FYI's (for your information) and

FAQ's (frequently asked questions)

about Back and Leg Pain

Do you want general information on back pain? 

Do you have numbness, weakness, bladder problems, or bowel problems? 

Do you have acute back pain or shooting leg pain? 

Do you have chronic back  pain or have been told you need a fusion? 

Do you have cramping in your legs when you walk ? 

Do you have scoliosis? 

Do you have more questions? 

More book and web site references.

Or

Back and leg pain general information.

Low back pain and leg pain definitions.

The word lumbago simply means back pain.  Low back pain sometimes occurs with leg pain.  Sciatica is another name for leg pain.  The distinction is important.  Back pain is usually due to a bad disc but leg pain is usually caused by a pinched nerve.

The lowest portions of the lumbar spine bear the most weight and also have to allow for the greatest movement.  Because of this they wear out the most easily.  After age 30 the center of the disc (the nucleus) begins to shrink and its capsule begins to weaken.  The height of the disc decreases.  this causes an increase in the loading of the other structures in the back.  The joints and ligaments have to bear more of the load.  Degenerative disc disease (or “DDD”) is a term used by doctors to describe almost any disc problem or "wear and tear" involving the discs and low back.  It is not always due to degeneration.  It can be due to injury.   It is not actually a disease.. 

Disc problems are the leading cause of lower back pain.  As people age, the problem becomes more common.  Almost everyone over 18 years old has some “wear and tear” in their discs.  By age 30 the discs are losing water.  With every decade of aging, there is a 10% increase in the probability of having at least one damaged disc.

At birth, a vertebral disc is about 80 percent water and functions as a shock absorber between the vertebral bones. As the disc ages, the water content decreases and the disc becomes stiffer and more fragile. Tears first develop in the outer shell of the disc.  These tears can allow the softer disc tissue inside can leak out. The tears cause back pain.  The leakage (or rupture) of the disc causes leg pain.

Magnetic resonance imaging (MRI) is most commonly used to diagnose disc disease but shows the bones only poorly.  Plain x-rays show the alignment of the bones, and are used to check for fractures or after surgery.  CT scans are better ways to visualize bones but do not show the nerves.  CT scans with myelogram contrast injected in the back are probably the best study to see both the bones and nerves but they do hurt a little.

Twenty-five to thirty million Americans suffer from chronic low back pain, the number one cause of lost days from work in the U.S. Certain jobs, excess weight, alcohol use, and smoking all increase the chance of disc disease.  About 80% of people will have the problem at some time in their lives.  At any given moment, 15% of adults over 30 will have back pain.

There are many things you can do to protect your low back.  If you have mostly back pain, you probably have problems with the bones and discs.  If you have mostly leg pain, you probably have problems with the nerves.  If you are older and have problems when walking you most likely have stenosis.  All are discussed below.

Information on Preventing both back and leg pain

Weight is perhaps the single most important factor in degenerative disc disease.  If you control your weight (stay within twenty pounds of your ideal weight).  Added weight shifts your center of gravity forward and pulls the back into an abnormally twisted position.  Malnutrition can cause bone loss and muscle loss.  Both yo-yo dieting and excessive thinness can be detrimental.  Well balanced diets, although hard to do, help greatly. 

Smokers are more prone to back pain.  Nicotine restricts the flow of blood to the discs and weakens the discs.  Smoking also blocks calcium absorption and leads to weaker bones. 

Regular core strengthening exercises and resistance or weight training, flexibility (stretching) and aerobic exercise (3 to 5 times per week) all improve overall fitness and decrease the risk of back injury.  In general do each exercise slowly, do each twice a day, do five reparations of each and work up to ten or more, stretch before and after each session.  Consult a doctor before starting exercise programs. 

Proper lifting techniques and good postured are only the beginning.  When standing keep one foot forward or up on a small box.  Knees should be bent.  Sit with the knees higher than the hips and with good hip support.  Stand on a stool or ladder instead of stretching to reach overhead.  Pushing a heavy box is better than pulling it.  When lifting, use the knees and not the backs.  Keep the object close to the body.  It is better to carry one small object in each hand than to hold one large one.  Keep them close to the body.  When sleeping, keep the knees on pillows or sleep on the side with a pillow between the knees. 

