Relieving Back Pain

Not too long ago, a bad back was something most sufferers just had to live with. Many patients were seniors whose health was too poor to risk open-spine surgery. Patients who did have surgery often found their relief was only temporary, forcing them to either have repeated surgeries or take powerful painkillers. And diagnosing exactly what was causing a patient’s chronic back pain was a matter of educated guesswork before the advent of high-resolution MRI scans, so nonsurgical treatments were often anything but personalized.

"You hear about a lot of people who had bad experiences with back surgery," acknowledges Dr. Bartosz Wojewnik, an orthopedic surgeon and assistant professor at Loyola University Medical School. "But with the correct diagnosis, back surgery can be very effective, or the patient can get relief without needing surgery."

Area orthopedic surgeons agree that only about 5 percent of the patients referred to them actually need surgery to relieve pain or restore spine function. Most of those patients suffer from pinched nerves that result from fractures or other damage to individual vertebrae. Unlike a muscle strain or spinal arthritis, a pinched nerve causes pain to radiate down the patient’s leg and sometimes blocks motor impulses from reaching the brain, which leaves leg muscles feeling weak and less responsive.

"If the primary problem is a pinched nerve, surgery relieves the symptoms more than 90 percent of the time," asserts Dr. Edward Goldberg, an orthopedic surgeon at Midwest Orthopedics at Rush in Westchester. "When a patient comes in with a bad foot drop, you don’t bother with physical therapy, you go straight to surgery because it’s a neurological problem."

Surgery also is a last-ditch cure for severely herniated vertebral discs that no longer keep the bones from grinding against each other or that are pinching nerve roots branching off the spinal cord. While removing the damaged discs, then fusing the affected vertebrae together, is still the only option to stop lower spine grinding, doctors now can offer disc replacement surgery to relieve neck and upper back pain without limiting the spine’s ability to move.

"You don’t realize how much time you spend looking up or looking down until you have cervical vertebrae fused and you can’t bend your neck as far," says Dr. Craig Popp, an orthopedic surgeon at Fox Valley Orthopedics in Geneva. "The goal is to perform disc replacement procedures whenever possible."

Unlike the first generation of all-metal artificial discs, today’s artificial discs are made from a shaped piece of polyethylene or other hard plastic sandwiched between two titanium endplates. Some manufacturers coat the plastic core’s top and bottom with lubricant so it can shift slightly between its endplates to match the spine’s motions, similar to the way the gelatinous core of the original disc shifts within its collagen fiber capsule.

As in a discectomy/fusion procedure, the surgeon performing a disc replacement — called a spinal arthroplasty — makes a 1- to 2-inch incision in the front of the patient’s neck or, more rarely, the lower back, in front of the damaged disc. After pulling aside the muscle and protective tissue that covers the spinal column, the surgeon cuts away most or all of the damaged disc and removes any bone spurs that have developed as a result of the damage. Then, instead of inserting a bone chip into the gap and cementing it in place to fuse the vertebrae, the surgeon jacks up the vertebra above the gap to restore its original width, then inserts the artificial disc and makes sure it’s properly positioned to be held in place by the vertebrae. Most patients can go home the day after surgery. "We want to get patients home as quickly as possible so that they don’t risk complications from a lengthy hospital stay, like infections, that can slow their recovery," Popp explains.

Doctors also prefer disc replacement to vertebral fusion because fusing two vertebrae together doesn’t eliminate the stress that destroyed the disc between them. Instead, the fusion just transfers that stress to other vertebrae above and below the original injury. The increased stress often makes those vertebrae’s discs wear out sooner than they otherwise might, sending the patient back to the orthopedic surgeon’s office with a new source of pain. "Cervical artificial disc replacement procedures comprise about a third of all the surgeries we perform," asserts Dr. Ronjon Paul of DuPage Medical Group’s Spine Center, which has seven locations throughout the western suburbs. "For many patients, it’s a better solution than fusion."

When surgeons must fuse two or more vertebrae because bone damage won’t accommodate artificial discs, they can use intraoperative MRI imaging to better align the vertebrae before immobilizing them. "Using intraoperative imaging, we can look at the curvature of the spine as we’re operating and adjust it to the optimum position for the patient as we go. That’s a pretty big innovation," Paul says.

But intraoperative imaging does carry risks for elderly or physically fragile patients, cautions Goldberg. "Using it can help achieve proper alignment, but it keeps patients under general anesthesia longer, which some patients don’t tolerate well," he explains.

Even patients who end up on an operating table usually go through weeks or months of nonsurgical treatment first. "I’m here to help patients exhaust every conservative measure we can before resorting to surgery," explains interventional physiatrist Dr. Madhu Singh of Midwest Orthopedics at Rush in Westchester. "Most back injuries can be successfully treated without surgery, so it makes sense to avoid the complications and risks of going through surgery if possible."

