Editing Back pain (section)

==Causes==
There are many causes of back pain, including blood vessels, [[internal organs]], [[infections]], mechanical and [[autoimmune]] causes.<ref name=":8" /> Approximately 90 percent of people with back pain are diagnosed with nonspecific, idiopathic acute pain with no identifiable underlying pathology.<ref name=":10">{{cite book | vauthors = Masterson R | chapter = Past, Present, and Future of Interventional Physiatry | chapter-url=https://books.google.com/books?id=ZocqaZxWgBUC&pg=PA13|title=Interventional spine : an algorithmic approach|publisher=Saunders Elsevier|year=2008|isbn=978-0-7216-2872-1| veditors = Slipman CW, Derby R, Simeone FA, Mayer TG |location=Philadelphia, Pennsylvania|pages=13 }}</ref> In approximately 10 percent of people, a cause can be identified through diagnostic imaging.<ref name=":10" /> Fewer than two percent of cases are attributed to secondary factors, with [[metastatic cancer]]s and serious infections, such as spinal [[osteomyelitis]] and [[epidural abscess]]es, accounting for approximately one percent.<ref>{{cite web|url=http://www.medscape.com/viewarticle/457101_3|title=Back Pain|archive-url=https://web.archive.org/web/20110506190633/http://www.medscape.com/viewarticle/457101_3|archive-date=May 6, 2011|url-status=live|access-date=April 30, 2018}}</ref>
{| class="wikitable"
|+Common causes
!'''Cause'''
!'''% of people with back pain'''
|-
|Nonspecific
|90%<ref name=":6" />
|-
|Vertebral compression fracture
|4%<ref name=":16" />
|-
|Metastatic cancer
|0.7%<ref name=":6" />
|-
|Infection
|0.01%<ref name=":6" />
|-
|Cauda equina
|0.04%<ref name=":17" />
|}

=== Nonspecific ===
In as many as 90 percent of cases, no physiological causes or abnormalities on diagnostic tests can be found.<ref>{{cite journal | vauthors = van den Bosch MA, Hollingworth W, Kinmonth AL, Dixon AK | title = Evidence against the use of lumbar spine radiography for low back pain | journal = Clinical Radiology | volume = 59 | issue = 1 | pages = 69–76 | date = January 2004 | pmid = 14697378 | doi = 10.1016/j.crad.2003.08.012 }}</ref> Nonspecific back pain can result from [[back strain]] or sprains, which can cause peripheral injury to muscle or ligaments. Many patients cannot identify the events or activities that may have caused the strain.<ref name=":4" /> The pain can present acutely but in some cases can persist, leading to chronic pain.

Chronic back pain in people with otherwise normal scans can result from [[central sensitization]], in which an initial injury causes a longer-lasting state of heightened sensitivity to pain. This persistent state maintains pain even after the initial injury has healed.<ref>{{cite journal | vauthors = Woolf CJ | title = Central sensitization: implications for the diagnosis and treatment of pain | journal = Pain | volume = 152 | issue = 3 Suppl | pages = S2–15 | date = March 2011 | pmid = 20961685 | pmc = 3268359 | doi = 10.1016/j.pain.2010.09.030 }}</ref> Treatment of sensitization may involve low doses of [[antidepressant]]s and directed rehabilitation such as [[physical therapy]].<ref>{{cite journal | vauthors = Verdu B, Decosterd I, Buclin T, Stiefel F, Berney A | title = Antidepressants for the treatment of chronic pain |url=http://chroniccare.rehab.washington.edu/resources/documents/antidepressantsinpain.pdf |archive-url=https://web.archive.org/web/20170809084235/http://chroniccare.rehab.washington.edu/resources/documents/antidepressantsinpain.pdf |archive-date=9 August 2017 | journal = Drugs | volume = 68 | issue = 18 | pages = 2611–32 | date = 2008-01-01 | pmid = 19093703 | doi = 10.2165/0003495-200868180-00007 | s2cid = 10509699 }}</ref>

