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Back pain is incredibly common; more than 75% of adults have had back pain in their life.
Common presenting concerns include:
To understand the types of problems you may have and potential treatments, it is important to know some basic anatomy. Your spine has multiple bones (vertebral bodies) that are stacked in a column. Between the vertebrae are shock absorbers (discs). They are like a jelly doughnut with a firmer outer layer (annulus) and softer inner layer (nucleus pulposus). The back half of the vertebral body has a bony ring (pedicle and lamina) that encircles the spinal cord to protect it. At each level, a window (neuroforamen) appears that allows a nerve root to exit on both sides. The nerve roots go out to the arms and legs to provide sensation and direct motor activity. Behind the spinal cord are the connection joints between the vertebrae (facets).
Vertebral body – Compression fracture (trauma, osteoporosis) Spondylosis (arthritis, bone spurs)
Disc – Degeneration (wear and tear thinning to allow bone on bone arthritis of vertebrae)
Bulge – (the jelly doughnut sags out of position, but the jelly has not leaked yet)
Herniation – (squishing the jelly doughnut allowing the jelly to squirt out and pinch nerves – pain worse in the lean forward position)
Lamina/Pedicle – Fracture/Listhesis (allow the vertebrae to lose anchor and slide out of column alignment/pinch nerves or spinal cord)
Spinal canal – Stenosis (narrowing from bulging disc and/or arthritis bone spurs, causing pain with exertion)
Neuroforamen – Stenosis (narrowing from bulging disc and/or arthritis bone spurs pinching nerve root, causing shooting electrical pain into leg or arm, and/or weakness/numbness)
Facet – Arthropathy (arthritis/bone on bone – pain worse with compression in the leaning back position)
Alignment – Scoliosis (abnormal curvature putting muscles and tendons out of alignment)
Muscle spasm – Contractures/spasms from acute and chronic overuse, worse with poor posture, obesity, muscle weakness. Commonly called Mechanical Low Back Pain: NOT surgical issue, and most common reason for back pain
When back pain first occurs, it typically is self-limiting (goes away on its own over time). If the pain is only in the low back, then x-rays are not needed in the first 6 weeks unless a “red flag” reason is present.
Red Flags for early imaging tests
Initial conservative treatment includes activity as tolerated (avoid bed rest!), anti-inflammatory medications (NSAIDs like naproxen/ibuprofen, turmeric), and physical therapy/chiropractic care. If symptoms persist more than 6 weeks, then x-rays may be ordered. To rule out spinal column instability from listhesis, flexion and extension views are performed to ensure the vertebral bodies are not significantly sliding across each other.
Based on symptom improvement or worsening and the x-ray findings, an MRI (magnetic resonance imaging) test may be requested. NOTE: the primary purpose of the MRI scan is to help plan for surgery or a related procedure by mapping the terrain. If a patient knows they are not ready for surgery or procedure, then MRI should NOT be performed. Why not? If nothing is going to be done with the information at the present time, then a test should not be done. If a patient decides later to pursue a procedure, then even if one was done prior, a fresh/current scan will be required again, and they are not cheap.
Another caveat on MRI is the over-sensitivity in detecting normal degeneration that is not responsible for causing pain, even in young patients. For example, the prevalence of disc degeneration in asymptomatic individuals varies from 37% of 20-year-old individuals to 96% of 80-year-old individuals. MRI also cannot show the exact muscle causing mechanical/ soft tissue pain.
Once the decision is made to pursue more aggressive treatment, referrals are based on the suspected condition.
Epidural steroid injection (ESI)
– Needle into spinal column to deliver anti-inflammatory medicine
– Pain relief can last weeks to months
Steroids help both mechanical nerve compression and the chemoinflammatory response caused by bulging discs and bone spurring.
Performed by Interventional Radiologists and Pain Management Physicians such PM+R or Anesthesiologists.
Medial Branch Block
– Local anesthetic injected at facet
– Pain relieved for several days
Diagnostic test to numb the nerves at a given facet joint. Commonly interpreted to mean that if the back pain is relieved, then the guilty arthritic joint has been confirmed, but since the numbing agent can spread to multiple levels, the value has been called into question.
Radiofrequency Ablation
– Pain relief for weeks to years, but unfortunately the nerves often grow back over time and the arthritis facet pain returns.
Energy device to burn/destroy the nerves from a facet joint
If procedures have failed or the patient desires to proceed to surgery directly after failing conservative treatment, it is CRITICAL to have accurate expectations. Most surgeries will likely help arm and leg symptoms (radicular symptoms) caused by nerve compression but will not fully resolve pain in the cervical or lumbar spine.
Which type of surgery chosen is based on the diagnosis and the surgeon’s recommendations. Historically, more extensive surgery was used with bigger incisions and longer healing times. Today, minimally invasive surgery with quick recovery times is more commonly available. At Treasure Valley Family Medicine, we work hard to keep a short list of reliable surgeons we trust to take great care of you; you are not left dangling to pick a random name off some list.
Performed to fix an unstable spinal level, due to listhesis allowing nerves to be compressed. Also useful to prevent facets with severe arthritis from rubbing across each other. More invasive (screws and rods) plus expensive. Can damage ligaments, tendons and muscle while cutting to the necessary areas.
Downside: by fixing motion at a given level, more tension and force is transferred to the adjacent segment/level, promoting faster break down at that adjacent spine level.
Preserves range of motion allowing the spine to continue to move as designed. Prevent excess wear and tear at the adjacent disc level.
This is NOT a good choice for severe facet disease since great motion at the disc will promote more bone-on-bone rubbing and pain at the facets.
Examples include: – M-6 disc
Hybrid option.
Examples include:
– Minuteman device with following indications: Lumbar Spinal Stenosis, Degenerative Disc Disease, and Spondylolisthesis.
– Coflex device with following indications: Lumbar Spinal Stenosis with maximum of grade 1 listhesis.
