Your Top Back Pain Questions Answered

YOUR TOP
BACK PAIN
QUESTIONS
ANSWERED
THE TOP 179 PLUS QUESTIONS THAT YOU FORGOT TO ASK YOUR
DOCTOR AND YOUR DOCTOR HAS NO TIME TO TELL YOU THAT
WILL MAKE OR BREAK YOUR BACK
Your Top Back Pain Questions Answered. The Top 179 Plus Questions.
Also by Andre Panagos M.D.

Spine: Rehabilitation Medicine Quick Reference Series
#topbackpainanswers
You can follow us using the hashtag #topbackpainanswers on
Twitter and other social media outlets, to join the conversation
because this is book is a tiny sample of what is possible.
ii
YOUR TOP
BACK PAIN
QUESTIONS
ANSWERED
THE TOP 179 PLUS QUESTIONS THAT YOU FORGOT TO ASK YOUR
DOCTOR AND YOUR DOCTOR HAS NO TIME TO TELL YOU THAT
WILL MAKE OR BREAK YOUR BACK
Andre Panagos M.D.

Marwa Ahmed M.D.
Second Avenue Press
New York, NY
iii
SECOND AVENUE PRESS

Your Top Back Pain Questions Answered
Andre Panagos, Marwa Ahmed
Copyright 2015 by Andre Panagos and Marwa Ahmed
All rights reserved.
No part of this publication may be reproduced, stored or transmitted in any form or
by any means including reprints, excerpts, photocopy, recording or any future means
without the express permission of the authors except in the case of brief quotations
in critical articles and reviews. If you would like to do any of the above please first
seek permission by contacting us at info.ssmny.com.
Limit of Liability/Disclaimer of Warranty: Although the author and publisher have made their best
efforts in preparing this book to ensure that the information in this book was correct at press time,
they make no representations or warranties with respect to the accuracy or completeness of the
contents of this book. The author and publisher also do not assume and hereby disclaim any
liability to any party for any loss, damage, or disruption caused by errors or omissions, whether such
errors or omissions result from negligence, accident, or any other cause. Also this book is not
intended as a substitute for the medical advice of physicians and the advice and strategies contained
herein may not be suitable for your situation. The reader should regularly consult a physician in
matters relating to his/her health and particularly with respect to any symptoms that may require
diagnosis or medical attention.
Printed in the United States of America by Second Avenue Press

10 9 8 7 6 5 4 3 2 1
iv
Andre Panagos MD, MSc, CAc, FAAPMR

A true pioneer in regenerative spine and sports
medicine, New York City physician Andre
Panagos M.D. has been treating, preventing, and
healing chronic pain for nearly two decades. His
practice is dedicated to regenerative spine and
sports medicine which makes Dr. Panagos a
physician at the forefront of a new renaissance in
medicine. He is board-certified by the American
Board of Physical Medicine and Rehabilitation,
with an additional board certification in Pain
Medicine. He is also a New York State certified
Medical Acupuncturist, a practitioner in
Functional Medicine and has extensive training in
interventional ultrasonography. Dr. Panagos
continuously reads medical texts and journals to
further his education and travels throughout the
country in order to learn cutting edge techniques in his field. He believes in utilizing
the most advanced practices and techniques to maximize function and improve
quality of life, irrespective of often severe medical conditions. Dr. Panagos believes it
is imperative to optimize health to allow the body to overcome disease. He has also
been very fortunate and humbled to treat patients who were thought of as untreatable
and return them to a fulfilling life, sometimes decades after the onset of serious
illness.
Dr. Panagos is a fellow of the American Academy of Physical Medicine and
Rehabilitation, and a member of several scientific organizations including the
American Medical Society for Sports Medicine, North American Spine Society,
International Spinal Intervention Society, Institute of Functional Medicine, American
Institute of Ultrasound in Medicine, New York County Medical Society and the
Hellenic Medical Society. He is involved nationally with the American Academy of
Physical Medicine and Rehabilitation and is a reviewer for the Archives of Physical
Medicine and Rehabilitation and PM&R journals.
Dr. Panagos received his medical degree and Master of Science degrees from St.
Georges University, School of Medicine. He completed his internship and residency
in Physical Medicine and Rehabilitation at the University of Washington, followed by
an Orthopedic Sports and Interventional Spine Fellowship at Beth Israel Medical
Center. Dr. Panagos also trained in medical acupuncture at the Helms Medical
Institute/UCLA and was educated at the Institute of Functional Medicine.
Dr. Panagos is currently a Clinical Assistant Professor in the Department of
Rehabilitation Medicine at New York University Langone Medical Center. He
previously served as an Assistant Attending Physiatrist at NewYork-Presbyterian
Hospital and as an Assistant Professor in the Department of Rehabilitation Medicine
at Weill Cornell Medical College. He was the founding co-director of The Spine
Center at NewYork-Presbyterian Hospital and was the recipient of the first Willibald
Nagler Clinical Scholar Award. Dr. Panagos was also honored with the 2009 Resident
teaching award in the Department of Rehabilitation Medicine at Weill Cornell Medical
College.
Dr Panagos has been involved in medical education for many years, including
research articles, textbook chapters, television and magazine interviews and has given
many national and international lectures. Dr. Panagos released his textbook, Spine A
Rehabilitation Medicine Quick Reference, in 2010 which broadly covered the complex field
of spine care and is looking forward to releasing several more titles for his patients.
vi
Marwa Ahmed MD, MSc, FAAPMR