The first line of attack for chronic back pain includes massage therapy to relax muscles locked in spasm, physical therapy to stretch and strengthen strained muscles, chiropractic treatment to correct vertebral misalignment caused by unequal muscle tension between the right and left sides of the spine, and medical acupuncture. Often physiatrists will prescribe acupuncture to provide pain relief while the patient is going through physical therapy, says Singh.

"Acupuncture as part of a traditional Western medical treatment model is far more accepted now than it was 10 years ago," explains Singh, who is a certified medical acupuncturist and uses acupuncture in her practice. "Medical acupuncture combines ancient Chinese teachings with modern medical training. It integrates the best of East and West."

When done properly, medical acupuncture stimulates nerves to signal the brain to release endorphins, Singh says. It also can block pain signals coming from spinal nerves by flooding the brain with neutral signals triggered by the acupuncture needles. "The needles don’t just go where the pain is," she adds. "They can go lots of places on the body that don’t seem to be related to the back, but they’re connected to the back through the peripheral nervous system."

A new technology can help give relief to people with severe chronic back pain who’ve tried other treatments without success, says Loyola’s Wojewnik. Spinal cord stimulators block pain signals from reaching the brain by sending electrical pulses into the spinal cord from an electrode implanted underneath the skin. Before implantation, the doctor sets the device to deliver the pulses for a specific amount of time per day, usually one to three hours.

"Spinal stimulation doesn’t work for everyone, so people who want to try it can start with an external device with wires that are implanted under the skin," Wojewnik advises. "If they like it, they can have the entire device implanted so they don’t have to worry about the wires sticking out." Some patients have experienced side effects ranging from headaches and infections to loss of bladder control and spinal fluid leakage, he warns.

If none of the first-line therapies work, patients can choose to try prescription painkillers or tranquilizers to manage their chronic back pain. One specialized medicinal treatment is trigger point injection, which treats chronic back spasms, Singh says.

"Spinal muscles are some of the strongest muscles in the body," notes Singh. "Once they experience a strain, they tighten up with the effort to keep the spine stabilized until they can’t relax anymore. This causes the muscles to spasm, which is painful for the patient and puts stress on other spinal muscles. It’s a vicious cycle."

After finding the primary knot of bunched fibers in the affected muscle — called the trigger point — the doctor injects it with a mixture of saline solution and local anesthetic, sometimes with a corticosteroid drug included. The anesthetic forces the muscle to relax, relieving the pain and the excess tension across that section of the spine. Sometimes the injection targets a nerve or group of nerves to block the motor signals that make the muscle stay contracted.

Doctors sometimes inject Botox into lower back trigger points because its effects are strong enough to overcome the increased strength of the lower back muscles, Singh says. "I try to avoid

doing that, though, because Botox is a neurotoxin and it takes three months to work. It’s better for chronic problems that can’t be fixed with therapy."

While a trigger point injection usually blocks spasms for about a month, that can give the patient enough time to cure the underlying muscle imbalance through physical therapy, adds Singh.

Of course, the real first line of defense against back pain is to prevent it from occurring in the first place. While eating right and getting plenty of low-stress exercise go a long way to keeping the spine in shape, the aging process can catch up to even the fittest individual.

"After age 35, most people get a lot of age-related schmutz in their spines,"  says Goldberg. "After about age 40, many of us are walking around with minor spine arthritis and herniated discs without even knowing it. By age 70, we don’t see new hernias because the discs are too worn out to herniate. Older people are seeking treatment more often now than they did in the past because they’re still physically active and they want to stay that way."

Surprisingly, the single most effective way to prevent vertebral disc damage is to quit smoking and/or avoid secondhand smoke. "Everyone knows now that smoking is bad for the lungs and heart, but patients are always amazed that it’s also bad for the back," Popp says. "The nicotine in tobacco is very harmful to the collagen that forms the outside of vertebral discs. Over time, the collagen starts to break down, gets injured more easily and doesn’t heal as well as it did. That leads to disc herniation and degeneration, which can cause pinched nerves and arthritis in the spine."

Maintaining a proper weight helps by keeping excess pressure off the vertebrae and surrounding muscles, Paul notes. Even high-stress exercise or athletic activity can help strengthen the back if it’s done with proper form to avoid spinal muscle imbalances. "A lot of people with bad backs think they can’t do strenuous sports like running or skiing, but with proper form those activities actually help relieve back pain," he asserts. "We believe in treating back pain with lots of exercise to prevent repeated muscle strain." Swimming, bicycle riding and other aerobic exercises are also good choices, he adds.

Stem cell therapy and human growth hormone treatments could someday make chronic back pain a thing of the past, doctors agree. But that day is not likely to arrive anytime in the next 10 years.

"The best innovations we can look forward to in the near future are changes in the way we provide care to back patients," maintains Paul. "We’re shifting to a far more interdisciplinary care model that brings surgeons, physiatrists, anesthesiologists, nurse practitioners and physical therapists together in one team that approaches each patient’s case cooperatively to get the best possible outcome."

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