Back & Neck

Anatomy of the Spine – Upper Back, Lower Back and Neck

An inside look at the structure of the back.

When most people mention their back, what they are actually referring to is their spine. The spine runs from the base of your skull down the length of your back, going all the way down to your pelvis. It is composed of 33 spool-shaped bones called vertebrae, each about an inch thick and stacked one upon another.

Each vertebra consists of the following parts:

The body is the largest part of the vertebrae and the part that bears the most weight.

The lamina is the lining of the hole (spinal canal) through which the spinal cord runs.

The spinous process is the bony protrusions you feel when you run your hand down your back.

The transverse processes are the pairs of protrusions on either side the vertebrae to which the back muscles attach.

The facets are two pairs of protrusions where the vertebrae connect to one another, including:

• The superior articular facets, which face upward
• The inferior articular facets, which face downward.

The connection points between the vertebrae are referred to as the facet joints, which keep the spine aligned as it moves. Similar to other joints in the body, the facet joints are lined with a smooth membrane called the synovium, which produces a viscous fluid to lubricate the joints.

Located between the individual vertebrae, discs serve as cushions or shock absorbers between the bones. Each disc is about the size and shape of a flattened doughnut hole and consists of two parts:

• The annulus fibrosis – a strong outer cover
• The nucleus pulposis – a "jelly-like" filling.

Running through the center of the spinal column is the spinal cord, a bundle of nerve cells and fibers that transmit electrical signals back and forth between the brain and the rest of the body via 31 pairs of nerve bundles that branch off the spinal cord and exit the column between the vertebrae. 

Supporting the spine, while providing it flexibility, are ligaments (tough bands of connective tissue that attach bone to bone) and muscles. Two main ligaments are:

• Anterior longitudinal ligament
• Posterior longitudinal ligament.

Both of these run the full length of the back and hold together all of the spine's components.

The two main muscle groups involved in back function are:

• The extensors, which include the many muscles that attach to the spine and work together to hold your back straight while enabling you to extend it.
• The flexors, which attach at your lumbar spine (lower back), and enable you to bend forward. Located at the front of your body, the flexors include your abdominal and hip muscles.

Although the spine is a continuous structure, it is often described as if it were five separate units. These units are the five different sections of the spine:

1. The cervical spine – the neck and upper back, composed of the seven vertebrae closest to the skull. The cervical spine supports the weight and movement of your head and protects the nerves exiting your brain.
2. The lumbar spine – the lower back, composed of five vertebrae, provides support for the majority of your body's weight.
3. The thoracic spine – the middle back, made up of the 12 vertebrae in between the cervical and lumbar spine.
4. The sacrum – the base of the spine that is composed of five vertebrae fused (joined together) as one solid unit. The sacrum attaches to ilium of the pelvis, forming the sacroiliac joints.
5. The coccyx – the "tailbone" located below the sacrum, composed of four fused vertebrae.

Back Pain Causes

Arthritis & Diseases That Affect the Back

From cartilage breakdown to muscle inflammation – problems that may be to blame for back pain.

Many forms of arthritis and related conditions that affect the joints, muscles and/or bones can cause problems like pain, stiffness and swelling in the back. While any part of the back can be affected, the lower back is the most common site of arthritis back pain, most likely because it bears more of the body's weight.

Several forms of arthritis – collectively referred to as the spondylarthropathies (meaning spinal arthritis)– primarily affect the spine. These include:

• Ankylosing spondylitis. Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine, particularly the sacroiliac joints near the pelvis, and the hip joints. Ankylosing is a term meaning stiff or rigid and spondylitis means inflammation of the spine.

  Enthesitis (inflammation of the place where ligaments and muscles attach to bones) accounts for much of the pain and stiffness of ankylosing spondylitis. This inflammation eventually can lead to bony fusion of the joints (where the fibrous ligaments transform to bone, and the joint permanently grows together).

  Other joints can also develop synovitis (inflammation of the lining of the joint), with lower limb joints more commonly involved than upper-limb joints.

• Reactive arthritis. Reactive arthritis is a chronic form of arthritis that often occurs following an infection of the genital, urinary or gastrointestinal system. Features of reactive arthritis include inflammation of the joints, eyes and structures within the gastrointestinal or genitourinary tracts, such as intestines, kidneys or bladder.
• Psoriatic arthritis. Psoriatic arthritis is a form of arthritis accompanied by the skin disease psoriasis. The skin disease often precedes the arthritis; in a small percentage the joint disease develops before the skin disease. For about 20 percent of people with psoriatic arthritis, the disease involves the spine. In some cases, bony overgrowth can cause two or more vertebrae to grow together, or fuse, causing stiffness.
• Juvenile Spondylarthropathy. Also called juvenile-onset spondyloarthritis (spinal arthritis), this term is used to describe spondylarthropathies that begin before age 16. In addition to affecting the spine, they may cause pain and inflammation in the joints of the pelvis, hips, ankles and knees. They may also affect other body organs such as the eyes, skin and bowels.
• Enteropathic arthritis. This is a form of arthritis that occurs in about 5 percent of people with inflammatory bowel disease, which includes ulcerative colitis and Crohn's disease. It commonly affects the sacroiliac joints, causing lower back pain.

