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BACK AND NECK PAIN EDUCATION CORNER AND ARTICLES PAGE

 What is Back Pain? What injuries can cause low back pain? How are the sources of back or neck pain ("pain generators") identified? Is chronic back or neck pain curable?

 We began construction of this page on 02-20-09. New articles will be added daily. In the meantime please read our "Pain Report", it contains important information on back pain, neck pain, arm and leg pain, arthritis, disc degeneration (slipped disc, also called herniated disc) and potential treatments.

What is Back Pain?

Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and range of motion, or an inability to stand straight. Chronic back pain is pain that persists for more than 3 months. It is often progressive and the cause can be difficult to determine.
 
Many things can cause low back injuries--muscle strain or spasm, sprains of ligaments (which attach bone to bone), joint problems or a "slipped disk." The most common cause is using your back muscles in activities you're not used to, like lifting heavy furniture or doing yard work.

A slipped disk (also called a herniated disk) happens when a disk between the bones of the spine bulges and presses on nerves. This is often caused by twisting while lifting. But many people won't know what caused their slipped disk. In most cases, slipped disks and other back pain can be relieved by following a few simple methods.
 
Is there any treatment?
Most low back pain can be treated without surgery. Treatment involves using over-the-counter pain relievers to reduce discomfort and anti-inflammatory drugs to reduce inflammation.  The goal of treatment is to restore proper function and strength to the back, and prevent recurrence of the injury.  Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies.  Although the use of cold and hot compresses has never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals.  Bed rest is recommended for only 1–2 days at most.  Individuals should resume activities as soon as possible.  Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles.   In the most serious cases, when the condition does not respond to other therapies, minimally interventional modalities as performed at the St Michaels clinics may relieve pain caused by back problems or serious musculoskeletal injuries.  Surgery should only be considered in very refractory cases with severe pain or when there is progressive neurological injury.
 
What is the prognosis?
Most patients with back pain recover without residual functional loss, but individuals should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.  Recurring back pain resulting from improper body mechanics or other nontraumatic causes is often preventable. Engaging in exercises that don't jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, vibration, repetitive motion, and awkward posture. Applying ergonomic principles — designing furniture and tools to protect the body from injury — at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back. 

As defined by the International Association for the Study of Pain, pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage". Such definition is based on the fact that there are several components contributing to the intensity of pain which are above and beyond the extent of the injury present in a primary pain generator. A primary pain generator is a certain body part or anatomical structure damaged by disease or trauma. Examples of pain generators are joints affected by arthritis, skin damaged by a burn or a fractured bone.

What is a "multidimensional" symptom within the context of chronic pain such as back pain, neck pain pain associated with a degenerated disc leading to chronic disc pain or sciatica?

One of the components unrelated to the pain generator, yet playing a large role in the experience of pain is called "pain centralization". This is a name give to a process whereby there is an abnormal activation of certain nerve cells in the brain and spinal cord that maintain and even augment the sensation of pain. One example of a condition associated with pain centralization is "phantom limb syndrome"; in this situation, the patient experiences pain in a previously amputated limb. In this syndrome, there are brain circuitries that abnormally maintain or even increase the level of perceived pain in an arm or a leg that is no longer there. Research has demonstrated that various degrees of pain centralization may affect not only those patients who underwent a limb amputation but also patients afflicted by many forms of chronic pain such as lower back pain, arthritis, neuropathy or chronic headaches. It is

important that patients understand this phenomenon (which should not be confused with "pain only being on their heads" in a psychiatric sense). In order to achieve effectiveness in the treatment of pain, each component contributing to the pain experience, such as pain centralization, must be addressed differently from the treatment delivered to the primary pain generator.

Another important example of the multidimensional nature of pain is the presence of associated mood abnormalities, such as depression. Take the example of Julia P. again, a person without history of psychiatric or mood problems before her back pain began; however, she was also becoming chronically depressed, she had lost interest in almost everything that was pleasurable in life. She was even told by one of her doctors that "her pain was in her head". But again Julia’s story was not uncommon with many patients afflicted with chronic pain. Mood is regulated in the brain by the same molecules (mainly norepinephrine and serotonin) that are implicated in pain tolerance. The levels of these substances frequently became diminished in chronic pain, leading not only to a vicious cycle of decreased pain tolerance but also to chronic depression, a condition characterized by persistent feelings of sadness and loss of interest or pleasure in usual activities. Interestingly, the reverse is also true as patients afflicted by depression are also more susceptible to developing chronic pain. Thus, if the treating physician determines that depression is contributing to the patient’s experience of pain, it is critical that additional treatments (pharmacologic and psychological) be prescribed to address the painful condition. Again, the patient must understand that such treatment does not imply that his or her pain "comes only from their head" in the psychiatry sense. Julia’s pain and mood improved substantially after she was prescribed an antidepressant medication that increased the brain levels of norepinephrine and serotonin.

Another factor contributing to the overall patient’s pain intensity is physical de-conditioning. As pain impedes normal physical activities of daily living, the body becomes de-conditioned; muscles atrophy to various degrees and supporting ligaments weaken. Sometimes de-conditioning is the result of other medical conditions, endocrine disorders or obesity. Unlike normal structures, de-conditioned ligaments and muscles are unable of handling the stresses and repetitive micro-trauma brought about by normal life activities and became vulnerable to even normal movements which further aggravate the original injury, the end result being additional pain. Depending on the structure involved body balance may be impaired because certain muscles, ligaments and tendons may play important role in the sense of balance and coordination. Thus, in addition to treating the pain generator, supporting structures like muscles and ligaments must be strengthened and healed. This is usually accomplished by a comprehensive physical therapy and rehabilitation program. When this is insufficient, treatments like prolotherapy may supplement the rehabilitation process.