Dr. Ahmed practices sports, spine and
musculoskeletal medicine which dovetail with her
love of the outdoors. Dr. Ahmed received her
medical
degree from
the
Weill
Cornell
Medical College in Qatar and was peer selected
as the recipient of the Good Physician
Award. She completed her internship at Virginia
Commonwealth University Hospital and residency
in Physical Medicine and Rehabilitation at
NewYork Presbyterian Hospital Columbia
College of Physician and Surgeons and Weill
Cornell Medical College. During residency, she also
rotated at the Hospital for Special Surgery and
Memorial-Sloan Kettering Cancer Center where she
treated and managed patients with complex
orthopedic and metastatic injuries. She is boardcertified by the American Board of Physical Medicine and Rehabilitation.
Prior to medical school, she earned a Master of Science degree in Human Genetics
from the University of Michigan, which ties into her strong research interest in
regenerative medicine and nutritional genomics as well as its applications to
musculoskeletal medicine, including sports injury management outcomes and the
molecular mechanisms that underlie physical performance, cellular injury and aging.
Dr. Ahmed participates in several scientific organizations including the American
Medical Society for Sports Medicine, American Academy of Physical Medicine and
Rehabilitation, International Spinal Intervention Society, and the New York County
Medical Society.
vii
We dedicate this book to our patients from around the world who we have had the profound privilege
of joining in their fight and ultimate triumph against back pain.
viii
The only way to keep your health is to eat what you dont want, drink what you dont like, and do
what youd rather not. -Mark Twain
ix
CONTENTS
Preface................................................................................................................................................ xvii
Acknowledgements ........................................................................................................................... xviii
Why Me! The causes of back pain ......................................................................................................... 1
What are the main causes of back pain? ..................................................................................................................... 1
Mechanical .................................................................................................................................................................. 1
Emotional.................................................................................................................................................................... 4
Acquired Injuries........................................................................................................................................................ 4
Tumors and Infections ............................................................................................................................................. 5
What does it mean when you have back pain? .......................................................................................................... 6
How long will my back pain last? ................................................................................................................................ 6
Is sciatica pain different from back pain? ................................................................................................................... 7
How can I tell if my back pain is from my muscles or spine? ................................................................................ 7
What causes middle back pain? .................................................................................................................................... 8
Why is back pain such a medical challenge? .............................................................................................................. 8
Could back pain mean hemorrhage? ........................................................................................................................... 9
What is pulsating back pain?....................................................................................................................................... 10
Can back pain come from having a total knee replacement? ................................................................................ 10
Can low back pain be caused by a tumor? ............................................................................................................... 10
Can back pain be caused by Lymes disease? ........................................................................................................... 11
Is back pain a symptom of ALS? ............................................................................................................................... 11
What are common causes of back pain in women? ................................................................................................ 11
Are liver lesions related to back pain? ....................................................................................................................... 12
Can too much beer cause severe back pain? ............................................................................................................ 12
Is there a connection between Accutane and back pain? ...................................................................................... 12
Can mopping cause back pain? .................................................................................................................................. 12
Does chemotherapy lead to back pain? .................................................................................................................... 13
Does radiation therapy lead to back pain? ............................................................................................................... 13
How can I tell if my back pain is due to my gallbladder? ...................................................................................... 13
Why do I have bulging discs and sciatica without back pain?............................................................................... 13
Should I be worried for the future if I have bulging discs with no back pain? .................................................. 14
How do I know if I have arthritis or if it's just back pain? .................................................................................... 14
How can I prove back pain to a disability doctor? ................................................................................................. 14
Can two herniated discs be the cause of my back pain? ........................................................................................ 15
What problems can back pain cause? ........................................................................................................................ 15
Why must localized back pain be treated before treating generalized referred back pain? .............................. 16
Why do I have back pain every time I do squats?................................................................................................... 16
Do statin drugs cause back pain? ............................................................................................................................... 16
Are weak abdominal muscles a cause of my back pain? ........................................................................................ 17
Does standing all day make my back pain worse? .................................................................................................. 17
How can foot problems result in back pain? ........................................................................................................... 18
I have back pain and I have had two MRIs and nothing was found, what should I do? ................................. 18
What can I do for back pain and the urge to crack my back all the time? .......................................................... 19
Do compression garments (Spanx) cause back pain? ......................................................................................... 19
Do shoes such as high heels or flip flops cause back pain? .................................................................................. 19
Should I be worried if I develop sudden back pain after coughing? ................................................................... 20
Does the time of day that I have back pain mean anything? ................................................................................ 20
Should I be worried if my back pain is worse at night? ......................................................................................... 21
How does cancer cause back pain?............................................................................................................................ 21
What should I do if my back pain wakes me up at night? ..................................................................................... 22
Seasonal back pain............................................................................................................................... 22
Why does my back hurt when the weather is colder? ............................................................................................ 22
Can weather influence the severity of my back pain?............................................................................................. 22
