Presented by Corinna Zygourakis, MD
Assistant Professor of Neurosurgery
April 4, 2019
Expect this: 90% of us will get low back pain sometime in our lives. It can hurt so much that some people feel like they can’t get out of bed.
But the good news is that it probably won’t last. Within 3 months of first getting low back pain, 90% of back-pain patients have stopped seeing the doctor.
Only about 5 percent of people getting a sudden bout of low back pain continue to endure back pain that becomes chronic—defined as 6 weeks or longer.
Corinna Zygourakis, MD, is a spine surgeon who has advice for people when they first get an intense episode of back pain: don’t panic.
“Try a hot shower. Or gentle stretching,” said Dr. Zygourakis, assistant professor of neurosurgery, in a recent lecture on back and neck pain at Stanford Health Library. “These things, over the first few days, should be very helpful.”
Other short-term remedies include:
- Heat, from a heating pad or wrap
- Nonprescription painkillers such as
- ibuprofen (brand names Advil or Motrin)
- naproxen (Aleve)
- acetaminophen (Tylenol)
Making a call
When should people be worried enough to call a doctor? Here are some red flags:
- The pain has lasted more than 6 weeks
- The pain is unremitting
- You also have fevers, chills, or sweats
- You feel numbness or tingling in your legs
- You are losing weight without trying
- You have a history of misusing IV (intravenous) drugs
- You have a history of cancer
- You have trouble controlling your bladder or bowels
- You’ve had a trauma or physical injury
Getting a picture
If your doctor decides tests are necessary, the first step may be an imaging test. “X-rays are a great way to look at the bones in the spine, and look at the alignment of the spine,” Dr. Zygourakis said. “We can see a collapsed disk.”
Other imaging tests can be done:
- CT (computed tomography) scans have more radiation, but they can provide more 3-dimensional detail of bones, including small fractures or degenerative changes of the spine, inflammation, or sclerosis (stiffening).
- MRI (magnetic resonance imaging) scans can show soft tissues including the spinal cord and nerve roots. “An MRI is a great way to look at something like a herniated disk,” Dr. Zygourakis said.
There are many causes of low back pain, Dr. Zygourakis said. Yet for most people (90%) going to see a primary care doctor for back pain, there is no specific cause identified.
Some of the causes that can be found include:
- A herniated spinal disk: usually, this causes not only back pain, but also leg pain. Spinal disks are rubbery cushions between vertebrae. When a disk is herniated (ruptured), it can irritate nearby nerves.
The pain often radiates down your back, then all the way down your leg, in a specific pattern. Some people call this “sciatica.”
The medical term for the full pain pattern is lumbar radiculopathy pain. In this condition, nerve roots in the lower spine are compressed, leading to pain in the legs.
- Spinal stenosis: this is a very common condition in which the spinal canal (which contains the spine) gets compressed or narrowed. Almost everyone has some degree of spinal stenosis, often without symptoms, Dr. Zygourakis said.
Older patients often develop symptoms of this condition in the center of the lower spine, causing pain in the lower back and buttocks. Legs really ache, especially down the front of the thighs. It gets worse when walking.
Leaning forward (onto a shopping cart at the grocery store, for example) can ease the pain. So can sitting down.
- Scoliosis: this is curvature of the spine. When you look at someone face-front who has scoliosis, their torso appears to curve sideways.
- Kyphosis: this is also a curvature of the spine, in a different direction. When you look at someone from the side who has kyphosis, their back curves to show a “hunchback” posture.
- Spondylolisthesis: this is slippage of one vertebral body over another. Many times it does not cause problems.
- Spinal infection: this can occur in someone with a history of infections in the bloodstream, and in people who have a history of IV drug use.
- Osteoporosis-related spine fractures: these are seen on an X-ray or CT scan. It can occur in advanced osteoporosis, even without a fall, when compression causes a fracture.
- Spinal cord injury: this can occur in the neck or back in a car accident, fall, or other traumatic event
- Tumors of the spine: the tumors can originate in the spine, or – more frequently – spread from other areas in the body.
Yet 90% of people who go to a primary care doctor for back pain have nonspecific back pain, without an identifiable cause, Dr. Zygourakis said.
Back pain is more common in women than men, but the reasons are unclear. Osteoporosis (which is more common in women) may have a role. So may pregnancy, peri-abdominal post-menopausal weight gain, and pain sensitivity linked to menstrual cycles.
