The Spine - Description and Pain TreatmentsFeb 28, 2023
The spine is separated into three major regions. That's cervical, thoracic, lumbar. Most of us are familiar with the term lumbar spine, but these three major regions are important to consider when diagnosing and treating spine pain.
The spine itself is divided into three main regions. There is a disc up front, which everybody knows, and two joints in the back, called facets. The facets are articular surfaces, much like the knee or the finger, and have synovium. Over time they can become arthritic, particularly in the lumbar region where it is much more so weight bearing in the cervical region.
The front part of the spine is called the disc, commonly associated with painful disorders. The disc is a vulnerable structure, absorbing its nutrients, and hydration by osmosis, which diminishes to a significant degree by age 30.
Within the following one or two decades of an individual's life, depending on physical habitus, lifestyle, and genetics, the disc is at risk for a number of potential problems. We have all heard of "ruptured disc," but the disc does not have to be ruptured to hurt. It can have a structural derangement, of varying degrees, and can develop into a chronic malady of which individuals believe something must be done. Often they seek surgery, when surgery is not always the best option.
Other structures that are important to understand are the facets. Up to 40% of low back pain, particularly axillary pain in the lumbar region is attributed to the facet. Usually pain stops above the knee, aggravated by arching the back called extension, and side bending. There is no real good diagnostic test for the facet, with the exception of imaging, which may include x-rays, MRIs or CTs. The degree of pain and infirmary is not correlated by the changes noted on imaging studies.
Sometimes further diagnostic studies such as nerve conduction studies need to be performed, or diagnostic injections such as facet blocks, transforaminal blocks, nerve blocks, etc. to better declare the pain process. Surgery is not always a good option when facet disease is evident, and minimally invasive procedures such as facet blocks and radiofrequency neurolysis might be better choices.
Stenosis is a problem that occurs when there just isn't enough room. Stenosis is crowding. Crowding around the nerve, crowding around other structures, and can interfere with function, quality of life, and ability to move. Often people with advanced stenosis will find themselves bending over, taking pressure off the stenotic structures. It is felt that sometimes venous drainage, and unloading of the spine improves function, so climbing stairs is better than going down stairs.
Leaning on the shopping cart is better than standing upright shopping. Stenosis might require surgery, but conservative management should win out most of the time. Modifiable features in health profile such as weight control, cigarette cessation, and other lifestyle enhancements as physical therapy and increasing activity are best predictors of outcome.
Cigarettes are always a bad idea, and are a leading predictor of continued spinal disorders. This cannot be over stressed. It is not uncommon that individuals don't believe that this is a problem, and are gripped by the addictions of cigarettes. We do have a compassionate tone here, as addiction to nicotine and tobacco products is more compelling to an individual than if they had heroin addiction. This is coming from a board certified addiction specialist, further management provided.
Low Back Pain
Low back pain has been the scourge of mankind for a Millennium, or at least as long as the written word. Low back pain affects 80% of the population, at least some time during the course of a year. Chronic low back pain, is a major source of impairment and disability, and is recognized as a major cost to Society. Lost wages, lost time with family and loved ones, disability, and even protracted infirmity place this painful malady at the top of the list of pain problems.
Common misperceptions about low back pain are abundant. The "I think it therefore it is" rule.
What do we mean by this?
"Low back pain goes away by itself".
A study by Croft, et al, on the outcome of low back pain in general practice took a look at the reality of this common misperception. 463 patient's with new low back pain to a primary care office. Only 32% made return appointments after 3 months. Only 8% returned after 12 months. "Therefore pain resolved". However. Follow-up telephone interview went as follows-
21% reported resolution of pain by 3 months. Only 25% by 12 months. 73% had difficulties with activities of daily living at initial interview, and 50% still had difficulties with activities of daily living after 3 and 12 months.
Although patient's did not return for follow-up, 75% had pain and disability after 12 months.
The prevalence of low back pain and children is low, anywhere between 1 and 6%. It rapidly increases in the adolescent population to up to 50%.Prevalence peaks around the 6 decade of life. 40% of patients complain of neck disorders, which is also very high. It affects about 10% of the general population, and those that are in a stressful job, and smokers, were likely to have more neck and low back pain. Osteoarthritis affects 16% of the US population, or approximately 45 million people. Age is generally greater than 45 years old and women, exceed men after age 60.
