The 7 Most Serious Causes of Back Pain

Back pain is extremely common and usually not a medical emergency. But some serious causes of back pain do warrant a trip to the emergency room. These include:

This article goes over the causes, symptoms, risk factors, and treatments for serious causes of back pain. It also covers when you seek immediate medical care.

Ouch...My butt hurts Shot of a businessman rubbing his aching back while sitting at his desk in front of his computer
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Osteomyelitis

Osteomyelitis is an infection of the bone. When bones in the back are involved, it can cause back pain. It's usually due to:

  • Invasive bacteria
  • Less often, fungi and other germs
  • Infection that starts somewhere else and travels to the bone

Symptoms include:

  • Bone pain in the back
  • Excessive sweating
  • Fever and chills
  • Malaise (general discomfort or sick feeling)
  • Swelling, redness, and warmth around the bone
  • An open wound, possibly with visible pus

You're more likely to develop osteomyelitis if you have any of the following risk factors:

  • Diabetes
  • Kidney dialysis
  • Poor blood supply
  • Recent back injury
  • Injected illicit drugs
  • Bone surgery
  • Weak immune system

Treatment involves:

  • Antibiotics, usually for at least 4 weeks, usually intravenously (IV), which means through a vein
  • Possibly more than one antibiotic at a time
  • Surgery to remove dead bone tissue if treatment is delayed or fails

Get medical attention quickly if you:

  • Have symptoms of osteomyelitis
  • Your osteomyelitis isn't getting better despite treatment

With prompt treatment, the outcome is often good.

Epidural Abscess

Epidural abscesses are rare but serious problem. It can lead to permanent nervous system damage or even death.

An abscess is a collection of pus from an infection. The epidural space is the area between your vertebrae (bones of the spine) and a membrane called the dura mater.

Causes include:

  • Recent spinal surgery
  • Bloodstream infections
  • Boils, especially on the back or scalp
  • Spinal infections

The abscess can lead to spinal cord compression. Symptoms include:

  • Back pain
  • Fever
  • Cognitive problems
  • Sensory loss
  • Weakness
  • Impaired bladder control

Depending on the location, additional symptoms may be:

  • Paralysis of a body part
  • Loss of sensation or abnormal sensation in an area of your body

Without prompt treatment, you may develop complications such as:

  • Brain damage
  • Osteomyelitis
  • Meningitis
  • Nerve damage
  • Recurring infection

You have a higher risk of epidural abscess if you have:

  • An impaired immune system from AIDS, cancer treatment, or immunosuppressant medication
  • Alcoholism
  • Chronic kidney disease
  • Diabetes
  • Spinal trauma
  • Injected illicit drugs

The treatment goals are to cure the infection and prevent permanent damage. Typical treatment involves:

  • IV antibiotics for at least 4 weeks
  • Sometimes, surgery to drain or remove the abscess and reduce pressure on the spinal cord

Early treatment makes a positive outcome more likely. The odds of permanent damage and death increase sharply once weakness, paralysis, or sensation changes begin.

Get immediate medical attention if you have symptoms of an epidural abscess.

Cancer

Many types of cancer can invade the spin and cause back pain, usually due to compression from tumors. The cancer may start:

  • In the spinal cord
  • In the meningeal tissues that cover the brain and spinal cord (meningeal carcinomatosis)
  • Anywhere in the body, then spread (metastasize) to the spine

Symptoms of spinal cancer, which are mostly related to nerve compression, include:

  • Back and neck pain from compression or changes in spinal alignment
  • Bowel and bladder problems due to pinched nerves
  • Numbness, tingling, and weakness
  • Problems walking
  • Paralysis

You may be at heightened risk if you've had:

  • Radiation exposure, such as from previous cancer treatment
  • A weak immune system
  • Possibly, exposure to chemicals such as vinyl chloride and petroleum products
  • Rarely, a family history of spinal cord tumors

Cancer treatments depend on many factors, including the tumor's type and location. It may include:

  • Chemotherapy
  • Radiation
  • Targeted drugs
  • Surgical removal

The outcomes of cancer treatment have improved significantly. Your healthcare provider can tell you what your prognosis is based on the specifics of your cancer and overall health.

Cancer isn't usually something you go to the ER for. However, if you have symptoms that could be caused by cancer, it's important that you see your healthcare provider as soon as possible. The sooner you start treatment, the better your odds are for beating cancer.

