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What is the cause of severe low back pain?

Q: I am 48 years old female and I have chronic pain due to degenerative disc disease (DDD), arthritis and fibromyalgia. I have had a lumbar fusion and have been undergoing pain management for the last one year. I had to change my pain management physician, since I was moving out of the area. The new doctor told me that I have S1 joint problems? Along with my current pain medicines, she recommended a back brace, Transcutaneous Electrical Nerve Stimulator (TENS) unit and facet joint injections. What is involved with the facet joint injections, what is it and what should I expect? I don't quite understand what she meant about the S1 joints. I find it a little strange that, she has told my mother that she too has S1 problems. Is this hereditary?

A:There are basically 3 types of low-back pain (LBP): 1. Sinister variety due to severe tuberculosis of the spine or due to cancer. Only about 0.2% of all the LBPs belong to this category and they are easily diagnosed because of severe weight loss, fever, rapid deterioration of general health and night pains. Unless detected and treated within a few weeks they may even not survive beyond a few months. 2. The second variety is the one that involves lower back and buttocks in the 2nd half of the night, is at its peak in the early mornings and quickly starts to improve as soon as the person starts to exercise including walking jogging and generally heavy activity. This is a disease of young men usually in their teens and twenties. They also have some blood changes including features of active inflammatory disease. If undiagnosed for a few years they start getting bending of the back involvement of the hip joints, knees and generally progressive arthritis of the spine with bad outcome unless seen by a rheumatologist within the first 2 years. About 1-2 % of all the LBPs belong to this category. 3. The third category of rest of the ~ 98% of LBP patients have symptoms that you have described i.e. increase of pain on physical exertion, etc. with no constitutional symptoms, like weight loss, fever or general ill health. This is called non-specific back pain. Its cause is a combination of anxiety (what will happen to me!), stress, usually associated with lack of REM sleep (the relaxing sleep that normal people get in the 2nd half of the night), occasionally due to poor posture, lack of regular exercises causing weakness of the lower back muscles and occasionally strenuous physical activity causing low back sprains. You have typical 3rd category of LBP that only requires reassurance that it is not a serious life-threatening disease but only requires relaxation, regular exercises, and some simple muscle relaxants. I strongly recommend that you see a rheumatologist so that you can be properly assessed and given appropriate advice on physical therapy and relaxants.

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