back cushion your vertebrae, the series of bones that make up your spine, maintaining healthy discs is crucial to your ability to move properly and without pain. When discs degenerate, through injury, smoking or as a result of poor physical condition, they break down or bulge (also called ruptured or herniated disc). Simply stated, this means they are pushing outward, creating pressure on nerves. When pain radiates down into your leg, a condition known as sciatica, it’s a possible (but not a certain) indication that pressure is being applied to a nerve that extends into your leg.

Scott Brown, M.D., chief of Physical Medicine and Rehabilitation at Sinai Hospital, concurs with Rosenthal. “Most back problems are muscular in nature. This is the sprain and strain type of problem. But the back is a complex structure; discs can be a cause of pain. Joints called facet joints may be involved with arthritis, and those can be injured in more severe types of injuries like car accidents or falls from great heights.”

Brown cites the importance of distinguishing between acute and chronic back pain, because this information determines the course of treatment. Each patient at the Sinai Spine Center, he says, receives a thorough examination to identify the problem. Chronic pain sufferers likely will be treated from several different angles at once. Maximizing medication options, acupuncture, aquatic therapy, among other possibilities, will all be employed to address longstanding problems.

The Sinai Spine Center employs conservative treatments as the first step for acute low back pain. Strategies include rest, physical therapy (a good therapist will address posture issues, muscle weakness, how you move, proper exercise and lifestyle), anti-inflammatory drugs and pain medication. Acupuncture may be prescribed to reduce pain. Further nonsurgical approaches may be prescribed if conservative treatments fail. For example, Sinai and Northwest Spine Centers are employing new techniques in interventional pain management, known as nerve blocks, that allow a precise application of powerful anti-inflammatory steroids into affected areas that can turn night into day for some patients. This method is sometimes used to help patients with significant back pain, but who, perhaps owing to a weakened heart, are not good candidates for surgery.

Patients are always informed as to risk factors as part of the treatment process, says Brown. While obesity, in his view, is not necessarily a risk factor for injury, it has significant consequences for recovery. “Once you have had an injury,” he says, “being heavy really does prolong recovery.” Brown adds this surprising fact: “For every one pound you lose, it's like taking three pounds of stress off your spine. So if you lose ten pounds, it’s like taking thirty pounds of stress off your spine.”

Overall fitness and conditioning are paramount. “A very big reason that people experience episodic, chronic back pain is because they have very weak abdominal muscles. These are a major stabilizer of your back,” says Brown. Weak muscles, because they fatigue quickly, can't support the spine and so other muscles and ligaments are overused, posture deteriorates and pain develops.

If you have back pain, it helps to identify and understand your particular experience, Brown says. Certain symptoms—accidents with bowels or bladder—indicate pinched nerves, are very serious and require immediate medical attention. Significant trauma, such as an accident, or loss of feeling in one or both legs requires medical attention. Pain that persists longer than several weeks is another warning sign. Fever accompanied by back pain indicates the presence of infection and the need for immediate attention.

In the vast majority of cases, surgery is a last resort and accounts for roughly one to three percent of all cases. Rosenthal notes that surgery for back problems is vastly superior and less invasive than it was even 10 years ago. A radically new approach to spinal fusion surgery is being employed at the Spine Centers. This approach, known as BMP (bone morphogenic protein) allows spinal fusion to take place without taking a bone graft from the patient. This means less postoperative pain, less blood loss, a shorter hospital stay, better function and less cost.

For sprains or strains, ice for the first 48 hours, suggests Brown, will help reduce inflammation and pain. Over-the-counter medications that reduce inflammation can help, but always check with your physician first. Rest is important, but excessive bed rest (more than two days) may contribute to decreased muscle tone. Slowly and gently return to your normal activities. Let your pain guide you in terms of what you can or cannot do. See your physician if in doubt.

Rosenthal, while re-emphasizing that only a tiny percentage of patients need surgery, nevertheless offers this point regarding surgical remedies: “Some patients have waited too long to see me, and if significant deterioration has occurred, there are instances where that long wait means there is little that I can do to help.”

Regarding heredity, you can’t do anything about your genes. But practicing avoidance techniques may be your best ally if you are genetically disposed to have back problems. Consider career choices carefully, think about improving your general level of fitness and flexibility.

Above all, preventing back pain means using common sense. We just aren’t meant to carry 50-pound bags of cement all day, or to move all of our grandmother’s furniture to the retirement home in one day with no help.

For an aging generation marching headlong into retirement, that’s a wise message to heed.

For information about the Sinai or Northwest Spine Centers, call 410-601-WELL (9355).

Related Links:

Sinai Spine Center

Physical Medicine and Rehabilitation at Sinai Hospital

Northwest Spine Center

Ten Tips to a Healthy Back
1	Stretch before exercising or other strenuous activity.
2	Don’t slouch when sitting.
3	If you smoke, quit.
4	At home or work, make sure your work surface is at a comfortable height.
5	Use a chair with good lumbar support and one that is the proper height for the task
6	Wear comfortable, low-heeled shoes.
7	Don’t try to lift objects too heavy for you. Always lift by bending your knees.
8	Sleep on your side and use a firm mattress.
9	Maintain proper nutrition and diet to reduce stress on the spine.
10	Exercise regularly.