My Doctor Online The Permanente Medical Group

Symptoms

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Low back problems can generate a wide variety of symptoms, depending on which structures are irritated or injured. Common symptoms of low back problems include:

• Pain in the lower back region. The quality of pain can vary and include sensations described as sharp, shooting, stabbing, throbbing, tender, burning, cramping, aching, dull, heavy, or pressure. 
• Pain that radiates into the buttocks, thighs, or even the feet.
• Stiffness in the back that makes it difficult to move.
• A sense of weakness or fatigue in the lower back, hips, or legs and a giving way in the legs.
• Numbness or tingling in the legs and feet.

Some body positions will make the pain worse, and others can make it better. For example, you may find that the pain gets worse with bending, squatting, and sitting – we call this flexion-sensitive pain. Alternatively, if standing and walking, arching the back, or lying on your stomach worsens the pain, this is known as extension-sensitive pain. Understanding which type of pain you have can help us identify which structure in your back is irritated or injured and plan the most effective treatment.

When to contact us

Although back pain does not usually indicate a serious medical condition, if you have any of the following signs or symptoms, please call our Appointment and Advice line immediately:

• Loss of bladder or bowel control or difficulty starting or stopping urination
• Weakness in the legs and/or numbness in the genital or rectal area 
• New or increased back pain with unexplained fever or recent infection
• New or increased back pain with a history of cancer, immune system problems, or use of the drug prednisone
• Pain that is intolerable and/or not relieved by rest or a loss of sensation or strength

Diagnosis

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The most important tools we use to help diagnose the cause of your pain are your medical history, including the information that you tell us about your low back pain, and a physical examination.

Medical history

We will ask you a number of questions including:

• Where does it hurt?
• Does the pain travel anywhere else?
• How did the pain start? 
• What does the pain feel like?
• What makes it feel better and/or worse?
• Does it stop you from going to work or exercising?

Physical examination

We will perform a physical examination of your low back to evaluate the following:

• Your muscles and joints
• The alignment of your back 
• Your range of motion 
• The location of your pain 
• The function of your nerves
• Specific body positions that provoke your pain

The results of your medical history and physical examination will help us decide the best way to treat your symptoms and determine if we need to order any further tests. 

Imaging Studies

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We rarely need to obtain X-rays, MRIs, or other imaging studies to determine what is causing your low back pain and what to do to make it better. Imaging studies do not show pain. However, if we suspect that a more unusual condition may be the source of your back pain, we may refer you for an X-ray, MRI, or CT scan.

X-rays

We usually order X-rays before ordering other more specialized tests. X-rays show bones and can give us a lot of information about your back, including:

• The alignment of the vertebrae
• Wear and tear – type changes in the joints
• Bone loss caused by tumors or infection
• The amount of space in the discs
• Narrowing of the holes where the spinal nerves exit the spine (neuroforamen)

Magnetic resonance imaging (MRI)

• We may order an MRI if an X-ray does not give enough information to explain your problem. 
• MRI lets us see soft-tissue structures such as discs, muscles, and nerves. It also enables us to look at bones such as the vertebrae and facet joints.
• Remember, MRIs do not tell us where pain is located; they only show us the status of different structures in the spine.

Computed tomography (CT)

• A CT scan is an advanced form of X-ray that helps us to get more specific information about problems with the bones.
• We typically order CT scans for people who have had spinal surgery with implanted hardware that may blur the image of an MRI.  
• We may also recommend a myelogram at the same time as the CT scan. During this procedure, we inject dye into the spinal canal so that structures show up more clearly. Pictures are taken before and after the dye is injected. 

Bone scan

• A bone scan is a test that looks for abnormal activity within the bones.
• We inject a radioactive dye into the blood via an IV and then take X-ray-type pictures 3 hours after the dye has circulated through your body.
• The pictures can help us find subtle fractures, areas of infection, or tumors.

