70-80% adults have experienced acute back pain, almost 30% seek medical attention, and this problem is one of the commonest reasons for a doctors’ office visit.
Most cases are caused by sprains or tears in one of the numerous muscles or ligaments in the back triggered by twisting or lifting something heavy.
These “soft tissue” injuries will usually improve on their own within a few weeks with anti-inflammatory medications and physical therapy.
However a recent study showed that more and more such patients are getting unnecessary imaging studies right away leading to surgeries and other invasive procedures that they don’t need.
Possible reasons cited for the necessary procedures include patient expectations and financial incentives for doctors.
Doctors shouldn’t immediately order an MRI or CT scan to determine the cause of back pain if a patient doesn’t have any red flags such as tingling in the legs — a sign of a nerve problem such as spinal stenosis — or a previous history of cancer.
Otherwise, imaging studies ordered for nonspecific back pain may reveal incidental disk problems, the result of aging, and not the cause of the symptoms.
This will then often lead to unnecessary and unproven interventional pain management procedures.
Most back pain patients simply need to be told that their pain will improve with antiinflammatory medications, physical therapy, massage therapy, and/or supervised exercise programs.
However, in the words of Dr. John Mafi, one of the study’s authors, “it takes longer to sit and reassure patients that their pain will likely resolve on its own than it does to order an MRI.”
NPR recently aired an interview between NY Times reporter Barry Meier and Fresh Air’s Terry Gross regarding prescription pain medicine abuse and his new ebook – “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake”.
Mr Meier suggested that physicians should be treating the actual cause of pain rather than just prescribing pain medications, that patients can reduce chronic pain by exercise, and questioned the role of drugs like Oxycontin for treating chronic pain.
In fact this is just one of many recent backlashes against doctors for prescribing narcotic medications. Doctors who prescribe narcotic pain medications now face multiple telephone calls from individual and insurance company pharmacists urging them to taper narcotic medications or try something else.
It is true that there has been a marked increase in the use of prescription narcotic medications for chronic non-cancer pain over the last 2 yrs, and this has led to many cases of prescription medication abuse, including unintentional overdose deaths:
There have certainly been many instances of rogue physicians writing narcotic prescriptions for cash during walk-in visits in so-called pain pill mills.
Critics of prescription narcotics have cited a concern about the lack of rigorous scientific outcome data showing any long term benefit from the use of narcotics for non-cancer related chronic pain.
Obviously, physicians should be encouraged to investigate the cause of chronic pain and look into treatments other than chronic pain medications. There are now many “pain management physicians” who will only treat back pain patients with interventional procedures and won’t prescribe narcotics. However, there iis little to no data demonstrating any long term outcome benefit from epidural injections for back pain. Furthermore, each of these procedures cost health care carriers up to a thousand of dollars. There can be no doubt that there are unethical physicians seeking insurance reimbursed for unnecessary procedures, just as their are unethical physicians writing narcotic prescriptions for cash.
There are studies that show chronic pain is under-treated in the community leading to poor quality of life, disability, and healthcare over-utilization.
It is clear that there are many patients currently being treated by ethical physicians for chronic pain with long-acting narcotic medications, and we need to be more careful that increased regulation does not deprive these legitimate pain patients of a necessary evil. There are many anecdotal examples of physicians who won’t prescribe narcotics or take on new patients who are already taking these medications for fear of state medical board scrutinization or action.
Clearly, we need some kind of a compromise here:
Yes, physicians should investigate the cause of pain, and if possible treat that underlying problem rather than just prescribing pain medications.
Nevertheless, it is not good medicine to let patients suffer needlessly while this is being accomplished.
Physicians need to know it’s OK to prescribe pain meds as long as they take steps to be sure they are doing their best to only prescribe narcotics to legitimate patients without causing drug addiction and overdose:
The media and regulatory authorities needs to do a better job distinguishing appropriate from inappropriate prescription narcotic use.
One wonders if reporters who write about prescription drug abuse have ever been unfortunate enough to experience severe pain themselves and then encountered physicians too afraid to prescribe pain medications?
…..The jury is still out!….
First, the problem:
Affected patients complain of back pain, leg pain and weakness, worse with prolonged standing and walking, better with sitting or flexing the spin forward (such as pushing a supermarket trolley).
Next, the solution(s):
This stenosis (or narrowing) is caused by degenerative bone spurs, disc disease and ligamental hypetrophy. While many patients try conservative measures including physical therapy and epidural injections, spinal stenosis is a mechanical problem, and usually necessitates a mechanical (surgical) solution to alleviate symptoms. Consider the analogy of a blocked sewer pipe – you can try pouring chemicals down the sink, but ultimately you know you are going to need to call a plumber (Rota-Rooter)!
Traditional surgical management calls for a lumbar laminectomy to decompress the spinal canal and alleviate symptoms.
In some cases, laminectomy can leave the spine unstable necessitating a spinal fusion using bone garft, rods and screws (“hardware”) done at the same time, and this major surgery can lead to an extended recovery period of months to a year.
