MEDICAL MONDAYS: News Notes
Chris Glattes, MD, orthopaedic spinal surgeon
Keith Nichols, MD, physiatrist
TOPIC: Back Pain: Surgical & Non-Surgical Treatments
Monday, October 20 2008
Understanding Back Pain - the Basics
What Is Back Pain?
We've all experienced back problems from time to time -- a pain in the lower back or strain of the neck. In fact, problems from back pain are the most common physical complaints among American adults and are a leading cause of lost job time -- to say nothing of the time and money spent in search of relief. Back pain includes sore muscles and tendons, herniated discs, fractures, and other problems. Most often, the causes of back pain have developed over a long period of time.
The spinal column is an extraordinary mechanism. It keeps us stable enough to stand upright but flexible enough for movement. The backbone, or spine, is actually a stack of 24 individual bones called vertebrae.
A healthy spine is S-shaped when viewed from the side. It curves back at the shoulders and inward at the neck and small of the back. It's the body's main structural support. It also houses and protects the spinal cord, the intricate network of nerves that runs through the vertebrae to transmit feeling and control movement throughout the entire body.
What Causes It?
Back pain ranks high on the list of self-inflicted ailments. Most of our back troubles happen because of bad habits, generally developed over a long period of time. These include:
Sometimes, the effects are immediate, but in many cases back problems develop over time. One of the more common types of back pain comes from straining the bands of muscles surrounding the spine. Although such strains can occur anywhere along the spine, they happen most often in the curve of the lower back. The next most common place is at the base of the neck.
Sometimes backache occurs for no apparent reason. This is called nonspecific backache. It may develop from weakened muscles that cannot handle everyday walking, bending, and stretching. In other cases, the discomfort seems to come from general tension, lack of proper sleep, and/or stress.
A condition called fibrositis causes chronic backache from localized muscle tension. Sometimes this original muscle tension comes from stress or other emotional problems.
Whether the muscle strain is from lifting heavy objects or from something as innocuous as a sneeze makes little difference -- the pain can be agonizing.
Injuries from contact sports, accidents, and falls can cause problems ranging from minor muscle strains to severe damage to the spinal column or the spinal cord itself.
Understanding Back Pain - Treatment
How Do I Know What Kind of Back Problem I Have?
Before a doctor can begin treating back pain, he or she may do tests to determine what is causing the patient's back pain. Unless you are totally immobilized from a back injury, your doctor probably will test your range of motion and nerve function and touch your body to locate the area of discomfort.
Blood and urine tests will make sure the pain is not due to an infection or other systemic problem.
X-rays are useful in pinpointing broken bones or other skeletal defects. They can sometimes help locate problems in connective tissue. To analyze soft-tissue damage, computed tomography (CT) or magnetic resonance imaging (MRI) scans may be needed. X-rays and imaging studies are generally used only for checking out direct trauma to the back, back pain with fever, or nerve problems such as extremity weakness or numbness. To determine possible nerve or muscle damage, an electromyogram (EMG) can be useful.
What Are the Treatments?
Because back pain stems from a variety of causes, treatment goals are pain relief and restored movement. The basic treatment for relieving back pain from strain or minor injury is rest. An ice pack can be helpful, as can aspirin or another nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation. After the inflammation subsides, applying heat can soothe muscles and connective tissue.
Long-term bed rest is not only no longer considered necessary for most cases of back pain, it is actually potentially harmful, making recovery slower and potentially causing new problems. In most cases, you will be expected to start normal, nonstrenuous activity (such as walking) within 24 to 72 hours. After that you should begin controlled exercise or physical therapy. Physical therapy treatments may employ massage, ultrasound, whirlpool baths, controlled application of heat, and individually tailored exercise programs to help you regain full use of the back. Strengthening both the abdominal and back muscles helps stabilize the spine. You can prevent further back injury by learning -- and doing -- gentle stretching exercises and proper lifting techniques, and maintaining good posture.
If back pain keeps you from normal daily activities, your doctor can help by recommending or prescribing pain medications. Over-the-counter painkillers such as Tylenol, aspirin, or ibuprofen can be helpful. Your doctor may prescribe prescription strength anti-inflammatories/pain medicines or may prefer to prescribe combination opioid/acetaminophen medications such as Vicodin or Percocet. Some doctors also prescribe muscle relaxants. But beware, these medications have their main effect on the brain, not the muscles, and often cause drowsiness.
If your primary doctor isn't able to help you control the pain, he/she may refer you to a back specialist or a pain specialist. Sometimes these doctors will use injections of steroids or anesthetics to help control the pain. Some newer treatments have been developed recently to help with the treatment of pain. One of these is radiofrequency ablation, a process of delivering electrical stimulation to specific nerves to make them less sensitive to pain, or by delivering enough electricity to actually destroy the nerve to prevent further pain. A similar type of procedure that delivers heat to a herniated disc can shrink the disc so that it no longer bulging onto the nerve root causing pain. Other medicines such as antidepressants and anticonvulsants are sometimes prescribed to help with pain related to irritated nerves.
