3 Ways to Treat Chronic Back Pain Without Surgery
By Dr. Raphael Ye
After years of treating chronic back pain patients with motor deficits, we’ve found that back surgery is frequently never 100% successful.
The thing is, surgery is the most invasive, intense, and risky of all treatments.
There is never a guarantee that the surgery will work, and there’s always the risk that your pain will persist and worsen, or the operation will introduce new pain sensations.
Some patients suffer from a condition defined by chronic back pain after surgery, called ‘Failed Back Surgery Syndrome’ (FBSS).
Before taking the risk with surgery, it’s always best practice to put as much space between you and the back surgeon, take the conservative approach, and exhaust all the highly successful non-surgical treatments available to you first.
Trigger Point Injections
Trigger points are painful “knots” in your muscles that form when your muscle contracts or tightens to the point where it can’t relax. Knots in the low back usually form from an injury, strain, sprain, or tear in a muscle.
Knots don’t typically cause problems, and in fact, many people manage minor back injuries conservatively with rest and ice at home. Knots become a problem when they start to hurt and cause enough discomfort that a patient seeks out a physician.
To understand how trigger point injections for knots work, you must note that the knot or muscle tightness generally doesn’t cause pain. Instead, it’s the inflammation from the injury that causes discomfort.
Inflammation is our body’s natural response and defense against injury. During an inflammatory response, the body releases various chemicals that trigger signs of inflammation like swelling, tenderness, and redness. It’s also these chemicals that also trigger pain to bring our attention to the injured area.
Thus, the knots (and resulting painful inflammatory response) in your back can be treated with trigger point injections that utilize anti-inflammatory steroids and local anesthetics for short and long-term back pain relief.
I find the patients who suffer from muscular back pain or soft tissue injury respond well to trigger point injections. And with a combination of other therapies like acupuncture, massage, and physical therapy, patients have higher levels of success.
However, if your back pain is from your spinal cord, facet joints, or discs, then trigger point injections will likely not help you. Though you may feel better for a day or two, trigger point injections will not give you the long-lasting relief you need.
Risks and Implications
As with all injections, a sharp needle is puncturing your skin, and thus, there is a risk of:
However, since trigger point injections are very superficial (the needle isn’t inserted deeply into your body), the risk of infection and bleeding is less than .01%.
There are also potential short term side effects of steroid use, such as:
- Facial flushing
- Increased blood sugar levels
- Immune system suppression
Different patients are more at risk of experiencing steroid side effects. Thus, it’s imperative to discuss your medical history with your doctor before receiving any type of steroid medication.
Epidural Steroid Injection
An epidural is an injection of a steroid and local anesthetic solution directly into the epidural space–the area that surrounds your spinal cord.
Epidural steroid injections are typically used for patients that have radiating back pain into their hips, glutes, legs, and feet.
Radiating pain is usually an indication that either the spinal cord or large nerve roots that emanate from the spinal column are being mechanically compressed, impinged, or pinched.
Impingement can happen from different causes. The most common reason is stenosis, the narrowing of the spinal canal and neural foramen (tunnels in which the spinal cord and nerve root traverse) which then cause compression to the spinal cord and/or nerve roots. Stenosis usually occur due to:
- Deposition of calcium to different parts of the spine
- A bulging disc towards toe spinal canal and/or neural foramen
A pinched nerve can cause inflammation that, in turn, can cause significant nerve root irritation and swelling that causes pain.
Epidural steroid injections utilize needles to inject steroids with or without local anesthetics straight into your epidural space to inhibit the inflammatory response caused by chemical and mechanical sources of pain.
Are Epidurals Painful?
Depending on where your pain is, your doctor may choose to inject the steroids using either the interlaminar (traditional) approach or the transforaminal (side) approach.
Each approach has a different technique and needle placement, which causes varying levels of pain.
The Interlaminar Approach
In the traditional epidural, your doctor will insert a needle midline down into your epidural space.
A physician may recommend an interlaminar approach for patients who typically have a wider area of pain because of stenosis to the spinal canal causing compression to the spinal cord or affecting multiple nerve roots.
That way, the steroid can address the crowding and inflammation around multiple nerve roots, not just one.
Most patients find the most painful part when inserting the needle through the skin and muscle layers. But as the needle gets closer to the spinal cord, most patients only feel a sense of pressure.
Epidurals are typically very tolerable with this approach when a local anesthetic is injected into the skin and muscle before.
The Transforaminal Approach
During a transforaminal approach, your doctor will insert the needle from the side of your spinal column to target a specific nerve root.
Doctors typically use this approach for patients who experience more focal pain because of stenosis to a specific foramen causing compression and inflammation of a particular nerve root.
For example, you only experience pain in the front of your left thigh, and you have an MRI that shows a bulging disk causing stenosis around the left L4 nerve root, your doctor can identify the exact nerve root that is involved in your pain.
