Nature of spinal pain

The majority of the patients we see have chronic spinal pain. The spine is a complicated structure. Its primary components are the bones, joints between the bones, discs, and nerves. In addition to these primary components, there are a variety of structures that support the spine, including the muscles. Injury or irritation of any of the primary components of the spine has the potential to cause chronic spinal pain. Once a painful condition occurs, muscles go into spasm to defend the spine from further injury. Although this muscle spasm is also painful, in most patients with chronic pain the muscles are not the primary cause of pain. In some patients the situation is complicated by stress and depression, which frequently accompany pain, and can even make pain worse. Chronic spinal pain is not a life-threatening condition. However, it can disable patients from work and other activities and prevents many people from fully enjoying their lives.


Diagnosis of spinal pain

The key tools that doctors use to diagnose the cause of spinal pain are patient history, physical examination, and x-ray studies, including MRI scans. Often the source of pain can be diagnosed using these tools, particularly in patients who have primarily nerve root pain (pain or weakness along the course of a nerve). However, in many patients, particularly those with primarily back or neck pain, it is difficult to localize the exact source of pain. MRI scans are frequently not helpful in these patients. They may show only the normal age-related changes that occur in most people, whether they have pain or not. The nerve supply to the spine is diffuse and overlapping, so a particular pain could have one of several possible causes. Diagnosing the exact source of pain may be difficult, but if your doctor knows the source of your pain, he or she may be able to treat you more effectively. This is particularly true if surgery is being considered.

Using diagnostic injections to diagnose the source of pain is an effective alternative to relying on only clinical evaluation and x-ray studies. These may be useful both in patients with nerve root pain and patients with back or neck pain. At the time of a diagnostic injection, individual structures of your spine are selectively injected with contrast dye and/or local anesthetic. Then the effect this has on your pain is carefully observed. If reproduction of your typical symptoms is experienced, that may be an indication that the structure injected is the source of your pain. If your pain goes away, even for a short period of time, that may also be an indication that the structure injected is the source of your pain. The degree of pain relief you experience immediately after a diagnostic injection is very important. So following the injection, you may be asked to perform certain maneuvers that usually increase your pain to determine if your pain level has changed. In addition to contrast dye and/or local anesthetic, we often include a small amount of cortisone with diagnostic injections. The cortisone used may provide prolonged relief beginning one to two weeks after the injection. If you have such pain relief following a cortisone injection, that may also be important diagnostically. Examples of diagnostic injections include disc, facet, sacroiliac, sympathetic, and selective epidural or nerve root injections. Using injections, in conjunction with clinical information and imaging studies, we are able to diagnose the source of pain in approximately 75% of our patients.

Treatment of spinal pain

In general, there are four treatment options for patients with chronic spinal pain. Physical therapy can be effective for many people, particularly physical therapy that emphasizes activity and return to function. For patients who have pain in spite of physical therapy, surgery can sometimes be effective. The success of surgery is highly dependent on an accurate diagnosis as to the source of pain. Another option for patients is to simply live with their pain as best as they can, sometimes with the assistance of pain medications or other methods such as acupuncture.

Another alternative for treating spinal pain is using therapeutic injections. If your doctor knows where your pain is coming from, he or she may recommend a therapeutic injection. Therapeutic injections differ from diagnostic injections in that they are intended to treat pain, rather than diagnose its cause. Most therapeutic injections use local anesthetic and cortisone medications, although sometimes other substances or even heat can be applied. Examples of therapeutic injections include epidural, facet, sacroiliac, sympathetic injections, facet rhizotomy, and intradiscal electrothermal therapy.

Therapeutic injections have two potential benefits. The first is that they have the potential of providing long-term pain relief. After a therapeutic injection, the likelihood of significant and lasting pain relief will vary according to the source of pain and the specific injection, but typically is in the 50% - 60% range. The second potential benefit of a therapeutic injection is that even though it only provides short term pain relief (e.g. two to three weeks), other treatments such as physical therapy will be much more effective during that time. The combination of the injection and additional treatments, as ordered by your doctor, may then eventually lead to long-term pain relief.


Risks and side effects

When done properly, spinal injection procedures are very safe. All of our procedures are done under x-ray guidance, both for safety reasons and to provide the greatest likelihood of success. However, with any medical procedure or treatment come possible risks. Any time a needle is placed into the body, there is a risk of bleeding. Usually, any bleeding that occurs after an injection is very minor. However, in rare circumstances bleeding can lead to serious complications. To minimize this risk, we have instructed you to stop taking anti-inflammatories for 3 days prior to your procedure, aspirin for seven days prior, and to notify us if you take blood-thinning medications. Another complication that can occur with needle procedures is infection. The chance of getting a significant infection after any needle procedure is very low. However, with certain procedures involving disc injections, including discograms and intradiscal electrothermoplasty, a minor infection could lead to a serious complication. For that reason, if you are having a disc injection, antibiotics will be administered to you both intravenously and directly into the disc at the time of the procedure.

All of our procedures are performed using local anesthesia and intravenous sedation. It is possible to have allergic or other reactions to the medications used during the procedure, including the contrast material or "dye" used to make the x-ray images clearer and make sure the injected medication will go to the correct site. Most reactions that occur are minor, although serious complications are possible. For that reason, it is important that you notify us of any medication allergies you may have, prior to the procedure. For your safety, oxygen will be administered during the procedure, while your blood pressure, heart rate, and oxygen levels will be constantly monitored.

Minor side effects are common after injection procedures. The sedative medications that are used may impair your coordination, so you should not drive or do other activities requiring coordination for at least 12 hours after the procedure. The local anesthetic injected into the spine may cause regional numbness or weakness for up to 6 hours after the procedure, which is another reason to limit your activity on the day of the injection. You may have local soreness at the injection site for one or two days, which usually responds to application of ice packs. Some patients, especially those having discograms, may have an increase in their usual pain for up to 10 days following an injection. If you experience this, you should try resting and taking your regular pain medication, then call us if your pain persists. If you received cortisone in your injection, you may notice an improvement in your usual pain within two to three days, although it may take as long as 10-14 days for the medication to fully take effect. Although most patients do not have any side effects from cortisone, the following side effects may be possibly experienced: sweating, flushing, palpitations, increased heart rate, insomnia, anxiety, hiccoughs, headache, menstrual changes, upset stomach, frequent urination, and slight fever with flu-like symptoms. If any of these side effects become significant or persists longer than three days, please contact us.

Although serious complications are rare, they can occur. Possible serious complications include: increased pain, headache, temporary or permanent nerve damage, hip (bone) damage caused by steroids, seizures, difficulty breathing, collapsed lung, death, paralysis. It is possible that serious complications, especially those related to bleeding and infection, could occur in the recovery period, at home, after you have left the clinic. For that reason, if you develop fever, progressive weakness or numbness, loss of bowel or bladder control or any other symptoms that you find concerning, please notify us immediately.

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