TREATMENT
In most cases, spinal problems are treated without surgery. Individuals with acute (sudden onset) episodes of back pain can expect symptoms to settle within 6 weeks in 90% of cases. Initial treatment may include 2-3 days of rest followed by a gradual return to normal activities. The treatment is largely symptomatic (aimed at relieving the pain rather than treating the cause which may not be possible). The various measures of pain control may include the following :
Heat - May help decrease pain to soft tissues. Heat may be applied for 20-30 minutes several times a day.
Medication - Analgesic medication - Usually simple "over the counter" tablets available without a prescription. Paracetamol is a particularly useful medication which is frequently underestimated in the treatment of musculoskeletal conditions.
Anti-inflammatory medications - These medications are specifically designed to reduce the pain of inflammation in the tissues of the spine. There are many varieties available, all with similar usefulness. The main side-effect of the medications as a group is stomach upset and a newer type of the medications has been developed in an attempt to avoid this problem.
Exercise or Physical Therapy - Often recommended to assist in decreasing pain and regaining normal function. Physiotherapy varies considerably and is largely dependent on the physiotherapist administering the treatment. Treatment aimed at pain control (massage therapy, manipulative physiotherapy, ultrasound and interferential) tends to be at best a temporary solution. Medium term strategies such as truncal/back muscle strengthening (including Pilates) seem also to be temporarily helpful for the period of the program however there is little evidence of improvement in the longer term. Perhaps the most useful physical approach to treatment is to regain and maintain greater general aerobic fitness which is not specific to any muscles in particular. Improved fitness not only reduces the risk of back pain episodes but leads to improved diet and eventual weight control which seems to be the real key to controlling the pain in the longer term.
Lumbar corsets - Back supports may help symptoms quite markedly particularly during periods of activity (eg. At work, whilst exercising, gardening, etc.) They work mainly by pushing the abdomen inwards and creating a type of "hydraulic support" for the lower back. Some people express the concern that a corset will lead to back weakness by taking over the job of the back muscles. It is, however, most unlikely that the corset works "well" enough to cause this problem and there is no evidence to suggest that this occurs.
Rehabilitation - Patients with spinal disorders which persist beyond a reasonable timeframe may benefit from an attempt at functional restoration through rehabilitation. Rehabilitation in a dedicated treatment centre offers a team approach to back pain with input from doctors, occupational therapists, physiotherapists, psychologists and nursing staff. The program seeks to provide not only short term functional improvement but also educational strategies aimed at long term avoidance of disabling pain recurrence. Dr. Williams' team works most closely with the Gregory Terrace Rehabilitation Centre.
Injection Therapy - One of the main problems in the treatment of lower back or neck pain is in establishing which part of the spine is mostly responsible for the pain. This is largely due to the complexity of the back or neck as a whole. Injections can be used not only in an attempt to improve the pain but also when further information regarding the cause of a patient's back condition would be useful. The injections are generally performed in a recognized Xray facility using (usually) the CAT scanner to guide the insertion of the needle. The risks of the procedures are few. In theory an infection could occur at the point of needle insertion however this is a very rare event. The risk of nerve damage is very small, being far less than 1%. The injections are done as "day procedures" and the patients may be driven home at the conclusion of the procedure. They are advised not to drive for the rest of the day.
Facet Joint Injection (Lower Back or Neck) - The facet joints are the small joints situated on each side of each back bone at the back of the spine. Pain of a certain type can be due to eg. arthritis of these joints and may be improved with an injection of cortisone and local anaesthetic. It's important to note that due to tiny crystals within the cortisone solution that the pain may actually intensify for the first 12 to 24 hours until the crystals dissolve after which the benefit of the injection is realized. To assist in the diagnostic part of the injection, a patient pain graph is given to each patient to record the pain level after the injection. This should be brought to the followup appointment.
Nerve root injection (Lower Back or Neck) - The nerve roots leave the spine one at each level and then join together outside the spine to form the major nerves entering the limbs. This why the pain of nerve pressure in the neck or back is experienced mainly in the arms or legs. Where Xrays have shown possible but inconclusive evidence of nerve pressure in one of these areas, a nerve root injection may help with the diagnosis and also improve the pain. A pain scoring sheet will be provided after the injection which should be completed and brought to the followup appointment.
Pain Clinic - For those patients in whom pain is severe and persisting and for whom no other treatment will provide relief, referral to a pain clinic/specialist may be recommended. There are numerous services available for the treatment of chronic pain and Dr. Williams works most closely with Dr. Brendan Moore and his team of pain specialists at axxonhealth and painlogic. There are many modern strategies of pain control which may be employed, including epidural cortisone injection, radiofrequency ablation and the newer classes of nerve pain medications amongst many others.