So how do we treat it?
That depends. We had to take into account your information. What does your MRI say. What does your provider say? Let's talk about this.
Let's start with what hurts.
To understand low back pain we understand it as a three compartment system. There is a disc up front, and two joints in the back that are called facets. The facets become arthritic, the disc loses its ability to be nourished (at about age 30) especially in smokers - quit smoking, and in between is all the nerves. The side has a hole, called a foramen, and when arthritis starts pushing in on all this, we call it stenosis. In other words there is just not enough room for the nerves. You may have noticed that you want to lean forward on a shopping cart (unloading the spine) and when you walk your legs cramp, but then stop cramping when you stop (bit of a caveat, this could also be vascular. Consult a physician). Facts are facts, as we age, our spine, particularly the weight bearing parts of the spine, are alive and do change.
Cervical, thoracic and lumbar pain
Cervical, thoracic and lumbar pain are addressed similarly, and differently. We can catch them coming and going. The thoracic spine is rarely operated on. If a disc protrusion or pathology is identified in the thoracic spine conservative management wins out. This includes kyphoplasty, or injecting cement for compressed vertebral bodies, which is common in the thoracic region. The cervical region, and the lumbar region are addressed interventionally, and with surgery.
The cervical spine can be accessed under direct fluoroscopic observation to identify painful structural entities. This includes the facets. By injecting the facet with local anesthetic, we can diagnose, and sometimes treat facet disease.
A cervical epidural might be chosen for a broader brushstroke. The same can be said for the lumbar spine. Options do exist beyond surgery. When surgery is indicated, the cervical region is often approached from the front position, and a small plate stabilizes the spine. Problematic added biomechanical stress above and below the surgical fixation site leads to problems down the road.
This is also true with the lumbar spine as fusion is a common lumbosacral procedure for advanced pathology. It is important to talk to multiple individuals, providers, and patients prior to embarking on a major spinal procedure as convalescence can be varied, sometimes unpredictable, and surgery does not necessarily make people better. It may just stabilize the spine, or allow more endurance. Often misunderstood by patients, surgery does not always fix the problem, surgery bears its own weight with potential for adverse outcome, as with any medical procedure.
An epidural is a general term, that applies to a varied number of procedures. Most folks are aware of epidural either anesthesia or analgesia that is utilized for labor and delivery. Sometimes epidurals are used for postoperative pain. Most commonly, particularly in the realm of the pain management specialist, epidural management is utilized to decrease inflammation and pain in tissues of the cervical, thoracic and lumbar spine. This includes the two facet joints, and the disc. There are three ways to approach the epidural space.
This is not translaminar. Translaminar is incorrect terminology. Interlaminar means that a needle is advanced under direct fluoroscopic observation (if your injectionist does not use floro don't get it done) to a space, that is clearly delineated, above the dura, therefore, called epi or above, and not through the dura, which would be subdural, undesirable. If the drug is injected "interthecal," it is the same as a spinal anesthetic, and may exact zero result.
Often times the most common complication from epidural injection results from the unintentional "dural violation," which is addressed with an epidural blood patch. Those that experience headaches, particularly from laying to rising, should be assessed for dural tear or violation. An epidural blood patch, which will be described later, is a fix. Fluids, caffeinated beverages can help sometimes, but are usually inadequate.
Epidural injections by transforaminal approach
Epidural injections by transforaminal approach address the nerve as it comes out the side through what we call a foramen, between the facet and the disc. This is where dense application of drug is placed on the nerve root, decreasing the signal intensity of pain, commonly used not only as a diagnostic maneuver, but a therapeutic maneuver to clearly define the particular nerve involved.
This may help the surgeon isolate the sited pathology most problematic, it might also decrease the irritability at the nerve, therefore allowing a healing and restorative process to continue. This is an effective injection, and technically difficult. It does have more potential for complication, particularly at the spinal cord level, and actually at the nerve itself. These needles can be sharp, and injury to the nerve can occur.
In competent hands, using direct fluoroscopic observation, and contrast, that risk is significantly diminished. Talk this over with your pain management specialist. These particular injections, transforaminal, should never be performed in unskilled hands. This is a medical doctor/DO procedure only. Under no circumstances should this procedure be performed by inexperienced hands. The cervical region should not be performed unless there is a vastly compelling reason to do so. Transforaminal injections in the cervical region has been associated with catastrophic outcome, and is largely avoided when other options exist.
