Is

low back
pain
getting on your nerves?
By Yvonne DArcy, CRNP, CNS, MS

ow back pain is a very common patient complaint.

The back is one of the most integral structures of
the body, providing support for muscles and tendons while protecting the spinal cord. Because it is the
foundation of the bodys support, it is subject to wear and
tear from overuse, incorrect use, disease, the aging process,
and obesity. Any of these can cause deterioration of the
vertebral bodies and disks, resulting in low back pain.
A 2002 study reported that 26% of respondents experienced low back pain during a 3-month period.1 Nonspecific
low back pain is the fifth most common reason for health10 The Nurse Practitioner Vol. 34, No. 5

care provider visits in the United States.2 It not only causes

pain and suffering for patients, but depletes healthcare resources. Correspondingly, the costs of time lost from work
and disability reach into the millions of dollars. Proper treatment of back pain can include medication, exercise, or even
surgery.
Patients at risk
The pain and disability of low back pain are the most
common reasons patients seek healthcare.3 The condition can be caused by a number of factors, including arthriwww.tnpj.com

2.1

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tis, aging, normal wear and tear, degeneration, arthritic

bone spurs, structural damage, or a malignancy. 4 Risk
factors that predispose patients to low back pain include
the following:
poor physical condition without a regular exercise regimen
age over 55 years
lifting heavy loads or engaging in daily hard physical labor
obesity
reduced spinal canal dimensions (spinal stenosis)
lower socioeconomic status (less access to healthcare).4-6
Workers who sit at desks for long periods of time or
stand all day may find that low back pain can be a life-altering
condition. Quality of life is heavily affected by chronic low
back pain, as pain may interfere with the ability to work,
sleep, and maintain relationships.
As the U.S. population ages, the prevalence of low back
pain resulting from degenerative changes seen in these
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patients will increase. There are 89 million baby boomers

who are at risk for degenerative disk disease (DDD).7 A
high prevalence of arthritis will contribute to a large number of patients with low back pain from facet disease and
bone spurs.
The spine and common spinal conditions
The spine consists of vertebral bodies and disks. The vertebrae are divided into three major sections: cervical, thoracic,
and lumbar. There are seven cervical vertebrae, identified as
C1 through C7; 12 thoracic vertebrae, identified as T1
through T12; and five lumbar vertebrae, identified as L1
through L5.
Below the lumbar vertebrae are the sacrum, consisting
of five fused vertebrae, and the coccyx with four fused vertebrae.8 The spine has normal curvatures at the cervical and
lumbar area (see The spinal column). Proper posture mainThe Nurse Practitioner May 2009 11

Low back pain

The spinal column

Below is a sagittal view of the spine with the normal
curvatures.
Sagittal view
External acoustic
Mastoid meatus
process

Occipital
bone
Atlas

C-1
C-2

Axis

C-3
C-4

Cervical
curvature

C-5
C-6

Vertebra
prominens

C-7
T-1
T-2
T-3

Superior articular facet

T-4

Facet for tubercle of rib

Spinal nerve

T-5
T-6

Thoracic
curvature

Intervertebral disk
Demifacets for heads of ribs

T-7
T-8

Body of vertebra

T-9

Spinous process

T-10

Inferior vertebral notch

T-11

Superior articular
process

T-12
L-1
L-2

L-3

Lumbar
curvature

L-4

L-5

Promontory
Sacral
curvature

Sacrum (5 fused vertebrae)

Coccyx
(4 rudimentary
fused vertebrae)

Source: Anatomical Chart Company.