=== Spinal disc disease ===
Spinal disc disease occurs when the [[nucleus pulposus]], a gel-like material in the inner core of the vertebral disc, ruptures.<ref name=":11">{{Cite book|title=Harrison's principles of internal medicine | vauthors = Jameson JL |isbn=978-1259644030|oclc=1041928452|date = 2018|page=| publisher = McGraw-Hill Education }}{{Page needed|date=February 2021}}</ref> Rupturing of the nucleus pulposus can lead to compression of nerve roots.<ref name=":18">{{cite book | vauthors = Donnally III CJ, Hanna A, Varacallo M | chapter = Lumbar Degenerative Disk Disease|date=2020| chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK448134/|title = StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=28846354|access-date=2021-01-29 }}</ref> Symptoms may be unilateral or bilateral, and correlate to the region of the spine affected. The most common region for spinal disk disease is at L4–L5 or L5–S1.<ref name=":18" /> The risk for lumbar disc disease is increased in overweight individuals because of the increased compressive force on the nucleus pulposus, and is twice as likely to occur in men.<ref name=":11" /><ref>{{Cite book | work = National Center for Biotechnology Information |url=https://www.ncbi.nlm.nih.gov/books/NBK279472/ |title= Slipped disc: Overview |location=Bethesda, MD|date=2020 |publisher=U.S. National Library of Medicine, Institute for Quality and Efficiency in Health Care (IQWiG)|language=en}}</ref> A 2002 study found that lifestyle factors such as night-shift work and lack of physical activity can also increase the risk of lumbar disc disease.<ref>{{cite journal | vauthors = Elfering A, Semmer N, Birkhofer D, Zanetti M, Hodler J, Boos N | title = Risk factors for lumbar disc degeneration: a 5-year prospective MRI study in asymptomatic individuals | language = en-US | journal = Spine | volume = 27 | issue = 2 | pages = 125–134 | date = January 2002 | pmid = 11805656 | doi = 10.1097/00007632-200201150-00002 | s2cid = 30267765 }}</ref> [[File:Disc herniation -- Smart-Servier.png|thumb|Lumbar disc herniation]]

Severe spinal-cord compression is considered a surgical emergency and requires decompression to preserve motor and sensory function. [[Cauda equina syndrome]] involves severe compression of the [[cauda equina]] and presents initially with pain followed by motor and sensory.{{Clarify|date=July 2022}}<ref name=":17">{{cite journal | vauthors = Orendácová J, Cízková D, Kafka J, Lukácová N, Marsala M, Sulla I, Marsala J, Katsube N | display-authors = 6 | title = Cauda equina syndrome | journal = Progress in Neurobiology | volume = 64 | issue = 6 | pages = 613–637 | date = August 2001 | pmid = 11311464 | doi = 10.1016/S0301-0082(00)00065-4 | s2cid = 27419841 }}</ref> Bladder incontinence is seen in later stages of cauda equina syndrome.<ref>{{cite journal | vauthors = Gardner A, Gardner E, Morley T | title = Cauda equina syndrome: a review of the current clinical and medico-legal position | journal = European Spine Journal | volume = 20 | issue = 5 | pages = 690–697 | date = May 2011 | pmid = 21193933 | pmc = 3082683 | doi = 10.1007/s00586-010-1668-3 }}</ref>

=== Degenerative disease ===
[[Spondylosis]], or degenerative arthritis of the spine, occurs when the intervertebral disc undergoes degenerative changes, causing the disc to fail at cushioning the vertebrae. There is an association between intervertebral disc space narrowing and lumbar spine pain.<ref name="Raa2015">{{cite journal | vauthors = Raastad J, Reiman M, Coeytaux R, Ledbetter L, Goode AP | title = The association between lumbar spine radiographic features and low back pain: a systematic review and meta-analysis | journal = Seminars in Arthritis and Rheumatism | volume = 44 | issue = 5 | pages = 571–85 | date = April 2015 | pmid = 25684125 | doi = 10.1016/j.semarthrit.2014.10.006 }}</ref> The space between the vertebrae becomes more narrow, resulting in compression and irritation of the nerves.<ref>{{cite book | vauthors = Lavelle WF, Kitab SA, Ramakrishnan R, Benzel EC | date = 2017 | chapter = Anatomy of Nerve Root Compression, Nerve Root Tethering, and Spinal Instability | title = Benzel's Spine Surgery | edition = 4th | pages = 200–205 | location = Philadelphia, Pennsylvania | publisher = Elsevier | isbn = 978-0-323-40030-5 }}</ref>

[[Spondylolisthesis|Spondylolithesis]] is the anterior shift of one vertebra compared to the neighboring vertebra. It is associated with age-related degenerative changes as well as trauma and congenital anomalies.