Both women and men who see a doctor for back pain have several options for relief. They include:
- Good posture and workplace ergonomics (sitting or standing in a healthy way)
“A lot of us have desk jobs that involve looking at computer screens for very long periods of time,” Dr. Zygourakis said. One of the first steps you can take is to raise the height of the computer screen, so you are looking up, rather than down.
- Physical therapy
This is one of the first steps for back pain that has lasted more than a few weeks.
Often the therapy involves exercises to strengthen your “core,” which includes the muscles around your spine. It eases pressure on the spine.
- Pilates and yoga are popular programs that emphasize core strengthening.
- Aquatherapy can also help people who find walking or exercising painful.
- Inversion tables that place your head lower than your feet (to ease nerve root compression)
- Chiropractic care
- Weight control
“When you have more body weight, especially in the abdominal section of the spine, that contributes to pain,” Dr. Zygourakis said. Weight loss in people who undergo bariatric surgery is linked to less pain in the lower back and legs.
- Stopping smoking
- Increase your intake of fish oil. One study found 80% of people taking fish oil capsules (1200 mg) reported improvement in their back or neck pain.
- Keeping bones healthy
About 50% of women over age 50 have an osteoporosis-related fracture at some time in their lives. Osteoporosis can result in compression fractures in the spine.
Osteoporosis is diagnosed with a special x-ray called a DEXA scan.
Anybody scoring low on this test should talk to their primary care doctor or an endocrinologist and get treatment to protect their bones, Dr. Zygourakis said.
Treatment options include pills or injections for medicines that protect your bones from further weakening. Medicines include:
- Bisphosphonates (like Fosamax) slow the breakdown of bone and can be taken by mouth.
- Denosumab (Prolia) is an injection that reduces osteoporotic fractures, also by slowing the breakdown of bone.
- Teriparatide (Forteo) is a newer drug that’s injected daily and can rebuild bones. This drug is expensive and often not covered by health insurance, Dr. Zygourakis said.
- Abaloparatide (Tymlos) is an even newer drug that can also rebuild bone.
If none of these methods for pain relief work, next steps to consider include:
- Injections to ease pain (usually done by pain management doctors, who may be anesthesiologists or physical medicine and rehab doctors)
- Epidural steroids are some of the most common injections to ease back pain. This kind of injection starts with a local numbing medicine, then a combination of steroid and pain medication that goes into the epidural space, which is the area above the dura that covers the spinal nerve roots.
- Facet block
This injection goes into side of the spine where the bone joints are. This affects smaller nerves that cause a different kind of pain. Once again, pain management doctors inject a combination of steroid and pain medication to this area.
- Selective nerve root block
This is an injection of steroid and/or pain medication targeted to the area around one specific nerve root.
- Procedures: kyphoplasty or vertebroplasty
These procedures are done for compression fractures of the spine.
They are not open surgery. Instead the doctor inserts a needle carrying a tiny inflatable balloon filled with medical cement. When injected into a fracture, the cement can relieve pain. It can also increase the height of the vertebra that was collapsed.
Most patients go home within a couple of hours after either an injection or kyphoplasty/vertebroplasty procedure.
The last resort, if other methods don’t help, is surgery. Dr. Zygourakis acknowledged that back surgery has developed a poor reputation for failing or causing complications. That’s because it should be reserved for only certain patients with specific conditions.
“It’s critical that we diagnose correctly and that we really know what’s causing the patient’s pain,” she said. “If you don’t know what the source of their pain is, then we’re not going to effectively treat it,” she said.
There are a lot of different kinds of spine surgery. “They really need to be done for the correct reason,” Dr. Zygourakis said. “Risks are high, and complications can be devastating.”
Spinal fusion is one of the most common kinds of back surgery. It is used to fuse together 2 vertebrae so they heal into a single, solid bone.
“If you get one thing from this, it should be: There are so many different types of spinal fusions,” she added. “They’re not all the same. It’s really, really important to get more information about what spinal fusion you’re having, and why.”
She has seen patients who have undergone several failed spine surgeries in a row, then come to her for help. “They end up on my doorstep, and we’re doing surgery for the fifth time around, and we’re doing much more challenging surgery,” she said.
When the right surgery is matched to the specific problem, the results can be good. She added, “Spine surgery can be highly successful when it’s done on the right patients.”
