Causes of low back pain

According to the National Institute for Public Health and the Environment in the Netherlands, in 2017 more than 2 million Dutch people (out of 17 million) were known to the general practitioner with complaints of back and/or neck. In about a third of people, the complaints give limitations in daily life. The costs involved (medical costs, absenteeism and more) run into billions of euros. If we knew what the cause of all these complaints is, and if we have a good treatment then that would give a huge cost saving.

Medical causes of back pain

hernia: it is an intervertebral disc that is damaged and presses against a nerve; in particular, leg pain can be the result
narrowing (stenosis) of the spinal canal so that nervous tissue is trapped in the spinal canal; this also gives especially leg pain
tumor: can be a metastasis of cancer elsewhere in the body, but also a so-called benign tumor or cyst that nervous tissue is compressed
infection: for example in people with weakened resistance (diabetics, the elderly, drug users, skin infections, kidney disease, endocarditis, dental procedures, operations)
breakage (fracture) due to a fall or osteoporosis (mosst of the times a so-called collapse fracture of the front part of a vertebra)
inflammatory process: such as Bechterew's disease (ankylosing spondylitis) or other rheumatic diseases
scoliosis: too large and/or unstable curvature of the spine, as a result of which the process continues; can eventually also lead to internal complaints (heart, lungs, intestines)
Slippage of a vertebra (spondylolisthesis) usually does not cause symptoms but becomes problematic if the slipping continues.

The medical causes explain about 5-10% of the cases of low back pain. These causes involve specific back complaints because there is demonstrable evidence in the body of a specific structure or process that explains the symptoms. The other low back complaints are called non-specific. Here the specific causes are virtually excluded.

Non-specific causes of back complaints

So in the majority of people with back problems no specific cause is found. What is going on? Officially we do not know and that gives room to all kinds of ideas for which there is limited evidence. An attempt has also been made to subdivide the group with non-specific low back complaints into subgroups. Again, various classifications have been suggested with varying success. Deepening in this is certainly interesting because it gives insight into all kinds of possibilities to do something about the problem of back pain. For now it is too much to deal with these classifications, because that requires a few course days. I do mention here a number of views on causes that are shared by most musculoskeletal doctors:

posture problem
overload
too little load
disturbed way of moving
disturbed stability
leg length difference
limited basic condition
tension/stress.

Tension and stress

That tension and stress cause back complaints is under discussion. What they do is increase the susceptibility to complaints, especially if there is already a (latent) problem, such as overloading the back.

Known factors of tension are:

changes in (close) family such as death, serious illness, divorce, marriage
work-related general: pension, dismissal, poor working atmosphere, no control possibilities, poor contact with manager
work-related specifically: working in education or health care.

Often, back complaints only occur after the period with stress. The awareness was first 'too busy' with the processing of the stress, and now only registers the back pain.

Chronic low back pain: why does not it recover?

Chronic complaints are the case when the same complaints return again and again (the problem is not resolved) or exist for a long time and as a result gives rise to new problems. For example: there are compensations in the body to avoid pain, other areas are overloaded, there are limitations in work or privacy or the person in question becomes depressed because of the condition. The original reason for the complaint (if it is present) has already disappeared for a long time, the doctor finds that there is nothing 'broken'. It seems as if the pain has started to lead a life of its own and various back therapies do not help (anymore).

Factors, as mentioned above for non-specific complaints, can play a role in maintaining the complaint. The art is to recognize them. So it is often about the way the person deals with the complaint. The environment also plays a role in this (what does the general practitioner, physiotherapist, neighbor say, what are the demands of the work or the partner). In addition, the nervous system itself can be in a kind of alarm state without it being necessary. It is as if the thermostat is too high and can not be lowered. With this, the person continues to have a kind of extra sensitivity to the complaints. If this is interpreted as a warning signal that you have to be careful, then there is a risk of inactivity, so that the circle with, for example, too little load as a cause is round again.

It will be clear that chronic low back pain is a complex event and that more different factors always play a role (multifactorial).

And what do we do?

For an overview of possible therapists for back complaints: see our guide for back problems.

In practice for musculoskeletal medicine, examination of the cause of low back pain is the most important. After all, if it is not known what the cause is, then no good policy can be made with effective treatments. That is why a lot of time is spent on the conversation and the physical examination. In the conversation, as many of the factors as mentioned above will be discussed. The physical examination is used to:
- to test the ideas that have come out of the conversation
- looking for other factors
- to exclude factors
- to search for the recovery and treatment options of the person.
On the basis of these data, a thorough and delimited policy can be drawn up.

References
Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain 102 (2003) 167-178.
Polder JJ, et al. Kosten van ziekten in Nederland: de zorgeuro ontrafeld. RIVM rapport 270751005, 2002.
Nachemson AL, Jonsson E. Neck and back pain. Lippincott Williams & Wilkins, 2000.
Henschke N, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009 60 (10): 3072–80.