First Choice Neurology

Back Pain is Not a Diagnosis

Back Pain written by Dr. Antonio Mesa

Back pain imageNeither is sciatica, which is a form of back pain that radiates into the leg.

Back pain is a symptom of one or more underlying problem such as:

  • Arthritis of the joints of the spine – also known as lumbar spondylosis
  • Degeneration of the discs between the vertebral bones of the spine – this is associated with both discogenic pain (from the discs themselves) and vertebrogenic pain (from irritation of the nerves inside the vertebral bones). These typically cause low back pain which is worse when sitting down, lying down, or lifting things although it can sometimes also cause pain while standing.
  • Disc herniation compressing a nerve – causing the classic sciatica symptoms
  • Neurogenic claudication – pain when walking or standing that is relieved by sitting or lying down.
  • Soft tissue pain – degeneration of the ligaments and tendons that insert into the spine, weak back muscles, and muscle spasms are all among the most common causes of back pain, particularly in younger, more athletic patients. Another name for this is musculoskeletal pain.

Aside from pain related to problems in the back itself, patients can also get back pain from serious conditions such as cancer, aortic aneurysm, Parkinson’s disease, peripheral artery disease, and many others. This is why we recommend looking into the cause of your back pain rather than simply accepting a diagnosis of “back pain” and leaving it at that.

Lumbar Spondylosis

People with arthritis of the joints of the lumbar spine have difficulty moving without pain. It’s typically worse in the morning when first getting out of bed. As the day goes on, the person “loosens up” or “warms up” and the pain gets better.

Bending or twisting of the waist provokes pain. Sitting down helps alleviate the pain, as does putting cold packs on the affected area. Sometimes, people with spondylosis notice a grinding or cracking sound on movement.

Usually, the low back pain corresponds to the area where the person has arthritis. This is known as axial back pain and it means pain that does not radiate into the person’s buttocks or legs. Sometimes, however, arthritis of the joints leads to formation of bone spurs that crowd a nerve root and can cause sciatica in addition to pain of the lower back.

Treatment ranges from something as simple as a home exercise program or physical therapy, with or without medications, all the way to having spine surgery. Often, we will use medial branch nerve blocks to help control the sensation of pain from the joints, although sometimes we will inject the joints themselves. If this pain is not controllable with blocks and medications, we will consider inserting a spinal spacer or possibly referral to spine surgery.

Discogenic Pain

This is pain from the discs between the vertebral bones of the spine. These discs have two parts – an outer fibrous ring made of cartilage (the annulus fibrosus) and an inner core made of a gelatinous substance (the nucleus pulposus).

There are 25 discs in the spine (7 cervical, 12 thoracic, 5 lumbar, and 1 sacral). These discs account for about 25% to 33% of the length of the spine. They allow the spine to be flexible while acting as shock-absorbers and preventing the vertebral bones from grinding together. With increasing age, the cartilage of the discs wears out (just like in other joints) and you tend to get shorter.

The annulus fibrosus consists of about 15 to 25 stacked sheets of collagen mixed with proteins and connective tissue cells. These sheets of collagen can tear or weaken and cause a disc herniation. With tears, there can be leakage of the gel from the nucleus pulposus, which inflames the nerve roots that are next to the disc. Over time, the torn cartilage can lead to degeneration of the disc and vertebrogenic pain.

Because it irritates the nerve roots, pain from a torn disc leads to sciatica or radiculitis. This is why we use a variety of lumbar epidural steroid injections to treat the tear, reduce inflammation, and allow the body to naturally heal itself, without requiring spine surgery.

Disc Herniation

painWeakness of the cartilage of the discs (the annulus fibrosus) can lead to bulges, herniations, and even extrusions of disc material. There is a mistaken belief that these things automatically prove the existence of back pain. In fact, there are several studies showing the presence of bulges, herniations, or extrusions on an MRI does not necessarily correlate with back pain. Over time, disc bulges and herniations tend to come and go. Extrusions can get reabsorbed.

