BACK
PAIN
FREQUENTLY
ASKED QUESTIONS
The following description of techniques and procedures is for informational
purposes only, and in response to frequently asked questions (FAQs). The
discussion is not intended as the offering of medical advice and should not, in
any way, be considered a substitute for proper informed consent between a
patient and physician. Disclaimer.
Q: WHEN DO I CALL FOR HELP?
A: If you have back pain with
chest pain, call 911 or other emergency
services immediately. This includes:
Pain
in the upper back with chest pain that is crushing or squeezing; feels like a
heavy weight on the chest; or occurs with any other symptoms of a heart attack,
such as chest pain that occurs with:
…
Sweating.
…
Shortness
of breath.
…
Nausea
or vomiting.
…
Pain
that spreads from the chest to the back, neck, or jaw or one or both shoulders
or arms.
…
Dizziness
or lightheadedness.
…
A
fast or irregular pulse.
…
Fever.
…
Severe
back pain that is not from any known injury.
Possible
spinal injury immediately following a severe injury to the back. Signs of
spinal injury include:
…
New
loss of bowel or bladder control.
…
New
weakness in the legs.
…
New
numbness or tingling in the buttocks, genital area, or legs.
…
Moderate
to severe pain following a severe injury to the back.
Note: If you suspect a spinal
injury, do not move the person unless there is an immediate threat to his or
her life, such as a fire. If there is immediate danger, keep the head, neck,
and back supported and aligned while you move the person to safety.
Q: I
have been told that I have a ìruptured discî. What does this mean? Will I have
to have surgery?
A: The term "ruptured disc" is a catchall, which encompasses a
variety of related conditions affecting the structural integrity of the
intervertebral disc, which is the cushiony material between the vertebral
bodies, or backbones. The disc is a complex structure containing a gelatinous
inner portion, called the nucleus pulposus or disc matrix; and a tough, fibrous
outer portion, called the annulus fibrosis. In many ways, the disc is similar
both in structure and function to a modern radial tire. The nucleus acts in
much the same way, as does the air in the tire, to dampen and absorb the forces
applied to it. And the annulus also contains many layers of fibers, like the
radial plies of a tire, to contain the nucleus and distribute the forces.
When the disc has been injured, there may be internal derangement of the disc
architecture; there may be radial tears through the annulus, or delamination of
the annular fibers. With further damage, nuclear material may protrude through
these annular tears, resulting in disc protrusion, which may be contained,
extruded, or sequestered (think of toothpaste being progressively squeezed out
of the tube). Each of these different types of disc protrusion has implications
for treatment, and different types of intervention, or surgery, may be
appropriate, depending upon the exact nature of the damage to the disc, and the
particular symptoms which you have been experiencing. In many instances (70% of
cases), effective relief of symptoms may be accomplished by a period of
relative rest, or avoidance of provocative activities. Prolonged bed rest is,
however, not generally beneficial. Physical therapy and medication may be
helpful in reducing inflammation and easing muscle spasm. However, protruding
disc material has been proven to be highly irritating and possibly toxic to the
nerves, causing pain, or numbness and tingling. In extreme cases it can also
cause weakness. If the disc actually presses on the nerve roots - a so-called
"pinched nerve" - the nerve may be damaged, and there may be symptoms
of weakness, or even disturbances of bowel and bladder function. Bowel and bladder
involvement is usually considered a ìsurgical emergencyî, due to the fragile
nature of the nerves responsible for those functions, and the fact that even
with prompt surgical attention, the damage can quickly become permanent.
A careful clinical examination is required, and appropriate tests, such as an
MRI scan, should be performed, to clearly delineate the precise nature of the
"ruptured disc". You should discuss this with your doctor, so that
you have a thorough understanding of the exact nature of your condition, and
the treatment options available to you.
Q: CAN A PLAIN X-RAY SHOW THE PROBLEM?
A: No, discs and nerves are
considered to be ìsoft structuresî. Plain X-Ray films, although they may give
ìcluesî, they will not show any ìsoft structuresî, only bone (ìhard
structuresî).
Q: I have been told that I have a ìPinched
Nerveî. What does this mean? Will I have to have surgery?
A: The term "pinched nerve" is a generic one, which
encompasses a variety of related conditions affecting the structural integrity of
the nerve root, which is the section of the nerve that attaches to the spinal
cord. This section of the nerve is susceptible to damage and compression,
specially, as it exits the spinal canal through the neural foramen. (Foramen is
the scientific name for an opening or a canal, whose borders are made of bone
structures.) Nerves can be affected in different ways, and depending on the
mechanism of injury, the treatment may also be different. The symptoms are also
very closely related to the type of pathology (= Problem), suggesting the
possible mechanism of injury, and therefore treatment. Some of the mechanisms
of injury may include:
…
Compression of the nerve at the level of the neural
foramen, causing a number of symptoms, which may range from back and/or leg
pain, and/or weakness, with or without bowel and/or bladder function.