12 The Nurse Practitioner Vol. 34, No. 5

tains spinal alignment and can decrease the possibility of

low back pain. The vertebral body has a central canal for
the spinal cord and transverse processes where the spinal
nerve roots are located.
Each vertebra has a vertebral body that is separated
from the adjacent vertebra by a soft, fluid-filled gelatinous
disk.8 This disk acts as a cushion for mechanical stress and
gives the spine its flexibility. It also maintains support and
posture. Each disk is surrounded by a fibrous envelope,
known as the annulus, that consists of 12 concentric layers
of fibrous tissue. This tissue helps secure the disk in place
(see Normal vertebra).
The aging process has an acute effect on these disks.
By age 20, the vascularity of each disk decreases, and by
age 30, the desiccation of the disk can cause fissures in
the vertebral body endplates. This leads to DDD, which
is not so much a disease, but part of the aging process.7
As degenerative changes take place and each disk becomes less supple, compression can cause the disk to rupture through the annulus, resulting in a herniated disk
(see Herniation and pain in disk injury). This can be extremely painful since the nerve root can be impinged
leading to radiculopathy.6 Patients with DDD develop
vertebral osteophytes; this condition is called spondylosis.7 The disk becomes flatter, cracks develop, and the
vertebra develop roughened edges where osteophytes
(bone spur type formations) form. It can also affect the
facets of the spine and develop into facet disease.
Two other spinal conditions can cause low back pain.
Spondylolysis is a defect in the vertebral arch caused by
mechanical stress. This injury is found in children who
participate in gymnastics and other sports,such as wrestling
or football, where hyperextension of the spinal body is
possible.7 The damage in the posterior part of the vertebra causes the vertebral body to become malpositioned,
generally in the lumbar spine. Because of the malpositioning, the patient will present with constant low back
painthere may also be motor or sensory loss at L4-5
and S1. Spondylolisthesis is a subluxation of the lumbar
vertebrae where one vertebra overrides the lower vertebra. It can present with severe pain and radicular symptoms, bowel or bladder dysfunction, and weakness in the
lower extremities.
Older patients with osteoporosis may experience
vertebral compression fractures. These compression
fractures are extremely painful as the nerve root of the
vertebral body is compressed. Osteoporosis causes the
vertebral bone to become porous and prone to fracture
(see Osteoporosis). Older patients also experience desiccation of the vertebral disks, which destroys the cushioning
function.
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Low back pain

Normal vertebra
Below is a superior view of a normal vertebra.

Superior aspect

Spinous process

Dura mater
Arachnoid

Internal vertebral venous plexus

Lamina
Spinal cord

Pia mater

Dorsal root
of spinal nerve
Superior
articular facet

Root sheath

Spinal ganglion
Ventral root of
spinal nerve
Vertebral veins

Anulus
fibrosus

Pedicle
Vertebral artery
Vertebral body
Nucleus pulposus

Posterior
longitudinal ligament

Intervertebral cartilage (disk)

Anterior longitudinal ligament

Source: Anatomical Chart Company.

It is estimated that 95% of the population will have DDD

by age 50.7 Patients with DDD present with deep midline
low back pain that can radiate to buttocks or thighs. There
may be motor weakness, sensory changes, absent or diminished reflexes, and, in more severe cases, bowel or bladder
dysfunction.8 Patients with spinal stenosis and herniated
disks account for 3% to 4% of low back pain patients;
cancer, 0.7%; and compression fractures, 4%.2
Diagnosing low back pain
The American College of Physicians and the American Pain
Society have developed a joint guideline for diagnosing
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and treating low back pain.2 The first guideline recommendation requires a complete focused history and physical
exam. A focused history and physical exam can indicate
the frequency of symptoms, location and duration of the
pain, history of the pain, and prior treatment. Information
about any concurrent infection or neurologic symptoms
such as numbness or muscle weakness should also be
investigated.
The physical exam should include the straight leg raise
to determine if a disk is herniated. Since most herniated disks
occur in the lumbar spine, this diagnostic tool, along with a
neurologic exam that includes great toe and foot dorsiflexion,
The Nurse Practitioner May 2009 13