Information on the causes of low back pain.

The cause is low back pain is often difficult to identify.  Pain can come from muscles, ligaments, joint capsules, cartilage, blood vessels, tears in the outside (annulus) of the disc, damage to the center of the disc (nucleus), damage to the nerves, and damage to the bones.  The pain can be severe from even minor damage.  The soft tissues (everything other than bones, discs, and nerves) are probably the most common culprits.  They are also the most difficult to treat.  

Acute pain is defined as lasting less than six weeks .  Chronic pain, on the other hand,  is defined as lasting more than three months.  Back pain may be burning, stabbing, aching, sharp, dull, well-defined or vague.  It may be mild or severe.  It can be variable during the day.  It is often worse after sleeping or sitting for a long time and is usually worse after strenuous activity.  It can come from a jarring or jerking activity, from lifting improperly, from lifting too much, and from a fall or a car accident.  (Treatments are described below, read on.)

For acute back pain or shooting leg pain start here.

Managing your own acute low back pain.

For an acute (new) back attack, the following can help you get better without the need for a doctor visit:

1. Rest in bed for a day or two but then begin gentle exercise such as walking or stretching;

2. Use ice or heat for comfort;

3. Elevate the legs when lying down;

4. Avoid prolonged sitting, change positions frequently;

5. Try over the counter pain medicines (like Tylenol) or nonsteroidals (like Advil, Motrin IB, or Naprosyn); and,

6. Return to normal activity (with mild pain medications if necessary) as soon as possible and certainly within a few days to a week.

Activity is the most important thing you can do.  Although most people think that you should stay in bed for back pain, studies have shown this to be wrong.  The sooner you return to your normal lifestyle (even if you have some pain), the less likely that you will need surgery.  If the pain is too severe to stretch or work after a few days, see your doctor (Schedule an appointment).

You should consider over the counter medications such as ibuprofen, Motrin, Naprosyn and similar medications.  You should follow the directions exactly.  Pain may cause trouble sleeping.  Benadryl, or its generic equivalents, are over the counter drugs which can help you sleep.  It has few risks.  A good night's sleep will help back pain. In addition, you can use herbs, see a complimentary provider (such as chiropractic, yoga, herbal medicine, and other non-traditional care). 

The good news is that 50% of acute back pain will resolve in two weeks or less.  Over 80% go away in 6 weeks.  Even the excruciating pain which is so disabling early on, it goes usually away very quickly.  In fact, back pain is rarely dangerous unless there are "red flags" (see below).   The bad news is that 30% if those with acute back pain will have a second episode within a few years.  In other words, the symptoms are usually self limited and unless they are associated with "red flags" as below, problems usually resolved.

For acute numbness, weakness, bladder or bowel problems start here.

Signs of an Emergency for acute pain (called "Red Flags" by your doctor)

If you have one or more of the following, do not treat yourself.  Go directly to your doctor or to an emergency room:

1. If the above "self help measures" do not work after a week or two;

2. For any bowel or bladder dysfunction, loss of sexual function, or numbness in the groin;

3. If you have severe weakness (including especially the inability to walk on one or both heels, this is called a foot drop);

4. Back pain that wakes you from sleep;

5. Back pain following a high speed trauma, like a car accident or significant fall;

6. Medication problems;

7. The need to use alcohol for pain control;

8. Worsening symptoms of any kind: or,

9. Worsening weakness or numbness.

If you think that you have something worrisome, or if you pain seems unusual, go to the doctor.  Your doctor will not complain.  An extra visit will not hurt you, or even cost much money, but it may save your life.  Your doctor will not be unhappy with you if you are just being careful.

What will your doctor do for your acute back pain?

Emergency treatment may be needed if you have a very large herniation, bowel or bladder problems, a foot drop or pain so severe that medications are ineffective.

