Diseases And Conditions

Back pain

Back pain is a serious cause of disability in the United States, affecting nearly 65 million Americans and 20% of the working population. In the U.S., back pain is the number one reason for health care expenditure.

While sudden back pain may be caused by muscle spasm, most cases of chronic, or long lasting back pain are caused by degeneration of spinal joints. These joints are called the intervertebral discs and facets. Most cases of back pain will improve with physical therapy and medications, though recurrence is common. Therapy should be intensive with the goal of restoring flexibility and normal spinal segment motion, building strength, removing muscle spasm and indirectly decompressing the spinal segment. Intensive therapy may involve muscle stimulation, thermal therapy, distraction, manipulation, range of motion exercises and resistance training.

Despite intensive physical therapy some patients may experience a recurrence in their pain. With recurrence, patients may benefit from pain injections. When these fail, minimally invasive spine procedures may offer a similar benefit as traditional spine surgery. Patients with complex disease or neurological dysfunction may have to undergo a traditional spine surgical procedure.

The pattern of pain that a patient may feel depends on the type of pain. In mechanical pain, pain may be present with motion or activity. In axial back pain, pain may be relegated to the back. With radicular back pain, pain may radiate down the leg. Finally, in spinal stenosis, pain may be present with walking or erect posture.

Mechanical back pain is back pain which worsens with activity such as sitting, standing, walking or exercise. In mechanical back pain, the pain is usually across the low back. The pain may radiate to the hip or thighs. Occasionally, the pain will radiate to the thighs, ankle or foot. Since joints not only stabilize the spine but also allow normal movement, degeneration of the facet or disc joints may be associated with pain on movement. This pain is axial (across the back) in nature. When motion results in nerve irritation or compression, the pain noted will radiate along the course of the nerve and will travel to the thigh, ankle or foot.

Mechanical back pain should first be treated with a trial of conservative measures such as pain medications, physical therapy and injectional therapy. When these measures fail, a minimally invasive procedure may be utilized.

Disc degeneration may be seen as flattening of the disc, bulging of the disc or herniation. Herniation refers to a tear of the outer fibers of the disc with protrusion or extrusion of disc material. Axial pain may also be caused by degeneration of the facet joints. These are joints that join each spinal segment to the one above and below. This degeneration results in joint inflammation or bony growth of the joint. When axial back pain worsens with activity it is also referred to as mechanical back pain.

The first line of therapy for axial back pain consists of conservative measures like medication and intensive back therapy. Treatment of axial back pain unresponsive to therapy involves targeting the pain generators. If pain is felt to be discogenic, or secondary to the discs, then a procedure involving the disc segment may be necessary. If the pain is due to arthritis of the facet joints then multiple minimally pain therapy options are available. These include facet joint block, facet nerve block, rhizotomy or minimally invasive facet augmentation.

Radicular back pain describes pain from irritation or compression of spinal nerves. Radicular pain is seen along the course of the nerve or in the region served by the nerve. As a result, patients will experiencing a searing or burning pain that travels from the back to the hip, knee, ankle or foot. The pain may or may not be associated with numbness, tingling or weakness, also due to nerve involvement. Radicular pain may be caused by mechanical compression of nerves due to joint arthritis or herniated disc. Radicular pain may also be caused by nerve irritation without compression. This irritation is caused by inflammatory chemical secreted by a degenerated disc.

Radicular pain unresponsive to rest, medications and therapy can be treated by various minimally invasive means. An epidural steroid injection/nerve root block anesthetizes the nerve and injects anti-inflammatory medications directly to the nerve site. If radicular pain does not improve with medications and injections, minimally invasive procedures such as percutaneous disc decompression or microdecompressive discectomy may be helpful. In patients with intractable pain who are not surgical candidates, a spinal cord stimulator may provide pain relief.

Mixed radicular and mechanical back pain is the most common type of chronic back pain. In this mixed syndrome, there are features of both axial and radicular pain. Therefore, patients will have both pain across the back and pain radiating to the leg. At different times, one type of pain may be more prominent than the other. Mixed radicular and mechanical back pain is caused by degeneration of the disc and facet joints along with nerve compression or irritation. Mixed pain is usually advanced and is seen in long standing cases.