Low back pain

dominal area of the body. The

use of plain radiography and
advanced imaging with computerized tomography (CT)
or magnetic resonance imaging (MRI) have not been assoThird lumbar
vertebra
ciated with improved patient
outcomes. For the majority of
Normal disk
patients with nonspecific back
pain, the use of imaging creates
increased exposure to radiation, increased cost of treatment, and does not positively
Herniated disk
affect treatment outcome.
The third recommendaHerniated nucleus
tion indicates instances where
pulposus impinging
imaging should be used.2 Paon spinal nerve
tients who have severe or progressive neurologic deficits or
Pain pathway
those in which serious underalong nerves
lying conditions are suspected
should have diagnostic imaging and testing. Conditions
that merit immediate imaging
Sacrum
include cancer with suspected
cord compression, vertebral
infection, and cauda equina
syndrome. MRI is preferred
Source: Anatomical Chart Company. Atlas of Pathophysiology. 2nd ed. Philadelphia, PA: Lippincott Williams &
over CT because it allows betWilkins;2006:141.
ter visualization of the spinal
structures. MRI can detect annular tears and disk fragments, and is helpful in identifyplantar dorsiflexion, and ankle reflexes, can identify the area
ing cancer and infection.
of pain. Practitioners should look for the patient to experiThe fourth recommendation states that those who preence pain when the leg is at a 30 to 70 degree increase, as that
sent with persistent low back pain and signs and symptoms
range affects the nerve roots.2
of radiculopathy or suspected spinal stenosis should be evalThis information can be used to categorize patients
uated using an MRI, the preferred imaging study, or CT
in one of the following groups: nonspecific low back pain,
only if the patient is a candidate for surgery or epidural
back pain potentially associated with radiculopathy or
steroid injection.2
spinal stenosis, or back pain potentially associated with
2
another spinal cause. Practitioners should also assess for
In addition to diagnosing the physical injury, practipsychosocial risk factors (for example, depression, lack of
tioners should be aware that depression is common in pacoping skills, anxiety disorder, and substance abuse distients with chronic pain, and the rate of suicide in patients
order) that could predict the risk for chronic disabling
with chronic pain is twice the rate of patients without pain.9
back pain. This assessment is more predictive of the outPractitioners should assess patients moods at each visit, and
come of treatment than the physical exam or the pain
explain to them that depression is not uncommon for those
severity or duration.
with chronic pain.
The second recommendation states that clinicians
should try to avoid imaging or other diagnostic tests in
Pharmacologic treatment options
patients with nonspecific low back pain.2 Rationale for
Acute low back pain generally resolves within 6 to 12
this recommendation includes the exposure of patients
weeks, regardless of treatment.10 The 15% of patients with
to unnecessary radiation in the lumbar and lower abacute low back pain who do not improve within that time
Herniation and pain in disk injury

14 The Nurse Practitioner Vol. 34, No. 5

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Low back pain

Osteoporosis
The illustrations below show the normal vertebrae, mild osteoporosis, and severe osteoporosis.

Normal
vertebrae

Mild
osteoporosis

Severe
osteoporosis

Source: Anatomical Chart Company. Diseases & Disorders. 2nd ed. Skokie, IL: Lippincott Williams & Wilkins;2005:53.

period are considered to have chronic

low back pain.3 Treatment approaches
differ, depending on the severity of
back pain.
Medications are the first line of
pain management for most patients,
but the challenge is: Which medication and for how long? In a recent
study, 80% of primary care patients
who complained of low back pain
were prescribed at least one medication at the initial office visit; more
than one-third were prescribed two
or more.11
Acetaminophen. One of the most
common medications patients use at
home and that is recommended by
clinicians is acetaminophen. It has
minimal risk when taken in dosages
lower than the recommended adult
maximum dose of 4,000 mg/day. Doses
of 4,000 mg/day can result in asymptomatic elevations of liver function
tests even in healthy adults, but the risk
profile to these increases has not been
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Adjunct pharmacologic treatment options2,11

Muscle relaxants

Short-term use for acute low back pain

No indication for medications that treat
spasticity

Tricyclic antidepressants

Used in chronic low back pain as an adjunct

for treating low back pain with a neuropathic
component (the drug dosage used for pain
management is much lower than the dosage
used to treat depression)

Systemic corrticosteroids

Not indicated for treatment of low back pain

with or without sciatica

Antiseizure medications

Gabapentin (Neurontin) can be used in

patients with radiculopathy
Not enough evidence to support the use of
other antiseizure medications

