The best treatment for each patient must be based first on an accurate diagnosis. Although it is appealing to have the latest procedure, the newest medication, the smallest micro-surgery or arthroscopic surgery, the best treatment must be appropriate for each individual patient’s unique problems. Treatment must also be based on scientific evidence, not marketing on television or in news magazines.
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:
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.
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.
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.
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.
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 CT 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.
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 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.