[[Spinal stenosis]] can occur in cases of severe spondylosis, spondylotheisis and age-associated thickening of the ligamentum flavum. Spinal stenosis involves narrowing of the spinal canal and typically presents in patients greater than 60 years of age. [[Neurogenic claudication]] can occur in cases of severe lumbar spinal stenosis and presents with symptoms of pain in the lower back, buttock or leg that is worsened by standing and relieved by sitting.

[[Vertebral compression fracture]]s occur in four percent of patients presenting with lower back pain.<ref>{{cite journal | vauthors = Jarvik JG, Deyo RA |url=https://jacobimed.org/public/Ambulatory_files/intern_ambulatory_block/spring/back%20pain%20imaging.pdf | title = Diagnostic evaluation of low back pain with emphasis on imaging | journal = Annals of Internal Medicine | volume = 137 | issue = 7 | pages = 586–97 | date = October 2002 | pmid = 12353946 | doi = 10.7326/0003-4819-137-7-200210010-00010 | s2cid = 860164 }}</ref> Risk factors include age, female gender, history of osteoporosis, and chronic [[glucocorticoid]] use. Fractures can occur as a result of trauma but in many cases can be asymptomatic.

=== Infection ===
Common infectious causes of back pain include [[osteomyelitis]], [[Discitis|septic discitis]], paraspinal abscess and [[epidural abscess]].<ref name=":11" /> Infectious causes that lead to back pain involve various structures surrounding the spine.<ref>{{Cite web |title=COVID and back pain - Omicron variant invades skeletal muscle cells |url=https://www.colcorona.net/covid-back-pain |access-date=2022-12-09 |website=www.colcorona.net}}</ref>

[[Osteomyelitis]] is the bacterial infection of the bone. [[Vertebral osteomyelitis]] is most commonly caused by [[Staphylococcus|staphylococci]].<ref name=":11" /> Risk factors include skin infection, urinary tract infection, IV catheter use, IV drug use, previous endocarditis and lung disease.

[[Spinal epidural abscess]] is commonly caused by severe infection with [[Bloodstream infections|bacteremia]]. Risk factors include recent administration of epidurals, IV drug use or recent infection.

===Cancer===
Spread of cancer to the bone or spinal cord can lead to back pain. Bone is one of the most common sites of metastatic lesions. Patients typically have a history of malignancy. Common types of cancer that present with back pain include [[multiple myeloma]], [[lymphoma]], [[leukemia]], spinal cord tumors, primary vertebral tumors and [[prostate cancer]].<ref name=":16">{{Cite book|title=Symptom to diagnosis : an evidence-based guide| vauthors = Stern SD |isbn=978-0071803441|oclc=894996548|date = 2014 |edition=3|page=| publisher = McGraw-Hill Education }}{{page needed|date=February 2021}}</ref> Back pain is present in 29% of patients with systemic cancer.<ref name=":11" /> Unlike other causes of back pain that commonly affect the lumbar spine, the thoracic spine is most commonly affected.<ref name=":11" /> The pain can be associated with systemic symptoms such as weight loss, chills, fever, nausea and vomiting.<ref name=":11" /> Unlike other causes of back pain, [[neoplasm]]-associated back pain is constant, dull, poorly localized and worsens with rest. [[Metastasis]] to the bone also increases the risk of [[Spinal cord compression|spinal-cord compression]] or vertebral fractures that require emergency surgical treatment.<ref>{{Cite journal |last1=Tsukamoto |first1=Shinji |last2=Kido |first2=Akira |last3=Tanaka |first3=Yasuhito |last4=Facchini |first4=Giancarlo |last5=Peta |first5=Giuliano |last6=Rossi |first6=Giuseppe |last7=Mavrogenis |first7=Andreas F. |date=2021-08-29 |title=Current Overview of Treatment for Metastatic Bone Disease |journal=Current Oncology |language=en |volume=28 |issue=5 |pages=3347–3372 |doi=10.3390/curroncol28050290 |doi-access=free |issn=1718-7729 |pmc=8482272 }}</ref>

=== Autoimmune ===
[[File:Discogenic Pain.png|thumb|Back pain can be caused by the vertebrae compressing the intervertebral discs.]]
Inflammatory arthritides such as [[ankylosing spondylitis]], [[psoriatic arthritis]], [[rheumatoid arthritis]] and [[systemic lupus erythematosus]] can all cause varying levels of joint destruction. Among the inflammatory arthritides, ankylosing spondylitis is most closely associated with back pain because of the inflammatory destruction of the bony components of the spine. Ankylosing spondylitis is common in young men and presents with a range of possible symptoms such as [[uveitis]], [[psoriasis]] and [[inflammatory bowel disease]].

