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Is your back just barking? Or is there a bite in there?

The Bark and the Bite of Low Back Pain

When you should worry about low back pain, and when you shouldn’t

2,400 words, published 2009, updated Aug 13th, 2013
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, a former massage therapist, and the Assistant Editor of Science-Based Medicine since 2009. I am nearly done with a long-procrastinated Bachelor of Health Sciences degree. I am a middle-aged runner and ultimate player with plenty of personal experience with athletic injury and chronic pain. Readers often want to know more about me and my qualifications, because my style and subject matter is controversial. Most importantly, yes, I used to actually believe and practice almost everything that I now debunk and criticize. I live by the ocean with my wife in beautiful downtown Vancouver.

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.

Cory Blickenstaff, PT

Chronic low back pain is serious, but rarely ominous

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).

Strangely, bad back pain is not a very worrisome symptom. In fact, it may be one of the least worrisome. Ordinary back pain can be fierce and awful … but not dangerous. It’s bark is almost always much louder than its bite.

Strangely, bad back pain is not a very worrisome symptom. In fact, it may be one of the least worrisome. Ordinary back pain can be fierce and awful … but not dangerous. It’s bark is almost always much louder than its bite.

Two kinds of back pain you should take seriously right away, no delay

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.

  1. incontinence and/or true numbness around the groin and buttocks in a “saddle” pattern4
  2. any accident with forces that may have been sufficient to fracture your spine

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.

Isn’t it rather obvious that a potential spinal fracture is an emergency?

You’d think so. But consider this story of a motorcycle accident: many years ago, a friend hit a car that had pulled out from a side street. He flew over the car and landed on his head. Bystanders showed their ignorance of spinal fracture by, yikes, carelessly moving him. In fact, his thoracic spine was significantly fractured … yet the hospital actually refused to do an X-ray because he had no obvious symptoms of a spinal fracture. Incredible! The next day, a horrified orthopedic surgeon ordered an X-ray immediately, confirming the fracture, and quite possibly saved him from paralysis.

Isn’t it rather obvious that a potential spinal fracture is an emergency?

You’d think so. But consider this story of a motorcycle accident: many years ago, a friend hit a car that had pulled out from a side street. He flew over the car and landed on his head. Bystanders showed their ignorance of spinal fracture by, yikes, carelessly moving him. In fact, his thoracic spine was significantly fractured … yet the hospital actually refused to do an X-ray because he had no obvious symptoms of a spinal fracture. Incredible! The next day, a horrified orthopedic surgeon ordered an X-ray immediately, confirming the fracture, and quite possibly saved him from paralysis.

The Big Three signs that you should investigate for an ominous cause of persistent low back pain (but it’s not an emergency)

You shouldn’t worry about low back pain until three conditions have been met:

  1. it’s been bothering you for more than about 6 weeks7
  2. it’s severe and/or not improving, or actually getting worse
  3. there is at least one other “red flag” (see below)

The presence of the big three does not confirm that something horrible is going on. It only means that you need to check carefully.

Andy Whitfield as Spartacus

At his physical peak, not long before getting sick. The first sign of his cancer was steadily worsening back pain. He may have already been in pain at this time.

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.

A film about Andy Whitfield, Be Here Now, is nearing completion as of mid-2013. It will probably be inspiring and heart-wrenching. (Spartacus is worthwhile too! And warning: rated very R.8)

The red flags

“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?

The tricky one:
Cancer as a cause of low back pain, and the necessity of testing “just in case” when the symptoms justify it

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.

What’s New In this Article?

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.

Further Reading

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:

Notes

  1. People often have no pain or other symptoms despite the presence of obvious arthritic degeneration, herniated discs, and other seemingly serious structural problems like stenosis and spondylolistheses. This surprising contradiction has been made clear by a wide variety of research over the years (particularly see several studies in the 1990s: Boden, Jensen, Weishaupt, Stadnik and Borenstein), and was well-established by 2001 when low back pain expert Dr. Richard Deyo wrote in a physician tutorial for New England Journal of Medicine that “…disk and other abnormalities are common among asymptomatic adults” (see Deyo). The point has been emphasized by many other experts since, and continues to be clarified by new research in many different ways, such as a 2006 experiment (see Haig) showing surprising evidence that even spinal canal stenosis (narrowing) is routinely painless; or a 2009 paper (see Chou) concluding that most therapies that try to treat low back pain by addressing alleged mechanical problems are still controversial and unproven after all these years . BACK TO TEXT
  2. Costa et al. Prognosis for patients with chronic low back pain: inception cohort study. British Medical Journal. 2009. PubMed #19808766.

    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
  3. Chou 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. Annals of Internal Medicine. 2007.

    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
  4. That is, the parts of your body that touch a saddle when riding a horse: groin, buttock, and inner thighs. I experienced rather intense, terrifying awareness of symptoms in this area in the aftermath of my wife’s car accident in early 2010. With a mangled T12 vertebrae, she was at real risk of exactly this problem. Fortunately, she escaped that quite serious problem. But, sheesh, I was vigilant about it for a while! “Honey, any numbness in your saddle area today?” BACK TO TEXT
  5. True numbness is not just a dead/heavy feeling (which is common, and caused even by minor muscular dysfunction in the area), but a significant or complete lack of sensitivity to touch. You have true numbness when you have patches of skin where you cannot feel light touch. Such areas might still be sensitive to pressure: you could feel a poke, but as if it was through a layer of rubber. Most people have experienced true numbness at the dentist. BACK TO TEXT
  6. The condition is cauda equina syndrome. It involves “acute loss of function of the neurologic elements (nerve roots) of the spinal canal below the termination (conus) of the spinal cord,” where the nerves spread out like a horse (equina) tail. Again, this condition causes symptoms in the “saddle” of the body: butt, groin, inner thighs. BACK TO TEXT
  7. This standard recommendation reinforces the alarming idea that low back pain that lasts longer than a few weeks is Really Bad News. It’s not. It’s a clue. It’s a reason for concern and alertness. But many cases of low back pain that last for 6 weeks will still go away. Once again, see the 2009 research published in the British Medical Journal, which showed that more than 30% of patients with “new” chronic low back pain will still recover without treatment. BACK TO TEXT
  8. Spartacus is worthwhile, but the sex and violence is over-the-top: there’s no sugar-coating it. Definitely not a family drama. But the dramatic quality is excellent. After a couple of campy, awkward episodes at the start, the first season quickly gets quite good: distinctive film craft, interesting writing, and solid acting from nearly the whole cast. Andy Whitfield’s Spartacus is idealistic, earnest, and easy to like. I found it downright upsetting when I learned that he had passed away — as did many, many other fans I’m sure. See my personal blog for a little bit more of a review of Spartacus. BACK TO TEXT

About Paul Ingraham

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.