Where Back Pain Begins

Back Pain

Pain in the low back, or lumbosacral region, is an ailment most people experience at some point in their lives. Lifting heavy objects, motor vehicle accidents, certain diseases and just getting older are a few of the diverse causes behind low back pain, which may disrupt daily routines and detract from quality of life.

When low back pain becomes a problem, the trusted pain experts at Wake Spine & Pain Specialists will work with you to develop the optimal treatment plan to eradicate your pain. Our pain clinic is staffed by experienced pain management doctors with exceptional training in leading techniques such as facet and epidural injection, spinal cord stimulation and radiofrequency ablation. Whether your treatment involves chiropractic manipulation, pain medicine, injections, electrical stimulation or a combination of proven therapies, Dr. Mandhare and his colleagues will develop a personalized plan of pain management to help restore your personal health and enjoyment.

If you suffer from low back pain, you are not alone. Researchers from the National Institutes of Health (NIH) found that low back pain was the most common type of pain among respondents of a survey (27%). Further, NIH researchers found that back pain is the leading cause of disability in Americans younger than 45 years old, and more than 26 million Americans between the ages of 20-64 experience recurrent back pain (NIH, 2006).

Anatomy of the Spine

In most people, the spine or vertebral column is comprised of 33 interlocking bones, or vertebrae, which are connected by fibrous bands called ligaments and divided into five regions: cervical, thoracic, lumbar, sacral and coccygeal. The vertebral column provides support for the upper body as well as protection for the spinal cord, and furnishes attachment points for the ribs and muscles of the back. Between the vertebrae are the elastic intervertebral discs, which provide cushioning for the bones of the spine and promote flexibility. Deterioration and deformity of these discs can lead to impaired movement as well as severe pain.

Spinal Ligaments and Muscles

The most common cause of low back pain is myofascial injury, or muscle and ligament damage sustained from exercise, physical accidents, lifting of heavy objects, poor posture, and other causes. When these structures become strained, irritation may occur in local nerves that exit the spine.

Typically, back pain from myofascial injury resolves in a few weeks. If your upper back pain persists, consult with the doctors at Wake Spine & Pain Specialists. We offer a variety of treatments for persistent back pain. Your pain doctor will choose the most appropriate treatment plan based upon the underlying cause of your pain and your medical history.

Spinal Bones

The vertebrae of the spine provide a mobile, supportive framework for the spinal cord and back. These bones interconnect, or articulate, smoothly with each other at special joints called facets. Each facet joint is comprised of articular and transverse processes. The articular processes of a vertebra include two superior (upwardly pointing) processes that are linked to two inferior (downwardly pointing) processes from the preceding vertebral body. These processes project outward and can be felt through the skin. The transverse processes are located on either side of each vertebra and serve as attachment points for muscles and ligaments.

Each vertebra contains a central opening to permit passage of the spinal cord, as well as apertures on either side to accommodate spinal nerves and vessels. Degeneration of the bone can lead to painful friction between facet joints and compression of nerves that exit the vertebral column.

Another bone-related ailment that can cause low back pain is facet joint arthritis. In this condition, harmful friction between the processes of the facet joints results from breakdown of the cartilaginous tissues between each joint. In healthy joints, these tissues provide a smooth cartilage surface and a lubricating fluid that facilitate smooth movement. When these tissues degrade, the bony surfaces grind upon each other, inhibiting movement and causing pain and stiffness.

Vertebral Discs

Located between neighboring vertebrae are pliable intervertebral discs filled with a soft, gelatinous substance. These discs cushion and promote smooth, flexible movement of the vertebral column. When excess pressure is put on a disc, it may bulge out of place, producing local nerve irritation and compression of the spinal cord, and you may be diagnosed with a bulging disc. Sometimes a disc tear or softening in the outer fibrous layer of an intervertebral disc forces the pliable inner material through the weakened part of the disc. This phenomenon is known as aherniated disc. As in the case of a bulging disc, a herniated disc causes local nerve irritation and compresses the spinal cord, producing pain.

Another way that intervertebral discs can contribute to low back pain is through degenerative change that occurs with the aging process. As a person ages, discs in the vertebral column can flatten, deform and lose their suppleness, inhibiting smooth movement and causing pain. Although disc herniation is associated with degenerative changes associated with aging, it can occur in younger people, generally by trauma or heavy lifting.

When spinal nerve roots are compressed from disc problems or other reasons, pain often radiates down the length of the nerve. Termed radiculitis, this pain is frequently described as “shooting” since it travels from the spine outward. For example, pain from a compressed nerve may shoot down an arm or leg. In the low back, radiculitis within the large sciatic nerve that extends through the buttocks down the back of the leg causes the common ailment sciatica.

When radiculitis goes untreated, complications such as muscle atrophy, reflex changes and sensory loss may occur over time. In addition, a patient may begin to favor their unaffected side, causing overdevelopment of unaffected muscles. This more severe nerve root condition is known as radiculopathy and underscores the importance of seeking help for your radiating nerve pain.

