Best Treatment for Lower Back Pain. ALL you need to know !!!!

Are you or your loved ones suffering from lower back pain? Looking for the best treatment for lower back pain? You are not alone. You are one of the 25 million Americans who suffer from back pain. Talk about misery loves company!!! In fact, lower back pain was the most common reported pain site, exceeding joint conditions, headache/migraines, neck, and facial, or jaw pain. Lower back pain and Neck pain are the leading cause of disability in most countries.

Ok, we now know lower back pain unfortunately affects a lot of us and it sucks. So, what should you do? Which professional should you consult? When should you see a doctor? What is the best treatment?

I am sure all these questions ran through your mind. I will attempt to answer these simple yet tough questions. What I will be discussing is based on the assumption that you lower back pain is coming from exclusively from your spine not other areas like the Aorta [large blood vessel in your abdomen] or the abdominal organs like pancreas.

MOST IMPORTANTLY ANSWER THIS FIRST QUESTION. HAVE YOU BEEN SUFFERING FROM LOWER BACK PAIN FOR LESS OR MORE THAN 3 MONTHS?

Why is this question so important that I had to use capital letters? Because, the treatment for lower back pain less than 3 months [it is called Acute back pain] is dramatically different than for pain lasting more than 3 months [this is called Chronic back pain].

Lets talk about Acute back pain first. If you had back pain or leg pain or both for less than 3 months, here is the good news. The odds of you getting better without any treatment is very high. Time to open the champagne? Maybe. However, it is important to rule out what we call as the “red flags” conditions. These are dangerous conditions which can cause Acute back pain. I will give you another good news. These conditions are extremely rare. So, what are they and how do you know you do not have them? I will name the conditions and a few screening questions will help us to rule them out.

Cancer. Do you feel excessively tired or have lost weight [unintentionally of course]? Do you have a history of cancer?
Infection of the spine. Do you have any recent fevers or chills or sweats? Did you have any procedure or surgery recently? Did you have chemotherapy recently? Are you receive an organ transplant recipient? Are you on any immunosuppressive drugs?
Spinal cord or nerve compression. Do you have rapidly progressing significant Numbness, Tingling or Weakness in your legs? Do you have recent severe constipation or difficulty in urination? Did you have either stool or urinary accidents recently? Do you have Numbness in the anal area?
Spinal Compression Fracture? Did you have any recent history of trauma or injury or a fall?
Most likely you have answered “NO” to all these questions because these conditions are very rare. However, is important to diagnose them and treat them immediately. The treatment is very specific to the condition and is different for each condition. In the interest of your precious time, I wont discuss these treatments now. Because if you have these “red flags” you should not be reading my blog and should be calling 911 or heading to the ER.

Good that you don’t have the red flags. You have the garden variety Acute back pain. Time to reach out for advil or motrin or naprosyn etc[ pick only one at a time but you can try different brands separately and see which works the best]. Add tylenol if needed. Experiment on different over the counter rubs. Get a massage. Use hot or cold packs [whichever works]. Most importantly, try to be as active as possible. Wait for a few days if you can.

Should you use narcotic pain killers like vicodin or percocet in acute lower back pain? Will you get addicted?

These are very good questions. Yes, you should use narcotics if pain is severe. They are very effective in this setting. And no, you will not get addicted. When 11,882 patients with acute pain who did not have a history of drug abuse were treated with narcotics, only 4 patients got addicted. I think chances of getting hit by lightening are higher. Bottomline is do not hesitate to use narcotics if pain is severe.

Still not better? Time to see a physical therapist or a chiropractor. Wait for a few days if you can.

Still not better? Time to call your family doctor and ask for a steroid dose pack. Wait for a few days if you can.

Most patients will start seeing improvement by now. If pain is still debilitating, its time to get an MRI of the lower back [good luck with your insurance] and get an epidural steroid injection[good luck with your insurance again].

Still not better? Hate to say the dreaded “S” word. SURGERY. Something to consider especially if you are having leg pain.

Still not better? You unfortunately belong to the 20% of patients who persist to have pain after an acute pain episode. Now we have to move on to the protocol for treatment for lower back pain which is chronic.

TREATMENT FOR LOWER BACK PAIN [CHRONIC]

As I have said before, back pain lasting more than 3 months is classified as Chronic back pain. This is a totally different animal. Unlike Acute back pain which resolves spontaneously in most cases, Chronic back pain will usually not get better unless it is treated.

