Written by Jesse Hatgis, DO of Anesthesia Pain Care Consultants
After a complete assessment, which includes a patient history, physical examination, and advanced imaging review, a proper diagnosis is then determined, and an individualized treatment plan is formulated.
Low back pain is mainly split into two types: axial and radicular.
Axial Low Back Pain:
A.K.A. “Non-radicular” pain
- Pain is mainly localized to lower back, with occasional “referred” pain to adjacent regions such as the thighs, groin, hamstrings, and glutes.
- Usually does not travel below the knee.
- Pain generators arise from facet joints/medial branch nerves, intervertebral discs, vertebral bodies, sacroiliac joints, thoracolumbar fascia, etc.
Radicular Low Back Pain:
- Pain travels to distant locations via spinal nerve pathway.
- Usually travels below the knee.
- Presents with sensory changes (i.e. numbness/tingling) and occasionally motor weakness.
- Pain generators arise from pressure on corresponding nerve root(s) resulting in spinal stenosis.
- Often caused by herniated/bulged disc, thickened spinal ligaments, bony overgrowth, or slippage of one vertebra over another.
1st Line of Treatment:
A.K.A. “Conservative measures”
- Physical therapy/chiropractic care: Improvement of posture, strength, stability, range of motion, alignment, endurance, etc.
- Modalities: Heat, ice, electrical stimulation, etc.
- Medication management: Simple OTC medications like acetaminophen & NSAIDS, and prescription medications such as anti-neuropathic agents, muscle relaxants, opioids, etc.
2nd Line of Treatment:
Typically reserved for pain beyond 6 weeks, which has failed the previously mentioned conservative measures.
- Facet joint injections/medial branch blocks: Injections into or surrounding the individual joints connecting one spinal level to another.
- Radiofrequency ablation: Heating of the smaller nerves that contribute to facet joint pain to disrupt the sending of pain signals, thereby resulting in pain relief.
- Epidural steroid injections: Injections into the epidural space where the nerve roots are present to reduce inflammation and radicular pain.
- Trigger point injections: Injections into muscle spasm “knots”.
- Sacroiliac joint injections: Injections into the joint(s) directly below the lumbar spine towards the tailbone.
- Regenerative medicine: Using materials to help heal damaged tissues such as PRP, stem cells, amniotic tissue allograft, exosomes, etc.
- Kyphoplasty/vertebroplasty: Injection of bone cement into the vertebra in cases of fracturing to better stabilize the bone and reduce pain.
3rd Line of Treatment:
Minimally invasive “surgeries”
- MILD procedure: Removal of thickened ligament pressing on the spinal nerve roots via a small tube.
- Micro/endoscopic discectomy: Removal of spinal disc material that is causing compression of spinal nerve(s) with radicular pain, or referred pain from the disc itself via a small tube.
- Transection of medial branches: Cutting of the smaller nerves that contribute to facet joint pain to disrupt the sending of pain signals on a more permanent basis.
- Basivertebral nerve destruction: Heating of the basivertebral nerve(s) that contributes to vertebral body pain to disrupt the sending of pain signals, thereby resulting in pain relief.
- Interspinous process device placement (ISP): Minimally invasive placement of a distraction/stabilization device to create more space for the nerve roots and reduce movement-induced inflammation in the lumbar spine.
- Sacroiliac joint fusion: Minimally invasive placement of a distraction/stabilization device to create more space in the sacroiliac joint(s) and reduce movement-induced inflammation.
- Spinal cord stimulation/neuromodulation: Utilization of a battery-powered device implanted under the skin to disrupt pain signals.
4th Line of Treatment:
- Orthopedic/neurosurgical intervention: More invasive surgical techniques when higher level neurological findings are present or previous treatments have not been effective enough.
- Quite often, large structures are removed, and metal hardware is used.
- The recovery process could be long and painful.
- As interventional pain management physicians, we do everything in our power to prevent patients from reaching this treatment stage.
Note: This summary provides a general overview of treating lower back pain. It is important to consult with a healthcare professional to determine the appropriate treatment option for your specific condition.