1. First and most importantly, your doctor  will make sure you are safe;

2. A complete physical examination to detect signs of weakness, numbness or reflex change;

3. Scans to diagnose the cause of the problem;

4. Tell you what the problem is, and explain what medications, conventional treatments, alternative or surgery might be best for you (we rarely recommend surgery); and,

5. Make sure that the back pain is not caused by some other illness (gallstones, kidney stones, some cancers, some gastrointestinal problems, some heart and lung problems and some joint problems can cause back pain).

If properly treated, 80% to 90% of patients with disc herniations will improve with conservative care.  Your doctor will likely make sure that you are doing the right exercises.  He or she will probably write a physical therapy prescription.  Physical therapists teach patients how to do the exercise right.  Therapists also provide ultrasound, electric stimulation, hot and cold packs, and hands on or manual therapy.  Chiropractic is much like physical therapy but chiropractors have more training in aggressive techniques. 

Your doctor can give you medications that are stronger and more effective than those you can get without a prescription.  Typically you will be treated with a combination of at least three drugs.  The drugs you may get include:

1. Stronger and better nonsteroidal medications such as Lodine (stronger than Motrin and Naprosyn), Relafen (a little easier on the stomach), or COX-2 inhibitors (like Celebrex, even easier than the stomach but with more risk);

2. Muscle relaxants such as Valium (good but addictive), Soma (almost as good but not as addictive), Flexeril (almost as good but with more side effects), or Norflex and Skelaxin (not as strong but not addictive);

3. Short acting (3 to 4 hours per dose) narcotic pain medications such as Tylenol #3, Tylenol #4, Vicodin, Norco, Percocet, and Demerol (these are all addictive);

4. Long acting (24 hour or longer per dose) narcotics including Methadone, OxyContin, and MS-Contin (these are all addictive);

5. Anti-depressants such as Elavil, Trazodone, Effexor; and others which calm overactive nerve cell pain centers and are not addictive;

6. Anti-seizure medications such as Neurontin or Tegretol which also calm overactive nerve cell pain centers and are not addictive; and perhaps,

7. Sleeping medications such as Ambien, which is a little addictive but may be needed for short periods.

IMPORTANT NOTE:  Do not drive a car, operate equipment, do anything dangerous or sign documents when using pain killers, muscle relaxants, or sleeping medicines.  Do not do so when starting new seizure or anti-depressant medications. 

Your doctor may order tests.  These may include x-rays (to make sure that there are no broken bones), CT scans or Bone scans (to further test the bones), MRI scans (to look at discs, nerves and some other soft tissues), or MRI scans with contrast (to check for scar tissue in those who have had surgery or whose plain MRI is not clear).

For acute pain, and depending on whether the above treatments work, and on what the scans show, you may need a shot, or even a surgery.  Trigger point injections can help to relieve muscle spasm.  Nerve blocks are very helpful for shooting leg pain from a pinched nerve.  They take only a few minutes and have few risks.  We used to do them in groups of three but have learned that just one is enough for most patients.  Facet blocks numb the small joints in the back.  They are good for some types of back pain from arthritis.  Discectomies (also called laminectomies or laminotomies) are operations that "un-pinch" a nerve which is causing leg pain.  Discectomies will work for about 90% of patients who do not improve with conservative care.  Discectomies work best for leg pain.  They will not fix all back pain.  Discectomies can be done using microscopes, endoscopes and lasers.  Using the correct technology will be up to your doctor and will depend on the shape and size of your disc herniation.

Surgery can be done under local anesthesia, spinal anesthesia or general anesthesia.  General anesthesia is the most comfortable and recent studies have shown that it is safer than regional or spinal anesthesia.

Discograms, Fusions and Artificial Discs are not usually considered for acute back pain unless there is a broken bone.

For chronic back  pain or if you've been told you need a fusion start here.

Managing your own chronic low back pain.

