Pain Management Procedures

Back pain is a common reason for absence from work and for seeking medical treatment. It can be uncomfortable and debilitating.

It can result from injury, activity and some medical conditions. Back pain can affect people of any age, for different reasons. As people get older, the chance of developing lower back pain increases, due to factors such as previous occupation and degenerative disk disease.

Lower back pain may be linked to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, lower back muscles, abdominal and pelvic internal organs, and the skin around the lumbar area.

Pain in the upper back may be due to disorders of the aorta, tumors in the chest, and spine inflammation.

Causes

The human back is composed of a complex structure of muscles, ligaments, tendons, disks, and bones, which work together to support the body and enable us to move around.

The segments of the spine are cushioned with cartilage-like pads called disks.

Problems with any of these components can lead to back pain. In some cases of back pain, its cause remains unclear.

Damage can result from strain, medical conditions, and poor posture, among others.

Strain

Back pain commonly stems from strain, tension, or injury. Frequent causes of back pain are:

• strained muscles or ligaments
• a muscle spasm
• muscle tension
• damaged disks
• injuries, fractures, or falls

Activities that can lead to strains or spasms include:

• lifting something improperly
• lifting something that is too heavy
• making an abrupt and awkward movement

Structural problems

A number of structural problems may also result in back pain.

• Ruptured disks: Each vertebra in the spine is cushioned by disks. If the disk ruptures there will be more pressure on a nerve, resulting in back pain.
• Bulging disks: In much the same way as ruptured disks, a bulging disk can result in more pressure on a nerve.
• Sciatica: A sharp and shooting pain travels through the buttock and down the back of the leg, caused by a bulging or herniated disk pressing on a nerve.
• Arthritis: Osteoarthritis can cause problems with the joints in the hips, lower back, and other places. In some cases, the space around the spinal cord narrows. This is known as spinal stenosis.
• Abnormal curvature of the spine: If the spine curves in an unusual way, back pain can result. An example is scoliosis, in which the spine curves to the side.
• Osteoporosis: Bones, including the vertebrae of the spine, become brittle and porous, making compression fractures more likely.
• Kidney problems: Kidney stones or kidney infection can cause back pain.

Movement and posture

Back pain can also result from some everyday activities or poor posture.

Examples include:

• twisting
• coughing or sneezing
• muscle tension
• over-stretching
• bending awkwardly or for long periods
• pushing, pulling, lifting, or carrying something
• standing or sitting for long periods
• straining the neck forward, such as when driving or using a computer
• long driving sessions without a break, even when not hunched
• sleeping on a mattress that does not support the body and keep the spine straight

A doctor will usually be able to diagnose back pain after asking about symptoms and carrying out a physical examination.

An imaging scan and other tests may be required if:

• back pain appears to result from an injury
• there may be underlying cause that needs treatment
• the pain persists over a long period

An X-ray, MRI, or CT scan can give information about the state of the soft tissues in the back.

• X-rays can show the alignment of the bones and detect signs of arthritis or broken bones, but they may not reveal damage in the muscles, spinal cord, nerves, or disks.
• MRI or CT scans can reveal herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
• Bone scans can detect bone tumors or compression fractures caused by osteoporosis. A radioactive substance or tracer is injected into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
• Electromyography or EMG measures the electrical impulses produced by nerves in response to muscles. This can confirm nerve compression, which may occur with a herniated disk or spinal stenosis.

The doctor may also order a blood test if infection is suspected.

Other types of diagnosis

• A chiropractor will diagnose through touch, or palpation, and a visual examination. Chiropractic is known as a direct approach, with a strong focus on adjusting the spinal joints. A chiropractor may also want to see the results of imaging scans and any blood and urine tests.
• An osteopath also diagnoses through palpation and visual inspection. Osteopathy involves slow and rhythmic stretching, known as mobilization, pressure or indirect techniques, and manipulation of joints and muscles.
• A physical therapist focuses on diagnosing problems in the joints and soft tissues of the body.

Chronic or acute pain?

Back pain is categorized into two types:

• Acute pain starts suddenly and lasts for up to 6 weeks.
• Chronic or long-term pain develops over a longer period, lasts for over 3 months, and causes ongoing problems.

If a person has both occasional bouts of more intense pain and fairly continuous mild back pain, it can be hard for a doctor to determine whether they have acute or chronic back pain.

Treatment

If home treatments do not relieve back pain, a doctor may recommend the following medication, physical therapy, or both.

Medication: Back pain that does not respond well to OTC painkillers may require a prescription NSAID. Codeine or hydrocodone, which are narcotics, may be prescribed for short periods. These require close monitoring by the doctor. In some cases, muscle relaxants may be used.

Antidepressants, such as amitriptyline, may be prescribed, but research is ongoing at to their effectiveness, and the evidence is conflicting.

Physical therapy: Applying heat, ice, ultrasound, and electrical stimulation — as well as some muscle-release techniques to the back muscles and soft tissues — may help alleviate pain.

As the pain improves, the physical therapist may introduce some flexibility and strength exercises for the back and abdominal muscles. Techniques for improving posture may also help.

The patient will be encouraged to practice the techniques regularly, even after the pain has gone, to prevent back pain recurrence.

Cortisone injections: If other options are not effective, these may be injected into the epidural space, around the spinal cord. Cortisone is an anti-inflammatory drug. It helps reduce inflammation around the nerve roots. Injections may also be used to numb areas thought to be causing the pain.

Botox: Botox (botulism toxin), according to some early studies, are thought to reduce pain by paralyzing sprained muscles in spasm. These injections are effective for about 3 to 4 months.

Traction: Pulleys and weights are used to stretch the back. This may result in a herniated disk moving back into position. It can also relieve pain, but only while traction is applied.

Cognitive behavioral therapy (CBT): CBT can help manage chronic back pain by encouraging new ways of thinking. It may include relaxation techniques and ways of maintaining a positive attitude. Studies have found that patients with CBT tend to become more active and do exercise, resulting in a lower risk of back pain recurrence.

Surgery

Surgery for back pain is very rare. If a patient has a herniated disk surgery may be an option, especially if there is persistent pain and nerve compression which can lead to muscle weakness.

Examples of surgical procedures include:

• Fusion: Two vertebrae are joined together, with a bone graft inserted between them. The vertebrae are splinted together with metal plates, screws or cages. There is a significantly greater risk for arthritis to subsequently develop in the adjoining vertebrae.
• Artificial disk: An artificial disk is inserted; it replaces the cushion between two vertebrae.
• Diskectomy: A portion of a disk may be removed if it is irritating or pressing against a nerve.
• Partially removing a vertebra: A small section of a vertebra may be removed if it is pinching the spinal cord or nerves.