This post was written by Dr. Marc Larsen-Hallock, Physical Medicine and Rehabilitation, Parkview Health.
Low back pain affects millions of people worldwide. For many, it's challenging to pinpoint exactly where the pain comes from. While most cases don’t have a specific, identifiable source, there are structural causes we've come to understand, which can offer clues toward effective treatment.
The role of discs in back pain
Discogenic pain, sometimes called vertebrogenic pain, often stems from issues within the spinal discs and the surrounding joint. These discs can develop small tears, collapse or fail mechanically, leading to discomfort. About 39% of people with chronic back pain have this kind of disc-related pain. You might experience both back pain from these tears and leg pain if the nearby nerve roots are irritated.
When the bones in the spine are involved, these can show up on an MRI as changes in the bone marrow of vertebrae near degenerated discs. These findings can indicate inflammation, fat replacement or hardening of the bone. Spinal issues like fractures are rare, but they represent a concern for some experiencing chronic pain.
Conditions like disc herniation also appear on MRI scans, with visible disc bulges or degeneration. However, the severity of disc damage doesn’t always match how much pain you feel. For some, the discs might visibly protrude significantly but cause little discomfort.
When nerves are involved
Radicular pain occurs when nerves are compressed or irritated, often due to herniated discs or a narrowing of the spinal canal called spinal stenosis. This pain might radiate down your leg and is often worse when standing or walking.
In the joints
Facet joints are small, paired joints located at the back of the spine that enable bending and twisting movements. When these joints wear down, they can become inflamed and, in some cases, pinch nerves when they degenerate. This results in discomfort in the neck or lower back. Similarly, the sacroiliac joint located at the base of your spine can become painful due to injury or inflammation.
Diagnosis might involve injecting a local anesthetic to see if it provides relief, as many types of low back pain can clinically mimic one another. If confirmed, treatments like radiofrequency can offer temporary relief.
Myofascial pain in focus
Muscle and ligament strains in the lower back can lead to what we call myofascial pain. This pain doesn’t show up on X-rays or MRIs, but if you've had an accident or stretched your back awkwardly, your muscles and ligaments could be the culprits.
The challenge with imaging
When doctors use MRI scans to look for causes of low back pain, they often find changes that could be linked to pain, such as disc degeneration, herniations, bone spurs and other forms of arthritis. However, these same findings are frequently seen in people with no back pain at all. In fact, studies show that 25% to 50% of all pain-free individuals have some degree of disc herniation, and this increases to nearly 3 in 4 people by the time they reach 40 years old.
The relationship between these imaging findings and pain intensity is surprisingly weak. While certain abnormalities, such as Modic changes and disc bulges, correlate with pain, the strength of this relationship is modest. Many individuals with significant MRI findings report little to no pain, suggesting that the scans often reveal incidental findings rather than clear sources of pain.
Moreover, imaging results do not predict future episodes of back pain. Research indicates that having certain abnormalities, like disc bulges or degeneration, does not mean you will definitely experience pain later on. This disconnect is why many guidelines recommend against routine imaging for nonspecific low back pain: early scans don't necessarily lead to better outcomes, and they can sometimes result in overdiagnosis, unwarranted treatments or unnecessary anxiety.
Putting it all together
With the potential overlap between various causes, diagnosing back pain can be complex. Often, symptoms don’t point to a single cause, and imaging findings may be present in those without pain, adding to the challenge. To manage chronic back pain effectively, adopting a comprehensive approach that includes medical, psychological, physical and possibly interventional treatments is key.
If chronic low back pain is affecting your life, consult a healthcare provider who can treat you individually and guide you through tailored diagnostic tests and recommend a treatment plan that might include physical therapy, lifestyle changes, and precise medical interventions. Working with professionals can help manage symptoms and improve quality of life.
Get started with Physical Medicine & Rehabilitation
Take the first step toward recovery. Talk to your provider about a referral to Parkview Physicians Group – PM&R. If you need help scheduling an appointment or establishing care with a provider, our Access Center can help. Call any time, at 877-PPG-TODAY or 877-774-8632 for assistance.