1. Bed rest longer than a few days is not appropriate and makes things worse;

2. Use ice or heat for comfort, do not use an electric heating pad in bed (they can cause third degree burns);

3. Consider A TENS unit (they are inexpensive and work at least half of the time);

4. Elevate the legs when lying down or sitting in a recliner;

5. Sleep with the legs up or sleep on your side with a pillow between the knees;

6. Try over the counter pain medicines (like Tylenol) or nonsteroidals (like Advil, Motrin IB, or Naprosyn), (if these do not work, your doctor can give you stronger  medications); and,

7. Do not stop your  normal activities if at all possible.

You should consider over the counter medications such as ibuprofen, Motrin, Naprosyn and similar medications.  You should follow the directions exactly.  Pain may cause trouble sleeping.  Benadryl, or its generic equivalents, are over the counter drugs which can help you sleep.  Benadryl is a strong drug with few risks.  A good night's sleep will help back pain. In addition, you can use herbs, see a complimentary provider (such as chiropractic, yoga, herbal medicine, and other non-traditional care  For chronic pain counseling is often very helpful.. 

Signs of an emergency or "Red Flags" for chronic  pain.

The "red flags" are almost  the same as those for acute pain and should get you to go directly to your doctor or the local emergency room:

1. If the "self help measures" do not work ;

2. Bowel or bladder dysfunction, numbness in the groin;

3. Severe weakness, including inability to walk on the heels;

4. Back pain that wakes you from sleep;

5. Back pain following a high speed trauma;

6. If medication do not control problems;

7. Worsening symptoms : or,

8. Worsening weakness or numbness.

If you think that your pain is unusual, go to the doctor.  Your doctor will not complain

What will your doctor do for your chronic back pain?

Chronic pain, by its very definition, lasts a long time and is difficult to treat.  The treatment depends on the type of pain.  Midline back pain is usually due to a broken bone, a bad facet joint, or a bad disc.  Leg pain can be due to spinal stenosis or a chronic disc herniation.
 

Multi-disciplinary pain clinics can be very helpful.  They provide counseling, help in coping with pain, special expertise in adjusting medications or using the drugs in combination.  The medications which can be used for pain are numerous and include many which are not narcotic or addictive.  Other non-procedural interventions include physical therapy and alternative medical treatments.

If all else fails, surgery may be needed.  For chronic midline pain, fusions are most commonly required if non-surgical treatment fails.  For leg pain, a decompressive surgery is often recommended.

If your chronic pain comes from a broken bone, a bad facet or a damaged disc there are a few treatments.  If you have a spondylolysis (a type of fracture), once it causes symptoms it almost always needs to be fixed.  The surgery to fix a broken bone is called a fusion.  Adjacent bones are set in a way that they will heal.  A mending plate with screws will hold the bones in place till they heal. 

Facet blocks numb the small joints in the back.  They can tell if the pain is coming from a facet.  If you have facet pain, facet rhizotomies can be done for more lasting relief.  Fusions can be done to remove the painful facet entirely.  

IDET procedures are operations done with a needle.  They work by heating the annulus or covering of the disc.  This may strengthen the proteins of the disc.  It may shrink a bulging disc.  It may kill some of the pain causing nerve roots.  They are controversial.  Although they work about 50% of the time, and have saved many people the need for a more invasive fusion, most medical insurance companies no longer are willing to pay for the procedure.

Discograms are tests that show if the pain is coming from a disc.  Fusions in the low back are for instability (a broken bone usually, but occasionally a positive discogram test.  Fusions are major operations that are done when all else fails.  They generally should not be done in people over 65 except for extreme cases (the risk is too high). 

Artificial discs are brand new.  They are still semi-experimental.  There are two types.  The first type (which is now available on a limited basis) is one where the entire disc is replaced with metal and plastic.  Since young people are often considered for this surgery, there is a great risk that the device will not last that long and will wear out or break.  The early data is not encouraging.  The second type is a replacement of the center of the disc only.  This product is not yet available in the United States and there is no good data indicating that it will be a good choice.  Based on current data, artificial discs may be good in certain very select individuals who have just one bad disc and are at risk of developing one more.  They cannot be used in the presence of a slippage or instability, after certain disc surgery done from behind, if the patient has any metal allergies, during pregnancy, if one is on steroids, or if one has autoimmune problems.  In this practice we do not advise experimental or semi-experimental surgery with rare exception.

