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Closeup photo of a dog barking fiercely, representing the scary “bark” of low back pain.

When to Worry About Low Back Pain

And when not to! What’s bark and what’s bite?

updated (first published 2009)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

The bark of low back pain is usually much worse than its bite. The pain almost always makes it seem worse than it is.

MRI and x-ray for low back pain are surprisingly useless, because things like herniated discs aren’t actually that big a deal,1 most back pain goes away on its own,2 and trigger points (“muscle knots”) are common and can be alarmingly intense but aren’t dangerous. Most patients are much better off when they feel confident about these things. The power of justified, rational confidence is huge (see The Mind Game in Low Back Pain).

Or you could be dying! What are the odds that back pain is something scary?

There are cases of low back pain that have alarming causes, but it’s rare. Once in a while back pain is a warning sign of cancer or an autoimmune disease. Or back pain could be associated with spinal cord damage. Or a few of other scary culprits.3 Over the age of 55, about one in twenty cases turns out to be a fracture, and one in a hundred is more ominous.4 The further you are from 55, the better your odds.

But how can you tell? It’s not always easy. This is a concise, readable guide to symptoms that need better-safe-than-sorry investigation with your doctor. (It’s basically just a plain English version of clinical guidelines for doctors.5) In other words, this article explains the difference between “dangerous” and “just painful” as clearly as possible. Tables, checklists, and examples ahead.

Drawing of a knob representing the intensity of back pain, dialed up to 11.

Ordinary back pain can be fierce and awful … but not dangerous. It’s bark is almost always much louder than its bite.

Drawing of a knob representing the intensity of back pain, dialed up to 11.

Ordinary back pain can be fierce and awful … but not dangerous. It’s bark is almost always much louder than its bite.

Chronic low back pain is serious…but rarely ominous

Back pain can suck the joy out of your days for week, months, even years. It can definitely be “serious” even when it’s not dangerous. I have worked with many truly miserable chronic low back pain patients, and of course the huge economic costs of back pain are cited practically anywhere the subject comes up. But your typical case of chronic low back pain, as nasty as it can be, has never killed anyone.

“Ominous” is medical jargon for “truly scary.” Cue Jaws theme music. Low back pain is ominous when it is caused by a spinal cord trauma, or a progressive disease that can maim or kill. Ominous causes of low back pain are rare, fortunately. But they are real. Awful things do happen, even the best doctors can miss them, and “alternative” health care professionals are even more likely to.

All of the worst possible causes of back pain and their major features

None of these are common. All of them usually cause serious symptoms that are easy to take seriously. Some of them can “fly under the radar” in early stages, but usually not for long. The names of the conditions link to carefully chosen articles from good sources.

The worst possible causes of back pain
what is it? major features
cancer a tumor in or near the spine Many kinds of cancer can cause many kinds of back pain, but some strong themes are: the pain grows steadily and is mostly unaffected by position and activity, worse with weight bearing and at night, and comes with other signs of being unwell.
cauda equina syndrome pinching of the lowest part of the spinal cord Hard to mistake for anything else: hard to pee, fecal incontinence, numb groin, weak legs. Caused by ruptured discs, trauma, cancer, infection.
spinal infection infection in or near spinal structures Hard to detect, often for a long time. Usually there’s a well-defined tender spot and then, eventually, deep constant pain, a rigid spine, sometimes fever and illness but not always.
abdominal aneurysm ballooning of a large artery next to the spine Pain may throb in sync with pulse. Mostly occcurs in people at risk of heart disease: older, heavier, hypertensive smokers and diabetes patients.
ankylosing spondylitis inflammatory arthritis of spine and pelvis, mostly Long term back pain starting well before middle age and progressing slowly and erratically, improves with activity but not rest, prolongued morning stiffness, possible involvement of other areas. More common in men.