=== Referred pain ===
Back pain can also be [[referred pain|referred]] from another source. Referred pain occurs when pain is felt at a location different than the source of the pain. Disease processes that can present with back pain include [[pancreatitis]], [[Kidney stone disease|kidney stones]], severe [[urinary tract infection]]s and [[abdominal aortic aneurysm]]s.<ref name=":4" />

===Risk factors===
Heavy lifting, obesity, sedentary lifestyle and lack of exercise can increase the risk of back pain.<ref name=":5" /> Cigarette smokers are more likely to experience back pain than are nonsmokers.<ref>{{cite journal | vauthors = Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E |url=https://scholar.google.com/scholar?as_sdt=0%2C5&q=+The+association+between+smoking+and+low+back+pain%3A+a+meta-analysis+&btnG= |format=PDF | title = The association between smoking and low back pain: a meta-analysis | journal = The American Journal of Medicine | volume = 123 | issue = 1 | pages = 87.e7–35 | date = January 2010 | pmid = 20102998 | doi = 10.1016/j.amjmed.2009.05.028 }}</ref> Excessive weight gain in pregnancy is also a risk factor for back pain.<ref>{{Cite web |last=Canada |first=Health |date=2010-09-22 |title=Prenatal Nutrition Guidelines for Health Professionals: Gestational Weight Gain |url=https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/healthy-weights/prenatal-guidelines-professionals-gestational-weight-gain.html |access-date=2025-03-28 |website=www.canada.ca}}</ref> In general, fatigue can worsen pain.<ref name=":5" />

A few studies suggest that [[psychosocial]] factors such as work-related stress and [[Dysfunctional family|dysfunctional family relationships]] may correlate more closely with back pain than do structural abnormalities revealed in X-rays and other medical imaging scans.<ref>{{cite journal | vauthors = Burton AK, Tillotson KM, Main CJ, Hollis S | title = Psychosocial predictors of outcome in acute and subchronic low back trouble | journal = Spine | volume = 20 | issue = 6 | pages = 722–28 | date = March 1995 | pmid = 7604349 | doi = 10.1097/00007632-199503150-00014 | s2cid = 21171676 }}</ref><ref>{{cite journal | vauthors = Carragee EJ, Alamin TF, Miller JL, Carragee JM | title = Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain | journal = The Spine Journal | volume = 5 | issue = 1 | pages = 24–35 | year = 2005 | pmid = 15653082 | doi = 10.1016/j.spinee.2004.05.250 }}</ref><ref>{{cite journal | vauthors = Hurwitz EL, Morgenstern H, Yu F | title = Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA Low-Back Pain Study | journal = Journal of Clinical Epidemiology | volume = 56 | issue = 5 | pages = 463–71 | date = May 2003 | pmid = 12812821 | doi = 10.1016/S0895-4356(03)00010-6 }}</ref><ref>{{cite journal | vauthors = Dionne CE |url=https://scholar.google.com/scholar?as_sdt=0%2C5&q=+Psychological+distress+confirmed+as+predictor+of+long-term+back-related+functional+limitations+in+primary+care+settings+&btnG= |format=PDF | title = Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings | journal = Journal of Clinical Epidemiology | volume = 58 | issue = 7 | pages = 714–18 | date = July 2005 | pmid = 15939223 | doi = 10.1016/j.jclinepi.2004.12.005 }}</ref>

Back pain physical effects can range from muscle aching to a shooting, burning, or stabbing sensation.  Pain can radiate down the legs and can be increased by bending, twisting, lifting, standing, or walking. While the physical effects of back pain are always at the forefront, back pain also can have psychological effects. Back pain has been linked to depression, anxiety, stress, and avoidance behaviors due to mentally not being able to cope with the physical pain. Both acute and chronic back pain can be associated with psychological distress in the form of anxiety (worries, stress) or depression (sadness, discouragement). Psychological distress is a common reaction to the suffering aspects of acute back pain, even when symptoms are short-term and not medically serious.<ref>{{cite web | publisher = International Asscosiation for the Study of Pain (IASP) | date = 9 July 2021 | title = Psychology of Back Pain. | url = https://www.iasp-pain.org/resources/fact-sheets/psychology-of-back-pain/#:~:text=Both%20acute%20and%20chronic%20back,not%20medically%20serious%20%5B35%5D }}</ref>