Additional Tests

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Blood tests

We may order laboratory blood tests to identify causes of back pain that are not related to gradual wear and tear conditions. Blood tests can help us confirm:

• Certain types of arthritis or infections that may be causing back pain 
• Problems with internal organs such as the stomach, liver, gallbladder, or kidney that may be causing you to feel pain in the lower back

Diagnostic spinal injections

In certain situations, we may use diagnostic spinal injection procedures to help identify the cause of your low back pain. These include nerve or joint blocks that are performed with the use of fluoroscopy (real-time X-ray). We use two types of diagnostic spinal procedures for low back pain: 

• Intra-articular injections. We inject anesthetic in the joints that we suspect may be causing your pain. If your pain goes away, that helps us confirm that the pain is coming from inside that specific joint.  
• Medial branch block. During this procedure, we inject anesthetic around the nerves in the area of your back that we suspect is the origin of your pain. The anesthetic temporarily prevents the nerves from sending pain information from that facet joint to the brain. If your pain goes away while the anesthetic is working, that helps us confirm that the pain is coming from the joint or tissue that we blocked. 

Causes and Risk Factors

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You can develop low back pain as the result of an injury; for example, one that causes a bruise or fracture. In general, however, most low back pain is caused by a process of wear and tear that is often described as degenerative disc disease. Although the medical term is "degenerative," it does not mean that your body is degenerating. It refers to the changes that occur over time. We prefer to describe this process as a degenerative cascade that involves multiple structures within the spine, not just the discs.  

Degenerative changes occur in all of us as we get older, but they don’t always cause pain. A number of factors can accelerate the changes caused by normal wear and tear:

• Age
• Activity levels 
• Load on the spine 
• Trauma or injury
• Obesity
• Weak and deconditioned muscles around the spine

The degenerative cascade

Over time, normal everyday stress and external trauma begin to affect the structures in your spine. Here’s how:

• Discs tear and rupture. Small tears develop in the tough outer part of your discs. Eventually, the inside of the disc (the nucleus) can begin to push through the small tears in the outer portion of the disc (annulus). This is called a herniation, also known as a ruptured or slipped disc. This process causes inflammation, which can irritate the spinal nerves, causing numbness, tingling, or pain in the low back, buttocks, legs, and feet.
• Ligaments get weaker. Wear and tear also puts strain on the ligaments that support the spine and causes protective cartilage in the facet joints to degenerate. As the ligaments get weaker, they can no longer keep the structures of the spine stable.
• The spine becomes unstable. Without strong ligaments to keep them in place, the structures in the spine begin to move slightly. This places even more force on the disc and the joints. Instability causes motion at the discs, facet joints, and surrounding muscles and ligaments. This may cause pain. Instability can also pinch the spinal nerves as they travel out of the spinal canal, causing nerve pain.
• The discs shrink and ligaments buckle. More and more small tears weaken the discs, reducing their capacity to cushion and bear weight. Eventually the disc shrinks significantly, causing the surrounding ligaments to buckle and the joint bones to rub against each other. This may cause pain.
• Bone spurs develop. Movement causes pulling on the ligaments, which leads to the formation of bone spurs that can narrow the holes where the spinal nerves exit. This can squeeze and irritate the nerves, causing numbness, tingling, or nerve pain in the low back, buttocks, legs, and feet. 

Prevention

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Almost everyone who has a first-time episode of low back pain will suffer another episode in the future. It’s important that you recognize an initial episode of pain as a warning sign that you are putting too much stress on your back. There are a number of things you can do to prevent back pain from occurring in the first place or recurring after the initial episode.

Core and lumbar stabilization exercises

Just as you care for your teeth by brushing and flossing to help prevent cavities, we recommend that people participate in basic core strengthening exercises to help prevent back problems. Core/lumbar stabilization exercises strengthen and coordinate the muscles in your back and help you prevent wear and tear from causing pain and affecting your normal function. Strong core muscles enable you to protect your lower back by maintaining good posture and a stable spine as you go about your daily activities.

Use good posture and lifting mechanics

Protect your back during everyday activities. For example, when you lift a heavy object, make sure that you contract your abdominal muscles and buttock muscles to stabilize your low back prior to lifting. Bend at the knees and carry items close to your body.