-
Due to a bulging, protruding, or herniated discs. A
disc may bulge, protrude, or herniate to the area of the foramen, which in turn
may decrease the space available for a nerve to safely exit the spinal canal.
This type of injury is usually sudden in onset.
ß
This type of injury may compress the nerve and its
blood supply, which if untreated, may cause permanent damage to the nerve and
its function.
ß
There may be swelling associated with it, which if
untreated, may result in scar tissue, which again, may cause permanent damage
to the nerve.
-
Due to bony overgrowth (Bone spurs). Calcium can
accumulate around the borders of the foramen, causing a decrease in its
diameter, with resultant nerve compression, very similar to that discussed
above, due to disc herniation. The symptoms would be similar, if not identical,
with the exception of a much slower onset.
-
Due to swelling of the nerve. Injuries to the nerves
may be temporary; nevertheless, they may cause chronic or recurrent swelling,
which in turn may trigger symptoms identical to those caused by compression,
due to a similar mechanism of action. The swelling may cause the nerve not to
fit in the confined space of the neural foramen, thereby causing compression of
the neural structure. Swelling, if untreated, may cause permanent damage to the
nerve and its function, due to decrease blood flow to the nerve, with
subsequent starvation and death of the nerve. Unfortunately, this can result in
chronic pain.
ß
A disc fissure or rupture, may allow nuclear
(nucleus pulposus) content to be spilled out and become in contact with the
nerves, causing a severe inflammatory reaction with severe swelling of the
nerve and the subsequent problems that accompany it. Nuclear material has been
demonstrated to cause severe inflammatory reactions of nerves, including
compartment syndromes. This is a condition where severe swelling of the
structures in a compartment of limited space, may cause the decrease of blood
flow to the neural structures, with subsequent decrease of nutrients. This may
result in permanent damage to the nerve.
…
Most of the time, the problem is an actual
combination of the above. In most cases, it can initially be treated with ìEpidural Steroid Injectionsî or
ìSelective Nerve Root Blocksî, to the affected area.
Q: My Doctor has told me that I have degenerative
disc disease. What does this mean?
A: Degeneration of the intervertebral discs can result from a variety of
conditions, including aging, trauma, and several types of arthritic conditions.
As we age, our tissues tend to lose water. That's why skin wrinkles with age,
and various body parts begin to sag. When this occurs in the intervertebral
disc, the disc tends to shrink, becoming thinner and less cushiony. The
condition is fairly common in adults past middle age, and may be asymptomatic
(causing no symptoms), other than occasional lower back pain, or stiffness. At
other times, however, the associated collapse of the disc space, especially in
the lumbar spine (lower back), can be the source of severe mechanical back
pain, or radicular leg pain. Under these circumstances, surgical intervention
may be appropriate.
The inner portion of the disc, the nucleus pulposus, is composed of
proteoglycans - chemical combinations of sugar and protein. When the disc
degenerates, small cracks or tears form in the outer annulus, allowing these
chemical substances to leak out into the epidural space. Proteoglycans have
been shown to cause irritation or inflammation of the nerves surrounding and
adjacent to the damaged disc. Minimally invasive procedures, designed to remove
the diseased or damaged portion of the disc, may be helpful in alleviating such
pain.
Under other circumstances, collapse of the disc space can lead to a condition
more recently termed "vertical instability". In this case, shrinkage
of the disc allows abnormal movement across a motion segment (2 vertebrae and
the intervening disc), and may result in mechanical back pain - pain that
arises from changes in position, or attempts at strenuous activities. In such
cases, fusion of the interspace may be the procedure of choice. (Perhaps, at
some point in the future, replacement of the disc by an artificial substitute
may become an option, when such devices are eventually developed and approved
for use, by the FDA - see below).
Q: I understand that there are different types of
surgery for a ruptured disc. What are my options?
A: There are many different types of procedures available to treat the
various conditions affecting the intervertebral disc, and conditions affecting
the cervical and lumbar spine. These are summarized below. Please bear in mind
that the various descriptions are brief, and cannot substitute for a full
discussion with your doctor, who has examined you and has access to the various
X-rays and tests, which have been, or will be, performed.
Q: I have heard that
there is an injection that can treat this, without surgery. Is this true?
A: Yes, there are multiple
types of interventional treatment that can be used to avoid surgery. The most
common and widely used one is the ìEpidural
Steroid Injectionsî. (Click on it to learn more) Nevertheless, this is not
the only option. We highly recommend an evaluation by a ìBoard Certifiedî
interventional pain physician, for further alternatives.
A: Yes. (Click HERE for information)
Q: I have heard that there is an injection that can
dissolve a ruptured disc. Is this true?