Finally, there are illnesses different from those directly causing the pain, which can contribute substantially to the patient’s pain intensity. Some examples are diabetes with associated neuropathy (which contributes to physical de-conditioning); sleep apnea (which in itself leads to depression and weight gain and sleep deprivation with decreased norepinephrine levels), hypothyroidism, obesity, inflammatory arthritis, smoking and many others. Treatment of these medical conditions is paramount to the management of chronic pain.

How are the sources of pain ("pain generators") identified?

A thorough physical and neurologic examination is considered the "gold standard" for identifying the primary diseased anatomical structure partly responsible for the patient’s pain. Once a potential pain generator is suspected, confirmation of the precise structure involved

can be achieved by several methods. One commonly used by pain specialists is numbing the pain generator (or the nerves that carry pain signals from such structure) using a local anesthetic like lidocaine. The importance of identifying and treating the pain generator is crucial to decreasing pain but also relevant to interrupting the self perpetuating cycle contributing to pain centralization and chronicity. For this purpose, the pain physician uses high precision injection techniques guided by imaging methods such as fluoroscopy or computerized tomography.

Once a particular pain generator is identified, such as a painful disc or a joint in the patient’s lower back for example, it can be treated in a more specific manner by either applying medications to the afflicted region or by treating the nerves that carry pain signals to the brain with image guided techniques, as explained in more detail below. Specialized testing may be needed including an MRI (magnetic resonance imaging) or a nerve and muscle study (electromyography) to help the doctor in determining the primary cause or mechanism of the pain. It is important for patients to understand that in many cases, there is no relationship between the intensity of pain and the extent of the injury or the degree of abnormalities present in an MRI or CT scan study. Conversely, many individuals with profound abnormalities detected by these imaging techniques have little pain or no symptoms at all. Therefore, these studies should never be interpreted in isolation (without clinical correlation).

Treatment of pain using interventional modalities. Is chronic pain curable?

Rick P. (a real patient) was a World War II veteran who after having sustained a back injury at the battle field developed chronic back pain which persisted for many years. He saw many physicians for his pain but the medications prescribed to him over the years seemed no longer effective. Over time, he became depressed and irritable. His mood changes interfered with his marriage and his relationships with friends and relatives. Despite taking more powerful antidepressants and pain killers, his pain and mood changes did not improve and he was now frustrated by the side-effects of his medications which he needed to take more frequently and in higher amounts to partially control his symptoms. Rick’s story is far too common to many chronic pain patients.

As already mentioned, many studies have demonstrated that in addition to addressing the multidimensional nature of chronic pain, treatment of the involved anatomical structure (once identified) is critical to breaking the cycle leading to chronic pain and also the associated mood abnormalities caused by the pain itself. For this purpose, imaging-guided procedures allow precise delivery of medications to the pain generator. The goals of these treatments are to decrease inflammation and accelerate tissue repair (healing) with the overall objective of providing powerful pain management. Examples of these procedures include injections into painful joints (which in the spine are called "facet" blocks) or selective nerve blocks. These techniques allow the interventional pain specialist to target selectively the particular nerves carrying the pain signals from various diseased structures. In the past, once the sensory nerves carrying pain signals were identified, they were sometimes cut by surgical means. For the most part, this approach has been abandoned because it was sometimes associated with abnormal painful re-growth of the nerve fibers. The abnormal re-growth, called neuroma, could lead to a paradoxical increase in pain severity. To reduce this and other potential complications, one technique developed to treat sensory nerves more accurately and effectively is radiofrequency ablation. Radiofrequency current, when delivered to tissues is converted to heat which is highly controlled in space and intensity. Radiofrequency is thus used to treat a small volume of nerve tissue, thereby disrupting transmission of pain signals along a specific nerve without completely destroying the nerve. With the help of imaging techniques, the procedure can reduce pain in target areas, leaving other nerves and the supporting structures of the treated nerve intact and preventing neuroma formation. Currently, radiofrequency therapy has become a mainstream approach in pain medicine and evolved as a safe, proven mean of treating chronic pain.

Rick was referred to Dr. Pappolla, who diagnosed him with painful facet arthropathy (a form of arthritis affecting certain joints in the spine called facets). He treated Rick’s pain by stunning the medial branch nerves of the spine (these are the nerves carrying the sensations and pain signals from the facets) using radiofrequency. Although it took four treatments to achieve pain control, his pain began to decrease after a few weeks of therapy and his negative mood dramatically improved. His relationships were revitalized and according to his wife, he was a different person altogether. He also reduced the amount of medications needed to control his pain. Many causes of chronic pain, like arthritic pain afflicting Rick or some forms of invasive cancers, are not curable because the extent of today’s medical knowledge is limited. However, pain can be dramatically reduced in intensity and managed very effectively by a multidimensional approach. In other words, although many forms of chronic pain are incurable (by today medical standards of care) it can be made much more tolerable to the point of interfering little with normal activities of daily living.

Many forms of chronic pain, however, are curable when a specific treatable condition underlies its cause. Heather was a physician treated by Dr. Pappolla, who presented with very severe leg pain distributed mainly to her left inner thigh and knee joint. She needed opioids for partial pain control which were clouding her thinking. A neurological investigation disclosed that the pain was the result of a compression of a nerve in the pelvis (the obturator nerve) caused by an enlarged uterine fibroid (called leiomyoma). Removal of the offending mechanism (the enlarged uterus) resulted in complete resolution and permanent improvement of her leg pain. Thus, for chronic pain to be completely curable, three conditions must be met. First, the primary cause of the pain should be identifiable. Second, it must be treatable (example, benign tumor). Third, the damage to tissues produced by the primary condition can be reversed.

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