Start with conservative therapies like phyisical therapy, chiropractic care, massage therapy, TENS machine and accupuncture. Braces help with back pain but should be used only when you are active. Using a brace all the time would weaken your spinal muscles and may worsen your pain.

With regards to medications, tylenol would be the first choice. NSAIDS like advil, motrin, naprosyn etc should be avoided. Long term use of NSAIDS is known to cause stomach ulcers, strokes, heart attacks and kidney failure. However, they can be used during acute flare ups. Other classes of drugs like anti-convulsants like [gabapentin and pregabalin] maybe helpful especially if you are having leg pain. Some patients find anti depressants like elavil and cymbalta also useful.

WHAT IS THE ROLE OF NARCOTIC PAIN KILLERS IN THE TREATMENT OF LOWER BACK PAIN[CHRONIC]?

This is a hot topic lately. There are a lot of misconceptions. I will make a humble attempt to clear them.

Narcotics like vicodin or percocet have an important role in chronic back pain. Unlike tylenol which causes liver damage, especially with high doses or NSAIDS which cause all the problems mentioned above, narcotics do not have any deleterious effects on organs. Among all classes of drugs used [like the ones mentioned above], narcotics seem to be the most effective in relieving chronic lower back pain. Some patients develop sedation, nausea and constipation when they first start taking narcotics. But as they continue to take this medication, these side effects disappear as the body gets used to them. Constipation sometimes may not get better but in most cases mild laxatives work. Many patients manage their chronic pain well using low dose pain killers without needing procedures or surgery.

Unfortunately, unlike in acute pain, the biggest risk of narcotics is addiction in the chronic pain scenario. This is due to long-term exposure to the drug. However, if they are taken solely for pain relief, the risk of addiction is extremely low. If they are taken for any reason other than pain relief, the risk of addiction is extremely high. There is a significant reduction of abuse and addiction if low doses are used. If a trial of low dose narcotics fail to provide meaningful pain relief, tell you doctor that you no longer need them. This is very important. IF LOW DOSES FAIL TO PROVIDE RELIEF, STOP TAKING THEM. UNFORTUNATELY, IF SMALL DOSES OF NARCOTICS FAIL, THE ODDS OF HIGH DOSES HELPING ARE EXTREMELY LOW.Higher doses not only increase your risk of addiction but also result in more side effects.

In case you feel that you are developing a “craving for the narcotic”, immediately inform your physician and tell him or her to gradually wean you off the medication. There is no role for anxiolytics like valium, xanax, ativan, soma etc in chronic back pain.

Some physicians make a good argument that opioids in chronic back pain should be used as a last resort and should be used only when all other modalities fail. I find it difficult to argue against that. But should narcotics be used before extensive surgery like fusion? I don’t know. Maybe. Hard to argue against that too. I usually let the patient decide.

TREATMENT FOR LOWER BACK PAIN [Chronic] WITH INJECTIONS.

If conservative measures as described above fail, it is time to consider the spinal injections.

“But doc, I heard they are painful and I may get paralysed?”

I have heard this question too many times. No, they are not painful and No, the risk of serious complications like paralysis is ridiculously low. Thank God.

Of course, you will have discomfort but if your doctor is hurting you, its time to look for another doctor. These procedures [except discogram which you will rarely need] are relatively painless if your doctor is worth his salt.

Interventional spine specialists usually consider discs, spinal nerves, facet joints and sacroiliac joints as the primary pain generators. Although muscles and ligaments can cause pain, they seem to be secondary. Because lower back pain is complex, history, physical exam and sophisticated tests like MRI cannot usually pinpoint the pain generator.

It is important that I introduce a very important concept of MRI of the lower back and pain. Many patients have significant changes on MRI but have no pain. Only when these changes are associated with inflammation, there is pain. We should not be treating the MRI. We should be treating the inflammation, thereby reducing pain.

Although not 100% accurate, spinal procedures tend to be superior in identifying the pain generator. In other words, spinal injections can aid with diagnosis and in some cases also help with providing pain relief.

Why is it important to identify the pain generator ?

Because identification of the pain generator enables us to target it for pain relief.

Now, lets look at the each of the primary pain generator and the treatment for lower back pain options.