About 80% of American adults will suffer from back pain at some point. Common causes include a muscle injury, herniated disc, or degenerative disease in the spine.

Lyme Disease

Back pain is a common early symptom of Lyme disease that's invaded the nervous system. About 15% of people with Lyme disease develop this condition, which is called neuroborreliosis.

Lyme disease is caused by a bacteria that's transmitted through tick bites. Other common symptoms include:

  • Fever
  • Headache
  • Fatigue
  • A skin rash called erythema migrans

Erythema migrans spreads in a circular or oval pattern and often takes on a bullseye appearance, with a large discolored ring, a skin-tone ring, and a solid circle in the middle.

Varied Color of the Rash

On light-colored skin, erythema migrans is pink or red. On a Black or dark brown person, it may be simply raised, slightly darker than the skin, or purplish.

You're at heightened risk of contracting Lyme disease if you:

  • Live, work, or play in the northeastern, mid-Atlantic, or north-central United States
  • Spend a lot of time in wooded or grassy areas, such as when hunting or camping
  • Live in a rural area
  • Work outdoors
  • Have pets who spend time outdoors
  • Have a genetic predisposition, which makes you more susceptible to the infection

Most cases of Lyme disease clear up in a few weeks with antibiotics. You may be able to prevent tick bites by:

  • Using insect repellent
  • Doing frequent tick checks and removing any you find
  • Using pesticides in outdoor areas you frequent
  • Reducing vegetation where ticks live

Most people recover fully from Lyme disease, but a small percentage develop a longer-lasting form called post-treatment Lyme disease, which may last for up to six months and causes symptoms like joint and nerve pain (neuropathy).

Spinal Cord Infarction

A spinal cord infarction (SCI) is a type of stroke that, unlike typical strokes, occurs outside of the brain. It can be in either the spinal cord or the arteries that supply the spinal cord with blood.

Like typical strokes, SCIs are caused by a buildup of plaque in arteries (atherosclerosis). Causes and risk factors for this buildup include:

  • High cholesterol and triglyceride levels
  • High blood pressure
  • Smoking cigarettes
  • Diabetes (types 1 and 2)
  • Obesity
  • Eating saturated fats
  • Physical inactivity
  • Family history of atherosclerosis

Some people have abnormal blood vessels that are called vascular malformations. They may predispose you to an SCI.

Symptoms of an SCI include:

  • Intermittent back pain that may be sharp or burning
  • Aching pain and/or weakness down both legs
  • Paralysis
  • Impaired deep tendon reflexes
  • Numbness
  • Loss of bowel and/or bladder control

Treatment of a spinal cord infarction is aimed at managing symptoms and regaining functionality lost to weakness or paralysis. It often involves physical and/or occupational therapy.

Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an autoimmune disease in which your immune system damages your nerves. Mistaking them for a virus or bacterium, your body makes special cells called antibodies to destroy your nerve cells.

It often begins after:

  • Respiratory illness
  • Diarrhea
  • Viral infection (flu, cytomegalovirus, Epstein Barr virus)
  • Rarely, after some vaccinations

Don't Skip Vaccinations!

While you may be tempted to skip a vaccination that may trigger GBS, it's important to know that your risk of GBS is higher after having the flu than after getting the flu vaccine.

GBS is a rare disease that's most common in:

  • Men
  • Adults over 50

Symptoms of GBS can progress over a period as short as a few hours or as long as a few weeks. They may include:

  • Early on, weakness and tingling, often in both legs or in the arms and back
  • Over time, weakness that increases until some muscles can't be used or become paralyzed
  • Loss of tendon reflexes in the limbs
  • Cramp-like muscle pain
  • Uncoordinated movement and difficulty walking
  • Low or erratic blood pressure
  • Abnormal heart rate
  • Blurred or double vision
  • Involuntary muscle contractions
  • Weakness in the facial muscles

It is possible to die from GBS, so treatment is important. Call 911 or go to the emergency room if you notice:

  • It's hard to take a deep breath
  • It's hard to swallow
  • You have decreased sensation or numbness
  • You lose consciousness (pass out)
  • You have an increasing loss of strength in your legs

GBS can't be cured. Treatment can lower your symptom load, treat complications, and help you recover faster. Treatment may include:

  • Apheresis/plasmapheresis (filtering antibodies and other cells involved in inflammation out of the blood)
  • Intravenous (through a vein) immunoglobulin (IVIg)
  • Breathing support at the hospital, if needed
  • Blood thinners to keep your blood from clotting
  • Pain management
  • A feeding tube, if necessary to prevent choking
  • Physical therapy

Most people will spontaneously begin to recover between 2 and 3 weeks after symptoms begin. It may take weeks or years to fully recover, and some nerve damage may remain. The faster symptoms begin to go away, the better the outcome generally is.

