Nothing begins, and nothing ends
That is not paid in moan;
For we are born in other’s pain,
And perish in our own.
(Francis Thompson 1859 – 1907)
Pain is a hugely complicated subject and, in all sincerity, I profess no greater knowledge of it than the next doctor. There are, however, new ideas, or theories, surfacing about pain, some of which may well replace the old ones. These included what appears to be the important role sensory fibres play in the central nervous system and how they function in transmitting pain to and from the brain. This is of particular interest to me because I believe, until someone shows me better, that these sensory fibres are central to my work in treating back pain.
Some facts and fallacies about back pain; while many aspects of diagnosing and treating back pain are uncertain, there are some observations that are factual.
• Recent onset – or new – back pain almost always reduces quickly. A common situation is when a person (of any age) is doing something that they may do every day when suddenly they develop severe back pain. The pain is often excruciating. If no active treatment is sought, the majority of these cases (95 per cent) resolve within 3-4 weeks.
• X-rays are not the most accurate way of diagnosing causes of back pain. It has been shown many times that there is no correlation between degeneration on X-ray and the severity of pain. People who have extremely bad-looking spines on X-ray may experience no back pain at all. Conversely, people who have perfectly ‘normal’ X-rays may experience severe back pain. This applies similarly to CAT scan or MRI investigation. Abnormalities that are detected do not necessarily cause the pain. A number of trials have been carried out where MRI scans are taken on people who have never had back pain. Sixty percent of these were shown to have a significant disc protrusion and yet experience no pain.
• In my opinion the most common misdiagnoses of back pain sufferers over forty years of age, include arthritis, joint degeneration, osteoporosis, spondylitis and ‘wear & tear’. But no matter what investigations are performed, no-one can ever be 100 per cent sure of the cause of pain. My belief that vertebral degeneration as shown on X-ray, in the absence of trigger points, is not a cause of back pain will probably be strongly criticised by some colleagues.
• It is not necessarily true that there is nothing that can be done for back pain and that sufferers will ‘have to live with it’.
Here is a list of treatment options that may be considered and explored by back pain sufferers and their doctors. Some of these treatments are well-known, others are not. They are listed alphabetically, not in order of importance – there are no doubt various other methods of back pain treatment, which are commonly practised in some parts of the world, and not known to the author.
Acupuncture is believed to work on the principle that the production of brief, moderate pain will cure severe, chronic pain. Stimulation, by placing small needles in various charted parts of the body, i.e. ear, calves, ankles, causes the release of pain-killing endorphins.
There has been a recent trend in acupuncture to specifically target the trigger points instead os set reference points and needle the same point on a number of occasions. This is thought to lead to localised muscle lengthening and to decrease pain that was due to muscle spasm. Although mainstream medicine has gradually embraced the theory of acupuncture and its effectiveness, it is still considered only an adjunct to conservative treatments and does not necessarily produce long-term relief from pain.
Use of these is common treatment for back pain. Research suggests that, while the drugs are frequently prescribed, their actual cure rate is insignificant and often cause a lack of well-being in patients, although they do help temporarily to alleviate pain.
Bed rest is the most common and successful (95 per cent success rate) form of treatment for the onset of new back pain. Generally, patients are advised to lie on their sides with their hips and knees slightly flexed. More than a few days in bed is not recommended.
Electrotherapy (transcutaneous electrical nerve stimulation – TENS)
The principle of electrotherapy is that by electrically stimulating nerves, pain will decrease, although how it works is unknown. Interestingly, electrical current passes more easily though painful tissue and non-painful tissue. It is thought that the electrical current produces endorphins, like acupuncture. It is a medically respected treatment and does help patients become more functional. (NB it is an accepted medical practice even though it is not understood).
Enzyme injection (chemonucleolysis)
This is a comparatively recent method where the damaged disc is injected with an enzyme (from papaya). It dissolves the disc, thereby relieving the pressure it is applying to the nerve roots. The procedure has a relatively high long-term success rate. Studies after two years show a 77 per cent success rate in the reduction of pain, with 45 per cent of patients enjoying a pain-free status. Very few people however are suitable for this treatment. The procedure is not without its risks and requires hospitalisation. Three per cent of patients suffer complications, and 40 per cent suffer back spasms in the immediate post-operative period. Patient assessment is crucial for this treatment; a handful of patients have died from allergic reaction.
This is often used where more conservative forms of treatment have failed. The theory is that injecting cortisone into the epidural space in the spine reduces inflammation on the damaged nerve root and surrounding tissue. The procedure requires hospitalisation, and is safe as long as meticulous technique is used to administer it. It has been known to cause tuberculous meningitis and other complications if not properly performed. Note that the procedure currently being carried out is considered medically ‘not proven’.
This is a common treatment designed to strengthen muscles surrounding back injuries, or to increase the patient’s flexibility and mobility as well as improving fitness levels to prevent further injury. In some cases, exercise appears to decrease pain levels; in others, it may u increase the pain. Exercise programmes have a mixed success rate and in some cases are impractical because of the pain of movement experienced by the patient.
These include braces and corsets. They are designed to take pressure off injured areas in the back and neck during recovery, although some patients wear them permanently. In themselves, these supports do not cure back pain, but may assist in the recovery process. Many feel that external supports actually weaken back muscles and worsen the problem.
This can be a successful treatment, at least in the short term. Because pain is thought by some not to be a purely physical phenomenon, but associated with thoughts, emotions and perceptions, it is possible to alter the state of awareness in a patient in a way that reduces, or changes their pain.