On the other hand, disc material from a bulge, herniation, or extrusion can definitely affect a nerve and cause not only sciatica, but also a radiculopathy (nerve pain, weakness, and/or numbness in an arm or leg) that might even require surgery. As with discogenic pain from tears of the cartilage of the discs, we use a variety of lumbar epidural steroid injections to treat reduce inflammation and allow the body to naturally heal itself while avoiding spine surgery.

Vertebrogenic Pain

Vertebrogenic low back pain is caused by damage to the endplates of the vertebral bones as the discs wear out. The endplate is a layer of bone and cartilage at the top and bottom of each of vertebral bone. Damage to these endplates cause pain of the basivertebral nerve that goes to each vertebral bone.

Vertebrogenic pain tends to be worse when sitting for a long time, bending forward, being physically active. It is a deep, aching, burning, twisting pain in the back that does not radiate into the legs. Since there are other conditions that can also cause this pain, we usually get an MRI to determine if there is evidence of endplate damage.

If oral medications, physical therapy, and lumbar epidural steroid injections do not control the pain, we offer the Intracept procedure alleviate the pain. This does not require surgery and can result in pain relief that lasts for many years.

Neurogenic Claudication

As the spine ages, arthritis (lumbar spondylosis) develops and the discs degenerate. This can lead to crowding of the nerve roots in the spinal canal (the central canal of the spine) or the foramina (where the nerve roots exit the spine). This is known as spinal stenosis.

While standing or walking, the weight of the body on the spine causes these spaces to narrow even further and begins to put pressure on the nerves. This pressure causes pain which gradually increases until the person is no longer able to stand or walk.

Sitting down for a few minutes, however, alleviates the pain and the person is able to get up again. Unfortunately, after standing or walking for a few minutes, the pain returns. This is known as neurogenic claudication.

In the past, the main treatment options were to either live with it or have spine surgery. Now, depending on where the spinal stenosis occurs, we will usually offer lumbar epidural steroid injections and either a minimally invasive lumbar decompression or a spinal spacer. These are very effective treatment options that can control the neurogenic claudication without needing major spine surgery. They are particularly useful for older patients who cannot have or do not want to risk spine surgery.

Lumbar Epidural Steroid Injections

Like other types of nerve blocks, these injections reduce inflammation and relieve irritated nerves. There are several types of epidural steroid injections – transforaminal (from the side, where the nerve root comes out), translaminar (from the middle, similar to what is done for women in labor), and caudal (from the base of the spine, just above the coccyx).

Unlike epidurals used for women in labor, we use fluoroscopic (x-ray) image guidance to make the epidural steroid injections safer and to precisely target the area we would like to treat. Because it is an injection to a specifically targeted area, we can use a much smaller dose of steroid but get a much better result, with fewer side effects, than using oral medications.

Medial Branch Nerve Blocks

These are nerve blocks of the small nerves known as the medial branch nerves that go to the joints of the spine. These nerves have no motor function (do not control muscles) so blocking them does not produce muscle weakness. If the blocks control the pain but the pain relief wears off quickly, we will repeat these blocks one more time. If the medial branch nerve blocks are not enough and the pain relief wears off quickly again, we will offer radiofrequency neurotomies of these nerves.

Radiofrequency neurotomies are sometimes erroneously referred to as “burning the nerves.” This is not the case. Instead, we use the a similar needle to the one used to do the nerve blocks but, rather than simply inject medication, we insert an electrode along the nerve and run an electric current through the nerve. This causes the nerve to stop transmitting pain signals for a few months. Eventually, the effect wears off and the radiofrequency neurotomies have to be repeated, usually
about every 6 months or so.

Nerve Blocks

This is a generic term for an injection used to control pain by blocking the pain signal coming from a nerve. Just as there are many nerves, there are many types of nerve blocks. Usually, we use a local anesthetic such as lidocaine or bupivacaine, with or without a steroid such as triamcinolone acetonide or dexamethasone.

Nerve blocks can be therapeutic (to help control pain) or diagnostic (to help locate the source of pain), or both. Certain nerve blocks are done with intravenous ketamine sedation to provide better pain relief, but that’s not usually the case. Depending on the type of block and the underlying condition, pain relief from nerve blocks can provide long lasting or even permanent pain control.

