Back Pain and You

Low back pain is a common clinical problem in day-to-day life. It is the 3rd most common cause of health care advice after diabetes and hypertension. Though all back pains are not serious. Sometimes it gets resolved after a day to a week without a single medicine. There is the role of lifestyle modification, physiotherapy, hydrotherapy, yoga, tai chi, etc. but sometimes it is not resolved on its own. Then we have to seek the advice of a pain physician on 1st go. There are a few red flags for which surgical intervention may be needed. These red flags are sudden onset of progressive weakness of legs during walking, decreased sensation of the limbs, unable to control bladder and bowel (no control over micturition and stool), fever associated with limb weakness. Hence surgery is not needed for all types of chronic low back pain.

 

So, what should the patient do if they have chronic (more than 3 months) low back pain which is not resolving with the over-the-counter medicines and physiotherapy?

 

 The answer is to seek the help of a pain physician.

 

The most common causes of chronic non-resolving low back pain are spondylosis, spondylitis, slipped disc, facet arthropathy, and sacroiliac joint pain.

 

Spondylitis: Inflammation of facet joints and adjacent ligaments is called spondylitis. The commonest cause of spondylitis is rheumatoid arthritis, ankylosing spondylitis, and other inflammatory diseases. Diagnosis is confirmed by clinical examinations, X-ray, CT scan, serological tests, etc. Treatment consists of :

    •  Some disease-modifying medicines
    •  Exercises to strengthen back muscles
    •  Interventional pain management procedures for pain relief. The main treatment is exercise along with different pain management options

Spondylosis: It is the degenerative changes of the spine. It may involve disc, facet joints of the spine, ligaments, and adjacent structures. It is very common after middle age. There is no direct correlation between these degenerative changes and pain. We frequently find severe degenerative changes in these structures without any pain. But sometimes it is associated with pain. We have to find out the exact pain generator or source of pain to start treatment. We may utilize different investigations like X-ray, CT-scan, MRI, etc but in most situations, these investigations are unable to locate the source of pain.

 

In such situations, we have to use diagnostic interventional pain management procedures to assess the source. All these spinal structures have their individual nerve supply and pain is carried through these nerves. In diagnostic interventional pain management, we are separately blocking one of these nerves to see the pain relief. If pain relief is significant that structure is the source of pain.

 

So, spondylosis is a non-specific term, which means degeneration of spinal structures and has no relation with pain. This is a radiological diagnosis and does not help in treatment. We have to identify the degenerated structure, which is the source of pain by diagnostic interventional pain management procedures. Ultimately name changes according to the structures involved (like facet arthropathy) and this helps in treatment.

Treatment options

1. Hot and cold therapy:

Simple hot and cold therapy can make a world of difference when it comes to back pain. Long hot showers or baths especially in the mornings, helps ease stiffness in your joints. Use an electric blanket or moist heating pad to keep your joints loose.

Cold treatments are best for relieving joint pain, swelling, and inflammation. Wrap a gel ice pack or a bag of frozen vegetables in a towel and apply it to painful joints for quick relief.

2. Right and healthy diet:

Everyone needs omega-3 fatty acids in their diet for optimum health. These fats also help your arthritis. Fish oil supplements, which are high in omega-3s, have been shown to reduce joint stiffness and pain.

Another fatty acid that can help is gamma-linolenic acid, or GLA. It’s found in the seeds of certain plants such as evening primrose, borage, hemp, and black currants. You can also buy the oils of the seeds as a supplement. However, be sure to check with your doctor before taking them. A diet rich in vitamin D and calcium is also important for bone health.

3. Consider herbal supplements:

There are many kinds of herbal supplements in the market that claim to reduce joint pain. Some of the herbal touted for arthritis pain are: Boswellia, bromelain devil’s claw, ginkgo, stinging nettle, and thunder god vine

Always talk to your doctor before trying a new supplement to avoid side effects and dangerous drug interactions.

4. Get a massage:

According to the arthritis foundation, regular massaging of arthritis joints can help reduce pain and stiffness and your range of motion. Work with a physiotherapist to learn self-massage, or schedule appointments with a massage therapist regularly.

5. Cooled radio frequency treatment:

It has a newer and advanced treatment for back pain.

It is a daycare procedure performed under local anesthesia. This procedure is used for sacroiliac joint pain and for low back pain secondary to facet joint arthritis. Here we apply cooled radiofrequency energy to nerves carrying pain signals from these pain-generating structures to the brain. Radiofrequency neuromodulates these nerves and gives a long duration of pain relief.

Advantages of this procedure include no requirement for hospital stays. Normal activities can generally be resumed soon after the procedure. Less pain can lead to improved functionality and reduced medication requirements Lasting pain relief for and has a low complication rate.

Slipped disc, bulging disc

When the gel from the disc leaks, it may produce pressure in the spinal cord or nerve roots, causing neck pain or lower back pain that goes to the hands or legs. This is known as a herniated disc, prolapsed disc, or slipped disc. Slip disc is one of the most common causes of sciatica. The pain is frequently electric shock-like pain or burning pain associated with some numbness, tingling sensations, and sometimes some muscle weakness. Disc prolapse is one of the important causes of low back & neck pain radiating to legs & hands. Apart from conservative therapy all other forms of treatment aim at decompressing the nerve roots. These can be done by taking the disc out by surgery or by decompressing the foramen and disc by different interventions.

Outcome studies of lumber disc surgeries document a success rate between 49% to 95% and re-operation after lumber disc surgeries ranging from 4% to 15%. Reasons for this failure are epidural fibrosis, arachnoidal adhesions, muscle & fascial fibrosis, mechanical instability resulting from the partial removal of bony and ligamentous structures required for surgical exposure and decompression, and the presence of neuropathy.

There has been a surge of interest in search of safer alternative nonoperative treatment of slipped disc to decompress the nerve roots maintaining the structural stability. Epidural steroid injection, transforaminal epidural decompressions have a high success rate (up to 85%) but chances of recurrences are there especially if these interventions are done at later stage.

Ozone discolysis Injection of ozone for slipped disc or discogenic radiculopathy (low back pain with radiation to legs) has developed as a nonoperative treatment of slipped disc which is an alternative to chemonucleolysis and disc surgery. Owing to its high success rate, less invasiveness, fewer chances of recurrences, and remarkably fewer side effects, ozone therapy for slip disc is becoming popular day by day in the whole world. This is called ozone nucleolysis or ozone discectomy. Percutaneous discectomy is another less invasive nonoperative treatment of slipped disc where the disc material is taken out with a motorized probe.

Endoscopic discectomy

Stitchless percutaneous endoscopic lumbar discectomy s[PECD] is safe, precise, targeted, and a complete endoscopic procedure to treat soft lumbar disc herniation with unilateral radiculopathy. It allows direct visualization of the herniated fragment and its removal, an inspection of a decompressed nerve root in an awake and aware patient. It reduces the risk related to general anesthesia and protects the neurological structures.

Conclusion:

This non-operative treatment of slipped disc has revolutionized the treatment of slipped disc/ slip disc. There is a quick recovery, fewer hospital stays, more economical, very little chance of side effects, and no chance of failed back surgery syndrome- the most fearsome complication of open surgery.