An Integrated Approach to Back and Neck Pain

Integrated pain management is a new approach to treating acute and chronic back and neck pain. Pain afflicts millions of patients suffering spinal stenosis (spinal sten-oh-sis), degenerative disc disease, osteoporosis (os-t-o-pour-o-sis), failed back surgery, facet disease, myofascial pain, and degenerative scoliosis (sko-lee-oh-sis). Today patients find that modern medical professionals have a different view of pain. Chronic pain is no longer considered long lasting acute pain and pain perception is individual to the patient.

Millions Suffer Each Year

Traditional spine care and pain management specialists have merged to form collaborative programs for the comprehensive treatment of pain. Patients find many advantages to these programs including the centralization of medical care with less duplication of services from different medical disciplines. An integrated pain management program educates the patient to understand their pain and to learn how it can be controlled. The patient and specialist work together as partners to determine the best treatment.

Pain Assessment
A pain management assessment begins with the patient's pain history, which includes the location, intensity, and duration of pain as well as factors that alleviate or aggravate pain. A physical and neurological examination is performed. Further, the patient's medical history and test results are reviewed including radiographs (e.g. x-rays, MRI).

Multidisciplinary Approach
A multidisciplinary approach means the patient's pain program may include different types of treatment. Treatment is provided by the medical professional that specializes in a specific type of treatment. Medical professionals may include a pain management specialist, physical therapist, rehab specialist, and occupational therapist. Conservative non-surgical treatment may include a combination of pain relieving medications, anti-inflammatory drugs, physical therapy, and injections. Alternative therapies include acupuncture, biofeedback, stress reduction, and diet modification. In this chapter different types of injection therapies are presented.

Epidural Steroid Injections
Steroid injections are potent anti-inflammatory agents injected directly into the epidural space located close to the affected nerve roots. The epidural space is the area surrounding the spinal cord and nerve roots. These injections are most effective in the presence of nerve root compression. Scientific studies demonstrate inflammation of the spinal nerves following prolonged compression leads to irritation and swelling. These injections are most effective when given during the first weeks after the onset of pain. Usually two or three injections one to two weeks apart are required. Only one injection is given when complete pain relief is achieved. The number of injections is limited to a maximum of three to avoid systemic side effects from the steroids. Side effects are minimal and consist mainly of mild tenderness in the injection area, which disappears in one to two days.

Sterile Procedure
Epidural steroid injections and nerve blocks are administered in a hospital or outpatient medical facility under sterile conditions. Through an IV (intravenous line), the patient is given medication to relax. Numbing medication is injected into the skin area where the injection will be placed. The physician uses fluoroscopy (floor-os-co-pee) to guide the needle into the epidural space at the appropriate spinal level (cervical, thoracic, lumbar). After the procedure, the patient is moved into the recovery area and monitored for about an hour.

Nerve Blocks are injections of anesthetic, steroid and/or opioid (oh-pe-oid) medications. Nerve blocks are performed to relieve pain and/or to determine if a specific nerve root is the pain source. Anesthetic (an-es-tha-tick) medications numb the nerves, steroids are potent anti-inflammatory drugs that reduce swelling, and opioids are powerful drugs that fight pain. In some cases, nerve blocks can provide extended periods of pain relief. Some of the different types of nerve blocks are listed below.

Cervical, Thoracic, Lumbosacral Medial Branch Blocks target the medial branch nerves. Medial branch nerves are very small nerves that communicate pain from the spine's facet joints (fah-set joints).

Facet Joint Blocks are performed to reduce inflammation and pain and to confirm that a particular facet joint is the pain source. The facet joints are small-paired joints on the back of the spine that help to provide spinal stability and guide motion in the back.

Selective Nerve Root Blocks are performed to reduce inflammation and pain and to determine if a specific nerve root is the pain source.

Conclusion
During the last decade, pain management has evolved into an integral part of patient care, which has dramatically affected the medical community. Medical professionals have a better understanding of pain. Attitudes are changing, diagnostic protocols have advanced, technology has improved procedures, and there are more medication options. The horizon continues to brighten for patients who suffer pain.

This article is an excerpt from Dr. Stewart G. Eidelson's book, Advanced Technologies to Treat Neck and Back Pain, A Patient's Guide (March 2005).