Other forms of arthritis and related conditions that can affect the back include:

• Osteoarthritis. The most common form of arthritis of the back, osteoarthritis is a chronic condition characterized by the breakdown of the cartilage that cushions the ends of the bones where they meet to form joints. In the spine, this breakdown occurs in the cartilage of the facet joints, where the vertebrae join. As a result, movement of the bones can cause irritation, further damage and the formation of bony outgrowths called spurs. These spurs can press on nerves, causing pain. New bone formation can also lead to narrowing of the spinal canal, known as spinal stenosis.
• Rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory disease of the joints that occurs when the body’s immune system – which normally protects us from infection – mistakenly attacks the synovium, the thin membrane that lines the joints. Although rheumatoid arthritis most commonly affects the hips, knees, hands, wrists, feet, elbows and ankles, it can also affect the facet joints in the spine, causing pain and, in severe cases, destruction of the joints. This may allow the upper vertebra to slide forward on top of the lower vertebra, a condition called spondylolisthesis. The slipped vertebra may put pressure on the spinal cord and/or the nerve roots where they exit the spine.
• Gout. Gout is a form of arthritis that occurs when excess uric acid, a bodily waste product circulating in the bloodstream, is deposited as needle-shaped monosodium urate crystals in tissues of the body, including the joints. For many people, the first symptom of gout is excruciating pain and swelling in the big toe – often following a trauma, such as an illness or injury. Subsequent attacks may occur off and on in other joints, primarily those of the foot and knee. Less commonly gout can affect the spine, causing extreme pain, numbness and tingling. It can be confused with a spinal infection.
• Infectious arthritis. Also called septic arthritis, infectious arthritis refers to arthritis that is caused by an infection within a joint. It can occur in the facet joints of spine. Infectious arthritis is often caused by bacteria that spread through the bloodstream to the joint. Sometimes it is caused by viruses or fungi.
• Polymyalgia rheumatica. An inflammatory disorder that causes widespread muscle pain and stiffness, polymyalgia rheumatica mainly affects the neck, shoulders, upper arms, lower back, thighs and hips. The disease often comes on suddenly and resolves on its own in a year or two.
• Fibromyalgia. An arthritis-related condition, fibromyalgia is a syndrome of chronic, widespread muscle pain and fatigue, which can be debilitating. The lower back is a common site of fibromyalgia pain.
• Osteoporosis. Osteoporosis is a condition in which the bones loose so much mass that they become brittle and prone to break with slight trauma. The condition, which can occur with aging, inactivity, a low-calcium diet or use of corticosteroid medications, commonly affects the spine. When this occurs in the spine, the inner spongy bone and more solid outer portion of the vertebrae become porous. The weakened vertebrae can break – an injury called a compression fracture – and lose about one-half of their height. In most cases, compression fractures, are painful. In some cases, the resulting back pain is severe. Usually, the pain resolves within a few weeks, but for some people, it is long-lasting.
• Spinal stenosis. Literally meaning &quotspinal narrowing,&quot spinal stenosis can occur when changes in arthritis lead to bony overgrowth of the vertebrae and thickening of the ligaments. This can occur with osteoarthritis or ankylosing spondylitis. If a significant overgrowth occurs, it can cause the spinal column to narrow and press on the nerves housed within. Because the affected nerves have many functions, the condition may cause diverse problems in the lower body, including back pain, pain or numbness in the legs, constipation or urinary incontinence.
• Paget's disease of bone. Paget’s disease is a chronic disorder in which excessive breakdown and formation of bone causes the bones to become enlarged, misshapen and weakened. The disease usually does not affect the entire skeleton, but just one or a few bones. The vertebrae are among the bones most commonly affected by Paget's disease.
• Sciatica. This is inflammation of the sciatic nerve. The largest nerve in the human body, the sciatic nerve runs from the lower part of the spinal cord, through the buttock and down the back of the leg to the foot. The most common causes of sciatica include compression of the nerve where it exists the spine by a herniated disc, or a rupture of one of the structures that cushions the vertebrae in the spine. Sciatica may be felt as a sharp or burning pain that radiates from the hip. It may also be accompanied by low back pain.
• Scoliosis. Instead of running straight up the center of the back, a spine with scoliosis twists to one side. Scoliosis can be classified as true (meaning it has to do with abnormal development of the spine) or functional (meaning its cause is not directly related to the spine). Functional scoliosis may occur when a discrepancy in leg length causes the pelvis to tilt to one side to compensate. The cause of true scoliosis is largely unknown, although doctors suspect that it may be the result of imbalanced growth in childhood.