Knowing the cause of the pain and fixing the problem if possible should be primary in the course of your treatment, however.
Some physicians advocate using a transcutaneous electrical nerve stimulator (TENS), although whether TENS is clearly helpful for back pain has not been resolved. Electrodes taped to the body carry a mild electric current that helps relieve pain. After appropriate training, patients can use TENS on their own to help reduce pain while they recover from strained or moderately injured backs.
Surgery for nonspecific back pain is a last resort. In cases of persistent pain from extreme nerve damage, rhizotomy -- surgically severing a nerve -- may be necessary to stop transmission of pain to the brain. Rhizotomy can correct the symptoms caused by friction between the surfaces in a spinal joint, but it doesn't address other problems, such as herniated discs.
Chiropractors have a role in the treatment of back pain. The U.S. Agency for Healthcare Research and Quality recognizes spinal manipulation by chiropractors and osteopaths as effective for acute low-back pain. Its effectiveness for treating chronic back pain is less well established. Some researchers suggest that early chiropractic adjustments for acute back pain may prevent chronic problems from developing. Other doctors warn against some chiropractic manipulations, particularly those that involve rapid twisting of the neck.
Osteopathic treatment is likely to combine drug therapy with spinal manipulation or traction, followed by physical therapy and exercise.
Acupuncture may bring moderate to complete pain relief for many sufferers. It can be used alone or as part of a comprehensive treatment plan that includes medications and other bodywork. Clinical achievements, along with positive research results, prompted the National Institutes of Health (NIH) to declare acupuncture a reasonable treatment option for those suffering low back pain.
If you consult a psychotherapist for cognitive behavioral therapy (CBT), your treatment may include stress management, behavioral adaptation, education, and relaxation techniques. CBT can lessen the intensity of back pain, change perceptions about levels of pain and disability, and even lift depression. The NIH considers CBT useful for relieving low back pain, citing studies that show CBT to be superior to routine care and placebo.
Other comprehensive behavioral programs have shown similar success, with participants able to lessen the amount of medication they needed while improving their outlook and pain-related behavior.
If lower back pain is related to muscle tension or spasm, biofeedback can be effective for lessening pain intensity, decreasing drug use, and improving quality of life. Biofeedback may help you train your muscles to respond better to stress or movement.
The Alexander Technique, Pilates, and the Feldendkrais Method are all specialized forms of body work that help you learn to move in a more coordinated, flexible, and graceful manner. They may help reduce pain and can relieve stress. Some of the postures of yoga may help diminish low back pain, improve flexibility, strength, and sense of balance. Yoga is good for stress reduction and can help with the psychological aspects of pain.
Aquatic therapy and exercise can also improve flexibility and decrease pain for those with chronic low back problems. The unique properties of water make it an especially safe environment for exercising a sore back; it provides gentle resistance, comfort, and relaxation.
Back Pain Surgery
Depending on the diagnosis, surgery may either be the first treatment of choice - although this is rare - or it is reserved for chronic back pain for which other treatments have failed. If you are in constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function at your job, or to perform daily activities, you may be a candidate for surgery.
In general, there are two groups of people who may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disc, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement. People in the second group are those with only predominant low back pain (without leg pain). These are people with discogenic low back pain (degenerative disc disease), in which discs wear with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.
Some of the diagnoses that may need surgery include:
Herniated discs: a potentially painful problem in which the hard outer coating of the discs, which are the circular pieces of connective tissue that cushion the bones of the spine, are damaged, allowing the discs' jelly-like center to leak, irritating nearby nerves. This causes severe sciatica and nerve pain down the leg. A herniated disc is sometimes called a ruptured disc.
Spinal stenosis: the narrowing of the spinal canal, through which the spinal cord and spinal nerves run.
It is often caused by the overgrowth of bone caused by osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but also to numbness in the legs and the loss of bladder and/or bowel control. Patients may have difficulty walking any distances and may also have severe pain in their legs along with numbness and tingling.
Spondylolisthesis: a condition in which a vertebra of the lumbar spine slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause not only low back pain but severe sciatica leg pain.
Vertebral fractures: fractures caused by trauma to the vertebrae of the spine or by crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back pain, but it may also put pressure on the nerves, creating leg pain.
Discogenic Low Back Pain (Degenerative Disc Disease): Most people's discs degenerate over a lifetime, but in some, this aging process can become chronically painful, severely interfering with their quality of life.
