Low Back Pain

Low back pain is one of the most frequent musculoskeletal complaints. Pain may arise from damage or irritation to structures of the lower back including the vertebrae (bony spine), facet joints, discs between the vertebrae, vertebral ligaments, muscles of the lower back, spinal cord and peripheral nerves, as well as internal organs of the pelvis and abdomen (spleen, kidney, pancreas, liver).

Typically the symptoms of LBP resolve within four weeks, depending on the pathology associated with the complaint. However, the pain often returns leading to a high percentage of the American population with a chronic condition and requires lower back pain management.

Anatomy of the Lower Back

Bony structures

Understanding the anatomy and physiological function of the lower back is key in evaluating a person with chronic pain. The bony spine is positioned so that individual vertebrae (bones of the spine) interconnect with other spine bones above and below. This provides a flexible support structure while also protecting the spinal cord. Conditions that can produce chronic pain from the spinal bones include:

  • Facet Joint Osteoarthritis
  • Spinal Stenosis (narrowing of the spinal canal)
  • Vertebral Body Fractures
  • Osteoporosis
  • Spondylolisthesis
  • Neoplasms (Primary vs. metastatic lesions)
  • Infections

Facet injections/denervation, Vertebroplasty, SI joint injection/denervation, Lysis of Adhesions, spinal cord stimulation, intrathecal pumps and other treatments can be extremely effective lower back pain treatment for many of these conditions.

In fact, a recent study in 2007 concluded that lumbar facet joint nerve blocks with local anesthetic may be effective in the treatment of chronic low back pain of facet joint origin. Physical therapy, cognitive behavioral therapy, biofeedback, diet and exercise, along with other alternative techniques have also been helpful

Vertebral Discs

Separating adjacent vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. Since the discs are designed to be soft and provide support, they have a tendency to herniate (bulge) posterior (or backwards) through the outer ligaments and cause irritation to the adjacent nerves.

Disc disease is one of the most common causes of chronic LBP and accounts for approximately 10% of all low back pain complaints. Disc disease may acutely be from herniation resulting from trauma or heavy lifting. More commonly chronic back pain is caused by degenerative disc disease. Degenerative disk disease is due to thinning and degeneration of the discs and can lead to spinal stenosis, nerve impingement, worsening facet arthritis, or peripheral nerve irritation.

Conditions that can produce chronic pain from the discs:

  • Degenerative Disc Disease
  • Disc Protrusion
  • Disc Herniation
  • Disc Extrusion
  • Facet Joint Osteoarthritis
  • Spinal Stenosis (narrowing of the spinal canal)
  • Nerve Root Irritation or Compression (Sciatica)
  • Disc Infection

Facet injections/denervation, epidural steroid injections, Lysis of Adhesions, epidural infusions, spinal cord stimulation, intrathecal pumps and other treatments can be extremely effective treatment for lower back pain in many of these conditions.

Spinal Ligaments and Muscles

There are ligaments that attach to each vertebrae and provide strength and mobility to the spine as well as the many groups of muscles that are responsible for the movement of the spine. The nerve roots are attached to the spinal cord and exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities. These muscles and ligaments have a tendency to become strained and irritated during strenuous lifting and excessive exercise and cause local nerve irritation. Myofascial (muscle and connective tissue) and ligament injury may account for the majority of low back pain. Conditions that can produce chronic pain from ligaments and musculature:

  • Myofascial Pain Syndrome
  • Muscular Strain
  • Torn Muscle
  • Ligamentous Strain
  • Ligamentous Tear

Trigger point injections widely popularized by Dr Travell are extremely successful in alleviating and managing lower back  musculoskeletal pain. An alternative therapy that specifically targets ligaments is called Prolotherapy. This sort of therapy, also called Regenerative Injection Therapy has been successful for many chronic pain suffers. Physical therapy, acupuncture, massage, yoga, diet and exercise have also proven to be effective in treating myofascial pain.