Back Injury

Common and some not-so-common injuries that cause back pain.

Back pain is often the result of injuries, which may be acute or occur over time. They include:

• Sprains. When ligaments in the back are torn, usually from a sudden injury, the result can be pain. The pain of a sprain can be severe, localized to one spot in the back or more generalized all of your back and in nearby areas of the body.
• Spasms. Sometimes overworked muscles of the back (and elsewhere) go into spasm – painful, involuntary contraction, similar to a charley horse (a cramp, usually occurring in the calf muscle). While spasms are painful, they are the body's way of protecting itself from the underlying problem. When muscles are in spasm, they become painful and rigid, so that you are temporarily unable to use or damage them further.
• Ruptured or herniated discs.When discs are weakened, the hard outer covering can rupture, allowing the squishy center to bulge out causing pressure and irritation to nearby nerves.

  Learn about herniated discs and their treatment from the American Academy of Orthopaedic Surgeons.

• Vertebral fractures. Fractures of the vertebra may be caused by a trauma, but more often are the result of osteoporosis, which weakens the vertebrae and causes them to crumble. These are called compression fractures.

Back pain caused by problems elsewhere in the body.

Sometimes back pain can be the result of a problem not located in the back. Possible causes include:

• Kidney stones or kidney infections. Because of the kidneys' location in the lower back, problems with the kidney may be felt as back pain.
• Pregnancy. Weight gain from pregnancy can both stress the back and stretch and weaken muscles that support the spine.
• Obesity. Being overweight or obese, particularly if excess weight is carried in the abdomen, places stress on back muscles, causing pain.
• Endometriosis. This is a condition in which the endometrial tissue (tissue that lines the uterus) migrates from the uterus and deposits on other organs and structures. Pain from endometriosis is often felt in the abdomen and back.
• Aortic aneurysms. In rare cases, the aorta (the body's main artery that originates at the heart and runs down the body just in front of the spine) develops an aneurysm, a balloon-like swelling in the artery's muscular wall. If the wall ruptures or causes compression of the blood vessels that run off it, the result can be pain that is felt in the chest, abdomen and/or lower back. This is a medical emergency, requiring immediate treatment.
• Tumors. In rare cases, tumors – either malignant (cancerous) or benign (not cancerous) – can affect the tissues of or near the spine, causing pain.

Back Pain Diagnosis

Nerve Tests for Diagnosing Back Pain

Tests that detect damaged nerves.

Nerve tests, also called electrodiagnostic studies, are used to determine whether the electrical activity of the nerves has been disrupted as a result of problems in the back. The most common is electromyography. Also called an EMG or myogram, electromyography is a procedure that involves inserting needle electrodes through the skin into a muscle. The electrical activity detected by the electrodes is displayed on a piece of equipment called an oscilloscope that resembles a TV screen with wavy lines crossing it. The presence, size and shape of the waves produced on the screen tell your doctor how able your muscles are to respond to nerve stimulation and can assist in the diagnosis of problems involving the nervous system.

Imaging Tests for Diagnosing Back Pain

Tests that allow your doctor to see inside your back – painlessly.

Imaging tests can allow your doctor to see the internal structures of your back non-invasively. It's important to note, however, that just because an imaging test shows a structural abnormality, it isn't necessarily the source of pain. For example, a large percentage of older people have changes due to osteoarthritis, disc bulges and even herniated discs that can be seen by X-ray, yet only a small percentage of those people have back pain.

The most common imaging tests to diagnose back problems are:

X-ray (radiography). A standard X-ray is a simple test in which an X-ray beam (a form of electromagnetic radiation) is passed through the hip to create a two-dimensional picture of the bones. Your doctor can use X-rays to view:

• changes of the spine due to osteoarthritis
• problems with the spine alignment
• a vertebral fracture
• bony changes characteristic of ankylosing and other spondylarthropathies.

Because X-rays only show the bones, your doctor will order different imaging tests if he wants to see the soft tissues of the back, including:

Learn more about x-rays of the lumbar spine from MedlinePlus. 

Computerized axial tomography (CAT) scan. Also called a computed tomography (or CT) scan, this is noninvasive test combines X-ray equipment with sophisticated computers to record two-dimensional slice images of your body and, in some cases, turning those slices into a three-dimensional view of the back. CT scan shows soft tissues such as ligaments and muscles more clearly than traditional X-rays do, so it is more useful for diagnosing certain problems, such as ruptured or degenerated discs, spinal stenosis, tumors or infections of the spinal cord.

