Diseases, Disorders information

Conservatively, if you see somebody with back pain very rational approach if they are neurologically intact, and you have done your good physical examination and kind of gone the mental calisthenics that I have outlined, and you decide this is mechanical pain, put them to bed for a very brief period of time, nonsteroidal, perhaps a modality in physical therapy if there is a good deal of soft tissue distress such as muscle spasm, a brief course of ionophoresis, ultrasound may help, before you mobilize the patient into an active physical therapy program, hopefully no later than 10 days after the onset of symptoms. If the patient doesn’t improve and the pain is incapacitating after six to twelve weeks, the next step would be to consider an MRI, that is the first line of investigation. Obviously you are going to be able to screen for tumor or infection, although if you would suspect those based on physical examination or constitutional symptoms, I would hope the MRI would be ordered before that time, but really what you are looking at is gathering information on the degenerative pathology and an attempt to localize the pain generator.
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The problem with localizing the pain generator is the MRI, as you know is very, very sensitive, but very nonspecific. There is a high percentage of degenerative change in many asymptomatic individuals, and that percentage increases as the particular sample ages, so that by the time you are looking at individuals in the 60s or 70s, degenerative changes is ubiquitous, even in asymptomatic individuals with ranges of 85 to 90%. So if you suspect that this degeneration may be the culprit, the next step would be to investigate the disc, and unfortunately, that requires an invasive study and this is obviously the point where you would probably consider a referral. One way to look at the disc is a test called discography, intradiscal injection, not without controversy.
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There two sorts of information available from this, one is the morphology, which you really shouldn’t need if you have a good MRI, but the other is the patient’s clinical response. If you pressurize a symptomatic disc and if the test is done correctly in capable hands, it should recreate the patient’s back pain precisely and enable you to localize the level from which the symptoms originate. North American Spine Society, has formulated guide lines for these, the pain, at least four months long, unresponsive to conservative treatment and other noninvasive modalities, unrevealing. Again, hopefully this would occur relatively rarely, as appropriate conservative care should get most patient’s without neuropathic pain better to the tune of 90 or 95%, but this would be the next line. Facet injections, that is one way to look at whether or not the facet is the culprit, that is a fluoroscopically guided injection which is diagnostic and hopefully therapeutic in some instances, whereby the medial branch of the posterior primary ramus is anesthetized. If that is the pain generator, the patient should get better. There are studies looking at duration of relief, depending on the concentration of the drug used in the facet injections and there has been a positive therapeutic effect assigned to that. There is one school that thought that all facet syndromes are secondary, that they accompany the degenerative symptomatic disc, that again, that is somewhat controversial. How can you treat discogenic pain, well in rare instances, you can perform a spinal fusion, and this is our paper from 1994 where we found we were able to successfully treat that in individuals where the fusion healed. Again, though, if you are operating on someone just for back pain without a deformity, without neurologic features, this should be fewer than 5% of the patient’s that come to your door with this diagnosis.