Many substances have been injected into people’s backs with varying degrees of success. Different compounds can be placed in one of three areas:
I. Trigger Points: by merely needling these tender points some pain relief can be achieved. This technique is called ‘dry needling’ but would seldom produce more than six month’s relief. These points can also be injected with local anaesthetic or cortisone. Pain relief is often longer than needling alone but seldom longer than six months.
II. Ligaments: The ligaments at the base of the spine can be injected with irritant (sclerosant) solutions. This is thought to set up an inflammatory reaction within the ligaments and, when this settles, the ligament will become thicker, shorter and stronger thus better supporting the vertebral bones. In well conducted trials, it would seem that many people get pain relief where they have not responded to other treatments.
III. Intravenous: In some countries the use of intravenous colchicines is a popular method of back pain treatment. Colchicine is a powerful anti-inflammatory agent and in various trials (some controlled) it has been shown to produce significant pain relief in a large percentage of patients.
Mainstream medicine still considers spinal manipulation a controversial therapy. It is mainly performed by chiropractors. Although studies have shown there is probably no relationship between vertebral misalignment and low back pain, there is no doubt that manipulation does provide relief, often permanent relief. It is considered appropriate for some types of low back pain, including sciatica, spondylitis and stenosis but not for osteomyelitis, osteoporosis, and fractures, ruptured ligaments, acute arthritis and should not be undertaken during pregnancy.
My own belief is that the benefit from manipulation may well be due to stretching the trigger points and not due to ‘re-aligning the bones’.
This, too, is a common treatment for back pain and usually works well on a temporary basis. Massage is used by physiotherapists and other professionals trained in the art, and others who have developed their own forms of massage i.e. Swedish, Japanese etc.
All forms of massage target the trigger points and the main stimulus is directed there.
Although these have been used as treatments for low back pain and muscle spasms for many years, their use is still considered controversial, particularly because some forms are addictive and others may cause depression. They appear to reduce back pain in carefully selected patients and should not be condemned outright.
This treatment is specifically targeted at restoring psychological balance in the back-pain sufferer, particularly overcoming depression. Clinical trials have produced mixed results, but the technique has been successful in improving patient attitudes and decreasing anxiety and stress levels. This technique is used extensively in pain clinics helping people to ‘live with their pain’.
Surgery can be considered for those suffering; pressure on nerve roots (most commonly by herniated discs); spinal stenosis (narrowing of the spinal canal); vertebral instability.
Unfortunately, if surgery is performed for other reasons, the results are usually poor. There are three main forms of surgery:
I. Laminectomy – this is performed in hospital under general anaesthetic and is the less complicated and safer of these procedures. Essentially, the injured disc is removed along with surrounding bone. The nerve root, upon which the disc had been pushing, is thus liberated. Surgery takes between 1-2 hours. There is a minimum of blood loss and the patient is encouraged to stand and walk soon after surgery. Laminectomy works very well for leg pain and numbness but no so well for back pain. New techniques are being developed to surgically remove herniated discs without removing any bone. These techniques are far less traumatic for the patient but suitable for only a narrow spectrum of people.
II. Fusion – This operation is performed under general anaesthesia. The object of the operation is first to remove the injured disc and any other material pressing on the spinal cord or nerve roots. The two vertebrae are then fused together by one of a number of techniques. One is using a bone graft (usually taken from the pelvic bone). Another is to join the vertebrae by screwing steel rods across them. New techniques are being developed to use a flexible material (Dacron) to stabilise the vertebrae but not to fuse them in a rigid fashion. Different techniques will suit different cases.
Post-operatively, patients experience a great deal of pain and need to be monitored closely for the first 48 hours and may remain in hospital for two weeks. It may take 12 months before normal activities can be resumed. The results vary enormously. Some claim 90% success whilst others claim 50% success. This variance may reflect different criteria to gauge success and failure.
Long term studies show that the success rate for laminectomy and fusion drops considerably after five years and may reduce to as low as 50 per cent.
III. The newer procedure of disc replacement is emerging as a means of correcting damaged discs without fusing the vertebrae.
There are three kinds of temperature therapies:
I. Cold (cryotherapy) This can be an effective treatment. It uses ice or cold packs. Studies show that two thirds of patients who undergo it will experience approximately a 33 per cent reduction in their pain, although it is usually only temporary. It should not be used on patients with sensitive skin and can sometimes produce muscle spasm. It usually only cools the skin over the injured area rather than the tissue under the skin.
II. Heat (thermotherapy) although this can be used to ease pain and reduce muscle spasm, it should not be used where patients suffer decreased circulation or sensation loss because it can cause damage to the skin i.e. burning.
III. Deep heat (shortwave diathermy/ultrasound) penetrates below soft tissue near the skin, delivering heat to bone, muscle and ligament. Should not be used in areas where the pain is acute or recent. Ultrasound delivers heat more deeply than diathermy.
This treatment has been used in one form or another for several hundred years. The basic theory of traction is that it stretches the vertebrae and surrounding muscles in order to provide relief and to return the spine to its original form. There are several types of traction, ranging from stretching patients on a bed either manually, or using mechanical devices that apply continuous stretching or sporadic stretching. Another form of traction is to hand the patient upside down by the ankles from a frame, using gravity to stretch the spine and surrounding muscles. Although it is a common treatment, traction does not have a high success rate in permanently alleviating back pain. In some cases it can make it worse.
I believe back pain relief occurs from this form of treatment more from stretching of trigger points rather than the bones.