Magnetic resonance imaging (MRI).   This procedure uses a strong magnet linked to a computer to create a detailed image of a cross section of the body in black and white and shades of gray. The advantage of MRI scans over X-rays and CT scans is that MRI provides clear, detailed images of the soft-tissue structures, such as the muscles, cartilage, ligaments, discs, tendons and blood vessels, in addition to the bones.

Bone scan. In bone scan, a small amount of radioactive dye is injected into a vein in your arm and allowed to circulate through your body, including the bones of your spine, for a couple of hours. A special camera is then used to scan the area in question and produce a picture. The scan works by detecting any area of the spine that has an increase in blood flow and bone-forming cell activity, which could possibly indicate a tumor, infection or fracture.

Discogram. A discogram is a test used to view and assess the internal structure of a disc and to determine if the disc is a source of pain. To perform a discogram, a doctor injects a radiopaque dye (a dye that shows up on radiological scans) into the disc or discs being examined. The doctor then performs a CT scan, in which any tears, scars or changes in the disc are illuminated.

Dual energy X-ray absorptiometry (DEXA or DXA). DEXA is used to diagnose osteoporosis. The test uses a small amount of radiation to determine the density, or thickness, of bone in the spine and other areas of the body. Although DEXA is the most commonly used test for bone density, there are others.

Diagnosing Back Problems

How your doctor can start to identify the cause of your back pain.

If you are experiencing muscular back pain, there's a good chance it will go away on its own with time. But you should see a doctor right away if back pain is severe, occurs after a fall or injury, doesn't improve when you lie on your back or is accompanied by one or more of the following:

• Weakness, pain or numbness in one or both of your legs
• Fever or unintentional weight loss
• Pain with urination or difficulty urinating

Diagnosing back pain will begin with a physical exam and medical history.

Medical History  

During the medical history your doctor will ask you questions, such as:

• What symptoms are you experiencing?
• Did they begin suddenly or come on gradually?
• Are your symptoms worse after activity or rest?
• Are there certain activities that make your symptoms worse – or better?
• Are you experiencing pain or swelling in other joints?
• Are you experiencing symptoms anywhere besides the back?
• Have you ever had cancer?
• Have you had unexplained weight loss?
• Do any of your family members have arthritis or other back problems?
• Do you have other medical problems that could be causing your symptoms?
• Do you spend a lot of time sitting at a desk?
• Do you exercise regularly? If so, what kind of exercise do you do?
• Do you smoke? If so, how much?

Physical Exam

During the physical exam your doctor will check your posture and look for problems such as curvature of the spine.

Your doctor may ask you to stand and walk to determine if back pain is affecting your gait (the manner in which you walk) or if an awkward gait (perhaps due to leg-length discrepancy or arthritis in the knee or hip) may be contributing to your back pain.  

Your doctor may ask you to move, bend and change position to see if a particular activity or position makes your pain worse. Your doctor may also press on different parts of your body – even parts where you may not be aware of pain – to check for tender points (tender painful areas that are characteristic of fibromyalgia) and trigger points (areas of the body that, when pressed, cause pain elsewhere) to locate the source of your pain.

As part of the physical exam your doctor may also perform one or more of the following tests:

• Lower body nerve evaluation. By running a device called a pinwheel along your skin, from your hips to your feet, your doctor can check for any areas that are either abnormally sensitive or insensitive to stimulus, which would suggest possible nerve involvement in the lower spine.
• Muscle-strength evaluation. By checking the strength of the different muscle groups in your lower body, your doctor can detect possible nerve problems. Because different nerves supply different muscle groups, a weakened muscle group may suggest damage to the nerve that supplies that group of muscles.
• Sciatic nerve stretch test. By raising your legs one at a time (while you extend and relax them) as you lie flat on a table, your doctor can determine whether stretching the sciatic nerve causes pain, suggesting possible nerve-root involvement.

Depending on the findings of your history and physical exam your doctor may also order one or more of the following: lab tests, nerve tests or imaging tests.

Lab Tests for Diagnosing Back Problems

Blood tests that can tell what's going on inside your body

Often a sample of blood or joint fluid can help your doctor confirm a diagnosis. For example, a blood test showing high blood levels of rheumatoid factor – an antibody that acts against the blood component gamma globulin – or antibody called anti-cyclic citrullinated peptide antibody (anti-CCP) may suggest rheumatoid arthritis. High levels of antinuclear antibodies (ANAs), abnormal antibodies directed against the cells' nuclei, could suggest lupus or another inflammatory disease.  