Why do I only have back pain in the summer? ....................................................................................................... 23
Sharp pains........................................................................................................................................... 23
Why do I have sharp back pain when bending forward and backwards? ........................................................... 23
Why do I have sharp back pain when I stand up after sitting for a while? ......................................................... 23
Chest pain with back pain ................................................................................................................... 24
What causes sudden chest and back pain when sneezing? .................................................................................... 24
Why do I have back pain when I breathe in? .......................................................................................................... 24
Why do I have burning in my chest with middle back pain? ................................................................................ 24
Leg pain ............................................................................................................................................... 25
I have a sore back with pain in both legs, what can I do for relief?..................................................................... 25
Are back and leg pain related to one another? ........................................................................................................ 25
Can persistent foot pain be connected to my back pain? ...................................................................................... 25
Can chronic knee pain that has not improved after local knee treatments be coming from my back? ......... 26
Rib pain................................................................................................................................................ 26
xi
How do I treat upper back pain in my ribs? ............................................................................................................ 26
Back pain and anxiety.......................................................................................................................... 26
Can anxiety cause back pain?...................................................................................................................................... 26
Back pain and nausea/vomiting ......................................................................................................... 27
What causes back pain and nausea? .......................................................................................................................... 27
Can gastrointestinal problems create back pain? ..................................................................................................... 27
Can the medications that I take for back pain also cause nausea? ....................................................................... 27
Why does my stomach and back hurt after eating or drinking? ........................................................................... 28
Back pain and urination ...................................................................................................................... 28
What can cause back pain and frequent urination? ................................................................................................ 28
Can back pain continue after passing a kidney stone? ........................................................................................... 28
Vaginal Pains ....................................................................................................................................... 29
Should I be concerned if I have vaginal discharge and back pain? ...................................................................... 29
Can back pain indicate ovulation? ............................................................................................................................. 29
What does back pain due to a fibroid feel like? ....................................................................................................... 29
Stomach pain and back pain................................................................................................................ 29
What causes lower abdominal pain and back pain? ................................................................................................ 29
Can constipation cause back pain? ............................................................................................................................ 30
Does diverticulitis cause back pain? .......................................................................................................................... 30
Can flatulence cause back pain? ................................................................................................................................. 30
Trauma..................................................................................................................................................31
What causes back pain after a fall? ............................................................................................................................ 31
Chronic back pain .................................................................................................................................31
I have had back pain for many years. What is it due to?........................................................................................ 31
What may cause recurring back pain? ....................................................................................................................... 31
What should I do if I have persistent back pain? .................................................................................................... 32
Upper back pain................................................................................................................................... 32
What causes upper back pain?.................................................................................................................................... 32
I have back pain in the center of my back. How do I stop it from hurting? ...................................................... 32
What should I do if I have back pain between the shoulder blades?................................................................... 33
Tailbone pain (coccyx pain) ................................................................................................................ 34
What causes tailbone pain? ......................................................................................................................................... 34
Do hemorrhoids cause back pain? ............................................................................................................................ 34
What can I do about my bad tailbone pain? ............................................................................................................ 34
xii
Back pain in children and teens .......................................................................................................... 34
What causes back pain in children and teens? ......................................................................................................... 34
Is it unusual for children and teenagers to get back pain? ..................................................................................... 35
How can I prevent back pain in children and teenagers? ...................................................................................... 36
How many young people suffer from back pain? ................................................................................................... 36
My teenager has back pain, should I be extremely worried? ................................................................................. 36
Pregnancy ............................................................................................................................................ 37
What are the most common causes of back pain during pregnancy? .................................................................. 37
What is the best way of fixing back pain while pregnant? ..................................................................................... 37
Will I have a lot of back pain after a cesarean section? .......................................................................................... 39
Back pain as we get older .................................................................................................................... 39
What is the best way to reduce back pain in an older person? ............................................................................. 39
As I get older can my back pain be debilitating? ..................................................................................................... 41
Back pain in special populations ......................................................................................................... 42
What can I do for my chronic back pain during airline travel? ............................................................................ 42
Do taxi drivers get back pain? .................................................................................................................................... 43
