My Nagging Back

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by Dan Nemeth, MD

Back pain is one of the most common complaints in the doctor’s office. It is also one of the most feared diagnoses by physicians. The reason for this is that back pain is not well understood by many patients and physicians. The true cause for the back pain isn’t thoroughly explored for many reasons. This is primarily due to the amount of time and cost associated with testing. It is easier to write for pain medications and have the patient follow up. The problem is that pain medications aren’t treating the underlying problem, rather just masking the pain. The upside is that 80% of acute back pain will resolve in less than 6 weeks. However, people with back pain are prone to recurrent episodes and if left untreated, can lead to chronic back pain. The key to relief is to find the exact cause and provide the proper treatment.

Back pain is commonly due to one of three reasons: disc related pain, facet joint related pain, or musculoligamentous pain. Discs are the shock absorbers in the spine with a tough outer shell and a jelly core. Without proper muscle support and with continued repetitive movement, younger individuals can tear their disc causing pain. Older individual’s discs lose height due to water content loss leading to degenerative disc disease. This is usually the result of repetitive wear and tear of the spine. Another major cause of back pain is facet mediated pain. The facet joints are the joints on the back part of the spine on either side. These can commonly become arthritic and can lead to back pain for the same reason that knees or hips become arthritic and cause pain. Joints, such as the facet joints, become enlarged and arthritic through repetitive, improper use. The third major cause of back pain is due to muscles and ligaments. There are many small muscles and ligaments that help stabilize the spine. These muscles and ligaments can become fatigued, sprained, or strained. This can all lead to a source of back pain.

Whether the pain is discogenic, facet mediated, or musculoligamentous, the initial treatment remains the same. It’s important to decrease inflammation and stabilize the spine to prevent further degeneration and breakdown. This is accomplished primarily through spine specific physical therapy in a neutral spine position along with anti-inflammatory medications. Many other treatment modalities can be used to help alleviate the painful symptoms. These may include offering pain medications and muscle relaxers that will help mask symptoms. Other modalities can help provide relief including massage, ice, heat, and manipulations. If the pain is severe enough or doesn’t improve with initial treatment, sometimes injections can be provided for their powerful anti-inflammatory effects. Ultimately, lasting relief and prevention of re-occurrences is due to a high quality home exercise program providing dynamic stabilization of the spine. The importance of dynamic stabilization using your muscles is the key that will hopefully prevent future spine surgery. Once a segment is surgically fused in the spine, motion is compensated for in the levels above and below the fusion resulting in rapid breakdown in the adjacent joints above and below the fusion.

If physical therapy doesn’t help alleviate the pain, it is important to determine which structure is the source of the pain as it will alter the treatment plan. This can in part be accomplished through imaging with xrays and an MRI. However, imaging is very sensitive and will almost always reveal abnormalities, even in healthy, pain free individuals. These are merely pictures that may help localize the pain generator, but usually will just reveal a multitude of abnormalities that may or may not be contributing to the patient’s pain. The gold standard to pin point the structure causing pain is with a diagnostic injection. These diagnostic injections use an anesthetic to numb localized, specific structures. Once the structure causing pain is identified, a targeted steroid injection can be used to calm down inflammation so that the patient can continue with the core stabilization program in order to provide lasting relief.

Back pain radiating down a patient’s leg is commonly due to a disc herniation or spinal stenosis leading to nerve root impingement. Again, performing a high quality stabilization program in a neutral spine position can provide relief. If pain persists, using a transforaminal approach can target the single involved nerve root so that an epidural steroid injection can provide the maximal amount of relief. Many physicians will provide a generalized epidural steroid injection which reduces its effectiveness. Nearly 85% of patients with radicular symptoms into the arms and legs due to a disc herniation will experience relief and avoid a surgical procedure.

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