Chronic Low Back Pain

The chronic low back is a back pain of more than three months duration. Frequently, there is no exact anatomical diagnosis, and the pathological process may not be apparent.

Many pathological processes can cause chronic low back pain. The list includes, but is not exhaustive:

  • mechanical or musculoskeletal pain
  • degenerative spine disease, including disc degeneration
  • nerve root compression
  • facet joint disease including inflammatory process
  • spinal deformities
  • spinal instabilities
  • trauma, including fractures and ligamental injuries
  • post-operative
  • inflammation
  • infection
  • tumours, both benign and malignant (cancers)

Psychological, emotional, and social factors have very prominent roles in chronic low back pain. There is considerable overlap between psychological, emotional, and social variables. These issues and their interplay must receive attention and be considered simultaneously.

Chronical low back pain,L2 vertebra osteoporotic fracture and collapse

L2 vertebra osteoporotic fracture and collapse, MRI saggital view

Metastatic tumour infiltration of the lower thoracic and upper lumbar spine

Metastatic tumour infiltration of the lower thoracic and upper lumbar spine, MRI saggital plane image

L1 vertebra fracture and collapse, MRI, saggital view

L1 vertebra fracture and collapse, MRI, saggital view

Failed Back Syndrome

Failed back syndrome describes long-term failure to improve low back pain or radicular pain (including sciatica) following surgery. Frequently more than one surgical intervention was performed on the individual suffering with failed back syndrome. There are two main groups of patients. The first group include patients where surgery, or that surgical intervention was never indicated. The second group include patients where the surgery was inadequate, incomplete, or badly done.

Individuals suffering with failed back syndrome often complaint of severe, constant, poorly localised, diffuse, dull, and aching pain involving the back and the legs. These patients may develop sharp, electric shock like pain in the legs. Sometimes there is sensory loss or increased sensitivity to touch in certain areas; this can be so severe that the pain is experienced even on gentle touch.

These individuals are frequently unable to return to work, often require regular painkillers, and may require various complex pain procedures.

There are numbers of possible causes of a failed back syndrome. These include incorrect initial diagnosis, permanent nerve injury, continuous nerve compression, inflammation of various structures, infection, and psychological factors like depression play important role. This list is not exhaustive.


Failed back syndrome possible causes-permanent nerve injury, continious nerve compression or inflammation of various structures


Lumbar spine, herniated disc and pinched nerve

The treatments of failed back syndrome include physical therapy, specific spinal manipulation therapy, nerve blocks, epidural injections, transcutaneous electrical nerve stimulation (TENS), non-steroidal anti-inflammatory (NSAID) medications, antidepressants, spinal cord stimulation, intrathecal morphine pump, psychological support like cognitive behavioural therapy.

Lumbar Disc Herniation and Sciatica

Lumbar disc herniation can be associated with low back pain and can be an integral part of degenerative spine disease. It typically does not cause any symptoms. However, in some cases lumbar disc herniation may cause compression on one of the nerve roots resulting in pain, sensory change, and weakness in the distribution of the affected nerve root. The name for this condition is radiculopathy, or sciatica if the pain and discomfort are within sciatic nerve distribution.


Bulging, herniated, thinning disc
Sciatic nerve, areas of pain and the most common causes of sciatica

In other cases, compression on certain nerve roots can result in loss of bladder and bowel control, incontinence, and loss of sensation in the genital area. This condition is a medical emergency; it is called cauda equina syndrome. It requires immediate assessment and management by a neurosurgeon. Intervention in a confirmed case of cauda equina syndrome should not be later than 48-72 hours after which time the effects of the syndrome may be permanent. The delay in surgical treatment can result in complete and permanent loss of bladder, bowel control as well as of sexual function.

There are multiple treatment options for a herniated lumbar disc. Most of the individuals with this condition will improve spontaneously over several months. In some cases, adequate pain control is all that is needed. Pain control can be achieved by taking appropriate painkillers, acupuncture, or pain specialist management. Physiotherapy and exercises such as swimming, yoga and Pilates are very helpful, especially over long period of time.

L4 - L5 Disc prolapse, MRI sagittal plane image

L4 - L5 Disc prolapse, MRI sagittal plane image

L4 - L5 Disc prolapse, MRI sagittal plane image

L4 - L5 Disc prolapse, MRI sagittal plane image

L4 -L5 Disc prolapse associated with multi level degenerative changes, MRI sagittal plane image

L4 -L5 Disc prolapse associated with multi level degenerative changes, MRI sagittal plane image

Less commonly, surgical intervention is necessary. An operation is essential in cauda equina syndrome; otherwise, the loss of bladder and bowel control accompanied by numbness in the genital area and impotence may be permanent. Persistent and worsening pain for more than 4 months duration and development of weakness or sensory loss often requires surgical intervention. Surgical intervention should be considered in cases where there is a sudden or recent development of weakness or loss of sensation (development of numbness).

L4 - L5 Disc prolapse, MRI axial pane image

L4 - L5 Disc prolapse, MRI axial pane image

L4 - L5 Disc prolapse, MRI axial pane image

L4 - L5 Disc prolapse, MRI axial pane image

Surgical options include discectomy or microdiscectomy, laminectomy, and disc arthroplasty procedures. In patients where there is evidence of spinal instability, a fusion procedure accompanying decompression may be necessary. Discectomy or microdiscectomy includes removal of the protruding or loose disc material, thus decompressing the affected nerve root. Laminectomy removes the laminas, which represent a bony "roof" over the spinal canal. The purpose of this intervention is to open up a spinal canal and thus decompress nerve roots. It is essential to discuss all treatment options (conservative and surgical) with the spinal specialist.

