Back pain is an extremely common problem. It affects nearly 70% of Americans at some point in their life. The pain can be debilitating and interfere with daily life. Unfortunately, there is no magic wand that can take away back pain.  Getting rid of back pain is often a process of trial and error. What works for one patient may make things worse for another. Surgery is not always the answer when it comes to back pain. There are many other conservative (non-surgical) options that can be attempted prior to entering the operating room. In order to determine the right treatment options for a patient, it needs to be clear why the pain is happening in the first place. To complicate things, back pain can often be associated with radiating leg pain. In this post, we will review the common causes of back pain (and possibly leg pain) and how to decide on the right treatment strategy for each.

Back pain does not always have to be associated with leg pain. Occasionally, back pain may be the only complaint. The next few diagnoses result in back pain only.

PULLED BACK MUSCLE/LUMBAR BACK STRAIN

What is a pulled muscle/lumbar strain ?

Stretching or tearing of a muscle or ligament is referred to as a pulled muscle or lumbar strain. This is an extremely common cause of low back pain and accounts for many emergency room visits. A lumbar stain us not commonly associated with any radiating leg pain but can be associated with local muscle spasms.

What are the common causes of a pulled muscle or lumbar strain?

Frequent causes of a pulled muscle or lumbar strain are lifting a heavy object, improper lifting mechanics when lifting a heavy object and twisting while lifting something. Sports are another common way to pull a muscle in your back.

What are conservative (non-surgical) options for treating a back strain?

Conservative options for treating a pulled muscle include anti-inflammatory medications and physical therapy, including modalities such as ice, heat, ultrasound and massage.

What are surgical options for treating a pulled muscle?

There are not routine surgical options for treating a pulled muscle.

DEGENERATIVE DISC DISEASE

What is degenerative disc disease?

Back pain can also be caused by degenerative disc disease of the lumbar spine. Normally, the intervertebral discs act as a shock absorber in the spine. In the typical aging process of the spine, the intervertebral discs begin to lose their spongy, water content and start to collapse down. This itself can attribute to back pain. The discs becoming degenerative can produce a lot of inflammation causing irritation to the surrounding muscles and tissues causing pain and spasm. Occasionally, this inflammatory process irritate the surrounding nerves as well which can give you radiating leg pain.

What are conservative (non-surgical) options for degenerative disc disease ?

The conservative treatment options for degenerative disc disease are the same as mentioned above for a pulled muscle. Degenerative disc disease can cause chronic back pain and if this is the case, evaluation and treatment by a pain specialist may be warranted.

What are surgical options for degenerative disc disease ?

There are no great surgical options for degenerative disc disease. A lumbar fusion, which will be talked about in more depth below, may seem like a good option for this ‘disease’ but the surgery itself can commonly leave the patient with continued back pain. It is best to stick with conservative treatment for degenerative disc disease with pain control, physical therapy and lifestyle modification.

LUMBAR (FACET) ARTHRITIS

What is lumbar arthritis?

Arthritis refers to inflammation in a joint and can be a significant pain generator. There are many joints in the spine called facet joints and just like you can get arthritis in your knees and hands, you can get arthritis in your spine. This is called lumbar arthritis. The primary symptom of lumbar arthritis is back pain, but as the arthritis worsens, it can lead to more problematic issues of the lumbar spine including lumbar stenosis and spondylolisthesis which will be talked about below.

What are conservative (non-surgical) options for lumbar arthritis?

Conservative treatment options that may improve back pain from lumbar arthritis include anti-inflammatory medications, physical therapy, steroid injections, and pain management.

What are surgical options for lumbar arthritis?

Like degenerative disc disease, there are no great surgical options for just lumbar arthritis. For example, a lumbar fusion is not a great treatment for lumbar arthritis because the patient can often be left with chronic back pain even if you take away the motion of the spine at certain levels. Surgery is warranted when the arthritis becomes more severe and causes instability of the spine (spondylolisthesis) and/or radicular leg pain due to nerve impingement from enlarging facet joints.

How do you choose between the conservative and surgical options for lumbar arthritis?

Since there are not great, effective surgical options for mild to moderate arthritis of the spine, the only real option is conservative treatment. As discussed, if the arthritis is severe enough to cause nerve impingement or spine instability, a lumbar decompression and fusion may be necessary. Keep reading to learn more about these options.