The caudal approach to a lumbar epidural is a safe, and important approach. The caudal approach may work for some where the other approaches don't work for others. It requires a larger volume of injectate, and may have a useful "washout" effect. It is injected right by the tailbone, and is a useful procedure if extensive lumbar surgery has already been performed, to avoid dural violation. It is also an approach that is used to try to break up scar material by adhesiolysis (credit Gabor Racz, MD) that was pioneered by one of the greatest pain management physicians of this century. Any century in that regard.
Expectation is variable. It doesn't help to ask your pain management physician how long this will last, or what can I expect. Each person is different.
Caution about Steroids
There is no specific number of procedures, but cautions to exposure of steroid have to be emphasized. Your pain management physician will be best trained and qualified to answer any questions you have about steroid. Generally speaking these steroid injections do not cause a problem with bone loss. Problems seen with regular oral ingestion of steroids are rarely seen, just as long as everybody knows how much steroid you're getting. If you're getting steroid from your surgeon, and you're getting it from your rheumatologist, your family doctor, and now your pain management physician, everybody's playing on different pages. You should talk this over with your provider prior to injection.
The facet is a joint. Often called zygapophyseal, it is a huge word that devolved to just be called a facet. It's a joint. It's just like your finger, your knees, other joints, where articular cartilage resides. This articular cartilage allows the gliding effect, so important in the knee. As we age, we lose this. As the facet ages, it becomes more arthritic. It's a joint just like any other. It ages, and it eventually starts to hurt. 40% of back pain has been attributed to the facet.
The facet presents primarily as low back pain, which is called axial pain. The facet is aggravated by extension and side bending. Extension is arching your back. It is sometimes relieved by bending forward. The facet can become very arthritic, and can encroach an area on the side of the spine called foramen, where the nerves exist. As the nerves exit the spine, called segmental nerve, the facet has an opportunity to not only irritate, but sometimes impede the nerve. This is called neurocompression.
Facets and Stenosis
The facet can become very problematic, called trefoil, along with other associated structures, inducing stenosis. Stenosis just means crowding, there's not enough room for the things that needed room, and had it when you were 19 years old. In stenosis, we note that you feel better when you're leaning forward over a shopping cart, going up the stairs, and when you walk, this process of neurogenic claudication evolves. That means your legs hurt. You stop walking your legs don't hurt. When we make this diagnosis we do so carefully, as the same process occurs with vascular, or blood vessel insufficiency. Your legs just don't get enough blood. Two different processes, both have to be distinguished. Usually an MRI of the spine helps us here, sometimes the physical exam helps us as well.
The facet is reached by fluoroscopic observation, with a needle at two places. It's either actually into the joint, which is useful sometimes, but most of the time we want to go around the joint to an area of anatomy that bares the medial branch nerve. The medial branch nerve is responsible for the back part of the disc, and the facet, and is called a sensory nerve. It does not affect movement of the leg, it affects pain. As we can get to this nerve, we can inject it with local anesthetic, and often define the facet as a painful generator.
Once this is done, we have the opportunity to ablate this nerve. Ablate means stun or extinguish, by heat energy, or cryoablation, which is freezing. Most commonly we do this with radiofrequency neuroablation, which is heat. Your pain management physician will talk to you about this. We most likely will ask you to participate in physical therapy, and have two different injections. One with a mild local anesthetic that doesn't last very long, and one with a dense longer acting local anesthetic to determine if they both can define themselves. This is pretty old school, and not always useful, but if you have the facet block you notice you could sit longer, move around better, better quality of life, less medication, etc. We're on the path to defining your low back and axial pain. RF is a good approach to dealing with this type of pain, and can often avoid surgery.
Surgery is not always the best option for arthritic pain. Surgery can be an option for stenosis, and pathology where the radicular component, or pain way down the leg is prevalent to the point where it doesn't work as well, or just doesn't get better. A number of decisions have to be made in the spine. It is not always black and white. The facet block is one of the diagnostic procedures to help us better define this pain, and should be considered. A logical option to the facet block that demonstrates a positive effect is to go onto ablation, and then continue to work out the rest of the aches and pains. Multiple structures exist in this region including the sacroiliac joint, and the disc that also may play a role, so it is strongly recommended that you talk to your pain management physician about options, and limitations of certain treatments, that can help you lead a better quality of life and avoid escalation of controlled substances such as opioids.
