Learn about Back Pain
Back pain is one of the most common problems afflicting the American workforce. At some point in time, 80% of Americans will experience back pain. From Physical Therapists to Pain Management Physicians, we offer complete back pain care with a customized plan relief plan specially created for you.
- Learn more about the Spine
What is back pain?
Put simply, it’s pain located in your back. Back pain is a very common condition and represents the most common category of musculoskeletal pain. This pain can radiate from muscles, nerves, bones, joints or other structures in the spine. Back pain can have a major negative impact on one’s quality of life. It can cause loss of productive work, inability to enjoy leisure activities and in time lead to frustration, anxiety and secondary depression.
Often, neck and back pain resolve in time and with simple measures such as rest and anti inflammatory medication, within several weeks. When such measures prove ineffective, the next level of treatment pursued is more hands-on. Treatments range from physical therapy, massage, acupuncture to chiropractic care. When a reasonable trial of one or more of these interventions fail to provide pain relief and restoration of physical function, the next level of diagnostic and therapeutic options are considered. Spinal injections represent one of these options.
Spinal Injections as a Diagnostic Tool
If simple measures fail to provide adequate pain relief, it is reasonable to perform more advanced diagnostic tests to determine the source of the pain. Completing a precise anatomic diagnosis allows pursuit of more specific treatment options. This is true for both more advanced non-surgical and surgical options.
X-rays, MRI’s, CT scans and bone (SPECT) scans represent common radiological tests to evaluate the anatomy of your spine. These tests are critically important to identify more serious conditions such as a spinal fracture, tumor and infection. When there is weakness, numbness and pain in the arm or leg, a MRI scan is the best test to find what is compressing and compromising a particular nerve root. Common causes of nerve root compression include a herniated disc, bone spur or cyst. These radiological studies, however, have limitations. Often they find minor abnormalities despite significant pain or multiple abnormalities, of which not all are the cause of pain.
Having a history and physical examination by a physician, for those patients with nerve root compression, neurologic signs and pain is a reasonably accurate method to determine the precise source of pain. However, in the absence of neurologic signs (weakness and numbness), a history and physical examination can yield a tentative, but not a definitive diagnosis. Physical examination is helpful to determine the level of spinal involvement and what are the potential pain generators (e.g. disc, facet, muscle).
Largely, in those individuals without nerve root compression associated pain is when spinal injections assist in making accurate diagnosis of the pain source. Under intermittent x-ray guidance (fluoroscopy), small caliber needles are placed into precise locations to numb (anesthetize) potential pain generators such as a spinal nerve or joint. Using a specific diagnostic injection to reproduce the discomfort determines if the disc is the pain source. This test is a provocation discography. This test simulates pressing to produce pain in a tender disc vs. lack of pain with pressing in a normal or asymptomatic disc. The test involves injection of x-ray dye (contrast medium) and monitoring of pressures and pain produced during an injection into the disc. When the radiological (MRI or CT) tests are used with anesthetic injections and at times provocational discography, the source of spinal pain is determined in the vast majority of patients.
Spinal Injections as a Therapeutic Tool
Not only can injection procedures provide diagnostic information, they can potentially be of great therapeutic value when injected with cortisone. Cortisone is a type of steroid. Cortisone is not, however, an anabolic steroid such as those used by body builders to gain muscle mass and strength. Cortisone is specifically used to reduce local inflammation and subsequent pain. It is commonly placed around irritated nerves (interlaminar, caudal or transforaminal epidural) or into irritated spinal joints (facet or sacroiliac joints.)
Additionally, other developed procedures do not involve injecting cortisone. Instead it relies on using a special insulated needle passing radiofrequency waves. Heat is then generated around the tip of the needle to destroy small nerves which transmit pain from symptomatic spinal joints. Essentially, this treatment acts to hide the underlying joint pain that did not resolve with other treatments by destroying the nerves that provide sensation to the target joints.
One should avoid receiving excessive cortisone injections in a 12 month period or one may risk developing secondary side effects and potential complications from too much cortisone. Generally, we limit one to 3-4 injection procedures in a 12 month period. We do not perform a cortisone injection more often than every 2 weeks to reduce the risks of receiving excessive cortisone.