Soft Tissue Pain/Musculoskeletal Pain

Weak muscles cause pain. Imagine trying to lift a very heavy weight. Over time, the muscles become fatigued and start to hurt. This is what happens when back muscles are weak. Whether from a muscle injury while playing sports, an accident, or even from bad posture, muscle weakness can result in both pain and spinal deformity. There are also certain neurological conditions that cause muscle weakness even when there is no injury.

Ligaments and tendons can also become damaged after an injury. Degeneration of the ligaments and tendons that insert into the spine, which occurs naturally as a person ages even without an injury, is the first sign of arthritis of the lower back (lumbar spondylosis) or neck (cervical spondylosis). As the ligaments and tendons wear out, whether from age or from a previous injury, the load on the joints of the spine increases and arthritis develops.

Muscle spasms usually occur in combination with an underlying injury to a muscle, tendon, or ligament as well as with arthritis. The body instinctively tries to protect the injured area by stiffening the muscles to prevent movement and avoid pain. The resulting back stiffness can make movement very uncomfortable.

The best treatment for these conditions is prevention – good posture, regular exercise, good nutrition, and adequate rest. When that is not enough, we often use anti-inflammatories and physical therapy. Sometimes, we might use muscle relaxants or steroids.

Injections can also be very helpful, particularly if oral medications and therapy do not provide adequate relief.

Anti-inflammatories

Anti-inflammatories (NSAID’s) are non-steroidal medications that help control pain and reduce inflammation. While their anti-inflammatory effects are not as potent as steroids, they have pain relieving properties that steroids do not have. These medications are safe if taken for limited amounts of time. Note that acetaminophen is not an anti-inflammatory, although it does help relieve pain.

Prolonged use of NSAID’s can increase blood pressure, cause gastrointestinal bleeding, increase the risk of heart attack and stroke, and cause kidney damage. They also increase the propensity to bleed so patients on blood thinners, take anti-platelet agents (clopidogrel, ticagrelor, etc.), or who have problems with clotting should avoid these medications. Because of the risk of gastrointestinal bleeding they are not recommended for patients who have had bariatric (weight loss) surgery.

Steroids

Steroids are potent medications that reduce inflammation. They are useful for a multitude of conditions associated with inflammation, including arthritis and soft tissue pain. While they have more potent anti- inflammatory effects than NSAID’s, they have no pain relieving properties.

Marketers selling a variety of “natural products” often exaggerate the side effects of steroids while neglecting the benefit. Steroids can have many side effects when taken for a long time (greater than 3 months). For a short course of 5-10 days of steroids, which is what we typically use, side effects are mainly limited to gastrointestinal upset (which is why we advise taking it with food and usually add something to protect the stomach), insomnia (which is why we recommend taking it in the morning), and can potentially increase blood sugar transiently. A short course of 5-10 days of steroids is very unlikely to cause significant weight gain without overeating.

Muscle relaxants

Muscle relaxants can help reduce muscle spasms. They work at the central nervous system to stimulate the receptors that relax muscle tone. Because these are similar to the receptors that cause sedation, muscle relaxants often cause sleepiness. In fact, we usually check for sedation to ensure the muscle relaxant is having an effect. This is why we prescribe them at bedtime. They typically do not cause any gastrointestinal problems.

Opioids

Opioids are potent pain medications but have no anti-inflammatory effects. Like all ligand gated channel agonists (a class of drugs), they can be addicting if used improperly. They can also cause constipation, sedation, and dysphoria (make you feel bad). When used for a long time, opioids begin to lose their pain relieving effects, but the side effects do not diminish. That is why it is best to minimize the use of opioids.

There are many stories about opioid abuse in the media, but these do not give a true picture of what is happening. Most of the problems with opioid abuse are related to illegal use of street drugs such as heroin and fentanyl rather than prescription medications. Nevertheless, addiction remains a major social problem in the US and throughout the West.

In order to minimize the risks associated with opioids, we will sometimes limit or reduce the amount prescribed. This is not because we are making a moral judgment but rather to preserve the patient’s ability to continue to benefit from these medications.

Addiction

Many people (including some professionals who should know better) confuse addiction with substance abuse. While addiction can include substance abuse, there are major problems with addiction to things like gambling, pornography, eating, social media, and shopping which do not involve substance abuse. As this list shows, addiction is not always related to something illegal, but it is always harmful.

