Spinal Pain. Summary of Pathology and Treatment Options

December 13th, 2012

The following is a quick summary of my understanding of spinal conditions and current treatment options.  I tried to attach references and links whenever I could. Hope this helps.  Feel free to email me to comment or to give feedback. Also watch for a Blog by Rochelle in the near future.  She will be putting together patient information sections specific to various regions of the body.  These can be  used as a resource to understanding a particular region and various treatment options when conventional therapy fails.  For the time been I will do a general summarization below. 

 

Bryan Shopka

 

Physiotherapist

 

Resolve Health Partners

 

Douglas Square

Back Ground of Spinal Conditions

Spinal problems are among the most common chronic conditions in Canada 1.. Four out of five adults will experience at least one episode of back pain at some time in their lives, 2.-5 although occurrence is most often between the ages of 30 and 50 6.

In Canada spinal problems generally occur equally in frequency in both men and women. Spinal pain is generally mechanical in nature resulting from traumatic injury (slip/fall, motor vehicle accident), sustained irritating posture (poor ergonomics or body mechanics), degenerative changes due to aging and genetics, or an underlying medical condition. Contributing factors include muscle imbalances, sedentary lifestyle, obesity, and lack of attention to posture. There is also evidence suggesting that psychosocial factors (e.g., chronic stress and depression) contribute to back pain7-8 .

Impacts Spinal Pathology Has On Quality Of Life

The affects of spinal pain can be debilitating and can significantly impact activities of daily living.  Spinal pain is generally severe and often activities are reduced or avoided because of the concern that the activity will increase the pain or cause further injury. Normal daily tasks can be difficult due to the limited range of spinal movement or due to the pain itself. People with acute spinal pain are often unable to work, and even if they can work, they may be less productive. The elevated levels of pain can affect sleep resulting in fatigue. The frustration that results from living with constant pain can also lead to depression 9 . In addition, the pain may affect the capacity to sustain social relationships due to avoidance of certain activities.

Anatomy and Pathology

Structures that make up a typical spinal segment are a spinal disc, two spinal joints, muscular tissue and nervous structures. All four of these structures must work in concert with each other along with all of the other spinal segments in the spine in order for the spine to be void of pain and dysfunction.  Because of the complexity of the spine and the numerous structures involved, a proper assessment is crucial in order to determine the structure(s) at fault when contemplating the source of an individual’s spinal issue. Any one structure or a combination of any of the above can be at fault when dealing with spinal pathology.  A good web page to visit to learn more about the spinal structures and various pathologies associated with them is http://www.spinehealth.com/blog/

Treatment Options

Ideally, you should have a physiotherapist do a thorough assessment of your spine to categorize your individual spinal problem.  After which your problem should be clearly defined and an individualized treatment program should be developed. Quality of assessments can vary. So ask around, and try to avoid high volume clinics.  Every physiotherapist is well trained through the educational system, but not every clinic is set up to allow these Physiotherapists to fully utilize their training and knowledge.

The main treatment approach accepted by medical practitioners treating patients with spinal conditions is that of conservative care.  Conservative care includes joint mobilization, massage therapy, strengthening programs, flexibility programs, lifestyle changes, and chronic pain management strategies including the possibility of psychological counseling.

Yes, I left out chiropractic.  This was purposeful. If your condition requires a manipulation my view is that you should have a manipulative physiotherapist do it. They will actually take the time to do safety checks prior to a manipulation to ensure that you are not a risk for serious damage and also inform you of possibilities that can not be ruled out prior to attempting manipulations.  Manipulations should be done by well trained practitioners who have more than 5-10 mins to properly assess you, and only utilize manipulations to remove a joint restriction; not to temporarily block out pain. Manipulations should be one of many tools in a practitioner’s tool box and should not be advocated for every patient that walks into a clinic with some sort of pain. Here is some info to think about regarding safety issues (http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.htm).

Non-conservative treatment includes a more invasive spinal surgery approach. Surgery is utilized only when conservative approaches fail and with  people who have neurological compromise resulting in serious impairments.  Surgeons will not guarantee relief from pain resulting from discs or spinal joints, thier goal is to reduce compression on compromised neural structures.  Quite often patients will still have back pain following surgery, but thankfully compressed nerves are usually relieved. Surgical approaches include lumbar fusions (http://www.spine-health.com/treatment/spinal-fusion/lumbar-spinal-fusion-surgery) and microdiscectomies (http://www.spine-health.com/treatment/back-surgery/microdiscectomy-microdecompression-spine-surgery). Besides the above situation or if a patient has a genetic condition requiring correction or a traumatically unstable spine, then spinal surgery is rarely offered.  However when a condition arises that requires a surgical approach, it is viewed with the upmost importance. Delays in treatment in these patients can result in irreversible damage to nervous tissue and seriously impair their quality of life.