If you have  mostly have cramping in your legs when you walk (spinal stenosis) start here.

Managing Your Own Spinal Stenosis.

Spinal stenosis is a problem of the elderly.  It is rare in people under If have pain which radiates to both legs when you walk, it is called "claudication."  This problem gets worse with walking a distance.  People with this typically can walk for a certain distance and then must sit for a few minutes before walking again.  If you are not bothered by the limitation, you may be able to ignore it.  If you have this pain, try stopping and bending forward when you have symptoms.  You can also try over the counter analgesics (Tylenol, Aspirin, Motrin, Naprosyn, or similar).  If you cannot comfortably do activities of daily living, you probably need either an epidural or a surgery.

If you cannot do the activities important to you, you should seek treatment.

Note that spinal stenosis may not cause symptoms.  If you have the stenosis (by MRI for example) but have no symptoms, you probably do not need any treatment.

Signs of an emergency or "Red Flags" for Spinal Stenosis.

The "red flags" are almost  the same as those for chronic pain :

1. If the "self help measures" do not work ;

2. Bowel or bladder dysfunction, numbness in the groin;

3. Severe weakness, including inability to walk;

4. Worsening symptoms : or,

5. Worsening weakness or numbness.

What will your doctor do for your Spinal Stenosis?

You may have either spinal stenosis or vascular disease.  You first step should be to see either a spine surgeon or a vascular surgeon.  Both spinal stenosis or vascular disease are correctable problems if properly diagnosed and treated.  If you pain is due to vascular disease, medication can sometimes help.  Surgically fixing the bad blood vessels  can often completely correct a vascular problem.  If your pain is due to spinal problems, it can be corrected using a limited and straightforward procedure called a spinal decompression. 

The first and most important task is to find the cause of the problem.  If the problem is from compression of the nerves, your spine doctor can tell by examining you.  One of the easiest test is to have you stretch your back into extension (backwards) and then into flexion (forwards).  If extension causes the pain and flexion relieves it, the problem is likely spinal stenosis.  Your doctor will then find out how bad it is by asking you some questions.  Spine doctors do not treat this problem unless:

     1.      you are healthy enough to stand surgery

     2.      you have no other problems (hip, knee, heart, etc.) that would stop you from walking even if your back were

               fixed; and

     3.      unless the stenosis is bad enough to make normal activities hard for you. 

If the doctor still thinks you need treatment, he or she will then likely order an MRI scan or a CT scan.  The scan will show whether the problem is from the discs, the joints, the ligaments or some combination.  An epidural steroid injection can relieve symptoms for months or for years.  In this practice we have a number of patients that we see once a year for a shot, and they can do everything while avoiding surgery.  Spinal stenosis can be fixed with a simple operation where the room for the nerve roots is increased by removing some of the arthritis.  This is the decompression.  The operation takes an hour or two, does not usually require more than a few days in the hospital, and is safe.  The scar may be long since many vertebral bones are involved and you may need a few days of rehabilitation.

Fusions are not needed for spinal stenosis.  Spinal stenosis is a disease of the elderly.  The bones are already naturally partially fused.  They are not unstable even if the shape of the spine is not ideal.  Long fusion operations for spinal stenosis are very major procedures which can take up to eight hours and which are too invasive for an older person.  The risk of complications is usually greater than the problem if a fusion is attempted.

If you have scoliosis, start here.

Back Problems From Scoliosis.

Scoliosis is divided into three categories:  congenital, Idiopathic and neuromuscular.  In some cases, treatment can involving only observation or bracing.  If the problem is severe, surgery is needed.  At Northern California Neurosurgery we do not do major scoliosis surgery.  We recommend that you seek a referral through the North American Spine Society web site.  In the East Bay area near San Francisco, we refer our patients with scoliosis to Robert Rovner, M.D., a scoliosis specialist.  His phone number is 925-275-8080.

If you have more questions, start here.

More Back Pain FAQ's (Frequently Asked Questions).

