How Acute Back Pain Becomes Chronic
In industrialised countries back pain problems limit physical abilities in people under forty-five years more than any other pathology. Chronic covers a problem persisting beyond three months, which is a typical healing time for bodily soft tissues which may be affected by the injury. There is a biological purpose to acute pain syndromes, to prevent us from continuing with an activity which is causing tissue damage and to force us to take care of the injury until it heals. Chronic pain syndromes have none of this useful biological function and appear to be without use.
Overall back pain is very common and up to 20 percent of the population may have long term and recurring problems but they are not continually severe. A small group of 5-7 percent of back pain suffers develop a chronic pain problem which is disabling and prevents work. It is a relatively common cause of undergoing a surgical procedure and because much of the structure of the intervertebral discs is avascular this may slow the healing period significantly and make resolution of the problem less likely.
Injuries occurring to the spine and the onset of degenerative changes in the joints and the discs may explain many of the back pain problems which arise but there is a poor relationship between the amount of pathological changes in the spine and the level of pain suffered by a patient. MRI scanning reveals many disc changes such as protrusions or prolapses in individuals who are not complaining of significant pain. The causes are not well understood but may include inflammatory and neurological influences.
Commonly the available diagnostic studies do not identify a particular pathology which can be connected with the back pain syndrome being investigated, at which time psychological factors are typically considered as possible causes. Psychological factors are known to be important in the development of severe pain and disability from simple low back pain but cannot be seen as causative factors as modern investigations may be insufficiently sensitive to pick up painful pathologies. Social and psychological factors should still be identified and treated as soon as they can be assessed and a management programme begun.
Claims for low back pain are highest in those occupations which involve repetitive heavy work such as operating heavy machinery, driving lorries and working on construction sites. The occurrence of back pain and sciatic leg pain appears to be high over the lifetimes of workers in work such as road construction. Sciatica only occurs in about 5% of low back pain cases but is one of the most frequent reasons for surgical management, with the L4/5 level being operated on most, followed closely by the L5/S1 level. In the United Kingdom surgery for sciatica is relatively low, but in the United States and other countries the numbers of such surgeries may be much higher.
It is in western industrialised countries that the levels of disability from chronic low back pain have become very high with typical social and economic consequences. No genetic factors have been distinguished between different races to explain the variation in causative mechanisms. The split between male and female sufferers is about equal and people report low back pain mostly in middle age when the large majority have evidence of spinal degenerative changes. Sciatica, closely related to disc changes, occurs mostly in the 30s and 40s with age 42 being the average age for lumbar discectomy.
The lumbar spine is the last part of the flexible spinal column and is meant to support the upper body weight as it is passed through to the legs in gait. Compared to its size the lumbar spine is able to cope with heavy loads which are passed via the sacroiliac joints to the pelvis and to the hips. The lumbar bones are relatively mobile whilst still managing to transmit significant loads by means of their internal bony architecture where the cancellous strut formations align in strengthened areas to fit the applied forces. The lumbar vertebrae have to transmit greater and greater forces as they go down and for this purpose the vertebral bodies become larger the lower they are.
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