Implantation of a interspinous spacer has been proposed as a less-invasive alternative surgical option than spinal fusion:
Which is better?
A recent study compared the outcomes of these techniques in 99,000 Medicare patients who underwent surgery for spinal stenosis from 2006 to 2009.
6,000 patients who underwent implantation of new interspinous spacers were compared with 76,000 who underwent laminectomy, and 17,000 patients who underwent laminectomy with spinal fusion.
The results showed that patients treated with spacers had the lowest rate of major medical complications: 1.2%, compared to 1.8%with laminectomy and 3.3% with spinal fusion. Patients receiving spacers also spent less time in the hospital: average 1.4 days versus 2.7 days in the decompression group.
However, patients receiving spacers had the highest rate of revision surgery – about 17% of patients receiving spacers needed a second operation on the lumbar spine, compared to only 8.5% in the laminectomy group and about 10% in the fusion group.
Patients receiving spacers tended to be older and to have other medical problems. With adjustment for these and other factors, patients in the spacer group were more than twice as likely to require repeat surgery.
Hospital payments for spacer surgery were greater for decompression alone, but less than for fusion procedures
Other than the need for repeat surgery (presumably because initial surgery was ineffective), the study did not look at pain control or functional outcome between the groups. More data is needed.
Nevertheless, so far it looks as if the higher cost and higher re-operation rate with spacers may argue in favor of conventional decompression surgery, except in higher risk older patients with medical problems.
Most people agree that emotional stress or psychological factors can make any pain, including back pain pain worse.
However, the concept of “stress-related” or psychosomatic back pain, which is primarily caused by psychological and emotional factors, is usually harder to grasp.
It is important to make affected patients understand that even though psychological factors may be causing the physical symptoms, the symptoms are not imaginary
Instead, the unresolved emotional tension is pushed out of awareness into the unconscious mind, which then causes changes in the body’s nervous system, leading to muscle tension, spasm and the back pain experienced by the patient. This chronic pain can lead to insomnia, fatigue, disability and then depression in a viscous feedback cycle:
This syndrome can be hard to recognize for 2 reasons:
First, the pain may actually start with an identifiable incident that caused lower back sprain or strain, but then continue as the result of emotional factors long after any physical injury should have healed.
Second, MR imaging studies are so sensitive, that when used inappropriately they may demonstrate incidental “findings” such as a “disc bulge” or “degenerative disc disease”, and the pain becomes attributed to this even when stress is the actual culprit.
The end result is that the affected patient gets sent for endless cycles of physical therapy, then epidural injections and even surgery. Despite these measures, many patients continue in chronic pain.
If the back pain can be correctly identified as stress related in the first place, then the patient can be encouraged to “think psychological, not physical”, and get some psychotherapy to address the unconscious issues.
Obviously, this approach is very different than the way most physicians manage patients with back pain.
Perhaps it’s time for a game change?
Compression of the affected nerve root results in pain (radicular pain), weakness, numbness, and/or loss of deep tendon reflexes.
In cervical radiculopathy (“pinched nerve in the neck”), the radicular pain is referred from the the neck down the arm on the affected side:
The pain and numbness are usually felt most strongly in the area of the arm innervated by the affected nerve root (dermatome). For example, pain from a herniated C67 disc compressing the C7 nerve root will radiate down the arm into the back of the hand and middle finger:
In lumbar radiculopathy (“pinched nerve in the back”), the radicular pain will usually radiate from the low back or buttock down the leg (“sciatica”):
A herniated L5S1 disc will usually compress the S1 nerve root, the sciatica will radiate down the back of the leg into the little toe, and the ankle jerk will be absent:
In most cases, the diagnosis of radiculopathy, as well as the spinal level involved, can be deduced from a careful review the history and examination findings.
An electrodiagnostic study (electromyogram, or EMG) can be useful for confirming the diagnosis of radiculopathy and quantifying the degree of nerve damage in selected cases.
Spinal imaging studies, including plain X-rays, computed tomography (CT) or magnetic resonance (MR) imaging studies are usually needed to identify the cause of the radiculopathy, such as herniated disc, osteoarthritis, tumor or infection.
Most cases of radiculopathy are treated conservatively with pain medicines, activity modification and physical therapy, and ultimately recover spontaneously.
The SPORT study found that while lumbar radiculopathy patients treated surgically with discectomy improved more rapidly that those treated conservatively, both groups improved to about the same degree by 2 years.
Epidural steroid injections are frequently advocated as a treatment modality for recalcitrant cases, despite a paucity of well-designed trials of their efficacy. In fact a recent randomized controlled study published in Evidence Based Medicine showed no benefit of epidural steroids over saline or sham injections, click here for more details.
Surgery is usually reserved for patients with intractable pain despite an adequate trail of conservative measures, or those with severe and progressive motor deficits or cauda equina syndrome (with bowel and bladder dysfunction).