For people with arthritis of the spine, a finding of a specific genetic marker called HLA-B27 in the blood can help the doctor identify a possible diagnosis of a spondylarthropathy, such as ankylosing spondylitis or reactive arthritis. Although the genetic marker is more common in people with these diseases, perfectly healthy people can have it. For that reason, a positive HLA-B27 test does not mean you have one of these diseases.

Tests of fluid drawn from the joint with a needle may reveal crystals of uric acid, confirming a diagnosis of gout, or a bacterium, suggesting that joint inflammation is caused by an infection.

Back Pain Treatment

Injections and Implants for Back Pain Relief

Sometimes doctors use injections or implanted devices to deliver pain relief medication locally instead of using oral pain drugs. Some implanted devices don’t deliver medication, but instead use other techniques for pain relief.

Doctors may give several different types of injections for back pain. The best one for you, should you need one, will depend on your particular problem. These injections include:

Epidural steroid injections. When inflammation within the spinal column causes nerve-root irritation and swelling, doctors sometimes administer a potent anti-inflammatory medication to reduce inflammation and ease pain. Steroids typically are injected directly into the epidural space – the area between the dura mater and the vertebrae – to deliver pain-relieving medication directly to the site of inflammation. Pain relief typically begins in less than a week and lasts anywhere from several days to a few months.

Selective nerve-root block. When a nerve root is compressed or inflamed, it can cause pain in the back and leg. A selective nerve-root block is an injection of a steroid and/or numbing agent into the area of the nerve where it exits the spinal column between the vertebrae. Pain relief begins within a few days to a week and may last up to a few months.

Facet joint block. If your doctor suspects the source of your pain is in the facet joints, where the vertebrae connect to one another, she may recommend a procedure called a facet joint block. In this procedure, a steroid and/or anesthetic medication is injected directly into the joint capsule. Pain relief may last several weeks or months.

Facet neurotomy. A facet neurotomy is a procedure used in people for whom a facet joint block has suggested that a particular joint is a cause of back pain. This procedure uses a heated needle to burn and disable the nerve responsible for the pain. Although the nerve usually grows back, allowing pain to return, this can take several months to a year.

Sacroiliac joint block. Sacroiliac joint blocks involve injecting an anesthetic or anti-inflammatory medication into the sacroiliac joint, which connects the sacrum (one of the sections of the spine, composed of five fused vertebrae) to the pelvis. These may be used to relieve low back pain that results from inflammation or damage within the sacroiliac joint.

Trigger point injections. These injections involve injecting a small amount of local anesthetic, sometimes along with a steroid medication, directly into painful trigger points, specific sites on the muscles that cause pain (both locally and throughout the back) when your doctor presses on one during an exam. These injections may be helpful if you experience back pain when pressure is applied to certain areas.

Two types of implantable devices are used to treat back pain – those that deliver electrical stimulation to the spinal cord and those that deliver medication to it.

Spinal cord stimulation. Spinal cord stimulation is believed to decrease the perception of pain by activating nerves in your lower back to block pain signals going to that area. As a result, pain is replaced with a pleasant tingling sensation. Spinal cord stimulation is delivered through a set of electrodes that are inserted between the vertebrae into the epidural space. A pulse generator or radio receiver surgically placed under the skin in the abdomen or the upper buttocks area activates the electrodes. The procedure may be appropriate for people with nerve-root injuries that haven't responded to conventional treatment and those for whom surgery has not been successful.

Implanted drug infusion. Also called intraspinal drug infusion therapy involves implanting a pump in the body to deliver a regular, predetermined dose of narcotic pain medicine via a tube into the painful area of the spine. By targeting medication to the precise site of pain, the device enables you to use much smaller amounts of medications than would otherwise be necessary to control pain. Precise targeting of small doses also reduces the risk of side effects you might experience with higher oral doses of pain-relieving medication.

Surgery for Back Pain

Options to consider when conservative treatments don't bring relief.

If you have a problem that can be physically corrected, such as a herniated disc, spinal stenosis or spondylolisthesis, surgery is an option worth considering – particularly when more conservative treatments fail to relieve your pain. To treat other problems, such as a serious infection or tumor, surgery may be a medical necessity.

The following are some of the most common back surgeries:

Discetomy. Discectomy is removal of part of a disc that is herniated and causing pain or other symptoms. There are two types of discectomy:

• Percutaneous, which involves removing a portion of the disc, using a laser or suction device, through a narrow probe placed through a small incision in your back.
• Microsurgical, which requires a small incision, usually less than inch long. During this type of discectomy, the surgeon, using a microscope, removes the damaged portion of the disc along with a small portion of the bone covering the spinal canal.

Laminectomy. Laminectomy is a surgery performed to enlarge the spinal column when spinal stenosis (narrowing) causes pressure on the nerve roots. A laminectomy involves removing the lamina, the backside of the spinal canal that forms a roof over the spinal cord. Along with lamina, doctors often remove any bony protrusions, or spurs, which may have formed as a result of osteoarthritis of the spine.