Another approach that adjuncts conservative care for spinal pain is utilizing joint injections, nerve blocks/rhizotomies, and selective epidurals.  Here is a few links to read further:

Facet joint injection discription:

http://www.eorthopod.com/content/facet-joint-injections

video:

facet joint injection

Info on Facet Nerve ablation/ rhizotomy

http://www.spineuniverse.com/treatments/pain-management/facet-rhizotomy

Video:

Facet joint ablation / Rhizotomy

Info on Selective epidural / spinal nerve block:

http://www.spine-health.com/treatment/injections/injections-back-pain-management

Video:

Spinal nerve epidural

These approaches are used when patients plateau utilizing conservative care and surgical care in not appropriate.  Moreover pain should be  significant enough to affective activities of daily living.  These injections and nerve treatments should only be used to help an individual control thier pain so that they can continue to focus on rehabilitative exercises to further improve their condition or to at least maintain their current state.  It is not wise to use pain blocking injections or rhizotomies without a rehabilitative plan / program unless the patient is fairly elderly and further progression of existing spinal conditions are less of a concern.

Another approach is Prolotherapy.  I will have a local Doctor comment on this and create a seperate post at a later date.

Summary

Spinal conditions are complex and can be very debilitating.  Because of this you should find a physiotherapist to properly diagnosis your condition properly.  A proper assessment of spinal conditions is usually lengthy and may require a few appointments to properly diagnosis.  Treatments should always start with conservative therapy, which should always incorporate a home program to adjunct the treatments given within the clinic.  A home program should include proper and selective strengthening / flexibility exercises aimed towards re-established normal range of motion, strength and postural control.  If conservative therapy fails, then ask about the various other adjunct therapies mentioned above.  If your condition includes irritation to nerve tissue, make sure your therapist is monitoring this properly and seeks advice from a spinal surgeon if necessary.  Spinal surgery should only be utilized when there is a risk of permanent nerve damage.  Surgery does not guarantee pain relief originating from disc or joint structures of the back.

References

  1. Schultz SE, Kopec JA. Impact of chronic conditions. Health Reports 2003; 14 (4): 41–53. [Statistics Canada, Catalogue 82-003].
  2. McPhillips-Tangum CA, Cherkin DC, Rhodes LA, Markham C. Reasons for repeated medical visits among patients with chronic back pain. J Gen Intern Med 1998; 13: 289–295.
  3. Mayo Clinic. What Is Back Pain? [Online]. Available at:
    http://www.mayoclinic.com/invoke.cfm?id=DS00171. Accessed December 2004.
  4. Hicks GS, Duddleston DN, Russell LD, Holman HE, Shepherd JM, Brown A. Low back pain. The American Journal of the Medical Sciences 2002; 324 (4): 207–211.
  5. Wheeler AH, Stubbart JR, Hicks B. Pathophysiology of chronic back pain. eMedicine [Online]. Available at:
    http://www.emedicine.com/neuro/topic516. Accessed December 2004.
  6. National Institute for Neurological Disorders and Stroke. Low back pain fact sheet [Online]. Available at:
    http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Accessed December 2004.
  7. Kopec JA, Sayre EC, Esdaile JM. Predictors of back pain in a general population cohort. Spine 2004; 29 (1): 70–77.
  8. Dunn KM, Croft PR. Epidemiology and natural history of low back pain. Europa Medicophysica 2004; 40 (1): 9–13.
  9. Wheeler AH, Stubbart JR, Hicks B. Pathophysiology of chronic back pain. eMedicine [Online]. Available at:
    http://www.emedicine.com/neuro/topic516. Accessed December 2004.

June 16, 2011

Jason wrote:

Thanks for the info Bryan, I live in Winnipeg and I noticed your clinic is located in Calgary.  Too bad! I am plagued with back pain for 10 + years.  I have tried various treatments with little success.  Do you know if these “non-conservative” options are available here.  Thx.

Sorry Jason, I’m no longer in the loop in Winnipeg.  I left about 10+ years ago.  I can tell you anything about Calgary though!  Good luck.  Read some of the other info located in Rochelle’s blog on Low back info, then go to your local Physio, or Doctor and ask them if any of these other procedures are appropriate.  Remember, that the best approach is the conservative approach. So make sure you working with a capable therapist and follow up with home exercises that they would have prescribed you.

Bryan

June 19, 2011

Jason: thnx.  I will check in again with my physio and see what she thinks.  Can she call / email if she has any questions?

June 19, 2011

For sure, I would be glad to helpp if I can.  Email Info@resolvehealth partners.com. Good luck

Bryan

June 21, 2011

Jullie wrote:

I have low back pain that is quite bad but I don’t have nerve pain in my leg.  I’m waiting for a consult for a surgeon (apparently 1year or so wait).  No one told me about the adjunct injections thank you.  I am meeting with my doctor next week to discuss this option.

June 21, 2011

Jullie, Keep in mind that you want to be doing a home program developed by a physio aiming to restoring normal range and normal strength proir or in conjunction with the injections.  Using the injections to mask pain without trying to change the cause of why you are wearing down in your back is not really the route that you want to take.  Let me know if you don’t have a home program yet. Or if you or the doctor have any questions.

Bryan

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