Back pain is one of the most common reasons people go to the doctor, but not all back problems require surgery. Most causes of the pain can be treated with non-surgical methods in a doctor's office.
"Back pain can be caused by a number of different factors. Most often it can be attributed to irritation or degenerative changes in the discs or the joints in the back, the facet joints, or the joints of the pelvis, including the sacroiliac joints and hips," says William Craig, MD, a Physical Medicine and Rehabilitation Specialist with Southlake Orthopaedics.
In his practice, Craig focuses on individuals who may not be candidates for surgery or who may not be ready for a surgical option and want to try a more conservative treatment approach. He specializes in epidurals for pain block, ultrasound-guided injections, physical therapy, and oral management, among other treatments, for both chronic and acute mechanical back pain.
Mechanical means the source of the pain may be in the spinal joints, discs, vertebrae, or soft tissues. "Acute mechanical back pain without neurological involvement or 'red flags' such as fever, unexplained weight loss, or pain unrelated to movement, has a favorable natural history," Craig says. "Up to half of patients with uncomplicated mechanical back pain recover within two weeks, and up to 90 percent will improve within three to four months."
Treatment options for acute mechanical back pain include reassurance and education related to the natural course of the back pain. "I also may recommend activity modification, ergonomic and lifestyle changes, chiropractic care, physical therapy and medications," Craig says. "When using oral medications, I tend to favor the NSAIDs and acetaminophen. In patients who do not respond to these medications or whose pain is severe, I suggest limited use of muscle relaxants and select opioids, such as Tramadol."
Pain that persists for more than 12 weeks is considered to be chronic mechanical back pain, which also has basic goals for its evaluation and treatment. "First, we rule out malicious causes of pain, such as an infection, a tumor, or a fracture," Craig says. "Next, we localize the source of pain with a comprehensive medical history, examination, diagnostic imaging and diagnostic injections. Diagnostic injections are helpful in determining the primary pain generator when history, examination and diagnostic imaging are inconclusive. The injections include medial branch blocks for facet mediated pain, discography, sacroiliac joint injection or ultrasound-guided hip injection."
Treatment for chronic mechanical back pain includes therapeutic injections in addition to the treatments commonly used for acute mechanical back pain. "Therapeutic injections include, but are not limited to, radiofrequency ablation for facet or sacroiliac joint-mediated pain, epidural injection for discogenic pain, and corticosteroid injection of the hip or sacroiliac joint," Craig says. "For patients who do not respond to conservative techniques, I typically refer them to my surgical colleagues for consideration of fusion."
Sometimes, however, the techniques may not work for people who have certain physical conditions or diseases such as Cauda Equina symptoms, cancer, tumors, or a malicious lesion in the spine that appears unstable. "In those cases, getting pain relief may require surgery," Craig says. "If someone has a pinched nerve with significant weakness, I often advise them to consider surgery, but it is not always inevitable. The main issue with back pain patients is getting them through the door. Once they are in the office, either I or my surgical partners do a thorough history, exam and imaging to try and identify the problem. At that point, we can decide what a patient needs."
