The Experts Weigh In on Low Back Pain Treatments
Low-Back Pain Treatments: The Experts Weigh In
Perhaps you injured your back lifting something heavy. Or you twisted your back awkwardly while playing tennis. Or maybe low-back pain came on suddenly one morning, seemingly out of nowhere. Whatever your situation, know that you’re not alone. Low-back pain is common—up to 80% of us will experience it at some point in our lives. 1
Fortunately, for most people, back pain resolves on its own with simple treatments and lifestyle changes. For others, chronic back pain can significantly diminish quality of life, reducing mobility and limiting a person’s activities.
Anyone who has experienced significant back pain for any length of time will probably agree that it can seriously impact a person’s life, to say nothing of the associated medical and lost productivity costs—the direct costs of low-back pain totaled $39 to $78 billion in 2014 dollars, and $62 billion in indirect costs. 2
Back pain should never be ignored, as it can quickly worsen—see a spine specialist in New York right away if you’re experiencing pain.
What Causes Low-Back Pain?
The lower back is made up of a complex network of spinal muscles, nerves, bones, discs, and tendons. Damage to any of these parts—from a slipped disc, herniated disc, muscle or ligament strain, or other problems—can lead to lower back pain that may travel to other parts of the body.
Low-back pain that originates in the lower back and travels through the buttocks and down the leg is known as sciatica; it occurs when the sciatic nerve (the largest single nerve in the body) becomes compressed. In addition to radiating pain, sciatica can cause numbness, tingling, or muscle weakness in the affected leg or foot or a combination of pain and numbness in different parts of the leg. The condition can decrease motor function and make performing certain movements difficult.
The Anatomy of the Spine
To understand sciatica let’s, let’s take a quick look at the anatomy of the spine.
The spinal column is divided up into four segments (or levels), according to the nerve roots that branch off from each segment. From top to bottom, they include the cervical, thoracic, lumbar, and sacral segments. Nerve roots run through the entire length of the bony spinal canal. A pair of nerve roots exits from both the lumbar and sacral regions—the lower segments of the spine where sciatica pain typically originates.
Both spinal stenosis and herniated discs can cause pinching, inflammation, and irritation of the nerve root(s), resulting in sciatica.
To better understand the cause of a patient’s pain, physicians may order any or all of the following imaging tests:
- Magnetic resonance imaging (MRI) scans, which can help reveal herniated discs.
- X-rays, which can help reveal any bone spurs.
- Computed tomography (CT) scans, which help spine doctors see the spinal cord and spinal nerves.
- Electromyography (EMG), which can help reveal nerve compression caused by spinal stenosis or herniated discs.
The information gathered from these tests helps physicians discover the extent of the nerve damage and the source of the patient’s pain in order to determine the best treatment plan.
Treatments for Low-Back Pain
Most cases of sciatica resolve with self-care measures such as stretching exercises, use of cold and hot packs, and over-the-counter non-steroidal anti-inflammatory drugs like ibuprofen and naproxen. Muscle relaxants, opioid painkillers, oral steroids, and even tricyclic antidepressants or anti-seizure medications may also be prescribed.
Epidural steroid injections (ESIs), which reduce pain by suppressing inflammation around the irritated nerve, may also be used. There are several delivery methods for ESIs, including:
- Interlaminar ESI: Delivered through the back of the spine in the space between two vertebrae, interlaminar ESIs distribute the steroid over a wider area.
- Transforaminal ESI (TFESI): Delivered into the opening at the side of the spine where a nerve root exits the spinal cord, transforaminal ESIs allow for more concentrated delivery to a specific nerve (TFESIs are also referred to as “nerve blocks”).
- Single-level TFESI: This targets the nerve roots that lie across a particular level of the spine causing pain.
- Two-level TFESI (or multilevel TFESI): This targets two levels of the spine that are causing pain.
In addition to the treatments above, physical therapy may help prevent future injuries once a patient’s acute pain is resolved. Surgery is a last resort and is reserved for cases where the compressed nerve is causing significant weakness, loss of bladder or bowel control, or pain that doesn’t improve with other therapies. Surgeons typically remove the bone spur, or the part of the herniated disc or discs, that is compressing the nerve.
Let’s look at a case study of a patient with low-back pain and hear what the experts have to say about the best treatment plan for him.
A Case of Persistent Low-Back Pain
Fifty-eight-year-old Matthew has been experiencing low-back pain for the last 3 months. At times, the pain spreads to his groin, as well as the right side of his buttocks and his entire right leg, causing tingling and numbness.
During a physical exam, Matthew’s physician finds that he experiences pain when he raises his right leg straight out in front of him. Matthew has full range of motion in his hip, with no pain, and the results of his sensory and motor function exams are normal, but his knee and Achilles reflexes are worse than normal.
Matthew’s physician orders an MRI to better understand the root cause of the pain. The MRI reveals mild to moderate stenosis in several regions (L4-L5 and L5-S1) of Matthew’s lumbar spine, as well as a herniated disc (L5-S1) that is pressing on a nerve (right S1) in his sacral spine.
Matthew’s doctor orders a trial of physical therapy, advises him to take oral anti-inflammatory medications and administers a steroid injection—specifically, an interlaminar ESI—which significantly reduces his pain for 4 or 5 days. Unfortunately, the pain returns, and Matthew has requested one more injection before he considers surgery.
Which Treatment Approach Is Most Appropriate? A Q&A with the Experts
Three doctors weigh in on which treatment they feel is best for Matthew. Ultimately, all of the doctors agree that an epidural steroid injection (ESI) is appropriate, but they don’t agree on which particular type of ESI is best.
