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A Review of Conservative Spine Treatments

Written by Farhad Mosallaie, DO, PhD.

Often we hear, "I don't want to have spine surgery!" The good news is ninety percent of people who experience back pain will never need spine surgery since most problems resolve with conservative care. Conservative treatments for back or neck pain include a wide spectrum of treatment options ranging from common medications to more uncommon methodologies such as acupuncture or biofeedback. Many strategies can be used together, although some are more helpful when one follows the other. The goal is to try the least invasive treatments first while more invasive options are considered when conservative options fail.

Acute and Chronic Pain

Pain can be divided into two categories: acute and chronic. Although traditionally chronic pain was defined as pain lasting more than six months, recently health care professionals view chronic pain as the persistence of pain after the original tissue damage has resolved. Although it may take six months to categorize non-resolving pain as chronic pain after major spine surgery, non-resolving pain after a simple back strain may be categorized as chronic pain much earlier.

Medical vs. Alternative Treatments

Alternative treatments usually refer to unconventional medical interventions not taught by western medicine and usually not available in hospitals or covered by insurance plans. However, alternative medicine is becoming more popular and accepted. The line between medical and alternative treatments is less defined. A good example is the increased popularity and acceptance of medical acupuncture.

Regardless of the conservative method, there is greater success when patients actively participate in their treatment with a focus on the restoration of function and not just elimination of pain.

Medications

Drug therapy is the most common medical treatment for both acute and chronic pain. Some drugs not only relieve pain but also reduce inflammation or help to relax muscle spasm. Typical medications categories that may be helpful include:

Physical Therapy and Exercise

Exercise is considered the backbone of treatment in the conservative management of spine care. When back or leg pain is present it is easy to become immobile in an attempt to reduce the pain. However, prolonged bedrest or immobilization causes de-conditioning, muscle and joint stiffness, leading to a vicious cycle of more pain and weakness so inactivity should be limited.

Exercises to strengthen and stretch the back should be initiated as rapidly as possible. These exercises should not induce back, neck or extremity pain. To begin, a prescription for physical therapy (PT) can be written by any physician but best if written by a spine/pain specialist with recommendations that fits each patient's specific issues. PT prescriptions usually have multiple components that can be divided into passive versus active treatments. Weight reduction, proper body mechanics and ergonomics at work and home should be considered in the evaluation so re-injury or exacerbation of pain can be avoided during recovery and maintenance.

Passive vs. Active Treatments

There is a specific distinction between passive and active treatments. Initially they can work in combination to mobilize you but in the long run, active treatments will have a more lasting effect on your spine health.

Passive Treatment is Done TO You

Passive modalities are done initially to reduce pain so the patient can prepare to regain comfort and activities. These treatments such as (heat, ultrasound, TENS and others) focus on reducing pain whereas active treatments center on musculoskeletal training that are learned and continued at home. A home therapy program is necessary for long term pain relief and restoration of function.

Active Treatment is Done BY You

The active part of physical therapy involves exercise routines including stretching, strengthening, and endurance components. Stretching helps to increase flexibility and range of motion. Strengthening uses weights or resistance to increase muscle force. Increased muscle strength helps unload the spine and the joints of your body. Of particular importance with back disorders is core strengthening. Called dynamic stabilization, this strengthening helps unload the forces on the spine, its discs and nerves. Endurance uses prolonged repetitious movements to increase aerobic capacity which reduces pain as well.

Spinal Injections

A variety of spinal injections can be used for diagnosis and/or treatment of pain in the cervical, thoracic, lumbar and sacrococcygeal regions. We will discuss the most common ones. Spinal procedures can be divided into either diagnostic or therapeutic, although some can serve both functions.

Spinal injections can be used for diagnosis and/or treatment of various types of pain in each region of the spine. The most common spinal procedures can be divided into either diagnostic or therapeutic, although some serve both purposes. An anesthetic agent and/or a steroid medication is used in these injections. Spinal injections are best done under imaging guidance to assure accuracy of the procedure. All injections performed for therapeutic purposes are designed to reduce inflammation and relieve pain. The type of injection used depends on your diagnosis and cause of your symptoms.

