The bark of low back pain is usually much worse than its bite, and this is the most important thing that most people need to understand about back pain, most of the time. The importance of things like herniated discs is usually exaggerated,1 most back pain goes away on it’s own (even “chronic” low back pain2), and most patients are much better off if they feel confident about this. The power of justified, rational confidence is one of the pillars of my comprehensive low back pain tutorial.
However, there are rare cases of low back pain that have alarming causes. Low back pain can be an early warning sign of cancer or an autoimmune disease, for instance; or it may be associated with spinal cord damage. How can you tell? This is a concise, readable field guide to more worrisome low back symptoms — symptoms that need better-safe-than-sorry investigation with your doctor. It is basically just a plain English translation of authoritative clinical guidelines for doctors, such as those published by the American College of Physicians.3
In other words, this article explains the difference between “dangerous” and “merely painful.”
Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door.
Back pain can be a terrible curse. It can suck the joy out of your days for years or even decades. It can definitely be “serious.” I have worked with many truly miserable chronic low back pain patients over the years.
But chronic low back pain has never killed anyone.
Cue Jaws theme music. “Ominous” is medical jargon for “truly scary.” Low back pain is ominous when it is caused by a spinal cord trauma, or a progressive disease that can maim or kill. Ominous causes of low back pain are very rare, fortunately, but they are real. Awful things do happen. Some examples are coming below, like the sad but informative story of actor Andy Whitfield (Spartacus).
There are two back pain scenarios that may constitute medical emergencies. They do not necessarily mean something horrible is wrong, but it’s important to make sure.
Let’s look at those in a little more detail.
If you are experiencing true numbness5 around the groin and buttocks and/or failure of bladder or bowel control, please consider it a serious emergency — do not wait to see if it goes away. These symptoms indicate spinal cord injury or compression6 and require immediate medical attention. (Few people will have symptoms like this without having already decided it’s an emergency, but I have to cover all the bases here.)
And, of course, if you’ve had an accident with forces that may have been sufficient to fracture your spine, please seek thorough medical assessment promptly, including an X-ray to look for a fracture. You need an X-ray to ensure that your spine is not actually broken.
You shouldn’t worry about low back pain until three conditions have been met:
The presence of the big three does not confirm that something horrible is going on. It only means that you need to check carefully.
The story of actor Andy Whitfield is a disturbing and educational example of a case that met these conditions — for sure the first two, and probably the third as well if we knew the details. Whitfield was the star of the hit TV show Spartacus. The first sign of the cancer that killed him in 2011 was steadily worsening back pain. It’s always hard to diagnose a cancer that starts this way, but Whitfield was in the middle of intense physical training to look the part of history’s most famous gladiator. Back pain didn’t seem unusual at first, and some other symptoms may have been obscured. (For instance, some weight loss could have even seemed like a training victory at first.) It was many long months before he was diagnosed — not until the back pain was much too severe and constant. A scan revealed a large tumour pressing against his spine.
“Red flags” are signs or symptoms that something medically ominous may be going on. A red flag is not a diagnosis. Red flags only indicate a need to look more closely. Check off all that apply … hopefully none or few or only the least alarming of them!
Some of these red flags are much less red than others, especially depending on the circumstances. For instance, “weight loss” is common and often the sign of successful diet! (Well, at least temporarily successful, anyway. ) Obviously, if you know of a harmless reason why you have a red flag symptom, it isn’t really a red flag (duh!). But every single actual red flag — in combination with severe low back pain that’s been going on for several weeks — is definitely a good reason to get yourself checked out.
Most people who check off an item or two will turn out not to have an ominous cause for their low back pain. But why not check?
Sorry I have to use the C word — I know it’s kind of a bummer. But C happens.
A few cancers in their early stages can be hard to tell apart from ordinary back pain — a bone cancer in the vertebrae, for instance — and these create a frustrating diagnostic problem. They are too rare for doctors to inflict cancer testing on every low back pain patient “just in case.” And yet the possibility cannot be dismissed, either!
Most cancers and ominous problems will cause other, distinctive, ominous symptoms, and it won’t be long before someone catches on that there’s more going on than just back pain. Being “freaked out” about persistent back pain poses a genuine threat: it can make low back pain much worse.So it truly is an extraordinary circumstance for back pain to be ominous without causing other symptoms that raise the alarm.
Meanwhile, it’s extremely common for non-life-threatening low back pain to be alarmingly severe and persistent — to have a loud bark! Your doctor may not appreciate how true this is, and may over-react to all persistent low back pain, even without other red flags. In most cases, you shouldn’t let them scare you. Being “freaked out” about persistent back pain is the real threat: it can make low back pain much worse, and much more likely to last even longer (a tragic irony).
This is an unholy combination of factors: the exact same symptoms can have either an extremely rare but serious cause, or an extremely common but “harmless” cause that can be greatly aggravated by excessive alarm!
The good news is that it’s easy enough to diagnose cancer if you look for it, so the answer to the dilemma is to simply do the testing when the time is right, but not before. There’s every reason to screen for cancer when the conditions merit it — that is, when the red flags appear in combination with persistent, severe pain.
Wednesday, May 8, 2013 — More editing and minor improvements. Added the barking dog image. Made the article more “shareable,” with new metadata for social media sites.
Tuesday, February 19, 2013 — Edits and miscellaneous minor improvements. Added one red flag.
Saturday, April 16, 2011 — Added some clarification about the position of symptoms of cauda equina syndrome, and a personal footnote related to that scary scenario.
Monday, October 12, 2009 — Added important and reassuring information about the chronicity of low back pain. See “Prognosis for patients with chronic low back pain: inception cohort study”.
Wednesday, July 8, 2009 — Publication.
If you found this article useful, you may also be interested in a the main low back tutorial here on SaveYourself.ca. There are also several other articles about low back pain:
This Australian study concluded that “prognosis is moderately optimistic for patients with chronic low back pain,” contradicting the common fear that any low back pain that lasts longer than 6-9 weeks will become a long-term chronic problem. This evidence is the first of its kind, a rarity in low back pain research, a field where almost everything has been studied to death. “Many studies provide good evidence for the prognosis of acute low back pain,” the authors explain. “Relatively few provide good evidence for the prognosis of chronic low back pain.” Their research differs from past studies of chronic low back pain, which tended to focus on patients who already had a well-established track record of long-term problems (in other words, the people who had already drawn the short straw before they were selected for study, and are likely to carry right on feeling rotten). Instead they studied new cases of chronic low back pain, and found that “more than one third” recovered within nine more months. This evidence is a great foundation for more substantive and lasting reassurance for low back pain patients.BACK TO TEXT
Marvelously progressive, concise, and cogent guidelines for physicians on the treatment of low back pain. These guidelines almost entirely “get it right” in my opinion, and are completely consistent with recommendations I’ve been making for years on SaveYourself.ca. They are particularly to be praised for strongly discouraging physicians from ordering imaging tests only “for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.”BACK TO TEXT
I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.