Addiction is rampant throughout Western society. Many organizations actively seek to create something addictive in order to have a captive audience that can be exploited. Similarly, there is an entire addiction treatment industry that thrives on people who have addictions. Despite all of this, there are good options for handling addiction – if the person is truly ready to get help. Ultimately, without a sincere commitment to change, there will not be much chance of success.

Physical Therapy

Physical Therapy in MiamiMany conditions require physical therapy to achieve lasting improvement. It is important to choose a good physical therapy center to get the best results, avoid worsening pain, and get the most out of the therapy benefits available on your health plan (which are often limited to a certain amount per year).

Ideally, patients should receive an initial evaluation by the therapist, who develops a treatment plan tailored to the patient’s specific conditions. This is followed by several weeks of therapy sessions.

Depending on the condition, therapy can include modalities such as heat or cold, massage, stretching and range of motion exercises, as well as strengthening or resistance exercises. Usually, patients are also given a home exercise program to supplement the work done in physical therapy.

There are many types of therapy in addition to the above. Some specialized therapy programs include gait rehabilitation to improve balance and walking, vestibular rehabilitation to control vertigo, pelvic floor rehabilitation for pelvic pain and incontinence, and aquatic therapy, which is done in a pool.

Depending on the patient’s condition, we may order more specialized therapy.

Home Exercise Program

Sometimes, patients are able to do a home exercise program without having to go to physical therapy. There are many good physical therapy sites with exercise videos online. One site we find useful is Bob & Brad | World Famous Physical Therapists (bobandbrad.com). There are a variety of exercise programs for different conditions on that site.

In general, most pain patients should:

  • Avoid overhead presses (also known as military presses). Chest presses and bench presses are a better choice.
  • Avoid jogging or running for exercise.
  • Avoid high impact exercises.
  • Exercise 3-5 times per week. Less than 3 times per week is not as effective. More than 5 times per week increases the risk of injury without much additional benefit.
  • Learn about prevention.

Ultimately, exercise is essential to good health. Not only does it help control pain, it also helps prevent many conditions such as diabetes, heart disease, and even depression. In addition, while exercise alone is not enough for weight loss, the only way to maintain a healthy weight is to exercise regularly. Note that it is always very important to use good form and the appropriate equipment to avoid injury when exercising.

Prevention

The best treatment is prevention. While each condition is unique and has its own risk factors, there are certain things that can help prevent pain in general. These include:

  • Good posture – both when standing and sitting. Many patients fall into the habit of bad posture as teenagers. Good posture distributes body weight appropriately and allows for the most efficient body mechanics, which helps prevent injury. The best way to maintain good posture is to strengthen the core muscles, maintain a regular stretching and range of motion exercise program, and make a habit of sitting or standing properly. Good ergonomics make good posture easier to maintain.
  • Good ergonomics is essential to avoiding injury. This includes using proper body mechanics while doing physical work, but good ergonomics is also important for people with sedentary occupations. Human beings were not meant to spend most of their waking hours sitting at a desk, staring at a computer, using a smartphone or tablet, or driving around. There are multiple online ergonomics resources.
  • Regular exercise – this includes aerobic exercise (any type of cardiovascular exercise such as using an exercise bicycle, swimming, etc. and not just Aerobics specifically), core strengthening exercises, and stretching and range of motion exercises. The goal is to exercise 3-5 times per week. Usually, patients who go to physical therapy get a home exercise program from their therapists but there are plenty of exercise sites online.
  • Good nutrition – modern diets are filled with junk food, but even “healthier” choices may contain multiple additives that can be harmful. The goal is not to live a life of austerity, but rather to enjoy food properly. This is frequently complicated by sophisticated marketing programs that might misdirect people into thinking something is healthy when it is not.
  • Adequate rest – this is essential not only for physical health but also for good mental health. Stress, lack of time, anxiety, and poor habits all lead to inadequate rest. In many cases, this is worsened by things like untreated or undertreated sleep apnea and insomnia.

Good Ergonomics

Ergonomics (or human factors engineering) is the scientific discipline concerned with understanding the interactions between humans and other elements of a system and applying this knowledge to optimize human well-being and overall system performance.