Weight loss

Excess weight can put more load on your spine than it is able to tolerate. Working on weight loss, aerobic exercise, and lumbar stabilization exercises will help you prevent back pain and help heal your back after an injury.  

Home Treatments

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Most people who suffer from a first-time episode of low back pain show significant recovery within 4 to 6 weeks. But up to 30 percent of these people may still have some discomfort 1 year later. There are a number of things you can do at home to help your back heal and prevent back pain from recurring. Home treatments include the following:

Relative rest

In the acute phase of pain, we recommend "relative rest" for a few days. Try to continue with your normal daily activities and use your pain levels to indicate when you need to slow down or change position. Studies show that prolonged bed rest (more than 3 days) is actually bad for your spine because your tissues need to be exposed to normal movements in order to heal correctly and not lose strength. Pace yourself by planning your activities ahead of time and taking frequent breaks.

Over-the-counter anti-inflammatory pain medications

Medications can help control your symptoms while your irritated or injured tissues heal. We may recommend pain medicines, such as acetaminophen (Tylenol), or OTC nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, to reduce pain, inflammation, and muscle spasms and help you sleep. Follow these guidelines when using OTC NSAIDs:

• Over-the-counter NSAIDs, such as ibuprofen or naproxen, can help manage your pain or discomfort. Even though you do not need a prescription for OTC NSAIDs, you should still be careful to consult the package so that you take the correct dosage.
• Also, please be aware that OTC NSAIDs can interact with other medicines you may be taking and cause problems for people with various medical conditions. If you have a complex medical condition, are pregnant or trying to get pregnant, or have been taking OTC NSAIDs and they do not relieve your symptoms, please let us know so that we can recommend an alternative.

Exercise therapy

Exercise is medicine for your back. We cannot stress this enough. During aerobic exercise, your body releases endorphins that can help improve your mood and reduce your pain. It is important to choose the right kind of exercise while you are recovering from an episode of low back pain. Here are some guidelines to follow:

• We recommend bicycling, walking, and swimming. Choose a form of exercise that does not aggravate your pain.
• If you can ride a bicycle or an exercise bike without aggravating your pain, then this is generally a safe thing to do, even in the acute phase of pain.
• If you have worked with a physical therapist before, after a previous episode of back pain, but have not been consistent with your lumbar stabilization exercises, please start them again. Start with the exercises that do not make your pain worse, then progress back into your entire home exercise program.
• These exercises are not a quick fix – it’s important to make these exercises a permanent part of your exercise routine and commit to do them for the rest of your life.

Sleep

Lack of sleep is closely related to the amount of pain that people feel. It is important to get plenty of sleep to help you manage your pain. If you find yourself waking up frequently during the night and do not feel well rested during the day, discuss this with us. Follow our guidelines for sleeping well.

Weight loss

Excess weight can put more load on your spine than it is able to tolerate. Working on weight loss, aerobic exercise, and lumbar stabilization exercises is critical to your healing. 

Treatments

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Medications

If OTC acetaminophen or NSAIDs are not controlling your low back pain sufficiently, we may prescribe additional pain medications. These may include opioid pain medications, such as Vicodin or Tylenol with codeine. We reserve opioids for very severe pain flare-ups, and they should generally not be taken for more than 2 weeks. Opioids are not always effective for nerve-type pain.

Physical Therapy

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We will develop a physical therapy plan for you that includes core stabilization exercises. These exercises strengthen the core muscles of your trunk and the muscles in your legs. Strong core muscles enable you to protect your lower back by maintaining good posture and a stable spine as you go about your daily activities.  

We will consider the body positions that make your pain worse and those that make it better (known as your directional preference), before recommending the type of exercises that are best for you. Current research shows that following an exercise program that works with the directional preference (i.e., flexion, extension, or a neutral low back) that causes you the least discomfort helps reduce pain in the short term and the likelihood that your pain will recur or get worse. 