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 359 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of PainScience.com’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

The worst back pain is rarely the scariest

People understandably assume that the worst back pain is the scariest. In fact, pain intensity is a poor indicator of back pain ominousness,6 and some of the worst causes are actually the least painful (especially in the early stages). Pain intensity is a poor indicator of back pain ominousness & some of the worst causes are actually the least painful. For instance, someone could experience the symptoms of cauda equinae syndrome, and be in real danger of a serious and permanent injury to their spine, but have surprisingly little pain — even none at all in some cases!

Meanwhile, many non-dangerous problems can cause amazingly severe back pain. A muscle cramp is a good analogy — just think about how painful a Charley horse is! Regardless of what’s actually going on in there, muscle pain is probably the main thing that back pain patients are feeling. The phenomenon of trigger points — tiny muscle cramps, basically7 — could be the entire problem, or a complication that’s more painful and persistent than the original problem. It’s hard to overstate how painful trigger points can be, but they are not dangerous to anything but your comfort.

Two back pain situations you should take seriously right away, no delay

These two back pain scenarios might be medical emergencies. They do not necessarily mean something horrible is wrong, but it’s extremely important to make sure.

  1. incontinence and/or true numbness around the groin and buttocks in a “saddle” pattern8
  2. any accident with forces that may have been sufficient to fracture your spine9

If you are experiencing true numbness10 around the groin and buttocks and/or failure of bladder or bowel control, please consider it a serious emergency — do not wait to see if it goes away. These symptoms indicate spinal cord injury or compression11 and require immediate medical attention. (Few people will have symptoms like this without having already decided it’s an emergency, but I have to cover all the bases here.)

And, of course, if you’ve had an accident with forces that may have been sufficient to fracture your spine, please seek thorough medical assessment promptly, including an X-ray to look for a fracture. You need an X-ray to ensure that your spine is not actually broken.

Picture of a man holding his painful back.

Isn’t it rather obvious that a potential spinal fracture is an emergency?

You’d think so. But consider this story of a motorcycle accident: many years ago, a friend hit a car that had pulled out from a side street. He flew over the car and landed on his head. Bystanders showed their ignorance of spinal fracture by, yikes, carelessly moving him. In fact, his thoracic spine was significantly fractured … yet the hospital actually refused to do an X-ray because he had no obvious symptoms of a spinal fracture. Incredible! The next day, a horrified orthopedic surgeon ordered an X-ray immediately, confirming the fracture, and quite possibly saved him from paralysis.

Picture of a man holding his painful back.

Isn’t it rather obvious that a potential spinal fracture is an emergency?

You’d think so. But consider this story of a motorcycle accident: many years ago, a friend hit a car that had pulled out from a side street. He flew over the car and landed on his head. Bystanders showed their ignorance of spinal fracture by, yikes, carelessly moving him. In fact, his thoracic spine was significantly fractured … yet the hospital actually refused to do an X-ray because he had no obvious symptoms of a spinal fracture. Incredible! The next day, a horrified orthopedic surgeon ordered an X-ray immediately, confirming the fracture, and quite possibly saved him from paralysis.

The Big Three signs that you should investigate for an ominous cause of persistent low back pain (but it’s not an emergency)

You shouldn’t worry about low back pain until three conditions have been met:

  1. it’s been bothering you for more than about 6 weeks12
  2. it’s severe and/or not improving, or actually getting worse
  3. there is at least one other “red flag” (see more list items below)

The presence of the big three does not confirm that something horrible is going on. It only means that you need to check carefully.

Andy Whitfield as Spartacus: At his physical peak, not long before getting sick. The first sign of his cancer was steadily worsening back pain. He may have already been in pain at this time.

Andy Whitfield as Spartacus

At his physical peak, not long before getting sick. The first sign of his cancer was steadily worsening back pain. He may have already been in pain at this time.