Office ergonomics is particularly important given the prominence of office work in modern society. The information below, from the Mayo Clinic Staff (https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/office-ergonomics/art-20046169 and https://newsnetwork.mayoclinic.org/discussion/home-office-ergonomics-tips) can help with understanding office ergonomics and properly arranging your workspace either at work or at home.

If your work involves sitting at a desk, discomfort doesn’t have to be part of the job. You may be able to avoid some of the health problems associated with seated work, such as neck and back pain and sore wrists and shoulders, by using proper office ergonomics. Chair height, equipment spacing and desk posture all make a difference.

Use this guide to ease stress on your body, protect your joints and help you stay comfortable as you work.

office ergonomics image

 

Chair

Choose a chair that supports your spine. Adjust the height of the chair so that your feet rest flat on the floor. Or use a footrest so your thighs are parallel to the floor. If the chair has armrests, position them so your arms sit gently on the armrests with your elbows close to your body and your shoulders relaxed.

Desk

Under the desk, make sure there’s enough room for your legs and feet. Don’t store items under your desk, as that can shrink the amount of available space and make it hard to sit correctly. If the desk is too low and the desk height can’t be changed, put sturdy boards or blocks under the desk legs to raise it. If the desk is too high and can’t be changed, raise your chair. Use a footrest to support your feet if necessary. If you don’t have a footrest, try using a small stool or a stack of sturdy books. If your desk has a hard edge that’s not rounded, pad the edge or use a wrist rest. This protects your wrists from a problem called contact stress that can happen as a result of extended contact with a hard edge.

Keyboard and Mouse

Put your computer keyboard in front of you so your wrists and forearms are in line and your shoulders are relaxed. If you use a mouse or another type of pointer connected to a computer, place it within easy reach, on the same surface as your keyboard. While you are typing, using a computer touchpad, or using a mouse or pointer, keep your wrists straight, your upper arms close to your body, and your hands at or slightly below the level of your elbows. If possible, set the sensitivity of the mouse or pointer so you can use a light touch on it.

Monitor

Place the computer monitor straight in front of you, directly behind your keyboard, about an arm’s length away from your face. The monitor should be no closer to you than 20 inches (about 50 centimeters) and no further away than 40 inches (about 100 centimeters). The top of the screen should be at or slightly below eye level. If you wear bifocals, lower the monitor an additional 1 to 2 inches (about 2 to 5 centimeters) for more comfortable viewing.

Laptop

Using a laptop computer may lead to discomfort because of the low screen height and cramped keyboard and touchpad. If you use a laptop at your desk, consider getting an external keyboard and mouse, along with a laptop stand, to more closely mimic a desktop computer setup.

Frequently Used Objects

Keep objects you use often — such as the phone, stapler or printed materials — close to your body to minimize reaching. Stand up to get anything that you can’t comfortably reach while sitting.

Telephone

If you spend a lot of time on the phone, or if you often type or write while you’re using the phone, put the phone on speaker or use a headset. Don’t cradle the phone between your head and neck.

Remember, no matter how well your workspace is set up for proper ergonomics, sitting in the same position for hours at a time isn’t good for your body. Get up and walk around as often as you can throughout the workday. If possible, do some work standing up. While you’re seated, stretch your hands, fingers and arms from time to time. Shifting your position, standing up and moving will ease strain on your body and help you stay healthier.

 

Miami Pain Management Center

Back Pain Center in MiamiOur Pain Management Center in Miami provides safe, unparalleled care to patients suffering from chronic pain in South Florida. Pain is not like other medical conditions. It will influence major organs affecting your overall health. Through a balanced approach and integrating different modalities of pain-reducing therapies, our Pain Management Center provides a full range of solutions for patients with different conditions, from diagnosis to treatment and rehabilitation. We offer individualized pain management procedures and treatments to meet our patient’s needs.

When you are dealing with chronic pain, you deserve the best treatment in Miami. Pain Specialist and Neurologist, Dr. Antonio Mesa and his staff provide the full spectrum of interventional pain management procedures and treatments for adults and children. Contact us today at (305) 670-7650.

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