How are these injections performed?
First, your referring physician will make a request for a particular procedure or an evaluation to determine if a procedure benefits you. You will be scheduled at a local surgery center and prepared for the procedure via our administrative office.
Upon check-in you may fill out personal information forms. Then brought back to the pre-op area where we perform a nurse assessment. Relaxation medicine will be given as needed. You will then be brought to the procedure suite where you will visit with the physician before the procedure. The physician will take your history, perform a focused examination, and review your radiological studies (MRI, CT, bone scans). Your physician will then discuss your options. Not all patients, however, are appropriate to receive spinal injection procedures. If it is appropriate, the physician will explain in detail what to expect before, during and after the procedure. All of your questions will be answered.
After medical consent is signed, you will lay on the x-ray table and your skin will be cleansed with betadine or hibiclens to reduce any risk of infection. Monitoring leads will be placed to measure your blood pressure, pulse and oxygen level. If you are receiving IV sedation it will be adjusted so that you are as comfortable as possible during the procedure. We use x-ray guidance (fluoroscopy) to visualize your spinal anatomy and plan the angles necessary to guide a small needle to the targeted area. The needle inserted in your numbed skin. Once the needle is in the correct location, we inject x-ray dye (contrast medium) to assure the flow is to the targeted location. If not, the needle will be gently repositioned and contrast medium re-injected. Once adequate flow occurs, anesthetic (numbing) and cortisone (if it is not just a diagnostic procedure) will be slowly injected.
You are taken to the recovery room for a 30 minute observation and recovery period. At this point, you will rate your pain after the procedure. You will be given discharge instructions and your next appointment before leaving. If you had a diagnostic procedure we will ask you to monitor your pain and mark your results every hour for 4 hours on a pain form after you leave the center. This form must be returned to the office upon your next visit. If you receive a cortisone injection you will also report any pain relief after 2 weeks. This form must be returned to your office when completed for review.
Post Injection Activities
We recommend you go home and rest the day of the procedure. You can cautiously return to your usual daily activities the day after the procedure. If the procedure provides substantial benefit you may increase your exercise, work or sporting activities slowly over 2-4 weeks. Remember, often you cannot tell if you have irritated the underlying problem until 2 days after the activity. If this occurs, cut back on your level of physical activity for several weeks before re-challenging it. You will follow-up with your physician for continued management and care. It is optimal to follow-up with our physician no sooner than 10-14 days after a therapeutic injection. This provides ample time for the maximum cortisone effectiveness.
All injection procedures have risk. Anytime the skin in penetrated there is a very remote risk of local bleeding and infection. When the needle is placed near various structures in the spine there are additional risks of more serious complications. Because we use x-ray guidance (fluoroscopy) and contrast dye to visualize flow of the medication before we perform the active component of the procedure, the risks are dramatically reduced. Complications from any injection procedure, however, remains a very remote possibility. Please call the office if you have any concerns regarding risks or symptoms you may feel after the procedure.
Why do we feel back pain?
We feel back pain due to our body’s dependence on our spine, located in our back. The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, all of which are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities. When an area of the spine gets damaged, pain can radiate all throughout the network of nerves.
What are some easy ways to relieve back pain?
Back pain is a common problem. You can strain back muscles by lifting too much weight or just by moving the wrong way. Back strain is uncomfortable, even painful and it can take weeks to heal. To help yourself feel better and prevent future back strains, try these tips:
Ice helps most during the first day or two after an injury by reducing muscle pain and swelling.
- Wrap an ice pack or a bag of frozen peas in a dishcloth. (Never place ice directly on your skin.)
- Place the ice where your back hurts the most.
- Don’t ice for more than 20 minutes at a time.
- You should use ice several times a day.
Over-the-counter pain relievers include aspirin, acetaminophen, and ibuprofen. They can help ease discomfort and may reduce swelling.
- Tell your doctor about any medications you are already taking.
- Take medications only as directed.
After the first 48 hours, heat can relax sore muscles and improve blood flow.
- Try a warm bath or shower. Or use a heating pad set on low.