The story of actor Andy Whitfield is a disturbing and educational example of a case that met these conditions — for sure the first two, and probably the third as well if we knew the details. Whitfield was the star of the hit TV show Spartacus (which is worthwhile, but rated very, very R13) The first sign of the cancer that killed him in 2011 was steadily worsening back pain. It’s always hard to diagnose a cancer that starts this way, but Whitfield was in the middle of intense physical training to look the part of history’s most famous gladiator. Back pain didn’t seem unusual at first, and some other symptoms may have been obscured. Weight loss could have even seemed like a training victory at first. It was many long months before he was diagnosed — not until the back pain was severe and constant. A scan finally revealed a large tumour pressing against his spine.

Don’t confuse threat and risk. Working at the edge is a risk. But then again, so is walking out your front door.

Cory Blickenstaff, PT

All the red flags for ominous causes of back pain

“Red flags” are signs or symptoms that something medically ominous may be going on. A red flag is not a diagnosis. Red flags only indicate a need to look more closely. Check off all that apply … hopefully none or few or only the least alarming of them!

Some of these red flags are much less red than others, especially depending on the circumstances. For instance, “weight loss” is common and often the sign of successful diet! (Well, at least temporarily successful, anyway. ) Obviously, if you know of a harmless reason why you have a red flag symptom, it isn’t really a red flag (duh!). But every single actual red flag — in combination with severe low back pain that’s been going on for several weeks — is definitely a good reason to get yourself checked out.

Most people who check off an item or two will turn out not to have an ominous cause for their low back pain. But why not check?

The tricky one:
Cancer as a cause of low back pain, and the necessity of testing “just in case” when the symptoms justify it

Sorry I have to use the C word — I know it’s kind of a bummer. But C happens.

A few cancers in their early stages can be hard to tell apart from ordinary back pain — a bone cancer in the vertebrae, for instance — and these create a frustrating diagnostic problem. They are too rare for doctors to inflict cancer testing on every low back pain patient “just in case.” And yet the possibility cannot be dismissed, either! It’s an unsolveable problem.

Most cancers and ominous problems will inevitably start to cause other, distinctive, ominous symptoms, and it won’t be long before someone catches on that there’s more going on than just back pain. Being “freaked out” about persistent back pain poses a genuine threat: it can make low back pain much worse.So it truly is an extraordinary circumstance for back pain to be ominous without causing other symptoms that raise the alarm.

Meanwhile, it’s extremely common for non-life-threatening low back pain to be alarmingly severe and persistent — to have a loud bark! Your doctor may not appreciate how true this is, and may over-react to all persistent low back pain, even without other red flags. In most cases, you shouldn’t let them scare you. Being “freaked out” about persistent back pain is the real threat: it can make low back pain much worse, and much more likely to last even longer (a tragic irony).

This is an unholy combination of factors: the exact same symptoms can have either an extremely rare but serious cause, or an extremely common but “harmless” cause that can be greatly aggravated by excessive alarm!

The good news is that it’s easy enough to diagnose cancer if you look for it, so the answer to the dilemma is to simply do the testing when the time is right, but not before. There’s every reason to screen for cancer when the conditions merit it — that is, when the red flags appear in combination with persistent, severe pain.

Is lower right back pain worrisome?

Many people find this article because they are searching for information on “lower right back pain” or “pain in lower right back,” so I’ve made a point of including extra information exactly about this question.

Pain on the right side of the back is not particularly worrisome, no. Same with the left. There are two main kinds of back pain that occurs only on one side:

  1. Back pain that could occur on either side, but just happens to be on the right or the left exclusively. This is very common. Most ordinary back pain dominates one side of the back.
  2. Back pain that comes specifically from structures that exist only on one side. This is a small category.

Most of the anatomy of the low back and abdomen is symmetrical. Some of the guts are not symmetrical, and only some of those are plausible causes of right-sided back pain. Here’s some of the key anatomy to consider:

By now you should be getting the idea that there the side of the pain on its own doesn’t tell us much, and most of the one-sided sources of pain are viscera that usually cause more abdominal pain. In other words, the only reason to worry about right or left lower back pain is if it is otherwise worrisome: if you have other significant non-back symptoms, or red flags from the lists earlier in this article.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and assistant editor of ScienceBasedMedicine.org. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Other articles about back pain and spines

What’s New In this Article?