Home remedies.................................................................................................................................... 43
What ointments are best for back pain? ................................................................................................................... 43
What are simple things I can do to ease my back pain? ......................................................................................... 44
Posture ................................................................................................................................................. 45
Are there any couches or sofas that prevent back pain? ........................................................................................ 45
What is the best way to sit if you have back pain? .................................................................................................. 45
To avoid back pain, what is the right way to bend over? ...................................................................................... 46
How do I stop back pain while working at my desk?............................................................................................. 46
Can slouching lead to back pain? ............................................................................................................................... 46
What is the best seat cushion for low back pain? ................................................................................................... 47
Would a chair massage help soothe my back pain? ................................................................................................ 47
Sleeping................................................................................................................................................ 47
Why would I have back pain after sleeping on my stomach? ............................................................................... 47
Why does my back pain limit my ability to turn in bed? ........................................................................................ 47
Why does sleeping on my back result in back pain? ............................................................................................... 48
What is the best sleeping posture if I sleep on a firm mattress?........................................................................... 48
What type of mattress is best if I have back pain? .................................................................................................. 48
Sex ........................................................................................................................................................ 48
xiii
Is it safe to have sex while I have back pain? .......................................................................................................... 48
What are possible causes of back pain during orgasm? ......................................................................................... 49
Sports ................................................................................................................................................... 49
I have occasional back pain, is it safe to play tennis? ............................................................................................. 49
I have back pain when I'm on my bicycle. How do I prevent this? ..................................................................... 49
What can be done for back pain from playing golf?............................................................................................... 50
Could you tell me what leads to lower back pain while running? ........................................................................ 50
Weight .................................................................................................................................................. 50
Does back pain come from being overweight? ....................................................................................................... 50
How can I lose weight to help with my back pain? ................................................................................................ 51
Butts and breasts ..................................................................................................................................51
If I gain weight, will I have back and hip pain? ....................................................................................................... 51
Could my breasts be the cause of my back pain? .................................................................................................... 51
Can a butt augmentation help with back pain?........................................................................................................ 52
Which doctor is the best? ..................................................................................................................... 52
What kind of doctor should I see for back pain? .................................................................................................... 52
What can my primary care doctor do to fix my back pain?................................................................................... 53
What can my physiatrist or pain management physician do to fix my back pain? ............................................ 53
What can my chiropractor do to fix my back pain?................................................................................................ 53
Should I see a physical therapist or chiropractor for back pain? .......................................................................... 54
What supplements can I take for bad back pain? ................................................................................................... 54
Will soaking in apple cider or Epsom salts help my back pain? ........................................................................... 55
What are suggestions for a good exercise DVD for back pain? ........................................................................... 56
What books would you recommend for back pain? ............................................................................................... 56
How do I get rid of my back pain without going to the hospital? ....................................................................... 56
What should I expect from the doctors visit? ..................................................................................... 57
Why does the doctor have to ask so many questions about my back pain? ....................................................... 57
What questions do I ask the doctor who is treating my back pain? ..................................................................... 57
What can a doctor's exam tell me about my low back pain? ................................................................................. 58
How effective is an x-ray at diagnosing the cause of back pain? .......................................................................... 58
Should I get an MRI for my back pain?.................................................................................................................... 59
Should I get medications for my pain right away or should I tough it out? ....................................................... 59
Medications ......................................................................................................................................... 59
Is ibuprofen suitable for back pain relief? ................................................................................................................ 59
xiv
Are muscle relaxants good for relieving back pain? ............................................................................................... 60
Can Tylenol #3 get rid of back pain? .................................................................................................................... 60
I am having back pain, what tablets should I take? ................................................................................................ 60
Is naproxen (Naprosyn) good for back pain? ...................................................................................................... 61
What is the best painkiller for back pain?................................................................................................................. 61
Can I take leftover Percocet for back pain? ............................................................................................................. 61
Why would my doctor continue prescribing Vicodin for back pain if it is so bad for me? ............................. 61
What pain medicines can I take if I have liver problems? ..................................................................................... 62
If ibuprofen and acetaminophen aren't helping my back pain what will?........................................................... 63
Can I take diclofenac (Voltaren) for my back pain if I am diabetic and hypertensive? ................................. 63
Can I take tramadol (Ultram) for back pain while I'm taking sertraline (Zoloft)? ...................................... 64
Is there a stronger pain medication than morphine for back pain? ..................................................................... 64
What do doctors think is the top pain medication for back pain? ....................................................................... 65
What is better for back pain, naproxen (Aleve), ibuprofen (Advil), or acetaminophen (Tylenol)? ...... 65