Epidural Block

An epidural steroid injection (ESI) refers to a type of steroid injection that is put into the epidural space. The term, epidural, refers to the space outside the dura or covering of the spinal cord but inside the spinal canal. There are various methods used depending on whether there was previous surgery and area of difficulty. A selective nerve root block (SNRB) is very similar to an epidural injection without the use of a steroid. This injection, used for diagnostic purposes, gives a few hours of relief helps to locate the origin of the pain.

Medial Branch Block

On each side of the vertebrae, there are the small joints where the vertebrae fit together called facet joints, which can be a common source for pain. When facet joint pain is diffuse and does not fit a particular nerve root pattern, we can use the medial branch block to diagnose pain originating from facet joint. A facet joint injection and/or medial branch block (MBB) is the gold standard. An intraarticular facet injection introduces the medication into the facet joints and is usually therapeutic. If the MBB is effective radiofrequency ablation (RFA) can be a next step, which uses radio waves to produce heat resulting in the cauterization for the medial branch responsible for facet pain. On average, one can obtain 12 months of relief with RFA.

Injections can also be used for sacroiliac joint (SI) pain which often presents after acute injuries, pregnancy and in patients with lumbosacral fusion. Injection into the joint capsule is both therapeutic and diagnostic.

Often we hear, "I don't want to have spine surgery!" The good news is ninety percent of people who experience back pain will never need spine surgery since most problems resolve with conservative care. Conservative treatments for back or neck pain include a wide spectrum of treatment options ranging from common medications to more uncommon methodologies such as acupuncture or biofeedback. Many strategies can be used together, although some are more helpful when one follows the other. The goal is to try the least invasive treatments first while more invasive options are considered when conservative options fail.

Acute and Chronic Pain

Pain can be divided into two categories: acute and chronic. Although traditionally chronic pain was defined as pain lasting more than six months, recently health care professionals view chronic pain as the persistence of pain after the original tissue damage has resolved.  Although it may take six months to categorize non-resolving pain as chronic pain after major spine surgery, non-resolving pain after a simple back strain may be categorized as chronic pain much earlier.

Medical vs. Alternative Treatments

Alternative treatments usually refer to unconventional medical interventions not taught by western medicine and usually not available in hospitals or covered by insurance plans. However, alternative medicine is becoming more popular and accepted. The line between medical and alternative treatments is less defined. A good example is the increased popularity and acceptance of medical acupuncture.

Regardless of the conservative method, there is greater success when patients actively participate in their treatment with a focus on the restoration of function and not just elimination of pain.

Medications

Drug therapy is the most common medical treatment for both acute and chronic pain. Some drugs not only relieve pain but also reduce inflammation or help to relax muscle spasm. Typical medications categories that may be helpful include:

Physical Therapy and Exercise

Exercise is considered the backbone of treatment in the conservative management of spine care. When back or leg pain is present it is easy to become immobile in an attempt to reduce the pain. However, prolonged bedrest or immobilization causes de-conditioning, muscle and joint stiffness, leading to a vicious cycle of more pain and weakness so inactivity should be limited.

Exercises to strengthen and stretch the back should be initiated as rapidly as possible. These exercises should not induce back, neck or extremity pain. To begin, a prescription for physical therapy (PT) can be written by any physician but best if written by a spine/pain specialist with recommendations that fits each patient's specific issues. PT prescriptions usually have multiple components that can be divided into passive versus active treatments. Weight reduction, proper body mechanics and ergonomics at work and home should be considered in the evaluation so re-injury or exacerbation of pain can be avoided during recovery and maintenance.

Passive vs. Active Treatments

There is a specific distinction between passive and active treatments. Initially they can work in combination to mobilize you but in the long run, active treatments will have a more lasting effect on your spine health.

Passive Treatment is Done TO You

Passive modalities are done initially to reduce pain so the patient can prepare to regain comfort and activities. These treatments such as (heat, ultrasound, TENS and others) focus on reducing pain whereas active treatments center on musculoskeletal training that are learned and continued at home. A home therapy program is necessary for long term pain relief and restoration of function.

