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The Journal of the American Board of Family Medicine 22 (1): 69-74 (2009)
DOI: 10.3122/jabfm.2009.01.080026
© 2009 American Board of Family Medicine
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Brief Report

Improvement of Chronic Back Pain or Failed Back Surgery with Vitamin D Repletion: A Case Series

Gerry Schwalfenberg, MD

From the Department of Family Medicine, University of Alberta, Canada

Correspondence: Corresponding author: Gerry Schwalfenberg, MD, CCFP, Clinical Instructor, Department of Family Medicine, University of Alberta, #301, 9509-156 St, Edmonton, Alberta, Canada T5P 4J5 (E-mail: gschwalf{at}telus.net)


   Abstract
Top
 Notes
 Abstract
Discussion
 Conclusion
 References
 
This article reviews 6 selected cases of improvement/resolution of chronic back pain or failed back surgery after vitamin D repletion in a Canadian family practice setting. Pub Med was searched for articles on chronic back pain, failed back surgery, and vitamin D deficiency. Chronic low back pain and failed back surgery may improve with repletion of vitamin D from a state of deficiency/insufficiency to sufficiency. Vitamin D insufficiency is common; repletion of vitamin D to normal levels in patients who have chronic low back pain or have had failed back surgery may improve quality of life or, in some cases, result in complete resolution of symptoms.

Back pain is the most common neurological complaint in North America, second only to headache. Chronic back pain is often progressive and the cause may be difficult to determine. In America, more than $50 billion are spent each year on treatment.1 Low back pain (LBP) and proximal myopathy are also common symptoms of vitamin D deficiency and osteomalacia.2,3 There are many risk factors for vitamin D insufficiency or deficiency, including lack of sun exposure, inadequate dietary intake, darker skin color, age, obesity, and the use of various medications. The prevalence of vitamin D insufficiency/deficiency is high in Canada (where the patients in this report are located), especially during the winter.

The case reports described in Table 1 were from one solo practice. There were 4 patients who had chronic back pain for more than a year and 2 patients who suffered for more than 3 years from failed back surgery. Repletion of inadequate vitamin D levels (<80 nmol/L) demonstrated significant improvement or complete resolution of chronic LBP symptoms in these patients, and has been reported in literature before.3,4


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  		Table 1. Summary of Patient Data: Demographics, Brief Description of Patients, Vitamin D Levels Before and After, and Result of Repletion Therapy

 

   Discussion
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 Discussion
Conclusion
 References
 
PubMed was searched for articles, using the search terms "low back pain," "disk surgery," "musculoskeletal pain," and "vitamin D deficiency." As stated before, LBP is a common condition; it is estimated at approximately 5% of patients presenting in primary care have LBP, many of which become chronic.

Vitamin D is required for the differentiation, proliferation, and maturation of cartilage cells and for the production of proteoglycan synthesis in articular chondrocytes. Restoring vitamin D levels to normal in patients with osteomalcia has resulted in complete resolution of pain within 4 weeks.5 Improvement in back pain and weakness in patients with osteomalcia has also been noted. Patients who have chronic, nonspecific LBP or have had failed back surgery may have an underlying vitamin D insufficiency/deficiency.6

Risk factors for persistence or recurrence of LBP after surgery include infection and smoking. A less common reason is low vitamin D levels. Repletion with 1000 IU/day improves vitamin D status by approximately 20 to 25 nmol/L, and 2000/day IU will improve levels by 40 to 50, except in darker-skinned people, who may require significantly more. Patients with back pain who also have other risk factors for low vitamin D levels may benefit from a screening 25(OH)D level and repletion therapy. Muscle pain has been commonly seen in patients with vitamin D deficiency,5 as well as myopathy, which usually resolves more quickly than bone pain (which may take up to 1 year to resolve).2

Physicians should have a high index of suspicion for low vitamin D levels in patients with LBP, and determining the vitamin D status in these patients may be important. In those cases with vitamin D insufficiency/deficiency, repletion of vitamin D may offer dramatic results. Determining vitamin D levels and vitamin D repletion before and after back surgery may be prudent. The patients in this study who responded best used between 4000 and 5000 IU of vitamin D3/day.


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This case series supports information that has recently become apparent in the literature about vitamin D deficiency and its influence on back pain, muscle pain, and failed back surgery. Doses in the range of 4000 to 5000 IU of vitamin D3/day may be needed for an adequate response.

Placebo-controlled studies looking at outcomes in patients requiring back surgery with supplementation of vitamin D are urgently needed. Likewise, randomized placebo-controlled studies assessing vitamin D status, vitamin D receptor genotyping, and outcomes (using standardized measures of the severity of LBP, function, and quality of life) on repletion of vitamin D in patients with chronic LBP are needed.


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This article was externally peer reviewed.

Funding: none.

Conflict of interest: none declared.

Received for publication February 2, 2008. Revision received April 16, 2008. Accepted for publication April 17, 2008.


   References
Top
 Notes
 Abstract
 Discussion
 Conclusion
 References
 

  1. National Institute of Neurological Disorders and Stroke. Low back pain fact sheet. National Institutes of Health Publication number 03–5161. Washington DC: National Institute of Neurological Disorders and Stroke; 2003.

  2. Francis RM, Selby PL. Osteomalacia. Baillieres Clin Endocrinol Metab 1997; 11: 145–63.[CrossRef][Medline]

  3. Al Faraj S, Al Mutairi K. Vitamin D deficiency and chronic low back pain in Saudi Arabia. Spine 2003; 28: 177–9.[CrossRef][Medline]

  4. Plehwe WE, Carey RP. Spinal surgery and severe vitamin D deficiency. Med J Aust 2002; 176: 438–9.[Medline]

  5. Ghose R. Osteomalacia: recovery of bone density. N Z Med J 2004; 117: U940.[Medline]

  6. Heath KM, Elovic EP. Vitamin D deficiency: implications in the rehabilitation setting. Am J Phys Med Rehabil 2006; 85: 916–23.[CrossRef][Medline]


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This Article
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