Treatments ........................................................................................................................................... 66
What do doctors do to treat back pain? ................................................................................................................... 66
When should I consider back pain surgery? ............................................................................................................ 66
When does someone NEED surgery for chronic back pain?............................................................................... 67
When looking for a doctor or treatment for back pain what should I be looking for? .................................... 67
What should I do for extreme back pain? ................................................................................................................ 67
How can I relieve back pain fast? .............................................................................................................................. 68
When should I have an epidural injection? .............................................................................................................. 68
Why should I do exercises at home for my back pain? .......................................................................................... 68
Why should I use a cane for back pain? ................................................................................................................... 69
How should I lift things to prevent back pain? ....................................................................................................... 69
Should I change my pillows if I have back pain? .................................................................................................... 70
Could you tell me ways to rid myself of back pain? ............................................................................................... 70
Is the McKenzie method effective for back pain relief? ........................................................................................ 70
What exercise can I do for back pain? ...................................................................................................................... 72
Pelvic rock................................................................................................................................................................. 72
Backward Bend ........................................................................................................................................................ 73
Wall Squat ................................................................................................................................................................. 73
Cat-Camel.................................................................................................................................................................. 74
Bird Dog.................................................................................................................................................................... 75
xv
Hip Flexor Stretch ................................................................................................................................................... 76
Double Knee-to-Chest............................................................................................................................................ 76
Piriformis Stretch ..................................................................................................................................................... 77
Bridging ..................................................................................................................................................................... 77
Clamshell ................................................................................................................................................................... 78
Pelvic Tilt .................................................................................................................................................................. 78
Curl-Ups .................................................................................................................................................................... 79
Press-Ups/Back Extensions .................................................................................................................................. 79
Hamstring Stretch .................................................................................................................................................... 80
Front Plank ............................................................................................................................................................... 80
Side Plank, Beginner ................................................................................................................................................ 81
Side Plank, Intermediate ......................................................................................................................................... 81
Rest Position ............................................................................................................................................................. 82
Is there any equipment that helps deal with back pain? ......................................................................................... 82
Is there a good safe cure for back pain? ................................................................................................................... 82
Is there anything I should do as a tall person to help back pain? ......................................................................... 83
What should I do if I think that my emotional problems are the cause of my back pain? .............................. 83
How effective are high-tech treatments for back pain? ......................................................................................... 84
What other things could I try for back pain besides medication? ........................................................................ 84
What is better for back pain - active or passive therapy?....................................................................................... 84
Will yoga help back pain? ............................................................................................................................................ 85
Can I take vitamin D tablets for back pain?............................................................................................................. 85
How does stretching my hamstrings help with back pain? ................................................................................... 85
Is it better to use a treadmill or stationary bicycle for back pain? ........................................................................ 86
How can a heat wrap therapy or a heating blanket help my back pain?.............................................................. 86
How often must someone do stretching exercises for back pain? ....................................................................... 86
Would getting a massage help or hurt my back pain? ............................................................................................ 87
How is back pain diagnosed objectively? ................................................................................................................. 87
What is back pain a symptom of? .............................................................................................................................. 87
Will back pain usually require x-rays? ....................................................................................................................... 87
Is it OK to go to spinning classes if I have back pain? .......................................................................................... 87
Conclusion ........................................................................................................................................... 89
Index .................................................................................................................................................... 90
xvi
PREFACE
We would like to thank our patients who have had the courage and creativity to ask
these questions. Sometimes there was a surprise, shock, acknowledgement and often a
brief chuckle following a question or two, but we appreciate our patients candidness
and we took the time to answer all of these questions, even if we had to review
literature and call them back with the proper answer.
We found that simple straight forward answers transformed a partial recovery from
back pain to a fully successful recovery. So we are pleased to share them with you.
To your health,
Andre Panagos M.D and Marwa Ahmed M.D.
New York, December 2014
xvii
ACKNOWLEDGEMENTS
There are many people who made this project possible. Of course, we need to start
with a big thank you to our patients who began to ask these questions and demanded
clear answers that were not always available online. We also need to offer a great deal
of appreciation to Keith and Emmy who keep the office in tip-top shape to allow us
the precious extra minutes to write between patients. Finally to our families who
sacrificed their time with us so we could spend time imagining, crafting, writing,
editing
and
placing
the
final
touches
to
this
book.
xviii
WHY ME?! THE CAUSES OF BACK PAIN