Wednesday, February 24, 2016 — Added a bunch of further reading suggestions.

Wednesday, January 13, 2016 — Added a substantial new section about left and right low back pain.

Monday, January 11, 2016 — More editing, more! Added some better information about pain being a poor indicator, and the role of myofascial trigger points. This article has become extremely busy in the last couple months — about 4,000 readers per day, as described here — so I am really polishing it and making sure that it’s the best possible answer to people’s fears about back pain.

Wednesday, January 6, 2016 — Added table of worst possible causes of back pain. Miscellaneous editing and organizing.

Wednesday, May 8, 2013 — More editing and minor improvements. Added the barking dog image. Made the article more “shareable,” with new metadata for social media sites.

Tuesday, February 19, 2013 — Edits and miscellaneous minor improvements. Added one red flag.

Saturday, April 16, 2011 — Added some clarification about the position of symptoms of cauda equina syndrome, and a personal footnote related to that scary scenario.

Monday, October 12, 2009 — Added important and reassuring information about the chronicity of low back pain. See “Prognosis for patients with chronic low back pain: inception cohort study”.

Wednesday, July 8, 2009 — Publication.

Notes

  1. People often have no pain or other symptoms despite the presence of obvious arthritic degeneration, herniated discs, and other seemingly serious structural problems like stenosis and spondylolistheses. This surprising contradiction has been made clear by a wide variety of research over the years (particularly see several studies in the 1990s: Boden, Jensen, Weishaupt, Stadnik and Borenstein), and was well-established by 2001 when low back pain expert Dr. Richard Deyo wrote in a physician tutorial for New England Journal of Medicine that “…disk and other abnormalities are common among asymptomatic adults” (see Deyo). The point has been emphasized by many other experts since, and continues to be clarified by new research in many different ways, such as a 2006 experiment (see Haig) showing surprising evidence that even spinal canal stenosis (narrowing) is routinely painless; or a 2009 paper (see Chou) concluding that most therapies that try to treat low back pain by addressing alleged mechanical problems are still controversial and unproven after all these years . BACK TO TEXT
  2. Costa Ld, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009 Oct;339:b3829. PubMed #19808766. PainSci #55422.

    This Australian study concluded that “prognosis is moderately optimistic for patients with chronic low back pain,” contradicting the common fear that any low back pain that lasts longer than 6-9 weeks will become a long-term chronic problem. This evidence is the first of its kind, a rarity in low back pain research, a field where almost everything has been studied to death. “Many studies provide good evidence for the prognosis of acute low back pain,” the authors explain. “Relatively few provide good evidence for the prognosis of chronic low back pain.”

    Their research differs from past studies of chronic low back pain, which tended to focus on patients who already had a well-established track record of long-term problems (in other words, the people who had already drawn the short straw before they were selected for study, and are likely to carry right on feeling rotten). Instead they studied new cases of chronic low back pain, and found that “more than one third” recovered within nine more months. This evidence is a great foundation for more substantive and lasting reassurance for low back pain patients.

    BACK TO TEXT
  3. The complete list, from Low Back Pain: Clinical Practice Guidelines:
    In the vast majority of patients with low back pain, symptoms can be attributed to nonspecific mechanical factors. However, in a much smaller percentage of patients, the cause of back pain may be something more serious, such as cancer, cauda equina syndrome, spinal infection, spinal compression fractures, spinal stress fractures, ankylosing spondylitis, or aneurysm.
    BACK TO TEXT
  4. Enthoven WT, Geuze J, Scheele J, et al. Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice. Phys Ther. 2016 Mar;96(3):305–12. PubMed #26183589. How many cases of back pain in older adults have a serious underlying cause? Only about 6% … but 5% of those are fractures (which are serious, but they aren’t cancer either). The 1% is divided amongst all other serious causes. In this study of 669 patients, a vertebral fracture was found in 33 of them, and the chances of this diagnosis was higher in older patients with more intense pain in the upper back, and (duh) trauma. BACK TO TEXT
  5. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478–491. PubMed #17909209. PainSci #56029.