Referred pain

Organs in the abdomen and pelvis can refer pain to the back. Specifically, the kidney, pancreas, spleen, and liver have been known to refer pain to this region. These organs may cause pain that is due to obstruction, inflammation, infection, decreased blood supply, enlargement and or cancer. These “activated nerves” cause referred pain by traveling into the spinal cord at the same level as other structures in the lower back. This can cause a person to experience pain in the back instead of their organs.

Pathology of Low Back Pain

Common causes of LBP consist of Herniated Discs, Spinal Stenosis, Strained Muscles Sciatica, Arthritis (auto-immune vs. non auto-immune), Fibromyalgia, Vertebral Body Fractures, and Osteoporosis.

Less common causes include infections, Ankylosing Spondylitis, Psychological causes and Metastatic Cancer. Risk factors for malignancy include an age greater than 50, pain not relieved by lying down, symptoms worse at night, and pain for longer than one month.

Acute Low Back Pain

Acute LBP typically comes on abruptly and occurs during a specific activity. Acute lower back injury is more commonly due to overuse by excessive exercise, lifting of heavy objects, motor vehicle accidents, or any trauma involving the lower back. The anatomy typically involved in acute LBP is the muscles and surrounding ligaments. Vertebral body fractures, ruptured discs and spinal cord compressions can also be seen acutely with pre-existing osteoporosis, cancer, or spinal stenosis. Acute pain due to ligament and muscle injury typically responds to activity and NSAIDs (Ibuprofen like drugs). Acute back pain should be evaluated by a physician to rule out other causes like: kidney stones, kidney infection, and acute pancreatitis. In some cases of acute back pain a specialists and proper imaging is required for immediate evaluation (Emergency Room, Pain Specialists, Spine Surgeon). These cases might include:

  • Acute Vertebral Compression Fractures
  • Acute Disc Herniation
  • Fever/Chills
  • Weakness or Paralysis
  • Loss of Bowel or Bladder Control
  • Spinal Cord Compression

Chronic Low Back Pain

Chronic low back pain is defined as pain over 3-6months in duration. Typically the symptoms are more gradual and occur over an extended period of time. With chronic LBP a person may experience pain in their back as well as down either leg. Causes of chronic LBP are numerous and include:

  • Arthritis, Facet Joint
  • Sacroiliac Joint Disease
  • Spinal Stenosis (narrowing of the spinal canal)
  • Fibromyalgia
  • Degenerative Disc Disease
  • Disc Protrusion
  • Disc Herniation
  • Disc Extrusion
  • Facet Joint Osteoarthritis
  • Nerve Root Irritation or Compression (Sciatica)
  • Central Sensitization
  • Excessive Breast Size
  • Poor Posture
  • Psychological and Emotional Factors
  • Vertebral Body Fractures
  • Osteoporosis
  • Spondylolisthesis
  • Ankylosing Spondylitis
  • Neoplasms
  • Infections

Central Sensitization is a common complication associated with chronic pain of all kinds. This is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain.

Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by very light touch of the skin activate neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce a harmless sensation now produces significant pain.

Sacroiliac Joint (SIJ) Disease is another major cause of LBP. The SIJ is located at the junction between the spine and the pelvis. Many muscles and ligaments support the SIJ. This joint allows the weight of the spine and upper body to be transmitted into the pelvis and finally into the legs. The SIJ is richly innervated by free nerve endings and spinal nerve roots, explaining the severe pain caused by inflammation in the SIJ. Pain associated with SIJ can worsen with sitting for long periods of time, or twisting motions and certain movements. Often the pain begins spontaneously, while others recognize a specific traumatic event that triggered the occurrence of the pain.

While conservative treatment for lower back pain such as NSAIDs and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular lidocaine injection into the SIJ was 96% effective in pain improvement in patients with SIJ complaints with minimal complications (2007 Murakami). Florida Spine Institute now offer SIJ injections and longer lasting denervation procedures for better management of lower back pain when warranted.

