How do I know if the treatment the physician offers me for my back pain makes sense? Why am I being offered a different injection then someone else I know? Can I avoid being on narcotic medications? Is therapy appropriate for my pain?
These are some of the questions that are asked when patients come to my office. I will break down the treatment of back pain as it relates to the pathology of your pain.
If you read my post “Understanding Your Back Pain,” you will have learned that your back pain can be caused because of a multitude of reasons. Additionally, the timing of when you present to your doctor’s office to treat your back pain can also make a difference in terms of how they will treat you.
The treatment of back pain not only generally takes the creation of a plan that includes a step wise processpossibly involving diagnosing your pain, medical management, therapy, interventional procedures and modalities, it also includes a multi-disciplinary approach with various specialists to treat your pain.
Acute back pain, or pain that started in less than four weeks because of injury, surgery, etc. may require a short course of narcotic medications to treat depending on the severity. This is the main time when narcotics are useful. Once your pain extends beyond four weeks and becomes subacute and eventually possibly chronic, narcotic medications should be tapered off and other alternatives to treating your pain must be considered. Again, this will depend on the reasoning of your pain or the on-going care you may need.
Treatment varies based on pathology of your pain.
Through history taking and physical exam, your physician will figure out what is causing your back pain, or at least narrow it down. Then with the help of imaging and diagnostic testing such as EMG/NCS, they will then hopefully have a good idea as to why you are experiencing the pain you are.
Often, your back pain may be caused by more than one factor and will likely take a step wise approach with medications, therapy, interventional treatments and modalities to control your pain. Most of the work to treat your pain is dependent on you as the patient, not your doctor. How committed you are to following the plan and caring for your own health will be the deciding factor of whether your pain can be alleviated.
If your pain is structural in nature, meaning there is problem with the spine, medications most often used are anti-inflammatories as they can help with reducing the inflammation from the degenerative process that is occurring. Steroid Injections can also be helpful to reduce the inflammation and pain. If your pain is “Axial” meaning running across your back in a beltline fashion, injections blocking the facet joints would be most helpful. These could include steroid injections to the joint themselves, blocking the nerves with numbing agents, or burning the nerves to the joints so the painful sensations can no longer be transmitted. Burning the nerves is called Radiofrequency Ablation or RFA.
If the structure of the spine is compromised and impinging on nerves, then an epidural injection may be warranted based on your clinical exam. Radiculopathy, or the radiation of pain down your leg because of a pinched nerve can be effectively treated with the right epidural injection. The level and type of epidural injection will vary based on the MRI and/or EMG/NCS findings and your clinic physical exam. The most common medications used that help stabilize your nerves, that are for neuropathic pain are Gabapentin and Lyrica. Acupuncture can also help alleviate this type of pain.
Pain due to muscle strain or spasms can be due to several reasons. If the muscles around the spine are not well conditioned, they will fail to help stabilize the spine and thus pain will be felt on a greater level. Trigger point injections with or without steroids can help alleviate myalgias or pain due to muscle pathology. Acupuncture is also a great tool to help alleviate this type of pain. There are several different types of muscle relaxers that are commonly used for muscle spasms. The most common would be Tizanidine and Cyclobenzaprine.
Referred pain generally comes from an organic cause that can be teased out with a good physical exam and history taking. These causes would need additional work-up including labs and diagnostic imaging to help identify the source of pain. Treatment would be based on the organ pathology causing pain.
Generally, almost all types of pain can be helped with therapy. While medications and injections help keep the pain in check, building the muscles in your back and core to help stabilize your spine, reduce any unwanted movement of your spine and improve your strength, flexibility and posture will be what ultimately improves your pain. Your physician can provide you with a prescription for therapy that is specific to the type of pain you are experiencing.
Once therapy is complete, you have received injections and/or acupuncture and medications to reduce inflammation, you should start to feel a difference in your pain. A maintenance program of home exercises is critical to you keeping your pain away. At this point, medications can also be tapered down if no longer needed. The goal at the end of the stepwise plan is to improve your lifestyle, ability to function and reduce your pain.
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