Spinal nerve. Herniated disc or a torn disc usually irritates the nearby spinal nerve resulting in back and leg pain. This is commonly called sciatica. In this case, the pain is predominantly in the leg. Epidural steroid injection can help calm the inflamed nerve thus giving pain relief. Although this injection does not cure disc herniation or tear, simply reducing the swelling of the adjacent nerve, sometimes provides long-term relief. Please don’t ask me how. Nobody knows. Epidural injections helped many patients avoid surgery. If epidurals fail to provide pain relief, we have a few more options. When a disc is bulging and physically irritating the nerve, the disc can be removed with a needle, avoiding surgery. Although insurance companies were not reimbursing this procedure in the past, they seem to be warming up to this procedure. This is called percutaneous discectomy. If this is not an option, Spinal cord stimulation should be used as a last resort, especially if there are no surgical options.
Facet joint. Facet joint arthritis is a common cause of back pain. Usually in this situation, leg pain is minimal. This pain can be treated by injected steroids into the facet joint. This alleviates pain stemming from the inflamed joint. If the steroid injection fails, the tiny nerve which supplies the joint [medial branch] can be ablated to provide pain relief. This procedure is called Radiofrequency Neurotomy.
Sacroiliac joint. This joint like the facet joint, when inflamed , causes predominantly lower back pain. It can be treated with injecting steroids into the joint. If steroids provide no relief or only short term relief, the nerves supplying this joint can be ablated using Radiofrequency energy. Unfortunately, Medicare and most insurance companies do not approve this procedure and hence its rarely done.
Lumbar Disc. Disc is one of the commonest structure causing lower back pain. It has an outer ring called annulus which encloses soft nucleus pulposus which is in the center. The annulus has nerve supply and when the disc is irritated, there is an over growth of these nerves resulting in pain. Disc pain is also predominantly in the lower back without much leg pain. It is usually midline. Unfortunately, there are no traditional procedures which are covered by insurance to treat disc pain. However, injecting stem cells into the disc seems to be extremely promising. Preliminary clinical reports are showing great results which seem to long lasting and with no complications. Unfortunately, insurance does not cover it. But, if you can find a right doctor and if you don’t mind paying from your pocket, stem cells seem to be the best option currently.
It is important to keep in mind that most lower back pain is multifactorial. By that I mean that most of the lower back pain is not coming from just one structure. Mostly, it is from 2 or 3 structures. This means multiple pain generators need to be targeted with injections. In our experience, a lot of patients get relief with these injections and by adding low dose narcotic pain killers, they are able to find the pain tolerable.

What are your options if injections failed to provide relief ?

Its time to introduce the new kid on the block who is shaking things up in the treatment for lower back pain.

STEM CELLS.

You may not have heard much about using Stem cells in the treatment for lower back pain. Not surprising. The whole stem cell arena is a new innovation in the medical field. Some even consider it as significant as discovering antibiotics and vaccines.

Stem Cells’ main job is to heal and repair. Although they may regenerate your discs, their main role is decrease inflammation long term by secreting very potent anti-inflammatory chemicals, thereby reducing pain. In fact, for this reason, Arnold Caplan, one of the discoverers of Stem calls, call them Medicinal Signaling Cells.

Your hip bone [iliac crest] has easily accessible stem cells. These are extracted and then placed in the spine. This is the basic concept of the minimally invasive, office based procedure.

There is some data that when stem cells are placed in your discs, it helps with pain. I do admit that there is not a lot of data. However, the limited data that exists, reveals that patients are doing very well and there are no complications. According to one study, the relief seems to be long lasting up to 3 years and more. Anecdotally, we are seeing excellent results in our clinic. At this time it seems like stem cells are a viable treatment for lower back pain especially when all other modalities fail.

The results from Stem cell therapy significantly depend on the expertise of the physician. Make sure your physician is well trained and certified in spinal injections. There are a lot of clinics who are taking advantage of desperate patients. These clinics typically hire poorly trained physicians or in the worst case use Physician assistants to perform the procedure. Do your research and check out the qualifications of the physician before getting stem cell treatment for lower back pain.

FDA allows Bone Marrow stem cells only. Because of safety concerns, FDA does not approve Stem cells from other sources like Fat, Amniotic fluid and Umbilical Cord. However, there are clinics who use them. Avoid these centers.

Unfortunately, insurance doesn’t cover this procedure. Do your research about cost as there is a big variation among different clinics.

What if Stem cells are not an option?

Now we are end of road in terms of conservative treatment for lower back pain. Its time to consider the “S” word.

SURGERY.

If you are reading this sentence, you have a lot of patience browsing this long tedious article. I applaud you. It means you really care about the treatment for lower back pain. Hope you got some of the necessary information you are looking for. Obviously, we barely scratched the surface. But, its a good start.