- Don’t use a heating pad for more than 15 minutes at a time. Never sleep on a heating pad.
Medial Branch Neurotomy
Back or neck pain is due to problems with certain nerves near your spine. If so, a medial branch neurotomy can help relieve your pain. The treatment uses heat, cold, or chemicals to destroy the nerves near a problem joint. This keeps some pain messages from traveling to the brain, and helps relieve your symptoms.
Medial Branch Nerves
Each vertebra in your spine has facets (flat surfaces). They touch where the vertebrae fit together. This forms a facet joint. Each facet joint has at least two medial branch nerves. They are part of the nerve pathway to and from each facet joint. A facet joint in your back or neck can become inflamed (swollen and irritated). Pain messages may then travel along the nerve pathway from the facet joint to your brain.
Blocking Pain Messages
Medial branch nerves in each facet joint send and carry messages about back or neck pain. Destroying a few of these nerves can keep certain pain messages from reaching the brain. This can help bring you relief.
Risks and Complications
Risks and complications are rare, but can include:
- Increased pain, numbness, or weakness
- Nerve damage
- Failure to relieve pain
Medial Branch Neurotomy: Your Experience
We perform the treatment in a hospital or surgery center. You’ll be asked to fill out some forms, including a consent form. You may also be examined. You may be given an IV (intravenous) line for fluids and medications.
Getting Ready for Your Treatment
- Ask your doctor whether you should stop taking any medications before treatment.
- Tell your doctor if you are pregnant or allergic to any medications.
- Stop eating or drinking 8 hours before you check in for your treatment.
During the Procedure
To help you relax, medication may be given through the IV line. You will lie on an exam table on your stomach, back, or side, depending on where the problem joint is.
- The skin over the treatment site is cleaned and then numbed with medication.
- Fluoroscopy (x-ray imaging) is used to help your doctor see the spine and guide the treatment. A contrast “dye” may be injected into the affected region to help get a better image.
- Heat, cold, or chemicals are used to destroy part of the nerve near the inflamed facet joint. Nearby nerves may also be treated.
Relax at home for the rest of the day after your treatment, even if you feel good.
After the Procedure
Most often, you can go home in about an hour. Have an adult friend or relative drive you. The treated spot may be swollen and may feel more sore than usual. It will be a few days before you feel relief from your symptoms. This is normal and may last for a day or so. Your pain doctor may prescribe pain medications for you during this time. Ask your doctor when it’s okay for you to go back to work.
Call your doctor if you have a fever over 101.0°F, chills, or redness or drainage at the treatment site.
Self-Care for Low Back Pain
Most people have low back pain now and then. In many cases, it isn’t serious and self-care can help. Sometimes low back pain can be a sign of a bigger problem. Call your doctor if your pain returns often or gets worse over time. For the long-term care of your back, get regular exercise, lose any excess weight and learn good posture.
Take a Short Rest
Rest your back for a day or two to begin healing. Use a firm mattress or the floor. Have your lower back firmly supported with a small pillow or towel. Keep your knees slightly bent, with another pillow under them. Every few hours, get up and walk as much as you can.
Reduce Pain and Swelling
Cold reduces swelling while both cold and heat can reduce pain. Protect your skin by placing a towel between your body and the ice or heat source.
- For the first few days, apply an ice pack for 10-15 minutes every hour while you’re awake.
- After the first few days, try heat to ease pain.
- Over-the-counter medications can help control pain and swelling. Try aspirin or an aspirin substitute, such as ibuprofen.
Exercise can help your back heal. It also helps your back get stronger and more flexible, preventing any re-injury. Ask your doctor about specific exercises for your back.
Use Good Posture to Avoid Re-injury
- When moving, bend at the hips and knees. Don’t bend at the waist or twist around.
- When lifting, keep the object close to your body. Don’t try to lift more than you can handle.
- When sitting, keep your lower back supported. Use a back support tool, such as a rolled up towel, as needed.
Call Your Doctor If:
- You’re unable to stand or walk.
- You have a temperature over 101.0°F.
- You have frequent, painful, or bloody urination.
