Back Pain and Sciatica

Description

Alternative Names

Treatment for Chronic Low Back Pain

Evidence strongly suggests that only intensive treatment using a combination of physical and psychological rehabilitation programs can reduce pain and improve function in patients with chronic low back pain. Even with the best treatments, many patients with chronic back pain do not experience complete pain relief and need to develop methods for improving daily life in the face of some persistent pain.

Noninvasive Therapies. In general, early treatments for severe low back pain or for episodes of chronic low back pain are similar to those of acute uncomplicated low back pain, including avoiding bed rest. The following are the most common noninvasive treatments for chronic back pain of unknown causes:

• Pain Relievers. Patients often take pain relievers, particularly NSAIDs, although they can have severe effects on the gastrointestinal tract over time. The newer agents, COX-2 inhibitors or coxibs, may have fewer effects on the GI tract, but their long-term safety is unknown. Some physicians have recommended long-term opioids for patients with severe chronic pain, but studies suggest they do not improve activity levels and can have significant side effects.
• Corticosteroid injections may be helpful for some patients.
• Exercise and Physical Therapy. Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although it is often very difficult to sustain.
• Antidepressants. In some patients antidepressants may be helpful, particularly those known as tricyclics.
• Cognitive-Behavioral Therapy. This form of psychological therapy helps change behavior and attitudes toward pain, and may be helpful for dealing with pain.
• Alternative Therapies. Some alternative therapies, particularly transcutaneous electrical nerve stimulation (TENS) and massage may relieve pain in certain cases. Other mind-body techniques such as relaxation and meditation may be helpful by reducing stress.

Other promising approaches, such as Botox injections and lidocaine patches, are also being investigated.

Surgery and Invasive Procedures. In severe cases, more invasive procedures may be needed. The most common reasons for surgery for low back pain are sciatica and spinal stenosis. Evidence of a herniated disc and nerve compression, however, is not an automatic indication for surgery. It is advised only for selected patients.

Back surgery rates are more than 40% higher in the US than in any other country. Some experts believe that less than 1% of back pain patients need aggressive medical or surgical treatments. Nevertheless, when it is appropriate, surgery can provide great relief. There are many approaches and procedures that are available or being investigated, including many minimally invasive operations. However, there are still few well-conducted studies to determine differences among them or if, indeed, some are better than no surgery at all. There are so many noninvasive options currently available that patients should investigative all possibilities before choosing surgery.

It is extremely important that the patient be sure that the surgeon has had significant experience with any procedure to be performed.

Specific Approaches for Patients with Herniated Discs

Nonsurgical Procedures. In patients with herniated discs, nonsurgical methods should be used for at least a month before considering surgery. Nonsurgical procedures include spinal manipulation, massage therapy, and physical therapy. (Patients should wait at least two to three weeks before using spinal manipulation, since early effectiveness and safety are not yet clear.)

Surgery. According to a 2001 review of studies, about 10% of patients experience pain after six weeks that is severe enough to warrant consideration of discectomy, the standard procedure for herniated discs. For many of these patients, surgery may bring significant relief. In one 2001 study, for example, 70% of patients with moderate to severe sciatica who had had surgery reported improvement. And the improvement was superior to that from nonsurgical treatments for about four years in most patients. After that, and by ten years, however, it is not clear if surgery maintains its advantage over nonsurgical approaches.

Specific Approaches for Patients with Spinal Stenosis

Preventing Falls. Falling is a risk for patients with spinal stenosis. They should avoid alcohol and sedatives. Leg strengthening exercises (walking, cycling) may be helpful, with brief resting if pain occurs.

Nonsurgical Treatments. The use of common pain relievers, such as NSAIDs, physical therapy, and steroid or other spinal injections may be helpful for some patients.

Surgery. If pain is persistent, patients may require surgery, most often a procedure called decompressive laminectomy. Some patients may require spinal fusion as well. Studies suggest that surgery reduces back pain in many patients, at least for a few years. By four years after surgery, however, 30% of patients have severe pain again and 10% have had another operation. It should be noted that surgery does not always improve outcome and in some cases can even make it worse. Surgery can be an extremely effective approach, however, for certain patients with severe back pain that does not respond to conservative measures.

Specific Approaches for Patients with Piriformis Syndrome

Nonsurgical Treatments. The general approach for patients with piriformis are corticosteroid injections and physical therapy. Botox injections are show promise.

Surgery. In carefully selected patients who do not respond to physical therapy and injections, some studies report dramatic pain relief with a procedure that releases the piriformis muscle.