Different kinds of conditions that can be improved by spinal fusion include:
When an x-ray shows one of the vertebrae moving relative to the other, that can only be fixed with fusion surgery, Dr. Zygourakis said. “You have to immobilize the spine in order to fix the movement that’s contributing to the pain.”
There are many different ways to do this, that usually include removing a disk, inserting a type of cage or bone to promote a fusion. Then the surgeon puts screws and rods in the spine to stabilize that spot.
One woman came to Dr. Zygourakis with severe scoliosis after undergoing multiple spinal surgeries elsewhere. Her posture had gone from straight to severely bent because her spine was so out of alignment near the top. She underwent surgery with Dr. Zygourakis that stabilized her spine with screws and rods and straightened her back significantly. “She’s a good several inches taller,” Dr. Zygourakis said.
Another woman had scoliosis beginning in her adolescence and gradually developed kyphosis as well. Rather than standing straight, she leaned forward drastically and to the side. Spinal fusion helped her posture and eased her pain.
Nonfusion surgery for the spine
There are many types of spinal disease that do not necessarily need a spinal fusion. For example, many types of lumbar stenosis and/or lumbar disk herniations can be treated with a simple spinal decompression surgery (removing part of the bone and part of the disk).
While back pain is one of the most common medical problems, neck pain also afflicts many people. Studies find between 6% and 39% of people have neck pain during the course of their lifetimes. It occurs most often in people aged 45 to 64.
Like back pain, neck pain is more common in women and those who smoke, have depression, and who work in jobs involving awkward postures.
Sometimes neck problems cause symptoms like sciatic pain but involving the arm instead of the leg. A disk herniation that compresses a nerve root in the neck can cause pain extending down your arm.
This is called cervical radiculopathy. The nerve compression can also cause numbness or weakness in the arm.
Neck and arm pain can also be caused by another condition, called cervical myelopathy. Instead of compressing the nerve roots that grow out the side of the neck spine, you get compression on the spinal cord itself.
People don’t always have pain from cervical myelopathy, but they may have other symptoms:
- Numbness or tingling in their hands
- Difficulty buttoning buttons or opening jars
- Unstable gait or walking
- Difficulty controlling urination
Cervical myelopathy is a much more serious condition that radiculopathy, and patients should seek medical treatment urgently.
Similar to back pain, neck pain can be treated with a variety of methods. That includes lifestyle changes like taking nonsteroidal anti-inflammatory painkillers (ibuprofen or acetaminophen) and gentle heat or stretching.
Other treatments include medicine to relax muscles and to protect bone health, steroid injections, and nerve root blocks.
Tinkering with the spine in the neck can be even trickier than the spine in the back. “In the cervical spine, everything is smaller,” Dr. Zygourakis said. “Everything is more delicate.”
A problem or complication from an injection in the neck can lead to paralysis, in the worst case. “It’s really important that you go to someone good, especially for neck injections, because that’s very high ‘real estate’ there. That is critical.”
Spinal surgery can help problems in the neck—if there is a clear diagnosis. “For the right patients, it is awesome,” Dr. Zygourakis said.
Younger neck patients without significant arthritis of their spine may get a disk replacement surgery rather than spinal fusion (for cervical radiculopathy), so they can keep the range of motion they had.
“The reality, unfortunately, is that most people aren’t candidates for motion-preserving surgery, but it is an excellent option for the appropriately selected patients,” Dr. Zygourakis added.
One man had a spinal cord injury that left him paralyzed. About 5 weeks after spine surgery was done by Dr. Zygourakis, he was able to use a walker. He progressed to walking on his own 2 weeks after that.
The latest improvements and most advanced techniques in spinal surgery include:
- “Minimally invasive” spine surgery that use small incisions to minimize blood loss and muscle damage, get patients out of the hospital sooner
- Computer-navigation assisted spine surgery to ensure the most accurate screw placement in all patients
- Robot-assisted surgery
Dr. Zygourakis repeated that, in general, surgery should be a last resort for patients suffering from back or neck pain.
Anyone considering surgery should understand their diagnosis and learn the pros and cons of various treatment options.
“It’s really important that you talk to your surgeon about what approach they’re doing,” Dr. Zygourakis said. “Ask why they think that one’s the right one to do for you, and what some of the specific risks and benefits are for that particular approach.”
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