The first physician opines that a single-level TFESI (transforaminal epidural steroid injection) is the best course of treatment, while the second and third physicians believe that a 2-level TFESI is most appropriate. Let’s drill down on how they made their assessments and arrived at their conclusions.
Q: Which type of ESI do you recommend, and why?
To improve Matthew’s quality of life, I believe that we, as physicians, should treat his symptoms. He experiences pain in his thigh, groin, and buttock, which may come from degenerated discs, facet joints, or muscles. Unfortunately, Matthew’s MRI does not clearly indicate which nerve root levels are damaged and causing this pain. It’s also unclear whether his sciatica is the result of damage to one or more spinal nerve root levels.
I recommend treating Matthew’s back pain in an incremental fashion, starting with conservative treatment options—in this case, a single-level TFESI—and moving on to more invasive interventions. The fact that Matthew experienced significant (albeit short-term) relief after an interlaminar ESI suggests that the injection did, in fact, reach the problem area(s).
Additionally, there is more evidence supporting the effectiveness of single-level TFESIs than multilevel TFESIs (the latter of which my colleagues are recommending). Finally, a single-level TFESI is the more conservative option, which is in line with my recommended treatment approach.
Studies have shown that when single-level TFESIs are injected precisely, the medicine spreads across two different spinal levels, achieving the same result as a multilevel TFESI. Studies also show administration of higher dosages of steroids (as with a multi-level TFESI) does not improve treatment results.
It’s also important to note that both single-level and multilevel TFESIs administered to the lower back carry a risk of catastrophic complications, including death and paralysis. Due to this risk, doctors should use this treatment option judiciously, carefully weighing the risks and advantages for each patient.
There is no evidence to support the routine use of multiple injections, based on a systematic review of the literature on ESIs, as well as the guidelines of multiple authoritative medical agencies. Given the available evidence, we as medical professionals must exercise self-restraint in deciding which patients should receive ESIs.
We must also educate patients about the fact that ESIs typically only provide temporary relief, and we must encourage patients to adopt lifestyle changes and undergo physical therapy as the cornerstone of back pain management, rather than treating patients with multiple steroid injections.
Physicians #2 and #3:
Our first choice would be to administer a diagnostic TFESI in order to determine the exact location of the source of Matthew’s pain. His response to the injection would help us determine the exact source of his pain, in which case we would deliver an additional injection to the precise location.
Since Matthew has said he is only willing to undergo one more procedure before seeking surgery, however, we believe it’s best to administer the epidural steroid injection with the greatest chance of alleviating his pain, which, in our opinion, is a 2-level TFESI. We believe the 2-level injection is most likely our “last shot” at improving Matthew’s condition and quality of life.
This type of ESI allows us to concentrate the medication where it will be most effective. If this approach does not provide Matthew with significant pain relief, we can comfortably state that we have no further steroid injections to offer.
Although only single level TFESIs were investigated in the studies referenced by physician #1, the data from Murthy et al suggest that repeating successful TFESIs yields nearly the same benefit as that of the initial injection.
It’s difficult to determine the exact origin of a patient’s back pain. Physicians cannot diagnose using only symptoms or only imagining scans, such as MRIs and EMGs—we must use both. Having said that, it’s difficult to draw specific conclusions from Matthew’s MRI alone; however, the MRI does indicate that Matthew’s pain originates in the right lower levels of his spine. Matthew’s diagnostic tests show that he does not have actual nerve damage, which suggests that he has a good prognosis for recovery, as long as he receives appropriate treatment.
It’s also helpful to consider how Matthew responded to previous pain treatment. The interlaminar ESI provided him with some relief, which suggests that the cause of his pain is in the lower spine. His response to the interlaminar ESI does not, however, help us determine the exact nerve root level.
Matthew’s case illustrates the challenge of determining the exact source of a patient’s back pain. The results of Matthew’s positive right straight leg raise test suggest that the pain may originate from multiple nerve root levels. A 2-level TFESI will deliver medication to two segments of his spine, increasing the likelihood that he will experience relief—for this reason, we suggest a 2-level TFESI in the L4 and L5 segments of his lumbar spine.
While each of the two treatment options presented here has its advantages and disadvantages, both can help alleviate low-back pain. Although Matthew’s spine specialists do not agree on the best short-term treatment for him, all three physicians acknowledge the difficulty of pinpointing the precise location of low-back pain, even with the most advanced imaging tools and diagnostic tests available today. Importantly, all three physicians have Matthew’s best interest at heart and will do their best to provide him with the best spinal care possible.
Pain Management Strategies: Dr. Singh’s Minimally Invasive Treatment Plans
As a board certified sports and pain specialist, Dr. Jaspal Ricky Singh, M.D. provides interventional pain management treatment for patients who suffer from lower back pain. In addition to patient education, his practice specializes in procedures ranging from acupuncture and injections to nerve blocks and regenerative medicine. Dr. Singh relies on state-of-the-art diagnostic tests to deliver targeted and minimally invasive treatments to each of his patients.
Visit the website to read more about Dr. Singh’s approach to pain management and the procedures he performs.
- Two Approaches to Transforaminal Epidural Steroid Injections for the Treatment of Radiating Low-back Pain: What is the Evidence? Point/counterpoint discussion between Drs. Michael Furman and Nicholas Weber, and Dr. Steven Cohen. http://www.pmrjournal.org/article/S1934-1482(15)00750-9/fulltext
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