Active Treatment is Done BY You

The active part of physical therapy involves exercise routines including stretching, strengthening, and endurance components. Stretching helps to increase flexibility and range of motion. Strengthening uses weights or resistance to increase muscle force. Increased muscle strength helps unload the spine and the joints of your body. Of particular importance with back disorders is core strengthening. Called dynamic stabilization, this strengthening helps unload the forces on the spine, its discs and nerves. Endurance uses prolonged repetitious movements to increase aerobic capacity which reduces pain as well.

Spinal Injections

A variety of spinal injections can be used for diagnosis and/or treatment of pain in the cervical, thoracic, lumbar and sacrococcygeal regions. We will discuss the most common ones. Spinal procedures can be divided into either diagnostic or therapeutic, although some can serve both functions.

Spinal injections can be used for diagnosis and/or treatment of various types of pain in each region of the spine. The most common spinal procedures can be divided into either diagnostic or therapeutic, although some serve both purposes. An anesthetic agent and/or a steroid medication is used in these injections. Spinal injections are best done under imaging guidance to assure accuracy of the procedure. All injections performed for therapeutic purposes are designed to reduce inflammation and relieve pain. The type of injection used depends on your diagnosis and cause of your symptoms.

Epidural Block

An epidural steroid injection (ESI) refers to a type of steroid injection that is put into the epidural space. The term, epidural, refers to the space outside the dura or covering of the spinal cord but inside the spinal canal. There are various methods used depending on whether there was previous surgery and area of difficulty. A selective nerve root block (SNRB) is very similar to an epidural injection without the use of a steroid. This injection, used for diagnostic purposes, gives a few hours of relief helps to locate the origin of the pain.

Medial Branch Block

On each side of the vertebrae, there are the small joints where the vertebrae fit together called facet joints, which can be a common source for pain. When facet joint pain is diffuse and does not fit a particular nerve root pattern, we can use the medial branch block to diagnose pain originating from facet joint. A facet joint injection and/or medial branch block (MBB) is the gold standard. An intraarticular facet injection introduces the medication into the facet joints and is usually therapeutic. If the MBB is effective radiofrequency ablation (RFA) can be a next step, which uses radio waves to produce heat resulting in the cauterization for the medial branch responsible for facet pain. On average, one can obtain 12 months of relief with RFA.

Injections can also be used for sacroiliac joint (SI) pain which often presents after acute injuries, pregnancy and in patients with lumbosacral fusion. Injection into the joint capsule is both therapeutic and diagnostic.

Other Spinal Procedures and Treatments

There are other spinal procedures that can improve back and leg pain. Once your diagnosis is determined through history, physical examination and the appropriate imaging studies, the spine or pain specialist can recommend which procedure might be best for you.

In some cases, there is benefit to seek chiropractic manipulation or osteopathic manual medicine. Both approaches can be used on the symptoms and diagnosis of the problem and usually provide the best relief when used in conjunction with active therapies such as an consistent exercise program to help restore functionality.

Other treatments to consider with varying success include acupuncture, prolotherapy and biofeedback. Specifically psychotherapy can help to reduce pain medication intake and increase activity levels through modifying behaviors through thoughts and self-awareness.

When Conservative Care Fails

When conservative care fails, it may be appropriate to evaluate whether you could benefit from spine surgery. Spine surgery is usually done for either nerve pinching or spinal instability. If non surgical options have not been helpful in reducing pain or restoring your desire level of functionality, spine surgery could be helpful. Remember, spine surgery outcomes are best when the spine surgeon evaluates you and confirms that it is the next step. It is imperative to select the right procedure for the right patient at the right time. There are other spinal procedures that can improve back and leg pain. Once your diagnosis is determined through history, physical examination and the appropriate imaging studies, the spine or pain specialist can recommend which procedure might be best for you.

When conservative care fails, it may be appropriate to evaluate whether you could benefit from spine surgery. Spine surgery is usually done for either nerve pinching or spinal instability. If non surgical options have not been helpful in reducing pain or restoring your desire level of functionality, spine surgery could be helpful. Remember, spine surgery outcomes are best when the spine surgeon evaluates you and confirms that it is the next step. It is imperative to select the right procedure for the right patient at the right time.

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