Q.  How can I avoid back problems?

At work, when lifting bend the knees and keep the back straight.  Push rather than pull.  Stretch before and after any strenuous work.  A back belt does not decrease the risk of injury, is hot and heavy, and may give you a false sense of security.  Do not use lifting belts.  When standing, keep one foot up.  use a box or a step.  When sitting, use a good chair with the knees above the back.  When reaching use a ladder or stool.  When carrying, use two small packages instead of one.  A small package in each hand will let you balance more easily and will decrease the risk.

Q.  What can women do to avoid back problems?

A.  All of the advice above (in the last question:  exercise, weight loss, and avoidance of smoking and drinking) apply to women as well.  Women also have special risks not shared by men.  High heels should be avoided.  Good scientific studies show that the height of the heels correlates strongly with the chance of developing a bad back.  Lifting heavy children is a great risk.  It is hard to use good lifting techniques when picking up a squirming child.  Instead of picking up your kids, get down on the floor or onto a bed to play with them.  Let the kids climb stairs with assistance.  Use a good quality stroller with quality wheels.  Women are especially prone to osteoporosis.  Take supplements and do exercise.

Q. What if the MRI Scan shows a herniated disc? What do I do then?

A. If you have a herniated disk, you should see a spine specialist.  The doctor will first diagnose the cause of the problem.  Unless there is severe pain or weakness, conservative care will usually be recommended.  Exercise and pain medications are used first.  Chiropractic or acupuncture may be helpful.  If these do not help, a steroid shot may be advised.  Surgery is usually the last resort.

Q. When is leg pain an emergency?

A.  You should see a spine specialist immediately if you have any of the following:  severe pain extending down your leg; if the leg pain increase when you lift your knee to your chest or bend over; if you have had a recent injury; if the pain lasts more than three to six weeks; if your back pain becomes worse at night or wakes you up from sleep;  if the pain is accompanied by a fever; or, if  you have bladder or bowel problems.  Night pain can be caused by some tumors. Bladder and bowel problems may indicate the presence of a cauda equina syndrome, that is a compression of all of the nerves in the low back, which needs to be fixed immediately.  Weakness in the foot is an emergency, especially if one cannot easily walk on one's heels (a drop foot).

Q. Are there other causes of sciatica?

A. Not all leg pain is caused by herniated discs.  Other causes of leg pain include: fibromyalgia (a generalized pain syndrome); sacroiliitis (inflammation of the sacroiliac joint); lumbar facet syndrome (damage to the small joints in the back);  piriformis syndrome (a pinched nerve deep in the muscles of the buttock); Iliolumbar syndrome (inflamed ligaments of the pelvis); or, lumbar spinal stenosis (a narrowing of the space for the nerves).  Each of these problems are treated differently.  Most can be handled with medication or minimally invasive procedures.

Q.  What is a Drop Foot

A. Drop foot is not a disease but a symptom.  It is caused by weakness of the muscle that lifts the foot up at the ankle (the tibialis anterior muscle).   The drop foot may be temporary or permanent.  Drop foot is most frequently caused by injury to the L₅ nerve root.  The L₅ nerve is usually injured by a bad L₄-L₅ disc. Of all the lumbar nerve roots, the L₅ root heals most slowly.

Occasionally, a drop foot can be caused by an injury to the peroneal nerve.  The peroneal nerve is a branch of the sciatic nerve and can be injured during hip or knee surgery. It can be injured by a deep bruise or a bad  laceration.  Drop foot can also be caused by Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS). The cause can be determined using MRI (magnetic resonance imaging), and EMG (electromyogram).   A drop foot can be an emergency condition, and you should see your spine doctor immediately if you develop this problem.

The type of treatment is dependent on the cause of the drop foot. An ankle foot orthosis (AFO) brace, can prevent falls. The damaged nerve should, however, be repaired as soon as possible.  If a disc is the problem, it should be corrected immediately.  If the nerve is damaged by a knife wound, repairing it is also urgent.