If physical therapy exercises on land are too painful, you can try doing your lumbar/core stabilization exercises in a pool. This puts less stress on your low back and may allow you to move more easily. Some people find that walking in the pool is the first type of aerobic exercise that they are able to tolerate after a low back pain episode.

It is important that you make these exercises a permanent part of your exercise routine. Committing to do them for the rest of your life will reduce the risk that your back pain will recur.

Ice and heat

We may use ice and heat to help ease the pain and stiffness in your lower back. Ice and heat work for different reasons, and you will need to try both to see which works for you. For some, using ice alternating with heat, called contrast baths, works best.

TENS therapy and ultrasound

As part of your physical therapy, we may recommend ultrasound or a TENS (transcutaneous electrical nerve stimulation) machine to help reduce pain and inflammation as part of your physical therapy program. TENS and ultrasound are particularly effective in the first week or so after the onset of an episode of neck pain (the acute phase). A TENS machine provides low-current electrical stimulation through the skin that can control or reduce localized pain. Our physical therapists can customize a TENS machine for you and show you how to use it.

Interventional Spine Procedures

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Spinal injections have a limited role in the treatment of low back pain.

Epidural steroid injections (ESIs) to treat nerve pain

We don’t usually recommend ESIs for treating an isolated episode of low back pain. However, we may recommend an ESI if your pain is coming from irritated spinal nerves that are causing sciatica-type pain down your buttock or leg and other treatments have not worked. During the procedure, we inject a corticosteroid into the area around the spinal cord and nerve roots. A corticosteroid is a medication used to reduce inflammation and relieve pain. The injection also includes a local anesthetic medicine to provide pain relief.

Excessive amounts of corticosteroids can increase the risk of developing osteoporosis, glaucoma, and cataracts and can have other side effects as well. 

Spinal injections to treat joint pain

There are several procedures that can help treat pain originating from the facet joints. They are:

Facet joint or sacroiliac intra-articular injection

If you have acute inflammatory pain that we believe is originating from either a facet or sacroiliac joint, then we may recommend a steroid injection directly into the joint to reduce inflammation and pain.

Radiofrequency neurotomy (RFN) 

If a diagnostic spinal procedure has already confirmed which joint your pain is coming from, we may refer you for RFN. RFN uses heat-generating radio waves to destroy the nerves that surround the pain-causing joint. Once these nerves are destroyed, they can no longer transmit pain signals from the joint to the brain. During the procedure, we insert needles into your skin to target the nerves with radio waves. It’s important to note that, in some cases, the nerves can grow back and your pain may return. 

In special circumstances, there are other interventional spine procedures that may be able to help reduce the pain emanating from a vertebral body, disc, or sacroiliac joint. If we think you are a candidate for any of those procedures, we will discuss them with you.

Surgery

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Surgery is not usually indicated for the treatment of uncomplicated low back pain.

If you have a tumor, fracture, unstable spine, or severe degenerative changes with unrelenting pain that is not responding to treatment, then we may discuss surgical options with you. Lumbar spine surgery for low back pain typically involves fusing structures in the spine to stabilize spinal segments.

Lifestyle Changes and Management

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There are many resources available to help you manage your low back pain.

Do lumbar/core stabilization exercises. It is important to strengthen and stabilize the structures in your spine and the core muscles in your trunk to prevent pain and inflammation from developing again. We will teach you to do lumbar/core postural stabilization exercises that you should integrate into your regular stretching and exercise routine. You can also ask us about a referral to our WebCare program for back pain.

Manage your weight. Your weight can contribute to back problems. Keeping to a healthy weight can reduce the load on your spine. 

Get enough sleep. Tiredness and fatigue can make pain feel worse. If you have trouble sleeping for any reason, discuss this with us.

Exercise. Regular aerobic exercise makes you feel good and reduces pain. We can work with you to choose activities, such as cycling and walking, that do not exacerbate your lower back.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will arrange an appointment for you in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will examine your back. If we ordered X-rays to be taken before your visit, I will review those with you as well. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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