A: Chymopapain
This is an enzyme derived from the papaya, chymopapain has been used
successfully for the treatment of lumbar disc protrusion for the past 25 years.
It continues to be widely used in Europe and Asia, but less so in the United
States, because of its limited availability and safety concerns. Chymopapain
has been shown to be effective in dissolving disc material, and may be used
alone, via direct injection into the protruding disc, or in combination with
other minimally invasive procedures. Rare side effects, including anaphylaxis
(life-threatening allergic reactions) and damage to the microcirculation of
neural tissue, have been a source of some concern, and have contributed to a
decline in popularity of chymopapain as a first line treatment for disc
protrusion. Nevertheless, used appropriately, this agent has repeatedly been
shown to be both safe and effective.
Q: What are minimally invasive procedures?
A: Minimally invasive procedures are those which can be performed
through very small skin incisions (or simply through needles), usually under
local anesthesia, or IV sedation; often on an outpatient basis, thereby
avoiding both general anesthesia and hospitalization, and contributing to a
speedier recovery and return to normative levels of activity. Often, these are
referred to as "band-aid surgeries", and some are similar to
arthroscopy performed by Orthopedic Surgeons, and laparoscopic procedures
performed by General Surgeons and Gynecologists. There are numerous advantages
to these procedures, and they are increasingly being adopted by spinal
specialists around the world. However, these procedures should not be treated
lightly, nor should the risks be minimized or dismissed; these are truly surgical
operations and carry their own subsets of surgical risk. Also, there are
definite technical limitations to these procedures, and they are not
appropriate for all patients, or all conditions. Some of the commonly performed
minimally invasive procedures are summarized below.
Intradiscal Electrothermal Therapy (IDET)
(Click on the link for more information)
A recently developed minimally invasive procedure, this technique is designed
to shrink and tighten the collagen fibers of the annulus fibrosis, the outer
layers of the intervertebral disc, which are frequently torn or disrupted in
the event of a disc protrusion. The procedure is performed under local
anesthesia, with percutaneous insertion of a flexible wire into the intervertebral
disc. The wire is then heated to a specific temperature. It may also work by
coagulating some of the nucleus pulposus, the inner, gelatinous substance of
the intervertebral disc; and by destroying some of the free nerve endings,
which have penetrated the outer annular layers of the damaged disc.
The procedure is designed to be performed from only one side (unilateral), but
may, on occasion, require bilateral insertion of the wires, for adequate
positioning within the confines of the nucleus.
Intradiscal Endoscopic Decompression
Laser-Assisted Internal Disc Decompression; Coblation (Coagulation + Ablation)
(Known as Nucleoplasty); Automated
Percutaneous Lumbar Disc Decompression; Percutaneous
Disc Decompression (Dekompressor)
These are minimally invasive procedures which work, in selected cases, by
various means, including vaporization (LAIDD), suction-curettage (APLDD), or
shrinkage (Coblation) of disc material, and alteration of the proteoglycan
substances of the intervertebral disc (which are toxic to nerves when they leak
out through tears in the annular fibers). The basic premise for these various
procedures is that removing a portion of the disc results in a reduction of
intradiscal pressure (reducing pressure within the disc, itself), and can lead
to reduction of the disc protrusion, moving the disc away from contact with the
nerve roots. These procedures can be performed on an outpatient basis,
precluding the need for hospitalization, or general anesthesia.
The LAIDD procedure is performed using fluoroscopy and an integrated laser and
flexible endoscope, permitting the surgeon to visualize the internal
architecture of the lumbar disc on a video monitor, during the procedure, and
to steer the laser fiber to a specific location within the disc space. The
other techniques are performed "blind", using fluoroscopic guidance
to direct placement of the instrument within the disc space.
These techniques have proven themselves safe and effective in selected cases,
but are generally not useful in cases of extruded fragments, or large ruptured
discs, and may not currently be used in the cervical spine (neck).
Endoscopic Disc Excision
The minimally invasive approach to intervertebral disc protrusion is gaining
increasing popularity worldwide, because of its safety and effectiveness in a
wide range of spinal conditions. As experience has increased, a greater number
of conditions have been shown to be amenable to endoscopic approaches, which
can be performed on an outpatient basis, and without general anesthesia. The
procedure is performed within the confines of a surgical cannula, a metal tube
similar in size and shape to a straw. Through this tube is inserted the working
endoscope, which contains several channels, permitting insertion of a wide
variety of surgical devices, including miniaturized grasping, cutting, and
shaving devices, as well as laser fibers, chemicals and irrigation solutions.
Depending upon the technique, and the experience of the surgeon, procedures may
be performed not only within the abnormal disc, itself, but also within the
spinal canal and neural foramen. Because of the nature of the approach, there
is some risk of injury to the nerve root, and this technique may not be
advantageous in the treatment of multi-level disc pathology.