Q.  What is a vertebroplasty?

A. Vertebroplasties and Kyphoplasties are procedures which are very similar.  Both are used for older patients with osteoporosis and vertebral fractures.  Both fill the collapsed or broken bone with plastic to strengthen it.  Both are minimally invasive and effective in relieving pain.  They do not restore the normal shape of the vertebral bone in most cases (in spite of some of the manufacturer's claims).  They have some risks.  The plastic can leak out and pinch nerves in the back.  The plastic can cause a spinal cord injury.  Dangerous drops in blood pressure are occasionally seen during the procedure.  Occasionally, bits of the plastic will migrate to the lungs and cause damage there.  Overall, the benefits still outweigh the risk.  Vertebral bone fractures are so painful that older people may remain in bed.  Prolonged bed rest has a higher risk than the Vertebroplasty or Kyphoplasty.

Q. What do I do if I have a spinal tumor?

A.  Spinal tumors are uncommon.  They are divided into several groups according to their source and their location. 

Metastatic tumors:  These are tumors that have spread from somewhere else in the body.  Lung cancers, gastrointestinal tumors, breast tumors, kidney tumors, myelomas and other cancers can spread to the spine.  These usually affect the vertebral bones.  If the diagnosis is known, the treatments are usually non-surgical.  Chemotherapy and radiation treatments are most commonly used.  Surgery is only recommended if the spine is unstable.

Dural tumors:  The most common dural tumors are "meningiomas."  These are typically benign.  They can usually be removed with a limited surgery and only a low risk of neurologic damage.  Once removed these can recur.  Radiation is sometimes used to decrease the risk of recurrence.

Nerve root tumors:  Nerve root tumors may be solitary or part of a syndrome (like neurofibromatosis).  When these are single, they can be removed with surgery.  When multiple, your doctor will usually try to avoid surgery unless absolutely necessary.

Other tumors:  There are a number of uncommon tumors that invade the spine.  These can include some that spread from the brain and some that occur in the other structures of the spine.

Tumors are easily diagnosed by MRI with contrast.  If you think you have a spinal tumor, you should see a neurosurgeon.  Neurosurgeons specialize in spinal tumors.

Q.  Can sports injuries affect my back?

A.  Yes.  Although sports injuries to the low back are much less common than neck injuries, they still happen.  They are most common in the young athlete.  Most back injuries are sprains or strains.  These can be treated with rest, instruction in proper body mechanics and over the counter analgesics.  Appropriate exercises will speed recovery once the pain is gone.

In young people a spondylolysis can occur.  This is presumed to be due to a type of stress fracture to the back of one of the vertebral bones.  An MRI can show the area of stress before a fracture develops.  By limiting activities, and removing the stress, one can prevent the fracture and avoid the need for surgery entirely.

If a young athlete already has a spondylolysis, he or she can still play sports if there is not significant slippage.  If there is significant slippage, the athletes should avoid very strenuous sports or contact sports.

Q.  What is Scheuermann's disease (juvenile kyphosis)?

A.  This is a common problem in young people and can present as a sports injury.  At puberty the thoracic part of the back develops an abnormal forward curve called a kyphosis.  Treatment is intended to relieve symptoms and surgery is rarely needed.  Bracing can be helpful if the curve is greater than about 50 degrees.

Q.  Do young people get disc herniations?

A.  Yes.  Although uncommon, we have seen children as young as 12 with ruptured discs.  Many recover with time and analgesics.  Some, like adults, require surgery.  When surgery is needed, the good news is that kids do much better than adults in healing.

Q.  What if I am a woman with a bad back and want to have a baby?

A.  Even if you have never had a back ache, there is a fifty percent chance that you will have back pain when pregnant.  The extra weight and the change in posture both increase the stress on the discs.  If you have had back pain, the chance that a pregnancy will cause more pain is almost one-hundred percent. 

If you want a baby, back pain should not stop you.  There are many ways to protect your back during pregnancy.  First, continue to do exercises during your pregnancy.  If you don't already have an exercise program, physical therapists can teach you a safe way to strengthen your back during pregnancy.  Second, you will gain some weight but avoid adding too many pounds.  Talk to your obstetrician about your optimal weight gain.  Next, remember to limit lifting and carrying.  Sleep on your side not your back.  Put a pillow between your knees.  Finally, do not take any herbs, prescription drugs, or over the counter medications without the approval of your obstetrician.