- You have severe abdominal pain.
- You have a sharp, stabbing pain.
- Your pain is constant.
- You have pain or numbness in your leg.
- You feel pain in a new area of your back.
- You notice that the pain isn’t decreasing after more than a week.
What Is Lumbar Epidural Injection?
Your pain doctor may have suggested you have a lumbar epidural injection. This procedure can help relieve and manage low back and leg pain by reducing inflammation (swelling and irritation). An injection also can help your doctor diagnose the source of your pain by numbing certain areas of your back. Where you are injected depends on the goal of the injection.
A Way to Relieve Pain
A lumbar epidural injection won’t stop all low back and leg pain. But it can reduce pain and break the pain cycle. This cycle may begin when back pain makes it hard to move. Lack of movement can then slow down healing. By getting you back on your feet, the injection can help speed your recovery. Some people may feel more relief from an injection than others while some people may need more than one injection to get relief.
A Tool for Diagnosis
An injection can help locate the source of pain. Also called a selective nerve block or a selective epidural, it numbs the roots of specific nerves. The effect lasts only briefly but, if you feel relief, it may indicate the source of the pain. If you feel no relief, it may mean that the pain’s source is at another level in your spine or something other than inflammation is causing the pain. Injection results also may be used to help plan back surgery, if needed.
Possible Risks and Complications of Lumbar Epidural Injection
- Spinal headache
- Bleeding (rare)
- Infection (rare)
Lumbar Epidural Injection: Your Procedure
A lumbar epidural injection is an outpatient procedure. It’s often done in a hospital or an outpatient surgery center. Before your injection, your healthcare provider will discuss how you need to prepare.
You may need to prepare by doing the following:
- Give the doctor a list of all medicines you take, including aspirin and anti-inflammatories. (You may need to stop taking some of them before the injection.)
- Don’t eat 6 hours before check-in, or drink anything 4 hours before.
- Arrange for an adult friend or family member to drive you home afterward.
- Bring any requested x-ray, CT, or MRI images on the day of the procedure.
During the Procedure
The injection takes just a few minutes. But extra time is needed to get ready. You may be given medicine before the injection to help you relax.
- Monitoring devices may be attached to your chest or side. These devices measure your heart rate, breathing, and blood pressure.
- You lie on your stomach or side, depending on where the injection will be given. Your back is cleaned and may be covered with sterile towels.
- Medicine is given to numb the skin near the injection site.
- If fluoroscopy (x-ray imaging) is to be used, a contrast “dye” may be injected into your back. This helps get a better image.
- A local anesthetic (for numbing), steroids (for reducing inflammation), or both are injected into the epidural space.
After the Procedure
You’ll spend up to an hour in a recovery area. Before going home, you may be asked to fill out another survey about your pain.
Lumbar Epidural Injection: Recovery at Home
You don’t need to stay in bed when you get home. In fact, it’s best to walk around if you feel up to it. Just be careful about being too active. Even if you feel better right away, avoid activities that may strain your back. And follow up on all treatment with your doctor.
What to Know About Pain Relief
Keep in mind that some patients feel increased pain at first. It usually goes away within a few days. You may also have headaches or trouble sleeping. These should also go away within a few days. In general:
- An injection to reduce inflammation takes a day or two to work. There may even be more pain at first.
- An injection to help locate the source of pain may give only brief pain relief. Later, you’ll feel the same as you did before the injection.
Tips for Recovery
Whether you were injected for pain relief or diagnosis, these tips will help you recover:
- Take walks when you feel up to it.
- Rest if needed, but get up and move around after sitting for half an hour.
- Don’t exercise vigorously.
- Don’t drive the day of the procedure or until your doctor says it’s OK.
- Return to work or other activities when your doctor says you’re ready.
When to Call Your Doctor
Call right away if you notice any of the following symptoms:
- Severe pain or headache
- Loss of bladder or bowel control
- Fever or chills
- Redness or swelling around the injection site
All the information presented is courtesy of the following organizations:
US Dept. of Health and Human Services
National Institutes of Health
Mayo Clinic Back Pain
WebMD Back Pain
Back Pain on Wikipedia