 Back Pain
Frequently
Asked Questions
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Back Pain (by MHNI Staff)
How common is back pain?
Low back pain is a common malady affecting millions of people. Anywhere from 50% to 85% of the population will experience at least one significant episode of back
pain that will last from several weeks to 3 months. Unfortunately, once a significant
episode occurs, individuals will be at risk for a repeat episode in the future.
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What is the source of back pain and how
is it assessed?
Approximately 20% of back pain sufferers who undergo diagnostic studies will have
findings that appear to point to the source of their symptoms. Therefore, the majority
of patients experiencing back pain (80%) will have no obvious etiology or cause
for their symptoms of pain.
After reviewing results of various studies and a patient's progress with treatments
provided, the primary care physician will often refer the patient to a specialist
for further evaluation and treatment.
A back pain specialist will complete a thorough workup including a comprehensive
pain and general medical history and physical examination. They will also review
and/or order diagnostic tests to help determine the cause of the pain and whether
it is arising in the back or "referred" from the abdomen or pelvis. The two most
common patterns of back pain are mechanical and nerve root pain patterns.
The distinction between these two patterns of back pain is the location of the pain
and the sites of referral. Mechanical pain originates from problems with joints, ligaments,
muscles, or discs. Typically it is confined to the low back region and
the pain rarely radiates below the knee.
Nerve root pain may originate in the low back but is usually referred down the leg
to the foot along the course of the sciatic nerve (sciatica pattern). Nerve root
pain is sometimes due to herniation of a lumbar disc.
Determining the origin of pain will help direct the course of treatment. The specialist
will assess whether the pain is acute (less than 3 months in duration) or chronic
(greater than 3 months in duration). They will also determine the course of treatment.
Fortunately, most patients improve without surgery.
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Are there different types of back (spine)
pain?
Spine pain may be divided into several distinct types of benign pain syndromes:
mechanical pain, radicular pain, and myofascial pain.
Mechanical pain is often confined to the neck or low back region. It may radiate
in a limited fashion, i.e., to the elbow in the upper extremities or the knee in
the lower extremities. It is often described as a dull aching pain.
Radicular pain originates in the nerve root and refers pain to another area of the
body. In the upper extremities it may radiate to the fingers, shoulder, or neck. In the lower extremities, it may radiate to the toes, calves, or heels. It may have
a sharp shooting quality or persistent, boring quality. Some cases are associated
with intermittent or persistent patterns of numbness and burning.
Myofascial pain can have qualities of both mechanical and radicular pain. It is
primarily the result of muscle pain patterns and may be well-defined or diffuse
in nature.
The majority of spinal pain difficulties, greater than 80%, occur in the lumbar
(lower) spine. While cervical pain syndromes are not as common, the nature of problems
that affect the cervical spine mirror those in the lumbar spine.
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What are the first steps in addressing
back pain?
If utilizing over-the-counter medications and other first-line interventions fails
to provide relief, patients typically see their primary care physician for an evaluation.
This physician may prescribe medications such as muscle relaxers,
anti-inflammatory medications, and possibly narcotics to address an individual's pain. Blood tests
to determine the presence of infection, arthritis, cancer, or other serious problems,
as well as diagnostic imaging such as x-rays, CT scans, MRIs, and bone scans may
also be ordered.
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How is spinal pain diagnosed?
The diagnosis of spinal pain has greatly improved with the utilization of fluoroscopy
when performing nerve blockade and joint injection. Fluoroscopy, a type of x-ray
that allows observation of needle placement, has resulted in more specific and safer
injections, facilitating more accurate diagnosis of acute and chronic pain.
Injection of local anesthetic to a joint such as the facet joint or a nerve can
help to determine the origin of pain. There are two different types of blocks utilized
by a pain practitioner: diagnostic blocks and therapeutic blocks.
A diagnostic block is used to determine the origin of pain. However, it may also
provide pain relief for a prolonged period. The response varies from patient to
patient and may depend on how long the pain syndrome has been present. To determine
a positive response to a block, a patient usually undergoes at least two injections
in succession, with both blocks relieving a significant portion of the patient's
primary complaint.
Therapeutic blocks are used to reduce the pain from a specific site that has been
predetermined through previous diagnostic injections or blocks. The expectation
is that the procedure will have a long-term effect in reducing the pain syndrome.
These blocks may contain small amounts of steroids or other medications.
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What other nonsurgical options
are available?
Nerve blocks and joint injections can be effective in treating patients who have
not responded to a variety of treatments and can improve a patient's response to
prescribed medications. However, as pain becomes more chronic, patients may become
more resistant or refractory to a single type of therapy (e.g., nerve blocks or
medications). Subsequently more aggressive therapies such as the use of intrathecal
pumps or spinal cord/peripheral nerve stimulation may be required.
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Summary
The development and advancement of interventional therapies for spine pain have
allowed physicians to provide relief to patients who previously were resistant to
available therapies. Through continued research, advances in spine pain therapy
may continue.
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INTERVENTIONAL
THERAPIES FOR SPINE
(NECK AND BACK) PAIN
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Epidural steroid injection
An injection into the epidural space. This space extends from the neck to the low
back region. All nerves that provide coverage to the arm, legs and trunk pass through
this space. With this procedure, a small amount of steroid is injected with either
a local anesthetic or a salt solution (saline) into the epidural space.
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Selective nerve root injection
This technique involves injecting only select nerves using x-ray guidance to confirm
the origin of a patient's pain. Nerves that are often injected are those associated
with the upper and lower extremities. Thus the nerves of the neck and low back are
typically injected with a combination of local anesthetic and steroid or just local
anesthetic. |
Facet joint injection
The facet joints are vertebral joints that interconnect one vertebra to another
and extend down from the neck to the low back region and are often involved in neck
and low back pain syndromes. These joints are often injected with local anesthetic
as a diagnostic procedure. If the pain improves, patients may undergo radiofrequency
ablation (RF), which uses heat to destroy the small nerves that supply the joints.
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Cryoanalgesia
Freezing of peripheral nerves for long-term nerve blockade (6-9 months). This treatment
may be utilized for intercostal nerves (after rib fractures), occipital nerves (headache/head
trauma patients), and other superficial nerves.
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Discogram (disc stimulation)
A test that determines where discs are to be injected under x-ray guidance with
dye. Specific patterns of dye spread and a patient's response to the injection help
to determine the pain diagnosis and the best treatment option.
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ADVANCED PAIN
THERAPIES
Intrathecal morphine pumps, peripheral nerve stimulators (PNS),
and spinal cord stimulators (SCS) are devices utilized after other treatments have
failed.
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Intrathecal morphine pumps (IMP)
deliver morphine or other opioids directly to the spinal cord where they bind to
sites specific for morphine-type medications. The medications are placed directly
where needed which allows the dose to be significantly lower, leading to fewer side effects.
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Spinal cord stimulation (SCS)
is designed to cover the patient's painful sensation with a "pleasant" stimulation
pattern. The SCS unit has
three components: the electrode (a thin electronic wire
placed in the epidural space), a "pacemaker" battery, and a remote control. The
electrode is used to treat a range of pain syndromes, i.e., head pain, neck/arm
pain, and low back pain as well as a number of nerve injury states.
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Peripheral nerve
stimulation
This technology is similar to spinal cord stimulation except that the electrode
is placed in proximity to specific nerves that have been injured or contribute significantly
to pain syndromes, e.g., ulnar nerve for injured arm or occipital nerve for head
trauma (whiplash, closed head injury, etc.), or refractory head pain not responsive
to medical therapy or nerve blocks.
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