WHAT ARE THE MAIN CAUSES OF BACK PAIN?
There are many reasons why people develop back pain. It is important to remember
that back pain is a complaint and not a precise diagnosis so the challenge is to identify
the specific cause of your back pain. Most conditions are diagnosed with MRIs
(magnetic resonance imaging), CT scans (computed tomography), ultrasound, or xrays. These imaging studies are used to identify abnormal tissues, although
occasionally the abnormalities may be too small to detect. There are four main
categories of back pain. These are in order of likelihood; mechanical, emotional,
acquired injuries, tumors and infections. If you are interested in more details, please
take a look at my book, Spine: Rehabilitation Medicine Quick Reference Series,
Demos Medical Publishing, 2009.
MECHANICAL
Back pain is a
complaint, not a
diagnosis.
Muscle spasms are the most common

mechanical condition that occurs in the back and
everyone suffers from fleeting to severe muscle
spasms in the back at some point in their life.
We do not see patients in the doctors office
unless the spasm pain is very severe or unrelenting. Muscle spasms can be caused by
chronic muscle overload and fatigue or can be a symptom of an underlying problem.
If the muscle spasm becomes a chronic problem, it can result in thickening of the
muscle and fascial tissues. Doctors can easily identify muscle and fascial thickening by
using ultrasound imaging.
Disc degeneration is the most common diagnosis that is found on imaging studies. It
is a mechanical condition that occurs when there is wear and tear of the shockabsorbing discs between the vertebral bones of the spine. As the intervertebral discs
wear down, there is more impact on the bones which start to grind together. As this
happens, the hole that the nerve passes through called foramina, from Latin foramen
hole, opening, or aperture, also narrows, which increases your risk of back pain and
nerve pain or sciatica. This process begins after the age of 35 and is found in everyone
by the age of 65, though you may never feel any pain from it. I have even seen disc
degeneration occur in children beginning in their early teens due to excessive physical
activities, so keep this in mind as your kids engage in sports.
Finally, a disc herniation is another example of a mechanical condition that is seen
clinically. Disc herniations are associated with mild to moderate degrees of disc
degeneration. And like disc degeneration, disc herniations can occur at either a single
or multiple levels. Disc herniations occur when a tear forms in the outer portion of
the disc called the annulus fibrosis. This allows the gelatinous interior of the disc
(called the nucleus pulposus) to herniate or ooze out, like your favorite toothpaste,
into the central canal that houses the spinal cord and nerves. If there is a lot of gel
that squeezes out, it can compress the nerves resulting in significant weakness,
numbness and tingling. Furthermore, your immune system does not realize that the
gel is part of your body. It thinks it is a foreign substance like a splinter so it begins
attacking and mounting an immune response. The attack begins with increased blood
flow and the release of chemicals that try to breakdown the gel, which also causes
inflammation. The pain that you experience is this inflammation. If it is minor then
you may only experience slight lower back pain, but if there is a tremendous amount
of inflammation then you may not only have severe pain but it may also travel down
the leg, a condition commonly referred to as sciatica. Disc herniations are more
commonly found in people aged 30 to 50 years old and are most likely due to
repetitive activities such as bending forward, lifting and twisting or sitting for long
periods of time. If any family members or relatives have this condition, you have a
much greater chance of having it. It is also related to smoking, so it may prove
imperative for you to quit in order to achieve an optimal recovery.
EMOTIONAL
The second most common cause of back pain occurs when you are emotionally
stressed. When this occurs, your back muscles instantly tighten, your flexibility
decreases and you put additional strain on your spine as well as the many muscles
surrounding your spine. If this is severe or goes on for a very long period of time,
it can result in chronic back pain. Unfortunately, not only is this area poorly
understood, but there has been very little research completed to further our
understanding of our emotions as they relate to our physical health.
ACQUIRED INJURIES
Acquired injuries, the third most common cause of back pain, can be some of the
simplest or the most dangerous causes of back pain. Muscle strains which are micro-
tears of the muscles, happen quite often and can resolve on their own. Ligament
injuries, micro-tears of the ligaments, can heal on their own as well, however if your
ligaments have loosened due to over-stretching or even more simple activities such as
slouching, although not dangerous, it can lead to chronic back pain. Fractures, on the
other hand, can be very dangerous as they can result in spinal instability which can
lead to a spinal cord injury or death. The most common causes of fractures are falls,
osteoporosis or high-speed injuries. Believe it or not, some fractures can occur
without your knowledge and are incidentally found when imaging your back for other
reasons.
Acquired diseases make up the largest number of diagnoses of back pain. These
include scoliosis, an abnormal S-shaped curve of your spine, and kyphosis which is an
abnormal forward hunch. Spondylosis is simple arthritis of the spine that occurs due
to wear and tear. Spondylolysis is a fracture of the small joints in the back. With this
type of fracture the bony segments of the spine at that level can slip and become
misaligned which is called spondylolisthesis. As arthritis gets worse in the lower back
you may develop spinal stenosis - a condition describing a narrowing of the canals
that the nerves transit through. Rheumatoid arthritis can loosen the ligaments in the
spine resulting in accelerated arthritis and inflammation. Other factors that do not
directly affect the spine but can cause back pain include kidney stones, pregnancy,
endometriosis and fibromyalgia. If you are interested in further information about
these subjects, please take a look at my book, Spine: Rehabilitation Medicine Quick
Reference Series, Demos Medical Publishing, 2009.
TUMORS AND INFECTIONS

