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, the lower back pain was the most commonly 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. 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 your lower back pain is coming exclusively from your spine and no other areas like the Aorta [large blood vessel in your abdomen] or the abdominal organs like the 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].
Let’s 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 some 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 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. 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 Aleve 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.
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, the Chronic back pain will usually not get better unless it is treated.
Start with conservative therapies like physical therapy, massage therapy, TENS machine, and acupuncture. 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.
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 paralyzed?”
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 a 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, let’s 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 herniations or tears, 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 it is rarely done.
- Lumbar Disc: Disc is one of the common structures causing lower back pain. It has an outer ring called the 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 overgrowth 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 be 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 painkillers, they are able to find the pain tolerable.
What are your options if injections failed to provide relief?
It’s time to introduce the new kid on the block who is shaking things up in the treatment of lower back pain.
STEM CELLS
You may not have heard much about using Stem cells in the treatment of 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 decreasing 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.
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, it’s a good start.
