Treating Disorders Affecting the Lumbar Spine
Using Minimally Invasive Procedures

Discogenic Pain
Pain that arises from the disc itself is often difficult to treat. Usually these patients complain of pain that is worse with sitting, and is improved with bending backwards. A part of what makes this condition difficult to treat is that the diagnosis is often difficult to make. Studies have shown that up to one-third of people without any low back pain whatsoever have abnormal discs when viewed with an MRI. In a patient with low back pain and multiple discs that look worn out on MRI, it is difficult to pinpoint the pain-generating culprit.

Discogram (Discography)
A discogram is a procedure that attempts to verify exactly which disc is painful by instilling dye into the disc. This allows the doctor to view the disc under x-ray and determine its structure, as well as determining if the disc is sensitive to the increased pressure from the dye. Often, a CT scan to get an even better look at the disc follows this procedure. It is not a treatment, but, like an MRI, is used to gather additional information. It may be used with pressure monitoring which may give the physician additional information.

Discogenic Pain: Treatment
Treatment consists of epidural steroid injections, preferably given via the transforaminal route. In theory, this allows the medication to be in close proximity to the painful disc. Unfortunately, this theory has never been proven and the best route of epidural steroid medication for discogenic low back pain is unclear.

If epidural injections do not help with the low back pain, another treatment possibility is Intradiscal Electrothermal Annuloplasty (IDEA, IDET). This technique involves inserting a heated catheter in the nucleus pulposus. The proposed methods of pain relief are 1) destroying ingrown nerves to the disc and, 2) collagen remodeling. A study is underway to help determine the efficacy of this procedure.

Spinal Joints
The facets, or zygapophyseal joints, have also been proven to be a pain generator in the low back. In health, these joints help to guide movement in the lumbar spine.

When these joints are dysfunctional, patients typically complain of pain located in the low back that does not radiate below the knee. Patients complain of pain worse at the end of the day, which improves with sitting. Low back pain may worsen with combining bending backwards and rotating.

Nerve Blocks and Neurotomy
MRI, X-ray and CT scan may show degenerative changes in the joints, or may be completely normal. Injections of steroid and numbing medicine directly into the joints may help relieve the pain.

Another alternative is to perform an anesthetic block to the nerves that supply sensation to the joint. These are called medial branch blocks of the dorsal ramus. An advantage of these injections is that the nerve also supplies some of the back muscles. This type of injection is very helpful for patients with muscle spasm in the low back. If either the facet joint injection or the medial branch block gives excellent relief but is short-lived, radiofrequency neurotomy is an option to induce long-term relief. The procedure is similar to the medial branch blocks, but instead of numbing the nerves that supply the facet joints, heat is used to destroy those nerves.

Sacroiliac Joint
The sacroiliac joint is often cited as a pain generator in the low back. Patients typically complain of low back pain in the upper buttock and may be worse on one side than the other. Also, their pain is increased with walking and does not go below the knee. Patients who have undergone a fusion in the lumbar spine are prone to this disorder. Injections directly into the sacroiliac joint can be helpful for this problem.

Conclusion
Again, the physiatric approach is to make an accurate diagnosis targeting the main pain generator. Injections are one tool in the bag of any good physiatrist. A main component of treatment that wasn't addressed in this brief introduction is physical therapy that is specific to the patient's diagnosis. Without the appropriate physical therapy, the injection techniques may offer only temporary relief from pain. Using therapy in conjunction with injections has given me, and my patients, the best results.