Diagnosis of LBP

Diagnosis of LBP can be difficult and the Pain Physicians at Florida Spine Institute have received extra training to examine and diagnose your painful condition. The physician may perform a physical exam demonstrating tenderness over certain areas of the spine as well as assessing the various limitations in movement. The physician may also order radiological imaging such as x-ray, CT scan, MRI, or bone scan depending on his clinical suspicion and the history obtained.

Lower Back Pain Treatment Options

Epidural Steroid InjectionsBed rest is contraindicated in most causes of LBP. Staying active and physical therapy are indicated. There are many interventions offered by Arizona Pain Specialists for those with severe LBP to assist you in managing your lower back pain. Below we list a basic overview of pain relief options.

We are happy to offer these exciting pain management techniques to the Phoenix area:

  • Pharmacotherapy – NSAIDs (Ibuprofen like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications are often effective in treating low back pain.
  • Epidural Steroid Injections – Epidurals are frequently used for pain syndromes due to common conditions such as degenerative disc disease. The method involves injecting a steroid into the epidural space of the spinal cord, where the irritated nerve roots are located. The medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.
  • Medial Branch Blocks/Denervation – Medial Branch Blocks (MBBs) are a minimally invasive non-surgical treatment that are used for arthritis related neck and back pain. The injections work by reducing the inflammation and irritation in the facet joints of the spine that is causing your pain.
  • Lysis of Adhesions – Also known as the “Racz Procedure,” this procedure has proven effective in removing excessive scar tissue in the epidural space when conservative treatment for lower back pain has failed. A study performed in 2005 said, “a spinal adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.” This procedure is used in vertebral body compression fractures, post-laminectomy syndrome, radiculopathy, and disc disease.
  • Infusions Techniques- The procedure involves inserting a small catheter through a needle into the epidural space or directly next to affected nerves. Local anesthetic and other medicines are often given through the catheter for extended time periods. When the nerves are blocked continuously with an infusion, pain relief can be dramatic and long lasting.
  • Spinal Cord Stimulation (SCS) – an implanted electrical device that decreases the perception of pain by confusing the spinal cord and brain pain processing centers. Initially a trial is done to see if this device will help you long-term. In the initial trial, your pain physician places a small electrical lead in the epidural space through a needle. Painful signals are replaced by tingling electrical signals. If you have success in your trial, you may decide to have a permanent SCS device implanted.
  • Peripheral Nerve Stimulation – this method involves tiny electrodes being placed close to the affected nerves. The electrodes release a small electrical current that inhibits pain transmission and causes pain relief.
  • Kyphoplasty and Vertebroplasty – are both minimally invasive procedures that can treat osteoporotic fractures. The method is to stabilize crushed vertebrae by injecting an acrylic cement into the vertebra. Vertebroplasty is effective in relieving pain, most likely because of the added support and stability it provides the spine.
