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 or interventional treatments because they usually use needles, electronic devices, and other, more “invasive” methods to treat back pain.
Here are some important facts about these procedures:
- Usually they are only meant for chronic back pain that persists over time and has not responded to other treatments. However, this practice may be changing and interventional treatment may at times be offered as an early form of therapy.
Because they are complex and have risks, they should only be performed by trained, licensed professionals, with appropriate pain management credentials, referred to you by your health care team.
- These can include anesthesiologists, physiatrists (physical medicine and rehabilitation specialists) and neurologists.
- When making a decision about considering an interventional procedure, it is best not to rely on word-of-mouth recommendations. Thought should be given about the reason for having these kinds of treatments so you can sort out the potential benefits from the potential risks.
- These procedures can sometimes also serve a diagnostic purpose: if one procedure does not work this may give your doctor useful information about your pain condition, and lead to better choices of treatment.
Injections (epidural, nerve block, facet block)
One theory about chronic pain is that it occurs in a vicious cycle. After a while, pain can sometimes fuel itself, even in the absence of a cause for the pain to continue. When other treatments don’t work, it may make sense to try 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 try to have this effect by interrupting the cycle of pain.
The following are several ways to temporarily interrupt the cycle of pain, or investigate the cause of the 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.
- An epidural injection is an injection of a steroid medication, sometimes along with a local anesthetic, into a space in the spine. It is meant to decrease swelling or inflammation of the nerves in that areas that could be the cause of the low back pain.
- A 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.
- A facet block is an injection into the joint that is between the vertebrae (the bones in your spine)where you have pain.
- A discogram is a diagnostic procedure and not a treatment, that is used to evaluate the discs in your spine. It can be a helpful way to figure out the cause of back pain.
- Trigger point injections of anesthetic into painful spots on the back can sometimes quiet down the source of the pain. Although absolute proof is lacking, this relief may last for days, weeks, or even permanently, depending on the cause of the pain.
Spinal cord stimulation (SCS)
For some people, implantation of a spinal cord stimulator may provide pain relief if other, more conservative approaches have failed. It is similar to putting in a pacemaker, just in a different part of your body.
Electrical impulses are introduced through a tiny wire threaded into your spine to try to interrupt the transmission of the pain signal from your back to your brain. Introducing electrical signals can clog the pain signals in the area (like a traffic jam) preventing them from getting through. Some researchers have reported that a significant percentage of people receiving spinal cord stimulation for low back pain and leg pain (with or without having surgery) can have some degree of pain reduction or pain relief when other more conservatives treatments have not worked.
The timing of the procedure to implant a spinal cord stimulator is important as the effects may wear off over time. More research is being done to learn the long term effect of this kind of treatment. Spinal cord stimulation should be done by clinicians with a lot of experience in these procedures. This can help minimize the risks involved and maximize the benefits.
These are pumps that infuse narcotic (opioid) medication directly into the fluid surrounding the spinal cord. They are often considered a last resort because they involve temporary tubes placed in the spine to evaluate response. If there is a positive response they are sometimes permanently implanted. Patients and providers consider this option very carefully, and the decisions to use these forms of therapy are usually made months or years after other less invasive treatments have been tried and failed. They are also used in patients with cancer pain who have not responded to other treatment of their pain.
IDET (Intradiscal Electrothermal Therapy)
This relatively new procedure uses a hollow needle and flexible tube, called a catheter. Heat that is sent through the catheter may shrink the disk responsible for the back pain, kill the small nerve fibers in that area, and toughen disc tissue that may be causing pain. This may provide relief for several months. This is a relatively new treatment, and more studies will likely be done to assess its safety and long-term effectiveness.
With any interventional treatment, it is important to talk with your health care provider about 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.
New areas of future interventional treatment exploration include:
- Botox® injections
- Injections that create an irritation in order to promote tissue damage, a process called prolotherapy.. The hope is that this will stimulate the body to promote tissue regeneration. There is no proof of effectiveness to date.
Cameron, T. (2004). Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: A 20-year literature review. Journal of Neurosurgery, 100, (3, Suppl Spine): 254–267.
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (2005). Handout on health: back pain. Retrieved June 19, 2008. http://www.niams.nih.gov
Paice, J.A. & Penn, R. (1994). Implanted drug systems for patients with chronic pain. Analgesia, 5(1): 7-12.
Raphael, J.H., Southall, J.L., Gnanadurai, T.V., Trehane, G.J., & Kitas, G.D. (2002). Long-term experience with implanted intrathecal drug administration systems for failed back syndrome and chronic mechanical low back pain. BMC Musculoskeletal Disorders, (3)17.