SaveYourself.ca helps you solve pain problems

published 7/08/09, updated 10/12/09

The Bark and the Bite of Low Back Pain

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

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.


The bark of low back pain is usually much worse than its bite, and this is the most important thing that most patients need to understand about it. The significance of problems like herniated discs and pinched nerves is generally 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. This idea is one of the pillars of SaveYourself.ca’s advanced 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 low back pain that deserves some better-safe-than-sorry investigation with your doctor. It is basically a plain English translation of authoritative clinical guidelines for doctors, such as those published by the American College of Physicians.3

Chronic low back is serious, but rarely ominous

Severe, chronic low back pain is distressingly common, but it is not a serious condition in the same sense as cancer or autoimmune disease. I don’t want minimize the importance of chronic low back pain: it can be ruinous, sucking 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 ordinary chronic low back pain never killed anyone.

“Ominous” is medical jargon for “truly scary.” Low back pain is ominous when it is being powered by a spinal cord trauma, or a progressive disease that can maim or kill. Such causes of low back pain are rare, but they are real.

Two kinds of back pain you should take seriously with no delay

There are two back pain scenarios that constitute medical emergencies.

  1. numbness around the groin and buttocks, and incontinence
  2. an accident with forces that may have been sufficient to fracture your spine

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

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 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 saving my friend from paraplegia.

Let’s look at those in a little more detail.

If you are experiencing significant numbness4 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 compression5 and require immediate medical attention. Few people will have symptoms like this without having already decided it’s an emergency, but of course it’s essential for me 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.

The big three indications that you should investigate for an ominous cause of persistent low back pain

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 weeks6
  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.

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!

The risk of an ominous cause for low back pain is generally higher if you are younger (under 20) or older (over 55).

Light tapping of the spine is painful.

Unexplained fever or chills.

Pain in the upper back is associated with a greater cancer risk.

Weight loss is particularly a potential sign of cancer.

Steroid use, other drug abuse, and HIV are all risk factors.

If you are generally feeling unwell in addition to having low back pain, this may be an indication that a disease process is underway.

Indicators of autoimmune disease include a family history of autoimmune disease, gradual but progressive increase in symptoms before the age of 40, marked morning stiffness, pain in other joints as well as the low back, rashes, difficult digestion, irritated eyes, and discharge from the urethra.

Difficulty urinating, incontinence, numbness around the groin, and significant weakness in the legs are all signs of a serious neurological problem. Astute readers will note that these red flags are a repeat from above: these symptoms can develop over time, so it’s important to keep considering 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 for a red flag, it isn’t really a red flag. But every single actual red flag — in combination with severe low back pain that’s been going on for several weeks — is adequate reason to get yourself checked out.

The great majority of 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 merit it

A few cancers in their early stages may 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 subject every low back pain patient to careful testing “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. 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 when there are no other red flags. In the great majority of cases, you shouldn’t let them scare you. Being “freaked out” about persistent back pain poses a genuine 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?

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 this advanced low back tutorial:

ADVANCED TUTORIAL

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 171 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

  $1995

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 . Return to text.
  2. Costa et al. British Medical Journal. 2009. 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. Return to text.
  3. Chou et al. Annals of Internal Medicine. 2007. Marvelously progessive, 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.” Return to text.
  4. This means true numbness: not 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. Return to text.
  5. 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. Return to text.
  6. 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, and it’s a reason for concern and altertness. 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 (cited above, first footnote), which showed that more than 30% of patients with “new” chronic low back pain will still recover without treatment. Return to text.