Lumbar Disc Herniation

What is a lumbar disc herniation and how do you treat it?

A herniated disc in the lumbar spine can cause acute and extreme, incapacitating back and leg pain. This type of issue can be treated either surgically or non-surgically. (Please see previous blog titled “What is a Herniated Disc?” to learn more about what a herniated disc is and how to treat it.)

What are the conservative (non-surgical) options for treating a disc herniation?

There are several non-surgical options for treating sciatic. Common options include oral steroids, anti-inflammatory medications, steroid injections and physical therapy. If the patient is able to take steroids, this treatment option will usually provide significant relief.

What are the surgical options for treating a disc herniation?

Spine surgery is not usually a great answer for relieving back pain; however, it is quite successful to relieve the patient’s leg pain from a herniated disc. The surgery for a herniated disc is called a microdiscectomy. This is performed through a small incision and the herniated piece of disc is removed to take the pressure off the nerve.

How do you choose between the conservative and surgical options for sciatica?

It is wise to try start with non-surgical options and try the “wait it out” approach before electing to have surgery. Usually, if a patient is going to improve from non-surgical treatment, it will occur in the first 6-12 weeks. If there isn’t much improvement by this time, surgery may be the next best step in order to get your quality of life back. A herniated disc can sometimes cause weakness in the lower extremities. If leg weakness is involved, surgery is usually suggested earlier in attempt to avoid permanent weakness.

LUMBAR STENOSIS

What is Lumbar Stenosis?

Another possible explanation for leg pain, numbness and/or weakness coming from the lower spine is  lumbar stenosis. Lumbar stenosis results from a narrowing of the spinal canal. This narrowing can pinch the nerves that travel out of the spine and into the legs. The pinching of these nerves is what can result in leg pain, numbness and possibly weakness. Lumbar stenosis is extremely common as people age. A common complaint of patients with lumbar stenosis is their legs feel painful, tired, heavy and weak after walking a short distance, but the symptoms usually improve if they sit down.  These symptoms may lead a patient to self-restrict their activity. Decreased activity can be problematic, especially in the elderly, because it can lead to many other health issues.

What are conservative (non-surgical) options for treating lumbar stenosis?

The non-surgical options for treating lumbar stenosis may include physical therapy, steroid injections and pain management. If there is an acute exacerbation of pain, an oral steroid pack can be tried. If a patient tries these options but does not get any relief of their symptoms, surgery may be the next step.

What are surgical options for treating lumbar stenosis?

If non-surgical options do not work for a patient with lumbar stenosis, surgery to relieve the pressure on the nerves may be beneficial. The surgical option for lumbar stenosis is a lumbar laminectomy which removes the bone from the back part of the spinal canal to take pressure off of the nerves.  Some patients with lumbar stenosis may also develop instability of the spine called a spondylolisthesis. If this is the case, a lumbar fusion may also be performed. This is done to help stabilize the spine to prevent future issues.  Screws and rods are placed in the bone to fuse them together and prevent any further motion.

How do you choose between the conservative and surgical options for lumbar stenosis?

Just like with a herniated disc, conservative measures are routinely tried first for a patient with lumbar stenosis. Having spine surgery isn’t without risk, so it should be the last option if all other treatments fail.

In rare and severe circumstances, lumbar stenosis or a massive disc herniation may cause significant lower extremity weakness as well as bowel and/or bladder incontinence. If a patient is having these symptoms and has imaging studies consistent with a massive disc herniation or severe lumbar stenosis, surgery is an emergency and conservative measures are not tried first.

SUMMARY

In general, spine surgery is not great at relieving back pain. However, it can be successful in relieving associated pain, numbness, tingling and occasionally weakness in the lower extremities. While some patients may get quicker relief if they have back surgery, patients have a high probability of improving without surgery if they are compliant with conservative methods and are willing to work hard in physical therapy.

It is important to be a part of the decision-making process when it comes to your body. Learn all of the information that you can about the surgical and non-surgical options and come to an informed decision with your doctor on which option is right for you. At Three Rivers Orthopedic Associates we have three orthopedic spine surgeons that would be happy to help attempt to relieve your pain and get you back on your feet. When you come in to see us, we will obtain an extensive history, perform a physical exam and order any appropriate testing to help determine the underlying cause of your pain.  All of this will allow us to determine the best treatment options for you.  Make an appointment to come see one of our physicians to discuss whether surgery is the right route for you.