Spinal Fusion. Spinal fusion is a welding process by which two or more vertebrae are fused together for form a single immobile unit. It is used to stop the motion that normally occurs between the vertebrae and, in doing so, relieve pain that is caused or aggravated by movement, such as bending, lifting or twisting, or to stabilize a spine that has been damaged by infections or tumors. It also may be used to stop the progression of a spinal deformity, such as scoliosis, to treat injuries of the vertebrae, or to stabilize vertebrae that become loose due to a defect in the facet joint.

Learn more about spinal fusion from the American Academy of Orthopaedic Surgeons.

Vertebroplasty and kyphoplasty. These two similar procedures are performed to relieve the pain and, possibly, other problems associated with compression fractures of the vertebrae. Both involve bolstering fractured bone with a cement-like material that is injected into the vertebra or vertebrae through a needle about as big around as a cocktail straw. Although the two procedures are essentially the same, kyphoplasty involves an additional step. Just before injecting the cement material, the doctor places a small balloon-like device into the compressed vertebra and inflates it. The goal of this additional step is to help restore height to the crumbled vertebra, which will reduce deformity.

Read about other treatments for osteoporosis.

Other less common surgeries may be performed for other problems.

Complementary and Alternative Therapies for Back Pain Relief

Acupuncture, manipulation and other natural alternatives.

When back pain is hard to control, people sometimes turn to treatments outside of mainstream medicine for relief. Here's what you need to know about complementary and alternative treatments for back pain.

Acupuncture. A key component of Chinese traditional medicine, acupuncture involves inserting thin needles at particular points on the body. According to Chinese theory, stimulating the points (called acupoints) can correct the flow of essential life energy called qi (pronounced "chee") to optimize health or block pain. Western doctors believe acupuncture more likely works by prompting the body to release pain-relieving substances called endorphins.
A National Institutes of Health (NIH) panel concluded that acupuncture could help in the treatment of musculoskeletal conditions, such as back pain and even fibromyalgia, without the side effects of medications.

Learn more about acupuncture.

Learn about the use of acupuncture for pain relief from NIH's National Center for Complementary and Alternative Medicine.

Spinal manipulation. Both chiropractors and osteopathic physicians use manipulation to ease back pain, although the way they do it varies. Osteopathic manipulation often involves massaging the soft tissues (such as muscles) around the spine, whereas chiropractic involves manipulating the ligaments and vertebrae of the spine.

Either type of manipulation can be effective for back pain, particularly if pain is caused by problems such as sprains (damage to the ligaments) or strains (damage to the muscles). If you have a problem such as osteoporosis or rheumatoid arthritis, that may cause your spine to be more fragile, you should be cautious about spinal manipulation.

Get the facts about spinal manipulation for low back pain from NIH's National Center for Complementary and Alternative Medicine.

Medications to Treat Back Pain

Relieving back pain with medications.

Treatment for back problems depends on a number of factors including the findings of diagnostic tests. In many cases, medications to relieve pain and inflammation, slow bone loss or even slow or halt the progress of inflammatory disease are an important part of a back treatment plan.  Depending on your diagnosis, medical treatment may include one or more of the following medications.

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Including more than a dozen different drugs, some of which are available without a prescription, nonsteroidal anti-inflammatory drugs (NSAIDs) are used to help ease arthritis pain and inflammation. They may also be useful for relieving back pain from muscle strain and other causes. By far, most are taken orally. Recently, however, new topical preparations, such as Voltaren Gel and Pennsaid, have been approved.
• Analgesics. Analgesics are among the most commonly used drugs for many forms of arthritis and other causes of back pain. Unlike NSAIDs, which target both, pain and inflammation, analgesics are designed purely for pain relief. For that reason, they may be safe for people who are unable to take NSAIDs due to allergies or stomach problems, for example. When taken as directed, analgesics also are an appropriate, and possibly safer, choice for pain not accompanied by inflammation.
• Topical Rubs. If back pain is in the soft tissues, you may find relief from an analgesic salve, rub or balm available over the counter under trade names such as Aspercreme, Ben-Gay, Capzasin-P, Eucalyptamint, Icy Hot and Zostrix. Although these topical preparations, which work through a variety of active ingredients, are usually used on peripheral joints, such as the knees or hands, you might find them useful – and safe – for back pain.
• Muscle Relaxants. These are drugs used to ease muscle spasms. For back pain relief, they are often prescribed along with NSAIDs. Commonly prescribed muscle relaxants include cyclobenzaprine (Flexeril), orphenadrine (Norflex) and carisoprodol (Soma). Muscle relaxants may cause drowsiness, so they may be helpful if back pain keeps you awake at night.

