Back pain procedures: Pros and cons

Written by: Roanne Weisman
Published: February 06, 2009
Reviewed by: Kevin Zacharoff, MD, January 2008

If you are reading this article, you probably have back pain that has not responded to conservative treatments, such as physical therapy, or medications. You are still in pain and you feel that you need more help. The options described in this article take pain management to a higher level. They are called "procedural" treatments because they use needles, electronic devices, and other, more "invasive" methods to treat back pain. Three important facts about these procedures:

• They are meant to be used only for chronic back pain that persists over time and has not responded to other treatments.
• Because of their complexity and potential for risk, they must only be performed by trained, licensed professionals, with appropriate pain management credentials, referred to you by your healthcare team. These can include anesthesiologists, physiatrists (physical medicine and rehabilitation specialists) and neurologists. Check the American Society of Interventional Pain Physicians for credentials. This is not the time to rely on word-of-mouth recommendations.
• These procedures also serve a diagnostic purpose: if one does not work, for example, this gives your doctor useful information about your pain condition, leading to further refinement of treatment choices.

Injections (epidural, nerve block, joint block)

One theory of pain is that it occurs in a cycle. After a while, pain will fuel itself, even in the absence of a stimulus. So it makes sense to interrupt the cycle in as many places as possible. If you think of pain as a circle of fire, you want to spray water on many places in the circle to douse the fire. Injections perform the same effect by interrupting the cycle of pain. Following are several ways to temporarily interrupt the cycle of pain. They may provide quick relief without eliminating the source of pain, and be useful in a program of rehabilitation. Your treatment specialist can tell you about the risks, benefits and evidence for each of these procedures.

• Epidural injection is an injection of a steroid or a local anesthetic into the spine to decrease swelling or inflammation that could be causing low back pain.
• Nerve block is a local anesthetic injected in the direct area of the nerve that numbs the nerve, similar to an injection of local anesthetic.
• Facet block is an injection into the joint between the vertebrae.
• Discogram is a diagnostic procedure used to evaluate the well-being of the discs in your spine.
  
• Trigger point injections of anesthetic into painful spots on the back quiet down the sentinels of pain. Although absolute proof is lacking, this relief may last for days, weeks, or permanently, depending on the cause of the trigger point pain.

Spinal cord stimulation (SCS)

Electrical impulses are introduced through a tiny wire threaded into your spine to interrupt the transmission of the pain signal from your back to your brain. If a road is clogged with traffic, then nobody gets through. Introducing electrical signals has the same effect, preventing the pain signal from getting through. Researchers have reported that more than 60 percent of people receiving spinal cord stimulation for low back and leg pain (with or without surgery) have pain reduction or pain relief. However, the timing of the procedure is important and the effects may wear off over time. This approach is best done by physicians with a high degree of experience in these procedures, to help minimize the risks involved.

Intrathecal pump

These are pumps that infuse narcotics directly into the spinal cord. They should be considered a last resort because they involve temporary wires or tubes placed in the spine to evaluate response, and if positive, they are permanently implanted. So you and your doctor will consider this option very carefully. Decisions to use these forms of therapy are usually made months or years after other less invasive treatments have been tried and failed.

IDET (Intradiscal Electrothermal Therapy)

This relatively new procedure uses a hollow needle and flexible catheter to use heat to kill nerve fibers and toughen disc tissue that causes pain. It may provide some relief for several months, but this is a newer treatment, and not enough studies have been done to assess its safety and effectiveness. An important thing to consider and discuss with your doctor are the risks and benefits associated with each treatment, as well as long-term effects. These treatments are not the first line of attack, but are available as more aggressive approaches to treat what can often be life-limiting back pain.

The following treatments have little research evidence to date, so until further evidence exists they are not recommended:

• Botox injections for pain are currently under investigation.
• Injections that create an irritation in order to promote tissue damage. The hope is that this will stimulate the body to promote tissue regeneration. But there is no proof of effectiveness to date.