Non-surgical Treatment

Whenever possible, doctors prefer to use treatments other than surgery. At first, you may be advised to place a cold pack on your low back for ten to fifteen minute increments, or you may be shown how to do a contrast treatment. Contrast treatments involve switching between a cold pack and a hot pack.

In cases of severe pain, doctors may suggest a short period of bed rest. The purpose is to help decrease inflammation and calm muscle spasm. Most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. However, in rare cases where bed rest is prescribed, it is usually only used for a maximum of two days.

A back support belt is sometimes issued when back pain first strikes. It can help lower pressure inside a problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to shrink (atrophy).

Patients may be prescribed anti-inflammatory medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) or high doses of plain aspirin. Some doctors prefer to start their patients on acetaminophen rather than NSAID's or aspirin.

Some medications are used only for a very short time. Oral steroid medicine with tapering dosages can be especially helpful when pain is thought to be coming from the disc or facet joint. Muscle relaxants are sometimes used to calm muscle spasm, but they tend to cause drowsiness.

Painkillers, such as morphine or codeine, may be used for the first day or two when patients require hospitalization for severe pain. Narcotics are highly addictive therefore doctors prefer not to use narcotics especially for people with chronic back pain.

Back pain can lead to mood changes, which is why some patients are given anti-depressant medication. There are a number of anti-depressant medications available by prescription for your doctor to choose from.

Back pain or pain that spreads down the leg may require treatment with an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories. In an ESI, medication is injected into the space around the nerve roots. This area is called the epidural space. Some doctors inject only a steroid, however most doctors combine a steroid with a long-lasting numbing medication. An ESI is usually most effective when the pain is coming from a bulging or herniated disc. ESIs do not always work and often times only provide temporary relief.

Another method used to get steroids to an inflamed nerve is called a nerve-root injection. Doctors use a special kind of X-ray, called a fluoroscope, to guide a needle directly to the painful spinal nerve. The nerve root is then bathed with the medication. Some doctors believe this procedure gets more medication to the painful spot.

Local injections of steroids or numbing medication are sometimes given in the muscles, ligaments, or other soft tissues near the spine. These injections can help relieve back pain and ease muscle spasm and tender points in the back muscles.

In addition to other non-surgical treatments, doctors often ask their patients to work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program to address a particular condition and to help the patient prevent future problems.

Surgical Treatment

Low back surgery is rarely scheduled right away. Doctors suggest immediate surgery for caude equina syndrome (pressure on the nerves going to the bowels and bladder) and nerve pressure that causes muscles to steadily weaken.

For other conditions, doctors prefer to try non-surgical treatments for a minimum of three months. Often people with back pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time. Only 1 to 3 percent of patients with degenerative lumbar conditions typically require surgery.

Surgery may be suggested when severe pain isn't letting up and is preventing a person from getting back to work and to a reasonable quality of life. Surgery may also be needed if symptoms are coming from an infection or a spinal tumor.

There are many different surgeries for back pain. In general, surgery for the low back is done to treat the following:

• Pressure in the spinal canal (spinal stenosis)
• Pressure on a nerve within the foramen (foraminal stenosis)
• Problems with a disc (herniated or degenerative disc)
• Extra movement in a spinal segment (spinal instability)

Following are descriptions of the more common types of lumbar spine surgery.

Laminectomy

The lamina is the layer that covers the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves.

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Disc Excision

Surgery to take out (excise) part or all of a problem disc in the low back is called discectomy. Surgeons generally perform this surgery through an incision in the low back. Traditional methods involve taking part of the lamina bone off the back of the spinal column (laminectomy). This allows greater room for the surgeon to take out the disc. It also enlarges the space inside the neural foramen, easing problems of foraminal stenosis.

Some doctors now do procedures that require only small incisions in the low back, also called "minimally invasive surgery. Advocates believe that this type of surgery is easier to perform. They also believe it prevents scarring around the nerves and joints and helps patients recover more quickly. Examples include percutaneous lumbar discectomy, laser discectomy, and microdiscectomy.

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Lumbar Fusion

Fusion surgery joins two or more bones into one solid bone. This prevents the bones and joints from moving. The procedure is sometimes done with a disc excision. Mechanical pain is eased because the fusion holds the moving parts steady, so they can't cause irritation and inflammation. Doctors can place a small block of bone graft or other material in the space where a disc was removed, increasing the space between the vertebrae. Opening up more space enlarges the neural foramen, takes pressure off the nerve roots, and eases tension on the facet joints.

Lumbar fusion is used to treat low back problems such as disc herniations, degenerative disc disease, fractures, and spinal instability. Doctors perform two main types of fusion for low back problems: anterior lumbar discectomy and fusion with cages and posterior lumbar fusion. Anterior lumbar fusion is done through the abdomen allowing the surgeon to work in front of the lumbar spine. Posterior fusion is done through the back of the spine.

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