Q.  What can older people do about back pain?

A.  Avoid surgery at all costs.  If you need an operation, pick the shortest and safest procedure.  The time needed for the surgery greatly increases the risk in older people.  Older people almost never need a fusion.  The risk of fusion is too great.

To prevent injury and decrease the need for surgery, begin an exercise program.  Exercise will help you develop better balance, faster reflexes, and of course stronger back muscles.  Exercise will cut the chance that you will have osteoporosis and improve your alertness.  Walking, swimming and using light hand held weights call all be helpful.  Many senior centers offer free or low cost exercise classes.

Q.  How can I prevent osteoporosis?

A.  Osteoporosis is bone loss.  The bones become brittle and break more easily.  This is especially true of the vertebral bones.  When they break, they can cause severe pain.

Curing osteoporosis is not possible.  Once the bone is lost, it is not easily rebuilt.  Preventing osteoporosis is, fortunately, fairly easy.  If others in your family have osteoporosis, you need to be especially careful since your chance of having problems is increased.

It is best to start in childhood but even the elderly can benefit from several simple tips.  First, get enough calcium and vitamin D.  Both are found in dairy and green leafy vegetables.  Supplements for both are inexpensive.  Second, exercise regularly.  Walking two miles a day is plenty to prevent bone loss and weight gain for most people.  Third, stop smoking.  Smoking kills bone cells.  Next, limit alcohol use.  Too much speeds bone loss.  Finally, avoid fad diets.  they do not contain enough nutrients.

Q.  What is bone morphogenic protein (BMP, OP-1, etc.)?

A.  This is a hormone that is a normal part of bone.  It promotes bone healing and bone growth.  It can now be made artificially and is used to increase the rate of success in lumbar fusions.  It may cause nerve injury if placed too close to the nerve roots so care is taken to keep it far away from the nerves.

Q. How can I protect my back?

A.   are recommended as below, and,

B.  follow several simple guidelines which have published by the North American Spine Society:

1. Strengthening exercises and stretching exercises - Do them every morning and every evening.

2. Standing - Keeping one foot forward of the other, with knees slightly bent, takes the pressure off your low back.

3. Sitting - Sitting with your knees slightly higher than your hips provides good low back support.

4. Reaching - Stand on a stool to reach things that are above your shoulder level.

5. Moving Heavy Items - Pushing is easier on your back than pulling. Use your arms and legs to start the push. If you must lift a heavy item, get someone to help you.

6. Lifting - Kneel down on one knee with the other foot flat on the floor, as near as possible to the item you are lifting. Lift with your legs, not your back, keeping the object close to your body at all times.

7. Carrying - Two small objects (one in either hand) may be easier to handle than one large one. If you must carry one large object, keep it close to your body.

8. Sleeping - Sleeping on your back puts 55 pounds of pressure on your back. Putting a couple of pillows under your knees cuts the pressure in half. Lying on your side with a pillow between your knees also reduces the pressure.

9. Weight Control - Additional weight puts a strain on your back. Keep within 10 pounds of your ideal weight for a healthier back.

10. Quit Smoking - Smokers are more prone to back pain than nonsmokers because nicotine restricts the flow of blood to the discs that cushion your vertebrae.

11. Minor Back Pain - Treat minor back pain with anti-inflammatories and gentle stretching, followed by an ice pack.

For Still More Information.

For more information on back pain, see the North American Spine Society Web Site of the American Association of Neurological Surgeons Web Site.

For common sense books see Your Spine, The Back Book or Back Pain Remedies for Dummies.  All can be ordered online.  For Your Spine, see http://www.spine.org/spine_owners_manual.cfm.  For The Back Book or for the "Dummies" series see www.amazon.com.  Studies have shown that merely reading one of these books will decrease the chance that you will develop chronic back pain.