From there, he can use the transforaminal approach to target the specific nerve and get a maximum concentration of steroid medication around that nerve.
The transforaminal approach tends to be more painful for patients because the needle comes up very close to the nerve root. The needle may brush up against the nerve due to the limited space between the nerve root and the narrowed foramen that is already compressing the nerve. In other words, there’s not much room to fit the needle in the appropriate space, and if the needle touches the nerve, there is pain.
Further, as the physician injects the steroid, the fluid pressurizes the compartment even more. Again the patient will have a transient increase in pain.
Numbing the skin and muscle layers makes inserting the epidural less painful. However, as the needle approaches the tunnel and nerve root, patients usually feel an increase in pain levels.
Since transforaminal approaches tend to be more painful, your physician may offer sedation to help you through the process.
Relief from epidurals varies from patient to patient, however many find temporary relief and receive two to four epidural injections per year.
Implications and Risks
An epidural is more invasive than a trigger point injection.
There is a higher risk of:
- Nerve damage
However, many precautions are taken and with the use of real time x-rays, the overall risk for patients is less than 1%.
Steroid Side Effects
Similar to trigger point injections, there are short-term side effects of injecting steroids into the body, such as:
- Facial flushing
- Increased blood sugar levels
- Immune system suppression
There are also long-term effects of overusing steroids, such as osteoporosis, which is why there are strict protocols that limit the number of epidural steroid injections per year.
Epidural steroid injections can cause a dural puncture or “wet tap” that may cause patients to experience temporary headaches when they are upright in a sitting or standing position.
A wet tap occurs when the needle accidentally punctures the thin outer lining or dura of the spinal cord. The puncture causes the fluid that surrounds your brain and spinal cord, the cerebrospinal fluid (CSF), to leak inadvertently.
The headaches are usually temporary and resolve on their own. However, if the symptoms are severe and persistent despite conservative measures, then an epidural “blood patch” may be required.
Lumbar Medial Branch Radiofrequency Ablation
During a lumbar medial branch ablation, a physician places a shielded needle with an exposed tip near the facet joints on the spine, where the sensory medial branch nerves lie.
A generator is connected to the needle to transmit high-frequency radio waves and heat the exposed tip. The needle tip heats the surrounding soft tissue and vicariously ablates or burns the nearby medial sensory nerve.
Physicians typically recommend lumbar medial branch nerve ablation for patients who experience low back pain due to pain caused by their facet joints.
Facet joint pain can result from a variety of reasons. Facets commonly become damaged and painful after:
- Facet arthropathy
Regardless, when a facet joint is injured, pain signals from the facet joints travel along sensory nerves called medial branches to the spinal cord and then to the brain. Ablation of these sensory nerves result in a decrease of the transmission of pain signals from the injured joint.
It’s not used for a patient experiencing pain from stenosis or compression at nerve roots because those nerve roots are involved in motor function. If a motor nerve were ablated, a patient may experience paralysis. Thus, radiofrequency ablation typically targets sensory nerves.
Is a Lumbar Nerve Ablation Painful?
The requirement for sedation depends on the patient’s tolerance to pain, how well they can remain still and how many needles need to be used.
Typically, facet joint damage comes in pairs–the joint on each side of the vertebrae are injured and transmit pain. Each joint has two medial branch nerves that require ablation. Thus, for one level (2 joints), you need four needles for the procedure to be a success. Imagine if you had multiple levels that needed pain relief, that would require even more needles and time.
For these reasons, most patients tend to choose sedation.
Risks and Implications
The risks during an ablation are similar to an epidural. A less than 1% chance of:
However, the risks of nerve damage are slightly different.
Even though the point of ablation is to damage sensory nerves intentionally, the risk comes with accidentally heating a motor nerve. If a motor nerve is unintentionally ablated, there is a risk of pain, weakness and paralysis in the corresponding limb.
Surgery Isn’t Your Only Option
Low back pain is very common, and you don’t have to go under the scalpel to find relief.
Plus, surgery may not be a guarantee, and in fact, you run the risk of developing FBSS after surgery.
Before you consider any spinal operation, it’s always best to utilize a multi-modal therapy or a mix of conservative treatments first.
Remember, there isn’t a silver bullet to chronic back pain.
Finding lasting relief is a combination of the right treatments and making lifestyle adjustments to prevent further injury.
These lifestyle adjustments include:
- Exercising and stretching to strengthen your core muscles may reduce your risk by 33%.
- Losing weight to reduce the load and pressure to your spine.
- Quit smoking to improve your cardiovascular system–a key system that heals our body.
At APC, we’ve seen a vast amount of patients experience back pain relief with a combination of treatments and positive changes in their lifestyle.
If you’re curious about how these treatments can also help you, reach out to us with questions or schedule an appointment with one of our pain specialists today.