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.
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.
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.
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.
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.
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.
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.