Low back pain

Low back pain is widespread. Almost 90% of people will experience low back pain sometime in their life. In nearly 85% of the cases, there is no specific diagnosis. It is essential to exclude any so-called "red flags symptoms." These symptoms and signs may point toward a more sinister pathology. If one suffers from any red flags symptoms, one must seek medical attention urgently.

The causes of low back pain are numerous. The list includes conditions such as:

  • Mechanical low back pain
  • Degenerative disease, including disc degeneration and stenosis
  • Spondylitis and spondylolisthesis
  • Trauma, including fractures and ligamental injuries
  • Scoliosis and other types of deformities
  • Post-operative problem
  • Inflammation and inflammatory disease (i.e. arthritis, ankylosing spondylitis)
  • Infection
  • Vascular malformations
  • Tumours, both benign and malignant (cancerous)

This list is not exhaustive.

A vast majority (up to 90%) of individuals with low back pain will improve within 1-2 months even without treatment. In some cases, it is necessary to take simple (non-prescriptive) painkillers, modify specific activities associated with pain, introduce work-place changes and perform exercises i.e. swimming, Pilates and physiotherapy. It is not recommended to have bed rest beyond 3 days. Prolonged bed rest can make this condition worse.

Mechanical low back pain is also known as "musculoskeletal" back pain. There are usually no anatomically identifiable causes. It is the most common type of low back pain. It results from muscle strain and irritation of surrounding structures, such as ligaments and joints.


Degenerative lumbar disease

Spine disc problems - Degenerative lumbar disease




L2 vertebra collapse due to metastatic tumour infiltration, MRI saggital view

L2 vertebra collapse due to metastatic tumour infiltration, MRI saggital view

Degenerative spine disease can affect any and/or every part of the spinal column (from top to bottom). Often it may cause no symptoms at all. In other cases, it is the cause of pain and discomfort of variable degree. It can affect discs, facet joints, ligaments and bony structures.

Radicular pain or radiculopathy is a dysfunction of a specific nerve root which may result in sensory loss, numbness, tingling, pain, weakness, or the combination of the above. process of degenerative disc disease and disc protrusion or extrusion may cause compression on a nerve root leading to the symptoms described in radiculopathy.

Sciatica is a specific pain along the root of the sciatic nerve. Often, radicular pain (including sciatica) and low back pain coexist. For "red flags symptoms", please refer to the relevant section. Experiencing any of the "red flags" symptoms and signs requires immediate medical attention.

Spinal Claudications

Spinal claudications are also known as neurogenic claudications. This condition is characterised by pain in one or both buttocks and calves. A hip, thigh and leg discomfort are frequently present. The pain may be described as a dull ache, cramps tightness or "burning pain". Patients may have some sensory loss. Spinal claudication is often precipitated by standing or walking. A person with this condition will often develop pain and discomfort in one or both legs after a variable walking distance. The pain and discomfort are typically relieved by sitting down or stooping forward. The pain relief is slow and gradual. These patients will commonly experience discomfort on lifting and bending. Spinal claudication is a progressive disorder; it tends to get worse gradually over months and years. With the progression of this condition the walking distance, before developing pain and discomfort tends to decrease, and the relief from changing the position tends to diminish.

Spinal degenerative disc desease

Some patients may develop leg weakness and sensory loss. Some individuals with spinal claudications will notice that they can walk further if they can lean forward (for example leaning onto a shopping cart). Equally, these patients tolerate riding a bicycle relatively well.

Primary differentiation is between spinal (neurogenic) claudications and vascular claudications. Vascular claudications result from vascular insufficiency as one of the critical arteries down a leg has been clogged up. Patients who suffer from vascular claudications are often smokers or have diabetes (sometimes both). There is a loss of sensation in stocking distribution and muscles affected are in the distribution of the particular artery. The walking distance is constant, the pain relief is achieved almost instantly on rest, and this is not dependent on posture (a patient can get pain relief while standing). There is other evidence of problems with vascular supply: pallor, skin thinning, loss of hair, decreased skin temperature, ulcers and loss of peripheral pulses. Vascular claudications require assessment by a vascular surgeon. Other possible conditions which can present similarly include hip disease, disc prolapse, tumours, infection, inflammation, neuritis, and vascular malformations (this list is not exhaustive).

The treatment for spinal claudications can be divided into two major groups:

  • Surgical treatment
  • Non-surgical - conservative

Surgical treatment often includes interventions like laminectomy and decompression of the nerve roots. Laminectomy is surgical removal of laminas, which represent a "bony roof" of the spinal canal. In some cases, and in particular where there is instability (sometimes described as "slippage") in the spine, a laminectomy is accompanied with fusion procedures. There are various fusion procedures, but in general, these interventions include placement of screws and rods, thus making a particular spinal segment fixed.

Conservative treatment includes good pain control, modification of daily physical activities and exercises including physiotherapy and hydrotherapy.

There are no guarantees that either medical or surgical treatment will be successful. A physician's or spinal specialist's assessment and opinion are essential. All treatment and management options should be openly discussed with the specialist at the time of consultations.

Lumbar canal stenosis at multiple levels, MRI sagittal plane image

Lumbar canal stenosis at multiple levels, MRI sagittal plane image

Lumbar canal stenosis, ligament and facet joint hypertrophy, MRI axial plane image

Lumbar canal stenosis, ligament and facet joint hypertrophy, MRI axial plane image

Disc prolapse, broad based, associated with ligament and facet joint hypertrophy - MRI axial image

Disc prolapse, broad based, associated with ligament and facet joint hypertrophy - MRI axial image