Doc Talk: Management vs. medications for spinal pain

04/16/2013 12:00 AM

08/08/2014 10:16 AM

Chronic pain originating from the spine affects many people at some point in their lives. Back pain is not a diagnosis but is a symptom of an underlying condition. Fortunately, there are non-invasive ways to determine the root cause of the pain and effectively manage it.

Percutaneous spinal interventions (PSI) procedures that are done with a needle puncture under the skin, are now widely used for the diagnosis and management of pain arising from the spine. These procedures are performed by medical specialists trained in interventional pain and often complement other pain management treatments, therapies and surgical interventions.

Using a combination of PSIs, the patient’s history, imaging studies and clinical diagnostic skills, an interventional pain management physician can diagnose a pain generator in more than 80 percent of patients. The physician can then consider treatment options unique to the specific diagnosis or refer the patient to other caregivers for physical therapy, surgical interventions or possibly medication management.

During the past two decades, PSIs have evolved into a broad range of useful procedures. Approximately 60 percent of individuals over the age of 50, without any pain complaints, are found to have a disc bulges or herniations on MRI. Since imaging studies such as MRI, CT scans and X-rays do not scan for “pain” and by themselves cannot give a complete picture of the source of a patient’s pain, interventional pain physicians can make a positive diagnosis in the majority of cases. This is accomplished through the use of X-ray guided, precision, selective injections.

The three most common causes of low back pain are internal disc pain, facet pain and sacroiliac pain, all of which require specific injections for an accurate diagnosis. Once a diagnosis is confirmed, a specific treatment can be considered. In the case of pain coming from the facet joints, radiofrequency energy can be used to safely disrupt the nerves carrying the pain signals from the joints. This treatment is quite effective and can provide excellent relief for well over a year.

Radicular pain, once referred to as sciatica, is described as pain shooting into and down the leg. This type of pain is seen in patients who suffer from herniated discs or constriction of the passages within the spine. The pain is caused by inflammation from chemicals within the disc that can “leak out” onto nerves, causing pain. The herniation may cause mechanical pressure on a nerve, which can result in more severe pain along with muscle weakness, numbness and/or tingling. Injecting anti-inflammatory steroid medication around these areas of inflamed nerves is a common PSI procedure to reduce pain and improve a patient’s ability to function. This technique can offer considerable relief, providing time for the body to heal and reducing the need for an invasive surgical procedure.

Other spinal structures such as muscles, ligaments and tendons also may be injured and cause chronic back and neck pain. However, in most cases, these pain generators cannot be accurately diagnosed and are most often addressed by oral anti-inflammatory medications, rest and physical therapy to maintain functionality.

Some have advocated the use of narcotic medications for chronic non-malignant pain. Although severe acute pain must be treated, the use of narcotics should be used cautiously and short term. Long term, chronic use of narcotic medications has not been useful in treating pain from non-cancer causes. Patients typically develop dependence, and most become tolerant to increasing medications doses. Eventually, patients on increasing high dose narcotics enter a state where the narcotics actually contribute to the painful condition. Since a 40-year-old individual with chronic pain would expect to live another 30 to 40 years, continuously increasing a narcotic dose is not ideal as the effects of a given amount of narcotic lessen over time.

For the most desirable long-term outcome, patients with low back and neck pain are encouraged to discuss the cause of their pain with their physician or mid-level health care provider. Further investigation by a well-trained interventional pain management physician using spinal imaging, physical examination and PSI techniques may lead to a better understanding of the pain and treatment options.

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