Benzodiazepines

Similar short-term pain relief as muscle

relaxants
Increased risk for abuse or addiction

Herbal remedies

Devils Claw and capsaicin (Trixaicin, Zostrix)

have limited benefits

The Nurse Practitioner May 2009 15

Low back pain

Nonpharmacologic interventions
When patients do not show improvement with standard
treatment, evidence-based nonpharmacologic therapies
should be added to the medication regimen. Acute low back
pain, which has been present for less than 4 weeks, may benefit from spinal manipulation or superficial heat. Exercise
therapy, both supervised and at-home regimens, has not
proved effective for acute low back pain.2
Subacute low back pain, which has persisted between
4 and 8 weeks, may benefit from interdisciplinary rehabilitation that includes a physician, NP, and nurses; physical
therapy; psychological, social, and vocational intervention; or cognitive behavioral therapy. Chronic low back
may benefit from acupuncture; exercise prescribed by a physical therapist,
massage, or Viniyoga yoga; progresPatients with chronic low back pain should
sive relaxation in which the patient
be encouraged to use a multimodal approach
relaxes various areas of the body, from
to managing their condition.
head to toe in sequence; spinal manipulation; and interdisciplinary rehabilitation that uses many different
can increase cardiovascular risks and renovascular events.
disciplines such as nursing, medical, physical therapy, psyNonselective NSAIDs have an increased risk of ulcerachology, etc.2,15-17
tion and gastrointestinal (GI) bleeding (using aspirin
Surgical options for treating vertebral fractures include
5
with NSAIDs can increase the risk for GI bleeding).
vertebroplasty, which repairs and strengthens the vertebra;
NSAIDs should be prescribed at the lowest dose for the
and kyphoplasty, which repairs the vertebra and corrects the
shortest period of time.2
curvature of the spine. In a review of vertebroplasty and
kyphoplasty, 85% of the patients who underwent vertebroOpioid analgesics. The third recommendation for medplasty and 92% of patients who underwent kyphoplasty
ication is an opioid analgesic or tramadol (Ultram). These
reported good pain relief with the procedure.18
medications should be prescribed for patients who have
failed to obtain relief with acetaminophen or NSAIDs. Pain
There is conflicting and insufficient evidence related to
should be severe or disabling before opioids are considered
the use of epidural or other injections for relieving low back
for treatment.3 In the short term, they may be efficacious,
pain.19 Prolotherapy, the injection of irritant solutions into
12
but long-term benefit is less clear. The incidence of subweakened back muscles, does not have evidence to support
stance abuse is high, with a finding of aberrant medication
its use alone; however, when added to a comprehensive regdisorder occurring in up to 24% of patients.12 In a study of
imen of rehabilitation, the injections were more effective
800 patients treated in primary care practices for chronic
than control injections.20
pain and prescribed opioids, the addiction rate was about
4% for patients who had been exposed to opioids or had a
Educating patients
history of substance abuse.13
Discuss medication options with patients carefully. Many
Another unfortunate occurrence is the development of
patients with chronic pain rely only on medication to manopioid-induced hyperalgesia. This condition is an atypical
age pain. It is important to see medication as a part of the
hyperalgesic state where pain severity is increased dramatitreatment regimen rather than the only option. All patients
cally unrelated to the original pain stimulus.14 The syndrome
with chronic low back pain should be encouraged to use a
multimodal approach to managing their condition.
is thought to be caused by long-term use of opioids that creIn the acute phase, remaining active, using heat, and
ate pain generation in the central nervous system and no
medication, such as acetaminophen and NSAIDs, will prolonger require nociceptive input to create pain.
duce the best outcome. If the pain persists, a rehabilitation
Other medications. Other medications can be used alone
program and relaxation can provide benefit.
or in conjunction with primary pain management regimens.
For chronic pain, the combination of medication and
These include antidepressants,antiseizure medications,muscomplementary techniques provide the best outcome. If
cle relaxants, benzodiazepines, and steroids.
clearly identified.11 Even though acetaminophen is less
effective than nonsteroidal anti-inflammatory drugs
(NSAIDs), it is still worth considering as a firstline option
because of its low cost and low risk profile.
NSAIDs. There are two different types of NSAIDs
nonselective NSAIDs that affect both COX 1 and COX 2
prostaglandin production and COX 2 medication (Celecoxib) that is COX 2 selective and does not affect the COX 1
prostaglandins that protect the stomach lining. The COX 2
medications are prescription-only, but nonselective NSAIDs
are available over the counter.
The risk-benefit profile is a concern when using
NSAIDs to treat low back pain. Both types of NSAIDs