Sacroiliac joint is where most people consider the hip bone coming together with the spine bone. Actually the sacrum is a complex structure, where the surfaces, called the articulating surfaces, meet with the lower part of the spine called the sacrum. So the sacrum, mixes with the iliac. Here's the clever name, sacroiliac. Actually this is a critical joint. The bottom third is a true articular joint, that has synovium, much like any other joint, and is potentially subject to aging. The sacral joint can become a painful structure, by the mere process of progressive arthritis, and is a significant pain generator. It was felt up until the 1930s that the sacral joint was responsible for most of the low back pain. Mixter and Barr identified the disc as a potential pain generator around that time, so the sacral joint kind of drizzled away. Actually it's responsible for a significant percentage of low back pain, particularly infragluteal (butt) and leg pain, extending to about the knee, and sometimes to the lateral calf, that is probably associated with the fact that the L4 and L5 nerve that go down that region are hanging out in the wrong neighborhood. The L4 and L5 nerve root go on the front side of the sacral joint and there is a rule in medicine (don't need to know the details) that if something is close to something, the other things affect it. The sacral joint is a rich target for the interventionalist to help you not only better understand your pain, but treat it.
The surface of the sacral joint is like the surface of the moon. It is a surface that is most receptive (can be painful, but is normal to be painful) and proprioceptive (helps you stand up). The sacral joint is accessed under direct fluoroscopic observation and must be under fluoroscopic observation to accurately place the drug at the proper diagnostic and therapeutic point. If your provider, or injectionist (could be anybody) sticks the thumb in your back and then puts medicine in there calling it a sacral joint injection without fluoroscopy, you've been withheld the opportunity to receive the significant result of pain relief, and diagnosis. I actually did a study a number of years ago where I, an experienced injectionist, blindly placed a needle to try to get to the sacral joint. I then looked where my needle was fluoroscopically, and I was nowhere close. This little dent in your back called the posterior superior iliac spine, we all have it, is no indication of where your sacral joint is. Any time that is injected, called a sacral joint when actually its a richly innervated (has a lot of nerves) area that is mostly ligament and soft tissue. It is not the sacral joint.
The sacral joint is a strong target to address low back pain, infragluteal pain, and should be addressed by your pain management physician, orthopedist, or others who deal with spinal pain. The sacral joint should not be underestimated, and is a commonly misunderstood area of pain. If an individual has had a fusion of the low back, it makes sense that anything above and below the surgical fixation site will take added biomechanical stress, and this is true with the sacral joint. If you had lumbar fusion, this is a target for relief, and talk it over with your healthcare providers.
Trigger point injections
"Why are you continuing to stick needles in me?"
Trigger point injections are something I still don't understand. Twenty five years into this and I don't think I understand it. Travell defined all these trigger points, I assume a very good physician, JFK's trust.
To this end, I think we're chasing pain. That's Rule 5. Pain is migratory, we all understand that, what hurts here today may hurt there tomorrow, does not necessarily mean that we need to address a peripheral manifestation of the central nervous system problem. I have said for years that fibromyalgia was a central nervous system disorder. I believe in this so much so, that in the late 90s I wrote a book chapter, and other articles, and invoked on a study with a well known centrally acting drug that was important for Pregabalin (Lyrica) to get legs. I didn't have anything to do with Lyrica, it is what it is, but I believe that pain occurs inside out as opposed to outside in. I get that bone breaks, bone hurts, but when chronic pain has evolved, the central nerve system is the demon. Trigger points are probably that peripheral manifestation (the regional demonstration of pain, that is actuated by the nervous system and not a problem with the muscle, the neck, low back, etc. Irritable bowel, chronic fatigue, muscle pain, pelvic pain, and headache will always be the fibro five. They can all be explained by addressing pain inside out from the central nervous system.
So do I think that trigger point injections are useful? Yes. There's something about addressing this type of pain with intervention. Do I think that massage therapy is a good idea? I don't know. I do know that many of my fibromyalgia patients after receiving a fantastic massage therapy, with descriptions of increasing blood flow, etc. based on no signs, come to me 48 hours later and say they are worse. I will leave that up to the individual.
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