Q: I have been told that I should undergo an open
surgical procedure, using general anesthesia. Why?
A: Microsurgical Laminoforaminotomy and Disc Excision
Often referred to as the "gold standard", by which other treatment
modalities are measured, the microsurgical removal of disc material, by means
of an open, operative procedure, is the most commonly performed treatment for
ruptured discs and related pathology. This technique permits the most
unrestricted access to the area(s) of abnormality, and is suitable for the
treatment of a wide variety of spinal conditions, and multiple levels of
pathology.
Because the operating microscope permits great magnification, and the delivery
of intense light to the depths of the operative field, handling of the nerves
and other delicate tissues can be very precise, using fine, microsurgical
instruments. The skin incision can be made very small, with minimal retraction
of muscle, and postoperative healing is rapid. However, surgical manipulation
of the nerve root(s) is required, and there may be some concerns about the
postoperative development of epidural cicatrix (scar tissue).
The procedure is customarily performed in a hospital environment, under general
anesthesia, although other variations have been reported. Patients are
generally allowed up to walk within a few hours, and are usually hospitalized
overnight.
Laminectomy and Decompression
Open surgical approach to the spine, with or without the use of magnification
(loupes or operating microscope), is a traditional surgical procedure, dating
to the earliest description of disc pathology, in the 1930's. Although less
frequently used today for the surgical treatment of single level disc protrusion
("ruptured disc"), it may be the procedure of choice in more
extensive surgical procedures for the treatment of spinal stenosis, spinal cord
tumors, and incident to the placement of interbody fusion devices.
Q: What about fusion? I read somewhere that there
are now alternatives to the use of pedicle screws.
A: Threaded Cage Fusion
Surgical fusion of the vertebrae is a type of procedure in which two or more
vertebrae are held together, usually by some sort of metallic fixation device,
until the vertebrae can grow together, by way of a bone graft, placed at
surgery. Based upon earlier approaches using bone, placement of interbody
fusion devices ("cages") is a relatively recent innovation in the
treatment of instability, recurrent intervertebral disc protrusion, and other
related conditions. This technique permits immediate stabilization across a
motion segment, or interspace, and has proven safe and very effective, in
appropriate patients, leading to solid, bony fusion. Although this is not,
strictly speaking, a minimally invasive approach, it requires considerably less
operative exposure of normal tissues than the older methods of posterior
instrumentation, using pedicle screws and rods or plates.
Note should be made that smoking, while not an absolute contraindication to
surgical fusion, has been shown to interfere with bone formation and fusion,
leading to a higher percentage of non-union (failed fusion). It is strongly
recommended that any patient intending to undergo a fusion procedure discontinue
smoking at least 6 weeks prior to surgery and not resume smoking following
surgery. Use of nicotine patches is not recommended, as nicotine, itself, is
considered to be one of the agents responsible for bone toxicity.
Q: I have had surgery before. Now, there has been
some talk about "going in from the front". What does this mean?
A: Anterior Approaches
For some years, now, the preferred surgical treatment of cervical disc disease
has been to approach the cervical spine from the front. This has a number of
advantages over the older, posterior technique, which approached the spine from
behind, including direct access to the disc space and the avoidance of
manipulation of nerve roots, or the spinal cord. Approaches to the lumbar spine
from anteriorly (e.g. "through the belly") are becoming more popular,
as experience is gained from similar approaches to the cervical spine (neck),
as well as the increasing use of endoscopic instrumentation. This procedure
avoids direct contact with the nerves and dura, which are located behind the
vertebral bodies, and may be appropriate where this is desirable.
Excision of the intervertebral disc, in this approach, is generally followed by
the insertion of a bone graft, "stand-alone cages", or a combination
of fusion and plating. Potential complications, which may limit this approach,
include injury of the major blood vessels (e.g. aorta and vena cava) and
development of retrograde ejaculation in men. Techniques are also being
developed for lateral (from the side) approaches to the lumbar discs, and this
may prove satisfactory for some conditions.
Q: Why can't I have a synthetic disc inserted?
A: The Artificial Disc
At present, use of prosthetic (artificial) disc replacements is under study in
Europe, with further testing scheduled in Asia and South America. Preliminary
reports are encouraging, and investigational use may begin shortly in the
United States. Several different mechanisms are under consideration, and are
composed of widely varying materials and designs. At present, however, no
prosthetic disc is FDA-approved, and usage must be considered investigational,
only, under specific protocol.
There is no single surgical, or medical, treatment, which is effective for all
conditions affecting the spine, intervertebral discs, and nerves. And no
procedure is entirely free of risk. The choice of the most appropriate approach
to the treatment of any condition can only be arrived at following detailed
examination of the patient and of the various diagnostic, clinical, radiographic,
and laboratory tests which have been performed. Hopefully, this information
will be helpful to you in your discussions with your doctors.