Tumors and infections are the most dangerous causes of back pain as they can be fatal
if not treated. These include infections of the bone (osteomyelitis) or infections of the
disc (discitis). Infections can result from prior surgery or procedures or from an
infection brewing in the body such as chronic gingivitis or phlebitis or more
dangerous infections such as tuberculosis. Tumors can sneak up at any time and can
grow within the spinal cord such as an ependymoma and astrocytoma or grow outside
the spinal cord such as a meningioma or schwannoma. Tumors can arise from cancers
that begin in other parts of the body such as the breasts, lungs, kidneys, colon and
prostate, and ultimately spread or metastasize to the spine. With most of these
conditions, back pain is associated with, what doctors call red flag symptoms to
INDEX
abdominal pain, 13
abscesses, 12
acetaminophen, 60, 62
acupuncture, 39
adenoma, 12
airline travel, 42
amyotrophic lateral sclerosis, 11
annulus fibrosis, 4
antibiotics, 11
anxiety, 26, 31
aortic aneurysm, 10
aortic dissection, 24
apple cider vinegar, 55
Arnica montana, 43
arthritis, 5
aspirin, 62
astrocytoma, 5, 10
back brace, 68, 82
backpack, 36
Backward Bend, 73
beer, 12
bicycle, 49, 86
bile duct cyst, 12
biokinetic chain, 10, 18, 20
bird dog, 75
bone marrow aspirate concentrate, 53
bones, 7
breasts, 51
Bridging, 77
bromelain, 55
bulging disc, 13
bulging discs, 14
butt, 52
cancer, 21
cane, 69
capsaicin, 43, 55
carisoprodol, 60
cat-camel, 74
cauda equina syndrome, 21
cesarean section, 39
chemotherapy, 13
chiropractic, 84
chiropractor, 19, 53
chronic muscle overload, 1
clamshell, 78
coccydynia, 34
cognitive behavioral therapy, 83
compression fracture, 8
compression garments, 11, 19
constipation, 30
cool mentholated ointments, 43
corticosteroid, 68
costovertebral joint arthritis, 32
couch, 45
coughing, 20
Coumadin, 9
CT scan, 1, 66
curl-ups, 79
cyclobenzaprine, 60
depression, 31, 41
devil's claw, 55
diazepam, 60
dilaudid, 64
disability, 14
disc degeneration, 1, 4, 46
disc herniation, 4, 7, 8, 26
discectomy, 66, 68
discitis, 5
discogram, 15
diverticulitis, 30
docusate sodium, 30
dorsal scapular nerve, 33
double knee-to-chest, 76
90
duloxetine, 65, 83
ectopic pregnancy, 29
emergency room, 67
endometriosis, 5, 11
ependymoma, 5, 10
epidural steroid injection, 11, 59, 66,
68, 84
epsom salts, 55
erector spinae, 17
fascial barbotage, 66, 68, 84
fat aspirates, 53
fentanyl, 64, 65
fibroids, 11, 29
fibromyalgia, 5, 31
flatulence, 30
flip flops, 11, 20
fluoxetine, 83
focal fatty change, 12
focal nodular hyperplasia, 12
foramina, 1
fracture, 5
fractures, 5
Front Plank, 80
gallbladder pain, 28
glucosamine sulfate, 55
golf, 50
hamstring stretch, 80
hamstrings, 85
heat, 86
heat wrap, 68
hemangioma, 12
hemorrhage, 9
hemorrhoids, 34
high heel shoes, 11, 19
hip flexor stretch, 76
hydrocodone, 65
hydromorphone, 65
ibuprofen, 59, 62
iliopsoas muscle, 23
infections, 5
inflammation, 4, 7
intervertebral discs, 1
inversion table, 82
isotretinoin, 12
joint block, 66
kidney stone, 28
kidney stones, 5
knee replacement, 10