Transverse Myelitis

Transverse myelitis is an uncommon condition that involves inflammation of the spinal cord, which transmits signals between the brain and nerves. That inflammation is called myelitis.

Transverse means going across something. In this condition, it refers to a band-like sensation across your torso that includes sensory changes below the band. Other symptoms include:

  • Pain, which may be in the back
  • Weakness in the limbs
  • Bowel and bladder problems (increased frequency, incontinence, constipation)

It causes inflammation to develop in a matter of hours or weeks. Symptoms may be on one side only or on both sides.

Anyone can get transverse myelitis. The exact causes are uncertain, but it's theorized that about 40% of cases are autoimmune or associated with an autoimmune disease like multiple sclerosis. The other 60% are believed to be caused by inflammatory activity.

Triggers for this condition may include:

  • Viral, bacterial, fungal, or parasitic infection
  • Inflammatory disorders that impact the spinal cord (lupus, Sjögren's syndrome, sarcoidosis, connective tissue disease)
  • Blood vessel disorders including malformations

Treatments generally are aimed at stopping the underlying infection, reducing inflammation, and managing symptoms. They may include:

  • IV corticosteroid medications for inflammation
  • Plasmapheresis to remove antibodies
  • IVIg
  • Pain medications
  • Antiviral medications, if the cause is viral
  • Medications for symptoms such as incontinence, painful muscle spasms, depression, and sexual dysfunction

Most people at least partially recover from transverse myelitis. Most of the recovery generally takes place in the first three months.

Some people recover fully, but it usually takes months or even years. Others have permanent impairments that may limit their functionality.

It's possible to have only one episode or to have periodic recurrences.

Call 911 or go to an emergency room if you have symptoms that suggest transverse myelitis.

Referred Pain

Sometimes, back pain comes from another region of the body and doesn't involve problems in the back at all. This is called referred pain. Pancreatitis and aortic dissection (a tear in a major blood vessel of the heart) both can cause referred back pain.

Summary

Any time back pain is associated with new weakness or changes in bladder or bowel control, it's a sign that the nerves in the spinal cord may be seriously injured. Anyone with those symptoms should go to an emergency room immediately.

It's important to remember these causes of back pain are relatively rare. Millions of people have back pain from more common causes. Even so, these diseases are so serious that it's important for you and your healthcare provider to consider them.

19 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Osteomyelitis.

  2. Johns Hopkins Medicine. Epidural abscess.

  3. BMJ Best Practice. Spial epidural abscess.

  4. National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Epidural abscess.

  5. Johns Hopkins Medicine. Spinal cancer and spinal tumors.

  6. American Cancer Society. Risk factors for brain and spinal cord tumors.

  7. American Cancer Society. If you're an adult with a brain or spinal cord tumor.

  8. World Health Organization. Early cancer diagnosis saves lives, cuts treatment costs.

  9. National Institute for Neurological Disorders and Stroke. Low back pain fact sheet.

  10. Halperin JJ. Chronic Lyme disease: misconceptions and challenges for patient managementInfect Drug Resist. 2015;8:119–128. doi:10.2147/IDR.S66739

  11. Centers for Disease Control and Prevention. Lyme disease.

  12. Centers for Disease Control and Prevention. Post-treatment Lyme disease syndrome.

  13. National Institutes of Health, National Institute of Neurological Disorders and Stroke. Spinal cord infarction.

  14. Cedars Sinai. Atherosclerosis.

  15. Centers for Disease Control and Prevention. Guillain-Barré syndrome.

  16. Mount Sinai. Guillain-Barré syndrome.

  17. National Institutes of Health, National Institute of Neurological Disorders and Stroke. Transverse myelitis fact sheet.

  18. Johns Hopkins Medicine. What is transverse myelitis?

  19. Hospital for Special Surgery. An overview of lower back pain.

Additional Reading
  • Ropper AH, Samuels MA, Klein J et al. Adams and Victor's Principles of Neurology 11th Edition. McGraw-Hill Education / Medical.

By Peter Pressman, MD
Peter Pressman, MD, is a board-certified neurologist developing new ways to diagnose and care for people with neurocognitive disorders.