Following are some of the most commonly performed back surgeries:
For herniated discs:
Laminectomy/discectomy: In this operation, part of the lamina, a portion of the bone on the back of the vertebrae, is removed, as well as a portion of a ligament. The herniated disc is then removed through the incision, which may extend two or more inches.
Microdiscectomy: As with traditional discectomy, this procedure involves removing a herniated disc or damaged portion of a disc through an incision in the back. The difference is that the incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disc through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar. It appears to take about the same time to recuperate from a microdiscectomy as from a traditional discectomy.
Laser surgery: Technological advances in recent decades have led to the use of lasers for operating on patients with herniated discs accompanied by lower back and leg pain. During this procedure, the surgeon inserts a needle in the disc that delivers a few bursts of laser energy to vaporize the tissue in the disc. This reduces its size and relieves pressure on the nerves. Although many patients return to daily activities within 3 to 5 days after laser surgery, pain relief may not be apparent until several weeks or even months after the surgery. The usefulness of laser discectomy is still being debated.
For spinal stenosis:
Laminectomy: When narrowing of the spine compresses the nerve roots, causing pain and/or affecting sensation, doctors sometimes open up the spinal column with a procedure called a laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the spine and removes the lamina and any bone spurs, which are overgrowths of bone, that may have formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.
Spinal fusion: When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal fusion, two or more vertebrae are joined together using bone grafts, screws, and rods to stop slippage of the affected vertebrae. Bone used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.
Although the surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body. With donor bone, there is a slight risk of disease transmission or rejection. In recent years, a new development has eliminated those risks for some people undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate bone generation, eliminating the need for grafts. The proteins are placed in the affected area of the spine, often in collagen putty or sponges.Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.
For vertebral osteoporotic fractures3:
Vertebroplasty: When back pain is caused by a compression fracture of a vertebra due to osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and inject a cement-like mixture called polymethyacrylate into the fractured vertebra to relieve pain and stabilize the spine. The procedure is generally performed on an outpatient basis under a mild anesthetic.
3 Used only if standard care, rest, corsets/braces, analgesics fail.
Kyphoplasty: Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine following fractures due to osteoporosis. Kyphoplasty is a two-step process. In the first step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the second step, he or she injects polymethyacrylate to repair the fractured vertebra. The procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.
For Discogenic Low Back Pain (Degenerative Disc Disease)
Intradiscal electrothermal therapy (IDT): One of the newest and least invasive therapies for low back pain involves inserting a heating wire through a small incision in the back and into a disc. An electrical current is then passed through the wire to strengthen the collagen fibers that hold the disc together. The procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDT is debatable.
Spinal fusion: When the degenerated disc is painful, the surgeon may recommend removing it and fusing the disc to help with the pain. This fusion can be done through the abdomen, a procedure known as anterior lumbar interbody fusion, or through the back, called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is successful in about 60 to 70 percent of cases. Fusion for low back pain or any spinal surgeries should only be done as a last resort, and the patient should be fully informed of risks.
Disc replacement: When a disc is herniated, one alternative to a discectomy - in which the disc is simply removed - is removing it and replacing it with a synthetic disc. Replacing the damaged one with an artificial one restores disc height and movement between the vertebrae. Artificial discs come in several designs.
Non-Surgical Back Pain Treatments: Anesthetic or corticosteroid injections for low back pain
Trigger point injections Sometimes, putting pressure on a certain spot in the back (called a trigger point) can cause pain at that spot or extending to another area of the body, such as the hip or leg. To relieve pain, a local anesthetic, either alone or combined with a corticosteroid, may be injected into the area of the back that triggers pain (trigger point injection).
How It Works
Local anesthesia is believed to break the cycle of pain that can cause you to become less physically active. Muscles that are not being exercised are more easily injured, so the irritated and injured muscles can cause more pain and spasm and can disrupt sleep. This pain, spasm, and fatigue, in turn, can lead to less and less activity.
Steroids reduce inflammation, so a corticosteroid injected into the spinal canal can help relieve pressure on nerves and nerve roots.
Why It Is Used
How Well It Works
Research has not demonstrated that local injections are effective in controlling chronic low back pain.1
Facet joint injections
Epidural steroid injections
Evidence supporting epidural steroid injection is mixed. Research does not demonstrate a clear benefit.2, 1 But some people seem to get short-term relief, especially from pain that spreads down the leg.3
Possible side effects include nerve or other tissue damage, infection, or excessive bleeding.
Facet joint injections
Possible side effects include pain at the injection site, infection, excessive bleeding, nerve damage, or spinal cord inflammation.
Epidural steroid injections
Rare possible side effects include headache, fever, spinal cord inflammation, or infection.
See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)
What To Think About
Most orthopedists and rheumatologists advise against repeated injections of corticosteroids directly into joints, including joints of the spine, because degeneration or damage to joint cartilage may occur.