    Marvelously progressive, concise, and cogent guidelines for physicians on the treatment of low back pain. These guidelines almost entirely “get it right” in my opinion, and are completely consistent with recommendations I’ve been making for years on PainScience.com. They are particularly to be praised for strongly discouraging physicians from ordering imaging tests only “for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.”

    BACK TO TEXT
  6. Or anything else. Pain is a poor indicator, period! The human nervous system is really terrible about this: it routinely produces false alarms, and alarms that are much too loud. See Pain is Weird: Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it. BACK TO TEXT
  7. There is controversy and scientific uncertainty about trigger points. It’s undeniable that mammals suffer from sensitive spots in our soft tissues … but their nature remains unclear, and the “tiny cramp” theory could be wrong. The tiny cramp theory is formally known as the “expanded integrated hypothesis,” and it has been prominently criticized by Quintner et al (and not many others). However, it’s the mostly widely accepted explanation for now. BACK TO TEXT
  8. That is, the parts of your body that touch a saddle when riding a horse: groin, buttock, and inner thighs. I experienced rather intense, terrifying awareness of symptoms in this area in the aftermath of my wife’s car accident in early 2010. With a mangled T12 vertebrae, she was at real risk of exactly this problem. Fortunately, she escaped that quite serious problem. But, sheesh, I was vigilant about it for a while! “Honey, any numbness in your saddle area today?” BACK TO TEXT
  9. Example: a friend of mine went to the hospital after a motorcycle accident. He’d flown over a car and landed hard on his head. Bizarrely, he was sent home with very little care, and no imaging of his back, even though he was complaining of severe lower back pain. A doctor reassured him that it was just muscle spasms. (This all happened at a hospital that was notorious for being over-crowded and poorly run.) The next day, still in agony, he went to see a doctor at a walk-in clinic, who immediately took him for an x-ray… which identified a serious lumbar fracture and imminent danger of paralysis. He had been lucky to get through the night without disaster! He was placed on a spine board immediately and sent for surgery. The moral of the story? Sometimes, when you’ve had a major trauma and your back really hurts, it’s because your back is broken. BACK TO TEXT
  10. True numbness is not just a dead/heavy feeling (which is common, and caused even by minor muscular dysfunction in the area), but a significant or complete lack of sensitivity to touch. You have true numbness when you have patches of skin where you cannot feel light touch. Such areas might still be sensitive to pressure: you could feel a poke, but as if it was through a layer of rubber. Most people have experienced true numbness at the dentist. BACK TO TEXT
  11. The condition is cauda equina syndrome. It involves “acute loss of function of the neurologic elements (nerve roots) of the spinal canal below the termination (conus) of the spinal cord,” where the nerves spread out like a horse (equina) tail. Again, this condition causes symptoms in the “saddle” of the body: butt, groin, inner thighs. BACK TO TEXT
  12. This standard recommendation reinforces the alarming idea that low back pain that lasts longer than a few weeks is Really Bad News. It’s not. It’s a clue. It’s a reason for concern and alertness. But many cases of low back pain that last for 6 weeks will still go away. Once again, see the 2009 research published in the British Medical Journal, which showed that more than 30% of patients with “new” chronic low back pain will still recover without treatment. BACK TO TEXT
  13. Spartacus is worthwhile, but the sex and violence is over-the-top: there’s no sugar-coating it. Definitely not a family drama. But the dramatic quality is excellent. After a couple of campy, awkward episodes at the start, the first season quickly gets quite good: distinctive film craft, interesting writing, and solid acting from nearly the whole cast. Andy Whitfield’s Spartacus is idealistic, earnest, and easy to like. I found it downright upsetting when I learned that he had passed away — as did many, many other fans I’m sure. See my personal blog for a little bit more of a review of Spartacus. BACK TO TEXT