Time Is on Your Side
In almost all cases the early treatment of low back pain should be conservative. Nonspecific strains and sprains account for 70 percent of patients who see their doctor with lower back pain. Ninety percent of them will recover within two weeks by simply following their doctor’s instructions.

A smaller percentage of lower back problems involve herniated discs, a very painful condition. Even here, patients tend to improve with time. Only about 10 percent of those with herniated discs are still in so much pain after six weeks that surgery is considered.
Early conservative treatment includes determining the source and cause of the pain. An obvious first step is to avoid re-injuring the back. Ice packs applied for 15 to 20 minutes five or six times per day for the first 24 hours usually help relieve inflammation. After that heat can be alternated with ice.

Although it hurts to move, back experts recommend staying mobile if possible. Prolonged inactivity creates muscle weakness. Talk to your doctor about what works best for your specific diagnosis.

Pain medication and muscle relaxants are usually the focus of treatment in the early stages. Acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs) are usually prescribed first to treat pain. If these aren’t adequate, your physician may prescribe a stronger drug such as codeine.

When conservative treatment has been followed for six weeks with little improvement, a patient may be considered for surgery.

More than 650,000 back surgeries are now performed annually; at least one third involve disc surgery. Back surgery continues to evolve but, as with any innovation, it often takes years before studies can give clear comparisons of new procedures with traditional techniques and overall success rates.

IDET (Intradiscal Electrothermal Therapy). This is a relatively new therapy to treat back pain caused by tears or small herniations in a lumbar disc. IDET is scalpel-free surgery performed under local anesthetia and may be used as an alternative to more traditional surgery involving fusion of the spine. It involves puncturing the skin with a needle and threading a thermal catheter into the disc, then heating the tissue inside the disc.

The heat is believed to work by causing the collagen fibers that make up the disc wall to contract and thicken, closing tears and cracks. Tiny nerve endings may also be desensitized by the heat.

When pain is strictly limited to a disc problem, IDET appears to help about 70 percent of patients, decreasing their pain by about half. It brings complete pain relief to about 20 percent of patients.

At the 2001 meeting of the North American Spine Society, studies of IDET showed conflicting results, with two case studies positive, two negative and one uncertain.
Some studies also showed postoperative pain that flared up after the procedure and lasted about a month. Patients need to wear a brace during the recovery period.

If IDET proves beneficial in larger controlled trials currently under way, it will offer patients a minimally invasive approach to treating many disc problems.

Endoscopic Spinal Surgery offers another minimally invasive alternative to traditional surgery. Arthroscopic joint surgery has become standard for many knee and shoulder procedures in recent decades. Proponents hope that endoscopic spinal surgery will become more common in the future as more surgeons are trained in the technique.

The surgeon passes instruments and a scope through small incisions, allowing access to difficult to reach areas in the spine with a minimum of damage to surrounding tissues.
Endoscopy may also make it possible to pinpoint and treat back problems more precisely. One of the problems with magnetic resonance imaging (MRI), currently widely used for diagnosis, is that although it is effective in identifying structural abnormalities, these may not be the cause of the pain. Endoscopy makes it possible to probe the spine with the patient in an aware state so the surgeon can correlate actual areas causing pain with an abnormality that might then be corrected.

Spinal endoscopy is an emerging field and involves a fairly steep learning curve. Patients considering this option should choose a surgeon with considerable experience. The specialty is expected to continue to expand as more specialized tools and equipment are developed.

Spinal cages were approved by the Food and Drug Administration in 1997 as alternative equipment for use in surgical spine fixation. Traditional spine fixation surgery uses bone screws, plates and rods to support the spine after the cartilage discs between vertebrae have degenerated seriously enough that the spine has become unstable.

Spine cages are alternative hardware. They are actually hollow titanium screws packed with bone, usually taken from the patient’s own femur. Pairs of cages are inserted between the patient’s vertebrae, stabilizing the spine and relieving pressure on nerves. The cage is designed to promote fusion of the spine and ultimately provide relief of pain.
One study evaluating spine cages found good or excellent outcomes for more than two thirds of subjects–both spine cage patients and patients receiving the traditional rods and screws.

New therapies and technologies continue to emerge to help those with long-term pain. The rest of us can take comfort in the knowledge that when back pain strikes, it will probably resolve with your doctor’s care and a little patience.

REFERENCES:
Robert Cohen et al, “Low Back Pain, Part 2,” Geriatrics, November 2001.
Richard A. Deyo et al, “Low Back Pain,” NEJM, February 1, 2001.
“Early Results Announced from First Back Pain Surgery - Posterior Endoscopic Spine Fusion,” Pain and Central Nervous System Week, January 13, 2001.
Scott Hensley, “Quicker Fix for Back Pain: Device Speeds Healing,” Modern Healthcare, August 11, 1997.
“Intradiscal Electrothermal Therapy: Conflicting Results, Lively Debate,” The Back Letter, December 2001.
“Is Discectomy Effective?” The Back Letter, November 2000.
C.E.Lee, “Effect of Spinal Surgery on Pain and Physical Performance: A Pilot Study,” Physical Therapy, May 2001.
“New Program and Material for Persons with Back Pain,” The Journal of Musculoskeletal Medicine, December 2000.
“What Is the Success Rate for Disc Surgery?” The Back Letter, April 2002.
Verdell Williamson, “Spine Surgeries Becoming More Common, “ Orthopaedic Nursing, November 2000.
Anthony Yeung, “Endoscopic Spinal Surgery: What Future Role?,” :The Journal of Musculoskeletal Medicine, November 2001.