By: Colton Salsbury, OMS-IV
Back pain, specifically low back pain, is the second most common reason for seeking medical care and is the leading cause of disability and missing work world-wide1. Approximately 84% of will suffer from back pain at some point in their lives, however, 60-70% of cases resolve within 6 weeks and 80-90% resolve by 12 weeks3,12. Despite of how common it is, back pain is rarely a sign of serious disease. Risk factors for back pain include smoking, obesity, age, female sex, physically strenuous work, sedentary work, psychologically strenuous work, low educational attainment, Workers’ Compensation insurance, job dissatisfaction, and psychologic factors such as somatization disorder, anxiety, and depression12.
Back pain can be divided into three main categories: acute, subacute, and chronic. Acute back pain can last up to 4 weeks before resolving. Subacute pain can last up to 12 weeks. If the back pain continues beyond 12 weeks, it is considered chronic. Upon initial evaluation, 85% of back pain in nonspecific, meaning that it does not have a reliably identifiable cause at its onset. Many of these complaints are musculoskeletal in nature. Some common musculoskeletal causes of back pain include muscle or ligament injury, osteoarthritis, disc degeneration/herniation, vertebral compression fracture, spinal stenosis3,12. A number of these conditions, such as spinal stenosis and disc herniation, may cause narrowing of the space in which the nerve roots exit the spine, causing lumbar radiculopathy. Radiculopathy is characterized by radiation of the back pain down the legs.
Because of the high rate of resolution of acute and subacute back pain, the mainstay of treatment for back pain that is less than 12 weeks old is physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and exercise. A 2008 review of 11 different studies showed that patients with acute back pain that used NSAIDs had significantly lower pain after 1 week than patients that took a placebo. For pain that is not well-managed with NSAIDs alone, a muscle relaxer can be added to the regimen8. Exercise therapy and physical therapy have not been shown to improve outcomes for acute low back pain. However, it can be reasonable to prescribe physical therapy on a case-by-case basis for patients who are at risk for developing chronic back pain so that they may be educated about body positioning that may help them prevent further injuries. However, it is important to understand that it is encouraged to continue daily activities and normal exercise regimens as tolerated while having back pain, as studies have shown that patients who are active have less pain and better function than those who remain sedentary. Formal physical therapy and exercise therapy can be prescribed if back pain continues to linger past 4 weeks and has been shown to decrease pain in subacute and chronic back pain4,6,8.
Back pain that persists past the 12-week mark is considered chronic and frequently requires additional therapies in conjunction with analgesics and physical therapy for successful treatment. Denver Back Pain Specialists specializes in treating common causes of chronic back pain such as facet joint syndrome, discogenic back pain, and SI joint pain, which are outlined along with their common treatments below.
Facet joint syndrome is caused by degeneration of the joints between the vertebrae in the spine. This process causes cartilage to break down and leads to inflammation that irritates the nearby nerves, which causes pain. Injections of anesthetic to block the medial branch of the primary dorsal ramus, the nerves that innervate these facet joints, are useful in treating pain associated with facet joint syndrome. A trial found no difference between facet corticosteroid injection and medial branch block with anesthetic through 12-24 months5. Because of this, it is important to note that steroids are commonly not used in these injections any longer. Radiofrequency ablation (RFA) is a minimally invasive procedure that used heat to burn the nerves that are responsible for causing pain so that they can no longer transmit pain signals from the facet joints to the brain. Pain relief is variable, with some patients reporting no to modest benefit, while others report 100% pain relief. RFA for facet joint pain may provide pain relief in 45-60% of patients lasting 6 months to 2 years. After this period, the nerves will regenerate, and the procedure can be completed again7. A medial branch block is used as a diagnostic procedure prior to an RFA to confirm the target nerve and that the patient is a good candidate for the procedure.
Discogenic back pain is a complex condition that is characterized by low back pain in the presence of radiology-study confirmed degenerative disc disease. Discogenic back pain can occur with or without radiculopathy depending on whether there is a disc herniation that is compressing the spinal nerves. A mainstay for treatment of discogenic back pain are epidural steroid injections, where a corticosteroid is injected into the spinal cord between the ligamentum flavum and the dura. The best evidence for benefit for this procedure has been shown to be short-term benefit in radiculopathy caused by disc herniation. One study showed that intradiscal steroid injection can provide short-term relief can be considered if there is evidence of inflammation within the disc on MRI, but this is typically only done if there no response to epidural steroid injections5. Another possible treatment for discogenic back pain is intradiscal platelet-rich plasma (PRP) injection. A 2021 study collected data from multiple studies completed between 1980 and 2020 and found that PRP injections are effective at reducing discogenic back pain and associated disabilities, but that it is important for patients to know that they will not start to feel relief from the procedure for approximately 2 to 6 months2.
The sacroiliac (SI) joint can also be the culprit for low back pain. The SI joint is a stiff joint that is designed to provide stability during activities where the legs are moving, such as walking. Pain can be generated when this joint becomes arthritic or when the joint is hypermobile. Similar to other causes of back pain, SI joint pain can also be treated with injections, RFA, and PRP. A small study showed corticosteroid injections in the SI joint are slightly more effective than local anesthetic injection, but evidence is limited. Regardless, a local anesthetic injection is usually still completed as a diagnostic measure and can be followed up with a corticosteroid injection if the patient notices relief for a few hours after the injection. After injection of the corticosteroid, the patient can expect several months of pain relief5,10. RFA for the SI joint provides pain relief for 75-86% of patients and duration is similar to that of RFA for facet joint syndrome7. PRP injection into the SI joint provides pain relief and continued joint stability for up to 4 years post-injection9. SI joint pain can also be treated by treating pain that is caused by movement in the setting of hypermobility or arthritis. The LinQ procedure involves the placement of a small piece of cadaveric bone between the sacrum and the ilium to encourage fusion of the joint. Once the joint is fused, it is more difficult for the joint to move and generate pain. A 2021 study followed 50 patients that had undergone the LinQ procedure and reported an average pain relief of 66.5% after 20 months11.
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