16 The Nurse Practitioner Vol. 34, No. 5

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Low back pain

pain is severe or disabling, opioids may be an option. Yoga

and exercise can help increase flexibility in tense muscles.
Using different types of exercise therapy can be helpful,
such as exercise classes, swimming, or water therapies.
Teaching patients to use relaxation techniques can help
them conquer feelings of helplessness and decrease stress.
Encourage patients to stay as active as possible, and help
them choose pain management that fits their lifestyle. For
example, yoga and massage may not be realistic options for
all patients. Relaxation, stress relief, and meditation can help
build useful coping skills.
REFERENCES
1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates
for U.S. national surveys, 2002. Spine. 2006;31(23):2724-2727.
2. Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American
Pain Society. Ann Intern Med. 2007;147(7):478-491.
3. Von Korff M, Saunders K. The course of back pain in primary care. Spine.
1996;21:2833-2837.
4. DArcy Y. Pain Management: Evidence-Based Tools and Techniques for Nursing
Professionals. Marblehead, MA: HcPro; 2007.
5. Dorsi MJ, Belzberg AJ. Low back pain. In: Wallace MS, Staats P, eds. Pain Medicine & Management. New York: McGraw-Hill; 2005.
6. DArcy Y. Low back pain relief. Nurse Pract. 2006;31(4):17-25.
7. Lower S. Oh my aching back. Paper presented at: Nursing 2008 Symposium
Conference; March 2008; Las Vegas, NV.
8. Smeltzer S, et al. Textbook of Medical Surgical Nursing. Philadelphia, PA:
Wolters Kluwer, Lippincott Williams and Wilkins; 2008.

9. Tang NK, Crane C. Suicidality in chronic pain: a review of prevalence, risk

factors, and psychological links. Psychol Med. 2006;36(5):575-586.
10. Hagan KB, Hilde G, Jamtveldt G, et al. Bed rest for acute low back pain and
sciatica. Cochrane Database Syst Rev. 2005 ;(4):CD001254.
11. Chou R, Huffman L. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2007;147(7):505-514.
12. Martell B, OConnor P, Kerns R, et al. Systematic review: opioid treatment
for chronic back pain: prevalence, efficacy, and association with addiction.
Ann Intern Med. 2007;146(2):116-117.
13. Flemming M, Balousek S, Klessig C, et al. Substance abuse disorders in primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573582.
14. DuPen A, Shen D, Ersek M. Mechanisms of opioid-induced tolerance and
hyperalgesia. Pain Manag Nurs. 2007;8(3):113121.
15. Chou R, Huffman L. Nonpharmacologic therapies for acute and chronic low
back pain: a review of the evidence for an American Pain Society/American
College of Physicians clinical practice guideline. Ann Intern Med.
2007;147(7):492-504.
16. Khadlikar A, et al. Transcutaneous electrical nerve stimulation (TENS) for
chronic low back pain. Cochrane Database Syst Rev. 2005 ;(3):CD003008.
17. Manheimer E, et al. Meta-analysis: acupuncture for low back pain. Ann Intern
Med. 2005:142(8):651-663.
18. Hulme P, Krebs J, Fergusson S, et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine. 2006;31(17):1983-2001.
19. Marcus A. APS Guidelines for low back pain show little love for interventional therapies. Pain Medicine News. 2008;6(6).
20. Yelland M, et al. Prolotherapy injections for chronic low back pain: a systematic review. Spine. 2004;29(1):21262133.
The author has disclosed relationships with Ortho-McNeil Pharmaceuticals Inc.,
Abbott Laboratories, and Pfizer Inc.. This article has been reviewed, and all potential or actual conflicts have been resolved.
Yvonne DArcy is a pain management and palliative care nurse practitioner at
Suburban Hospital in Bethesda, Md.

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