• Corticosteroids. These quick-acting drugs, similar to the cortisone made by your own body, are used to control inflammation. If inflammation is due to a systemic inflammatory disease, such as polymyalgia rheumatica or rheumatoid arthritis in the back, your doctor may prescribe oral corticosteroids. If inflammation is limited to an inflamed joint in the spine, your doctor may inject a corticosteroid preparation directly into the inflamed joint.
• Disease modifying anti-rheumatic drugs.  Disease-modifying anti-rheumatic drugs (DMARDs) work slowly to modify the course of inflammatory disease. Different DMARDs may be useful for a number of different forms of arthritis that may affect the spine, including rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis.

• Biologic response modifiers. The newest category of medications used for rheumatoid arthritis and a few other inflammatory forms of arthritis are the biologic agents. There are currently eight such agents approved by the Food and Drug Administration (FDA). Each blocks a step in the inflammation process without suppressing the entire immune system. In addition to rheumatoid arthritis, certain biologic agents may be used in juvenile arthritis, ankylosing spondylitis and psoriatic arthritis.
• Gout medications. Some medications for gout are designed to reduce levels of uric acid in the blood to prevent future attacks of joint pain and inflammation. Others are designed to relieve the pain and inflammation of an acute attack. Many people with gout take both types of medication.

• Osteoporosis medications. Osteoporosis medications are those used to slow the loss of bone or help the body build new bone. Although they are not used specifically to treat back problems, strong bones are less prone to fracture. Certain medications – called bisphophonates – in this category are also used to treat Paget's disease of the bone, which can also affect the spine.

• Fibromyalgia medications.  Doctors prescribe medications from a variety of drug classes to treat fibromyalgia. Only three of these drugs – the anti-seizure medication pregabalin (Lyrica) and two antidepressants, duloxetine (Cymbalta) and milnacipran (Savella) – are FDA-approved to treat fibromyalgia. Many others are used off-label in fibromyalgia treatment because they have been shown in clinical trials to ease different symptoms. These include some other antidepressants, muscle relaxants and analgesics.

Back Care

Exercises to Strengthen the Back and Relieve Pain.

How exercise can help and step-by-step moves to try.

One of the best things you can do for your back – and your overall health and well-being – is to be physically active. A regular and varied exercise program can ease pain and stiffness, strengthen muscles and bones, burn calories, improve flexibility, increase energy, improve sleep, boost your mood, increase your sense of well-being and reduce your risk of cardiovascular disease and certain cancers. If your back is so stiff or painful that you can hardly imagine exercising, speak to your doctor or physical therapist about exercises that might be appropriate for you. Then start slowly, set small goals and build from there. You also can start with these back exercises from Arthritis Today.

Chest Stretches for Back Pain and Neck Pain

Upper Body Exercises: Dos and Don'ts

Tai Chi: Stretches of the Spine

Preventing Back Pain

Tips to prevent back problems – or progression

For most people, back pain is a fact of life at some point. But there are many things you can do on your own to reduce the risk of injury, minimize back pain, and prevent its recurrence and speed recovery if you experience problems. Most of it boils down to developing healthy lifestyle habits. Here are six you should adopt now for your back's sake.

Exercise. One of the best things you can do for yourself, whether you have health problems or are healthy and want to stay that way is to be physically active. A regular and varied exercise program can ease pain and stiffness, strengthen muscles and bones, burn calories, improve flexibility, increase energy, improve sleep, boost your mood, increase your sense of well-being and reduce your risk of cardiovascular disease and certain cancers.

If your back is so stiff or painful that you can hardly imagine exercising, speak to your doctor or physical therapist about exercises that might be appropriate for you. Then start slowly, set small goals and build from there.

Read about exercises that can keep you healthy and active.

One type of exercise that is safe and helpful for people with virtually any back problem and or form of arthritis is aquatic exercise.

Learn the basics of walking in water.

Proper posture. Knowing the right way to sit, stand, walk and lift can help prevent back pain. Poor habits such as slouching, hunching over a desk or even pushing your shoulders back too far with your buttocks protruding (known as swayback), on the other hand, can put tension on the spine.

To evaluate your posture try this: Stand with a full-length mirror to your side so that when you turn your head you can see your profile. Now, imagine that you have dropped a weighted string from the top of your head to the soles of your feet. Look in the mirror and imagine where the string would fall. If you are standing properly, it should pass through your earlobe, the front of your shoulder, the center or your hip, behind your kneecap and in front of your anklebone.

To improve your posture, practice standing in a way that would make the string pass through the spots mentioned.