SURGICAL OPTIONS
Most people with spine problems do not require surgery. Individuals who fail conservative methods, or continue to have nerve compression pain or a neurological deficit (i.e. weakness in muscle, loss of a reflex) and have ongoing disability may be candidates for surgery.
As deep bruising within the spinal wound may be a sesrious problem after surgery, it is of the greatest importance that any medications which thin the blood (eg. Astrix, Cartia, Ecotrin, Aspirin, Persantin, Asasantin, Plavix,) be stopped for at least 2 weeks prior to surgery. Warfarin is also noteworthy. If you take any of the above medications please inform Dr. Williams' team well in advance of surgery.
Lumbar Discectomy - An operation performed on patients with a herniated (ruptured) disc in the lower back. Of the many patients who suffer leg pain due to this problem, only a small number will need to consider surgery as an option for treatment. At least 80% of the time the symptoms resolve regardless of the treatment. In this surgery, the herniated part of the disc is removed which relieves leg pain. It is important to realize that the surgery is performed only for persisting leg pain. Pain in the middle of the lower back is rarely an indication for surgery of this type. Leg muscle weakness or skin numbness is a sign of nerve damage which has occurred due to the compression of the nerve. These problems will not be improved specifically by surgery to take the pressure off the nerve and after the operation in all likelihood these problems will persist for many months as the nerve regenerates very slowly. In the operation only the small piece of disc causing compression will be removed (not the entire disc). The disc prolapse has occurred due to internal wearing within the disc and this will not be repaired by the surgery. This means that, in the future, back pain due to this disc wear may occur from time to time. This pain is not related to the discectomy operation and is rarely disabling. Complications of surgery are uncommon however a full discussion of the risks and benefits of surgery will be undertaken by Dr. Williams prior to the procedure.
Laminectomy - An operation performed on patients with spinal stenosis. Spinal stenosis is a narrowing of the canal through which the spinal nerves pass. This operation is a removal of the "roof" of the spinal canal to allow more space for the underlying spinal nerves.Part or all of the back surface (lamina) of a back bone is removed (-ectomy) to enlarge the opening through which the spinal cord and spinal nerves run. This permits removal of any protruding disc material or bony spurs and the spinal nerves at the affected level of the back are dissected free of compression individually.
Spinal Fusion - An operation performed to prevent or limit abnormal motion in the spine by fusing two or more vertebrae. A spinal fusion may be performed as treatment for lower back pain due to "wear and tear" or for numerous other reasons including infection, tumours or broken bones as well as in deformity of the spine such as in scoliosis. The actual fusion (joining together) is done by surgically applying bone graft and/or spinal instrumentation to the level to be fused. A decompressive procedure, such as a laminectomy, may also be performed if required. Any problematic protruding disc material as well as arthritic areas of the spine may also be addressed at the same time.
Generally spinal fusion surgery for back pain is reserved for patients with very specific and disabling pain. Few patients with back pain are considered likely to benefit from the surgery, and for those considered appropriate the likelihood of improvement in the pain following the surgery is around 70%. It should also be remembered that it may take many months for the pain to improve even if the surgery is successful. This relates to the long healing process which follows the surgery.
The bone graft used for a spinal fusion may be autograft (bone taken from your own body) or allograft (bone from a bone bank). As the harvesting of bone (usually from the hip) may be painful, alternatives to using the patient's own bone are being sought very enthusiastically. Some alternative methods include using specific blood cells taken from the patient at the time of surgery which contain bone growth proteins and combining them with allograft, artificially produced bone substitutes and proteins and electronic implants which generate an electric current around the bone graft and encourage its growth and maturation.
It is generally held that success of a fusion operation is improved by holding the bones in the desired position with screws and rods. There are many different types available although all are similar and there is very little to favour one type over another. If metal is used, it cannot be felt through the skin, mostly does not need to be removed and will not set off the metal detectors at airports!
There are several different ways in which vertebrae may be fused together and the particular technique depends largely of the characteristics of each individual case.
- Anterior/Posterior fusion - In this operation, the disc is removed by approaching the front of the spine (through the abdomen). In place of the disc a ring of bone is inserted (usually thigh bone) from the bone bank. This is then held at the front with a screw. On occasions, a metal cage made of titanium may be used instead of bone bank bone. Because this insert in the disc space is a relatively weak construction, screws and rods are also required at the back of the spine to hold the implants in place while the bone heals into its new environment.
- Posterior fusion - For situations where there is no clear advantage to removing the intervertebral disc, a fusion may be achieved by joining the bones together from behind only. This would usually also involve metal screws and rods.
- Posterior Interbody fusion - it is possible to fuse two back bones across a disc space by placement of a special cage made of carbon fibre from the back of the spine without surgery through the abdomen (TLIF). This surgery may be employed to provide a weight bearing strut at the from between two adjacent bones and particularly to allow free passage of individual nerves out of the narrowed apertures at the site of the spine where the nerves may be "pinched".
