Coping With Back Pain - Part 2 - What Works?
What if the pain does not go away?
Sometimes, there is what we call a "mechanical" reason for back pain. For example,
arthritis can cause bony overgrowths on the spine that narrow the passageway
for various nerve roots exiting the spinal cord, causing pain.
Degenerative disk disease, a common condition as we age, can also cause mechanical pain. As the material of the disk degenerates, other structures in the back may shift in response to the changed anatomy and be more cramped. Muscles may go into spasm to protect the affected portion of the spine. A portion of the inner disk, the nucleus, may bulge out and press on a nerve root, causing pain.
Patients with these problems will need a longer time to recover and must be vigilant about avoiding future episodes. Recurrence is common for back pain sufferers, but the McKenzie exercises can be done prophylactically for just a minute or two a day to keep recurrence at a minimum.
How can a doctor tell when there is a problem more serious than a muscular
strain or sprain?
If the patient doesn't get better - or worsens - despite the combination of
initial rest, exercises and medication, imaging scans are considered. Magnetic
resonance (MR) and computed tomography (CT) are excellent procedures for viewing
the spine, since they show soft tissues as well as bone. Conditions that may
show up include disk herniation (bulging) or degeneration, spinal stenosis (narrowing
of the spinal canal), arthritis, or nerve root compression. Rarely, spinal infection
or tumor will be seen.
Are there other effective treatments?
Sometimes an epidural injection of a corticosteroid is recommended. At the Cleveland
Clinic, this is done by anesthesiologists in the Pain Center. Steroids are powerful
anti-inflammatories, so such injections can help relieve pain by alleviating
swelling. This is an especially useful therapy when the problem is in soft tissue,
meaning a muscle, ligament or disk. It is less likely to be helpful for people
with arthritic changes or pinching and narrowing due to disk degeneration and
bony spurs.
A real benefit of a steroid injection is that it can decrease the pain long enough to give the patient a chance to begin a strengthening exercise program.
What about seeing a chiropractor?
Chiropractors manipulate the spine, which is essentially what the McKenzie exercises
do. Some doctors prefer the McKenzie Method as it teaches the patient to take
care of himself, rather than relying on frequent visits to a healthcare provider.
Chiropractic is not recommended for fractures, infection or cancer, so be sure
of your diagnosis before scheduling an appointment.
Is massage safe?
Massage feels wonderful. It certainly won't cure you, but if it makes you feel
good and you can afford it, "Go for it!" Anything that relaxes the muscles can
may help you relieve pain.
What about acupuncture?
Acupuncture for low back pain is being increasingly accepted in Western medicine.
Sometimes acupuncture is prescribed when other methods have failed to bring
adequate relief. Acupuncture has been found to be quite effective as a second-line
therapy for soft tissue injury, for example, from a car accident.
Another useful treatment is transcutaneous electrical nerve stimulation, or TENS. Tiny charges of electricity are delivered to electrodes attached to the lower back. The current stimulates the spinal cord and relieves pain. A newer version of this therapy call percutaneous electrical nerve stimulation (PENS). PENS delivers the electric charges to tiny needles that are actually inserted in the lower back.
When might surgery be considered?
Conditions such as infection, cancer, trauma, or severe scoliosis often require
surgical treatment. Disk herniation is another matter.
Rushing into surgery for a herniated disk is usually not the best idea. Not every disk that ruptures requires surgery, and many patients get better without an operation. The unfortunate truth is that many people who have had surgery for back pain find their condition is not any better postoperatively - and sometimes it's worse. On average, only about 2-5% of patients require disk surgery.
If, however, the herniated material from the disk presses on a nerve root that governs strength and sensation in the foot or leg, bladder or bowel control, then the patient may be referred to a consulting a surgeon when medical treatment is not effective. Allowing the disk material to continue pressing on the nerve root in these circumstances may lead to permanent damage. This type of surgery has a success rate of 90-95%. Often, it can be done with a minimally invasive approach that requires just a one-to-two-week recovery. Obviously, you would want to carefully consider your options with an experienced team of specialists.