laminectomy, 66, 68
large breasts, 11
lifting, 69
liver lesions, 12
Lymes disease, 11
magnesium, 30, 55, 56
massage, 39, 47, 87
mattress, 44, 48
McKenzie method, 70
meningioma, 5, 10
menstrual changes, 11
metastasize, 5
methadone, 64, 65
methylsulfonylmethane, 55
micro-tears, 5
milnacipran, 83
mobile devices, 36
mopping, 12
morphine, 63, 64, 65
MRI, 1, 59, 66
muscle relaxant, 60, 65
muscle spasms, 1
muscle strain, 4, 8
myofascial pain, 8
naproxen, 61
91
nerve hydrodissection, 33
nerve rhizotomy, 66
nerve root, 14
nerve tests, 8
neurontin, 65
nodular regenerative hyperplasia, 12
nonsteroidal
anti-inflammatory
medication, 59
nortriptyline, 83
nucleus pulposus, 4
nutrition, 41
obliques, 17
office chair, 45
omega-3 fatty acids, 54
orgasm, 49
osteomyelitis, 5
osteoporosis, 5, 13
ovarian cysts, 11
overweight, 50
ovulation, 29
oxycodone, 65
pain management, 52, 53
paroxetine, 83
pelvic inflammatory disease, 29
pelvic rock, 72
pelvic Tilt, 78
Percocet, 61
pes planus, 18
physiatrist, 53
physical therapist, 54
physical therapy, 11
pillow, 70
piriformis stretch, 77
platelet-rich plasma, 9, 53, 66, 84
polyethylene glycol, 30
poor posture, 6, 8, 35
posture, 8, 38
prednisone, 59, 68
pregabalin, 65
pregnancy, 5, 37
press-ups, 79
primary care doctor, 52
prognosis, 57
prolotherapy, 53, 66, 84
radiation therapy, 13
rectus abdominis, 17, 37
red flag symptoms, 5
referred pain, 16
relaxin, 37
rest position, 82
rheumatoid arthritis, 5
rib fracture, 24
running, 50
sacroiliac joint pain, 38
s-adenosylmethionine, 55
Scheuermanns disease, 32, 35
schwannoma, 5, 10
sciatica, 4, 7
scoliosis, 5, 8
seat cushion, 47
selective serotonin reuptake inhibitors,
83
serotonin and norepinephrine reuptake
inhibitors, 83
sertraline, 64, 65, 83
sex, 48
side plank, beginner, 81
side plank, intermediate, 81
sitting, 39
sleep, 40
slouching, 5, 46
smoking, 4
sofa, 45
spinal cord injury, 13
spinal cord stimulation, 66
spinal fusion, 66
spinal instability, 5
spinal stenosis, 5
92
spinning, 87
spinning classes, 87
spinous process, 8
spondylolisthesis, 5
spondylolysis, 5, 35
spondylosis, 5
sports medicine, 52
standing desk, 82
statin drugs, 16
stress, 26
subcutaneous perineural injection
series, 8, 9, 26, 33, 66, 68, 84
surgery, 59
taxi drivers, 43
tennis, 49
topiramate, 65
tramadol, 64, 65
transcutaneous electrical stimulation
device, 82
transversus abdominis, 17
trauma, 67
trigger point injections, 33, 66
turmeric, 54
ultrasound, 1
ultrasound-guided procedures, 9
urinary tract infection, 28
vaginal discharge, 29
vertebral bodies, 8
Vicodin, 61
vitamin D, 32, 54, 85
wall squat, 73
weakness, 57
wear and tear, 5, 8
weight gain, 37
willow bark, 43
x-ray, 1, 58, 66, 87
yoga, 85
zero gravity chair, 82
93

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Also by Andre Panagos M.D.

Andre Panagos M.D.

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Andre Panagos MD, MSc, CAc, FAAPMR

Marwa Ahmed MD, MSc, FAAPMR

WHY ME?! THE CAUSES OF BACK PAIN

Muscle spasms are the most common

TUMORS AND INFECTIONS

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