  • Intrathecal Pump Implants – Implanted pain pumps are also available which can be extremely helpful providing long-term pain control. The effectiveness of intrathecal therapy in patients suffering from nociceptive pain showed a pain reduction in 66.7% of patients experiencing pain due to cancer
  • Percutaneous Discectomy – a needle is inserted through the skin into the affected disc. Disc material is suctioned out of the bulging disc and pressure is relieved within the disc.
  • Disc Denervation – Needles are placed along the vertebral bodies in close proximity to the discs and electrical stimulation is initiated. When the appropriate nerves are located they are anesthetized and destroyed using electricity.
  • Cryotherapy – A probe is placed through a needle near affected painful nerves. Electrical stimulation is done to verify position and freezing cycles are initiated over the painful nerves.
  • Peripheral Nerve Blocks and Ablation – Nerves away from the spinal cord are called peripheral nerves. These nerves can often be sources of pain and can be blocked with local anesthetic. When pain relief is obtained, ablation or destruction can be initiated.
  • Trigger Point Injections – can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and steroid into a “Trigger Point.”
  • Botox – used in treating neck pain is an exciting new treatment that is widely accepted among modern medicine. In 2005 “Botulinum toxin Type A (BtA) became the first line therapy for the treatment for cervical dystonia.” Although a single injection of BtA is effective, multiple injection cycles seem to work better for patients . Botox injections have also been found to be effective in patients with whiplash injuries. Along with reductions in pain patients were found to have improved range of motion
  • Transcutaneous Electrical Nerve Stimulation (TENS) – is a technique that relieves pain by applying mild electric current to the skin at the site of the pain. The electric impulses interfere with normal pain sensations and alter perceptions that were previously painful.
  • Biofeedback – is a treatment that teaches a patient to become aware of processes that are normally thought to be involuntary inside of the body (such as blood pressure, temperature and heart rate control). This method enables you to gain some conscious control of these processes, which can influence and improve your level of pain. A better awareness of ones body teaches one to effectively relax and this can help to relieve pain.
  • Physical therapy – In order to decrease or prevent functional limitations, physical therapy and occupational therapy are recommended as well as medical treatments,
  • Acupuncture – Small needles are inserted into the skin. These needle cause your body to release hormones called “endorphins”, which are your body’s natural pain reliever. Acupuncture can also help you relax; decreasing stress, tension, and muscular spasm.
  • Nutrition and Exercise – Exercise improves the pain of sciatica by increasing flexibility and range of motion. Another benefit is the releases hormones called “endorphins,” which are your body’s natural pain reliever. Nutrition and healthy eating may be powerful treatments to combat nutritional deficits.
  • Massage – Gentle focal rubbing of the tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with it. Massage can also help you relax, decreasing stress and tension.
  • Chiropractic Manipulations – targeted “adjustments” especially combined with other modalities may significantly reduceback pain. Manipulations are undertaken in order to allow correct nerve transmission.
  • Prolotherapy – also known as Regenerative Injection Therapy is a technique of injecting irritating substances into painful ligaments and tendons. The procedure is used to initiate the bodies healing of a damaged ligament or tendon.