Other Causes of Back Pain

Spinal stenosis is a painful chronic condition that can be responsible for low back pain. In spinal stenosis, pathological narrowing of the spinal canal puts painful pressure on the spinal cord. The condition may result from a variety of causes including arthritis of the spine, herniated discs, congenital defects (abnormalities present at birth) and Paget’s disease, a bone disorder involving abnormal breakdown and regrowth of bone tissue. If your doctor diagnoses you with central spinal stenosis, the narrowing is occurring around the central region of the spinal canal directly surrounding the spinal cord and cauda equina, or the downward-extending bundle of nerve fibers at the bottom of the spinal cord. If your spinal stenosis is “neural foraminal” or “neuroforaminal,” the narrowing is affecting spinal nerves where they exit through the foramen, which are openings in the vertebrae.

Another pain-producing ailment of the low back is osteoporosis, an age-related disorder where bones become weaker and more brittle due to loss of bone mass. This weakening heightens the risk for painful vertebral compression fractures of the vertebrae and irritated nerves. Osteoporosis can be diagnosed following a bone fracture using imaging and bone density tests. Treating osteoporosis early can prevent deformity, back pain, broken vertebrae and other fractures.

Chronic low back pain from any long-term condition like osteoporosis, facet arthritis, radiculitis, and spinal stenosis may lead to central sensitization. In central sensitization, chronic injury and inflammation in peripheral tissues eventually prompt pain receptors in the central nervous system to overreact to normal physical sensations. Low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli. As a result, harmless stimuli eventually provoke feelings of pain. To avoid central sensitization, do not delay seeking help for your low back pain.

Rarer mechanisms of low back pain include cancer and infection. In the case of cancer, tumors or metastases to the spine weaken or expand bone in the vertebral column, often leading to fracture, nerve compression, or spinal instability. And any source of infection (e.g., dental abscess, pneumonia) can seed the spine; urinary tract infection is the most common (Siemienow et al, 2008).

Referred Pain

Another typical cause of low back pain is referred pain. Although this type of pain originates from structures located in the same region as the spine, it is interpreted by the brain as pain felt in the back. For example, problems with reproductive organs can be perceived as low back pain. In cases of referred pain, treating the underlying cause helps eradicate discomfort felt in the low back.

One common cause of referred pain in the back or legs is shingles, or reactivation of the varicella zoster virus that causes chicken pox. Back pain with shingles occurs when the dormant chicken pox virus becomes active within one or more spinal nerves, causing flu-like illness, back pain, and a distinctive localized rash. A complication of shingles is postherpetic neuralgia, or nerve damage that manifests as chronic pain, sensitivity to touch, itching, and weakness or paralysis.

Acute Low Back Pain

Generally, acute low back pain appears suddenly during a specific activity. Strenuous exercise, heavy lifting, motor vehicle accidents and trauma are some of the common causes of acute low back pain. Typically, damage to muscles and ligaments sustained during these events is the cause of acute low back pain; less commonly, spinal bone fracture or compression of the spinal cord can cause acute low back pain. Although acute low back pain is generally associated with an event, it may occur from a pre-existing chronic condition such as spinal stenosis, osteoporosis and cancer. Since it can also occur from conditions in unrelated organ systems such as kidney stones or infection, your physician may evaluate you to rule out these causes.

Acute low back pain can be an emergency situation. For example, spinal cord compression can be life-threatening. Always seek immediate help if you experience fever and chills, weakness or paralysis, or loss of bowel or bladder control.

Chronic Low Back Pain

Most people with back pain recover within 4 to 6 weeks. Although low back pain may resolve in a relatively short period of time, it often recurs, contributing to the large number of Americans who seek help from pain management doctors for a chronic low back pain condition.

Beyond facet joint arthritis, degenerative disc disease, spinal stenosis, osteoporosis and cancer, another chronic condition responsible for enduring low back pain is fibromyalgia. This chronic disorder is characterized by generalized muscle, bone, ligament and tendon pain, in addition to fatigue and heightened sensitivity to tactile pressure (allodynia). Some experts believe fibromyalgia results from lifelong alterations in the central nervous system. In addition to low back pain, patients with fibromyalgia may experience a lower general pain threshold. This is because fibromyalgia is another of the many chronic disorders believed to provoke central sensitization, or an oversensitivity of the central nervous system to physical stimuli.

Current research suggests early intervention decreases the chance of developing chronic pain which can lead to central sensitization, so it is important to consult with a pain specialist promptly to explore your treatment options.

The specialists at our  pain center will inquire into the nature and history of your pain, conduct a thorough physical examination, and may order tests to help diagnose your condition accurately. Wake Spine & Pain Specialists understands the stress and inconvenience of living with a painful condition and strives to bring you back to health as quickly, efficiently and non-invasively as possible. With our numerous combined years of experience, we are confident we can design the best pain management plan for you.