Maintaining a healthy weight. Excess pounds shift your center of gravity forward, creating added stress on your lower back. Maintaining a healthy weight or losing weight, if you are overweight, can reduce your risk of back pain. If you already have back pain, losing weight may make it better. Need help losing weight?

Eating for strong bones. Getting enough calcium and vitamin can help keep bones strong and reduce your risk of osteoporosis, which can lead to painful and sometimes debilitating fractures of the vertebrae.

Calcium. If you are between the ages of 19 and 50 you need 1,000 miligrams (mg) of calcium per day. If you are 51 or older, you need 1,200 mg daily.   If you already have osteoporosis, your doctor may recommend that you get more calcium. Good sources of calcium include dairy products, canned salmon with bones and green leafy vegetables. If you don't get enough calcium in your diet, speak to your doctor about a calcium supplement.

Vitamin D. Vitamin D is important for your spine because it helps your body use the calcium you get from foods to make bones stronger. Your body makes vitamin D in response to sunlight on your skin. If you spend little time outdoors or wear a strong sunscreen when you go out, you may need more than your body makes. Food sources of vitamin D include egg yolks and fortified grain products. You may also want to ask your doctor if you need a vitamin D supplement.

Wearing proper shoes. Sometimes preventing or easing back pain is as simple as wearing the right shoes, particularly if you spend a lot of time standing or walking. Shoes with high heels and uneven wear, for example, can throw off your posture and, in turn, place unnecessary stress on your back.

Choose the right walking shoe.

Not smoking. Research has shown a high prevalence of spinal stenosis and back pain among smokers. One suspected reason is that smoking damages the blood vessels that supply the back.  In addition to that, cigarette smoking is bad for your bones. It is a risk factor for osteoporosis, and it if you need back surgery, it can interfere with healing. Spinal surgeries performed in smokers are significantly more likely to fail than the same surgery in nonsmokers.

Ways to Prevent Pain and Get Around

Helpful devices and ways to manage back pain.

Most back problems will never require surgery, injections or implanted devices; some may not ever require medications. For back pain, there are many remedies to try on your own or with a health professional either instead of or along with more invasive treatments. These can help relieve and prevent pain and make getting around a little easier.

Here are some remedies worth trying:

Physical Therapy. Taught or administered by a health-care professional called a physical therapist, physical therapy is a rehabilitation program focusing largely on exercise to strengthen the muscles in your back. Your doctor may recommend physical therapy to strengthen a bad back, which can help prevent the recurrences of pain or help you recover from back surgery.

Massage therapy. Massage therapy is one of the most widely used therapies for back pain. Many doctors recommend it for their patients. Some have massage therapists working in their clinics. Although there are many forms of massage, the type most people are familiar with is Swedish massage, a full-body treatment that involves stroking or kneading the top layers of muscles with oils or lotions. Other forms of massage include:

• Deep tissue massage, in which the massage therapist uses fingers, thumbs and even elbows to put strong pressure on deep muscle or tissue layers to relieve chronic tension.
• Neuromuscular massage, in which the therapist uses his or her fingers to apply pressure to certain spots that can trigger pain in other parts of the body.
• Myofascial release, a type of massage that involves applying slow, steady pressure to relieve tension in the fascia, or thin tissue around the muscles.
• Heat and Cold. Using heat and cold treatments, easy relief methods you can do at home, can temporarily reduce back pain and stiffness. Cold packs can numb the painful area and reduce inflammation and swelling. They are especially good for back pain caused by injuries. Heat, on the other hand, relaxes muscles and stimulates blood circulation.

Braces and corsets. Corsets are adjustable and made of elastic; braces are sturdier and have metal stays. Both are typically worn under clothing and have the same purpose: to reduce pressure on the discs, provide back and abdominal support and stabilize and restrict movement of the back during healing. They are often prescribed for short-term use during recovery from a fractured vertebra or some spine surgeries. For some people with certain conditions, including spondylolisthesis or scoliosis, braces may be prescribed longer-term to support the back and restrict movement.

Often braces are prescribed for temporary pain relief, especially during times you'll be particularly active or sitting for long periods of time. However, recent research shows they may not be effective for pain relief.

Transcutaneous electrical nerve stimulation (TENS). As its name suggests, TENS is a technique that uses electrical stimulation to the nerves to block pain signals to the brain. TENS is administered through electrodes placed on your skin near the painful area. The electrodes are attached to a small battery-operated box that emits low-level electrical energy. When the box emits its energy, you receive a low level shock that will give a tingling sensation and, if all goes well, some temporary relief from your pain.

Shoe insoles. Many people use special insoles or orthotics in their shoes to correct over pronation, or rolling over of the feet, which causes the lower leg to rotate and the pelvis to tilt forward, stressing the lower back. While insoles may be useful for treating other problems, a recent study shows that for treating or preventing back pain, they are probably not helpful.