Minimally Invasive Procedures Used to Treat
Disorders Affecting the Lumbar Spine

Most low back pain is self-limiting. Eighty-five to ninety percent of low back pain resolves in 6-12 months spontaneously and 75% of "sciatica" resolves in this same time span. But, is it necessary to suffer for a year? Can one year be taken off of work? Also, recurrences of low back pain occur in 60-70% of patients. Clearly, untreated low back pain can also lead to chronic pain conditions as well.

Physiatric Approach
The physiatric approach to low back pain is a very simple one. The first principle is to attempt to identify the main pain generator. Is the patient's pain going down their leg related to a nerve that is being pinched, or is it related to tight muscles? Is it the vertebral bones causing the pain, or is it the joints in the back that are making it difficult for the patient to enjoy their life.

These are the types of questions we try to answer. This is made more difficult by the ambiguity of symptoms that some people experience. To help answer these questions, physiatrists perform a very careful history and physical exam, in addition to using imaging studies (such as MRI, X-rays), and different spinal injection techniques.

Pain Generators
The main types of pain generators that are encountered, and can be treated effectively with minimally invasive techniques are the nerve root, annulus fibrosis of the intervertebral disc, the zygapophyseal joints and the sacroiliac joint.

Why perform spinal injections?
The most pertinent reason for most patients is to relieve the pain. We can diminish the pain response with an injection and, hopefully, facilitate participation in a therapeutic exercise program. We also attempt to hasten recovery and obtain diagnostic information with each injection. Lastly, we may be able to avoid spinal surgery if the injections are successful.

These injections work through the inhibition of prostaglandin synthesis, inhibition of phospholipase A2, nerve membrane stabilization, and blocking C-fiber conduction. In addition, we perform all of our injections using fluoroscopy (an X-ray machine) to ensure the proper placement of the medication.

The most common injection that is performed is an epidural steroid injection. It is most commonly used for either nerve root generated pain or discogenic pain, i.e., pain from the outer portion of the disc, called the annulus fibrosis.

Nerve Root Pain: Radiculopathy
Nerve root pain is also called radiculopathy and is pain that starts in the low back, goes down the leg, below the knee. It typically is worse with bending forward and patients may experience weakness and/or decreased reflexes. A herniated disc usually causes this condition.

Medication taken by mouth usually helps decrease the pain and epidural steroid injections can be very helpful. These injections can be given through any of a number of routes. The most selective injection is given through the transforaminal route. Two other routes of administration for these injections are caudal and interlaminar injections. Research is currently under way to determine which route is most effective in relieving pain from a radiculopathy. As the transforaminal route is the most selective manor in which to deliver medication, it can also help with diagnosis.

Nucleoplasty
For a persistent herniated disc causing a pinched nerve that does not respond to epidural steroid injections, a new procedure may help alleviate pain. Nucleoplasty is a technique that uses radiofrequency energy to shrink the herniated disc. Studies of this new technique are very promising in relieving leg pain from a herniated disc.