Diagnosing Back Pain

Your doctor may order a variety of tests to help diagnose the cause and severity of your pain. Some of these tests may include:

• Imaging studies – MRI, CT scan and X-ray are used to help our practitioners visualize structures that may be causing your pain.
• Medial Branch Blocks (MBBs) – Medial Branch Blocks are a minimally invasive non-surgical treatment used for arthritis-related neck and back pain. Diagnostically, MBBs are used to test whether your pain-producing medial branch nerves will respond to more permanent interruption by a radio-frequency ablation. They also have a therapeutic effect in that they reduce inflammation and irritation in the facet joints of the spine.
• Selective Nerve Blocks – These are used to help your practitioner identify which nerves are causing your pain. By selectively numbing each nerve, pain-causing nerves can be identified and treated.
• Discography – Discography involves the use of contrast dyes to obtain a detailed image of intervertebral discs. It is used to evaluate patients whose back pain has not improved with comprehensive conservative care regimens. It provides the doctor with detailed information on the pain potential of the affected area, and is commonly used for surgical planning prior to a lumbar fusion.

Back Pain Treatment Options

Below is a basic overview of pain relief options:

• Pharmacotherapy – Administration of non-steroidal anti-inflammatory drugs (NSAIDs, or Ibuprofen-like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications is often effective in treating low back pain. Our doctors are highly trained in pain medication management.
• Epidural Steroid Injections – Frequently, epidural injections are used for degenerative disc disease and other pain syndromes. The doctor injects 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.
• Facet injections – These minimally invasive injections can temporarily relieve neck or back pain caused by inflamed facet joints.
• Spinal Cord Stimulation (SCS) – An implanted electrical device decreases the perception of pain by confusing the spinal cord and brain pain processing centers. Initially a trial is conducted to determine whether this device will help the patient on a long-term basis.
• Lysis of Adhesions (Racz Procedure) – This procedure helps remove excessive scar tissue in the epidural space. It is used in vertebral body compression fractures, post-laminectomy syndrome, radiculopathy, and disc disease.
• Peripheral Nerve Stimulation – This method involves placement of tiny electrodes near the affected nerves. The electrodes release a small electrical current that inhibits pain transmission and provides pain relief.
• Kyphoplasty and Vertebroplasty – These minimally invasive procedures can treat osteoporotic fractures. Crushed vertebrae are stabilized by injecting acrylic cement into the vertebra.
• Intrathecal Pump Implants – Implanted pain pumps are also available which can be extremely helpful in providing long-term pain control. A study examining the efficacy of intrathecal therapy in people suffering pain due to cancer showed a pain reduction in 66.7% of patients (Becker et al, 2000).
• Percutaneous Discectomy – A needle is inserted through the skin into the affected disc, material is suctioned out of the bulging disc and pressure is relieved within the disc.
• Cryotherapy – Affected nerves are identified via electrical stimulation and destroyed by freezing cycles.
• Radiofrequency Ablation – Nerves branching away from the spinal cord (peripheral nerves) can be blocked with local anesthetic, after which nerve ablation or destruction can be initiated.
• Trigger Point Injections – These injections can extremely successful in alleviating musculoskeletal pain. A local anesthetic and steroid are injected into a “Trigger Point.”
• Transcutaneous Electrical Nerve Stimulation (TENS) – This is a pain relief technique performed 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. The efficacy of this treatment is well-known; for example, a recent study examining the impact of long-term TENS therapy in patients with degenerative disc disease found TENS therapy contributed to pain relief and improvement of function and mobility of the lumbosacral spine and concluded TENS is an appropriate and effective treatment technique (Pop et al, 2010). In addition, 100% of patients given the treatment reported pain relief as well as improved spinal function and mobility.
• Biofeedback – This therapy teaches awareness of processes normally thought to be involuntary inside of the body such as blood pressure, temperature and heart rate, enabling some degree of conscious control of these processes. Biofeedback can influence and improve level of pain and promotes relaxation.
• Nutrition and Exercise – Exercise helps manage the pain of sciatica by increasing flexibility and range of motion. Another benefit of exercise is the release of pain-relieving hormones called endorphins. In conjunction with a reasonable exercise regimen, good nutrition helps combat nutritional deficits that may hamper the body’s functionality and healing processes.
• Massage – Gentle focal rubbing of tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with these events. Massage may also promote relaxation, decreasing stress and tension.
• Chiropractic Manipulations – Targeted physical “adjustments” may significantly reduce back pain, especially when combined with other modalities. Specialized manipulations intended to correct nerve transmission are delivered by a knowledgeable, experienced practitioner.
• Prolotherapy – Also known as Regenerative Injection Therapy, this technique involves injection of irritating substances into painful ligaments and tendons. The procedure is used to initiate the body’s natural healing processes.
• Surgery – Surgical procedures are a last resort when conservative treatments are unsuccessful in reducing pain or when the spinal cord or exiting nerves are being severely compressed. Serious compressions may be characterized by bladder and bowel incontinence, lower extremity weakness, spasticity, and loss of sensation. Invasive surgical procedures include discectomy, laminectomy, spinal fusion and spinal instrumentation. Since surgery carries the risk of complications, it is used only when less invasive procedures have failed to restore functionality and provide relief.

Wake Spine & Pain Specialists cares about your quality of life and understands the burden of living with pain. Our caring practitioners will listen to your concerns and work with you to develop a pain management program that will help you return to good health and happiness.