Surgery

Surgical procedures are typically done when all conservative managements are unsuccessful in reducing pain or when the spinal cord or exiting nerves are being severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation.

Invasive Surgical Procedures Include:

  • Discectomy
  • Laminectomy
  • Spinal Fusion
  • Spinal Instrumentation

Long-term, surgical fusion or discectomy may not provide relief. In addition, surgical options for LBP were found to be associated with a significant risk of complications, including bleeding, nerve damage, epidural scarring, and prolonged recovery times. Surgical procedures are typically done when conservative management by pain specialists have been exhausted, life-threatening complications have ensued, or neurological symptoms like weakness, bowel or bladder changes, and/or loss of sensation. The evidence at the present time does not support routine surgical fusion or surgery for the treatment of chronic lower back pain alone.

There have been great strides in lower back pain treatments and pain management. Early intervention can make a big difference.

Peer-Reviewed Supportive Research:

Stidd, D. A., et al. (2014). “Spinal cord stimulation with implanted epidural paddle lead relieves chronic axial low back pain.” J Pain Res 7: 465-470.

INTRODUCTION: Spinal cord stimulation (SCS) provides significant relief for lumbosacral radiculopathy refractory to both medical and surgical treatment, but historically only offers limited relief for axial low back pain (LBP). We aim to evaluate the response of chronic axial LBP treated with SCS using a surgically implanted epidural paddle lead. MATERIALS AND METHODS: This is a retrospective review of a consecutive series of patients with exclusive LBP or predominant LBP associated with lower extremity (LE) pain evaluated and treated with SCS using an implanted paddle lead within the dorsal thoracic epidural space. Baseline LBP, and if present LE pain, were recorded using the visual analogue scale (VAS) at an initial evaluation. At a follow-up visit (a minimum of 12 months later), LBP and LE pain after a spinal cord stimulator implantation were again recorded using the VAS. Patients were also asked to estimate total LBP pain relief achieved. RESULTS: Patients with either exclusive (n=7) or predominant (n=2) axial LBP were treated with SCS by implantation of a paddle lead at an average spine level of T9. The baseline VAS score for LBP was 7.2; after a follow-up of 20 months, the score decreased to 2.3 (P=0.003). The LE pain VAS score decreased from 7.5 to 0.0 (P=0.103). Patients also reported a subjective 66.4% decrease of their LBP at follow-up. There were no surgical complications. CONCLUSIONS: Axial LBP is refractory to many treatments, including SCS. SCS using a surgically implanted paddle electrode provides significant pain relief for chronic axial LPB, and is a safe treatment modality.

Al-Kaisy, A., et al. (2014). “Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study.” Pain Med 15(3): 347-354.

OBJECTIVE: The aim of this study was to investigate the long-term efficacy and safety of paresthesia-free high-frequency spinal cord stimulation (HF10 SCS) for the treatment of chronic, intractable pain of the low back and legs. DESIGN: Prospective, multicenter, observational study. METHOD: Patients with significant chronic low back pain underwent implantation of a spinal cord stimulator capable of HF10 SCS. Patients’ pain ratings, disability, sleep disturbances, opioid use, satisfaction, and adverse events were assessed for 24 months. RESULTS: After a trial period, 88% (72 of 82) of patients reported a significant improvement in pain scores and underwent the permanent implantation of the system. Ninety percent (65 of 72) of patients attended a 24-month follow-up visit. Mean back pain was reduced from 8.4 +/- 0.1 at baseline to 3.3 +/- 0.3 at 24 months (P < 0.001), and mean leg pain from 5.4 +/- 0.4 to 2.3 +/- 0.3 (P < 0.001). Concomitantly to the pain relief, there were significant decreases in opioid use, Oswestry Disability Index score, and sleep disturbances. Patients’ satisfaction and recommendation ratings were high. Adverse Events were similar in type and frequency to those observed with traditional SCS systems. CONCLUSIONS: In patients with chronic low back pain, HF10 SCS resulted in clinically significant and sustained back and leg pain relief, functional and sleep improvements, opioid use reduction, and high patient satisfaction. These results support the long-term safety and sustained efficacy of HF10 SCS.

de Vos, C. C., et al. (2012). “Spinal cord stimulation with hybrid lead relieves pain in low back and legs.” Neuromodulation 15(2): 118-123; discussion 123.

OBJECTIVE: The failed back surgery syndrome (FBSS) is the most common chronic pain syndrome. Whereas it is relatively easy to achieve pain relief in the lower limbs of FBSS patients with spinal cord stimulation (SCS), it is difficult to manage low back pain with SCS. The performance of a paddle-shaped SCS lead that can be inserted surgically as well as percutaneously (a hybrid lead) was evaluated in a prospective study on the relief of low back pain and leg pain in patients with FBSS. MATERIALS AND METHODS: Patients with FBSS being eligible for SCS were enrolled in the study, and a hybrid lead was placed surgically. Outcome measures included pain scores for low back and leg pain assessed by visual analog scale (VAS), pain medication, and patient satisfaction. These scores were assessed before and at regular intervals after implantation. RESULTS: It was shown that a single hybrid lead, generally positioned over the physiological midline of the spinal cord, is capable of alleviating both low back and leg pain in patients with FBSS. Forty-five subjects were eligible for SCS and received trial stimulation. Forty-two of them had a successful trial period and were converted to a permanent system. Their average VAS score at baseline was 8.0 for lower limb pain and 7.5 for low back pain. After six months of SCS, these average VAS scores were reduced to 3.2 and 3.5, respectively, and also pain medication was reduced significantly. CONCLUSION: SCS with a hybrid lead in subjects with FBSS is safe, and causes significant pain relief in both the low back and the lower limbs.