Written by: Janna Vilen M.D.
If you have lower back pain, you are not alone. About 80 percent of adults experience low back pain at some point in their lifetimes. It is the most common cause of job-related disability and a leading contributor to missed work days. In a large survey, more than a quarter of adults reported experiencing low back pain during the past 3 months.
Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache to a sudden, sharp sensation that leaves the person incapacitated. Pain can begin abruptly because of an accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine. Sedentary lifestyles also can set the stage for low back pain, especially when a weekday routine of getting too little exercise is punctuated by strenuous weekend workout. We spend most of our days sitting with also increases occurrences of low back pain.
The magnitude of the burden from low back pain has grown worse in recent years. In 1990, a study ranking the most burdensome conditions in the U.S. in terms of mortality or poor health because of disease put low back pain in sixth place; in 2010, low back pain jumped to third place, with only ischemic heart disease and chronic obstructive pulmonary disease ranking higher.
Most low back pain is acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care and there is no residual loss of function. Most of the acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Traditional treatments are focused on one specific area of the back, but it should be looked at as a functional unit as all of these components are interconnected and affect each other. At Rejuv Medical, we focus on a whole-body approach to not only figure out the source of your back pain, but why it did not resolve on its own and why did it happen in the first place. Many times, recurrent episodes of acute back pain, even if they resolved on their own, are a sign there is a bigger problem with your back that is developing over time and needs to be addressed.
What structures make up the back?
The lower back where most back pain occurs includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. The spaces between the vertebrae are maintained by round, rubbery pads called inter-vertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain.
What causes lower back pain?
- Sprains and strains account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful. Many times, the superficial nerves, those in the fascia, and those in the muscles get compressed, stretched, pulled, or irritated and can cause pain.
- Intervertebral Disc Degeneration is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
- Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain, and many times pain down the legs.
- Radiculopathy (Sciatica is a version of this)is a condition caused by compression, irritation, or inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
- Spondylolisthesis is a condition in which a vertebra of the lower spine slips forwards or backwards and can pinch the nerves exiting the spinal column.
- A traumatic injury, such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted to the spinal cord. When spinal nerves become compressed and irritated, back pain and sciatica may result.
- Spinal stenosis is a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
- Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.
Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention.
To optimize treatment and prevent re-occurrence multiple treatments may be recommended to work in synergy together for faster, longer lasting pain relief.
- Physical Therapy- A well trained physical therapist can help treat acute low back pain with modalities, stretching, and exercises. They can also help prevent future episodes by teaching proper body mechanics and a good core program
- Integrative Movement Assessment– a series of exercises performed by one of our PTs or MFS (medical fitness specialists) to evaluate where a deficit may be. You will then be given an Integrative Movement Program
- Exercise- For someone with recurrent acute pain or chronic pain we recommend seeing PT first followed by a structured program with one of our highly trained MFS. Many times, people go to fast into an exercise program, do exercises that are too hard on their body or incorrectly, and that can increase low back pain instead of healing it. Starting with walking and moving more every day while you are working on strength and form is a great way to start and easy on your back.
- Lumbar support brace- helps offload and support the structures that are injured and causing pain.
- Nutrition– sugars, refined grains, and vegetable oils are extremely inflammatory. Cutting these foods out of your diet are a great start to a healthier eating plan and decreasing pain.
- Supplements- turmeric, resveratrol, omega-3 are a few supplements you can start to decrease inflammation and improve pain.
- Avoid NSAIDs, prednisone, steroids, or narcotics. In some rare cases these may be needed, but there are many negative effects of these medications. NSAIDs are commonly prescribed but should be used with extreme caution due to the number of side effects. Opioids/narcotics are not good treatments for acute or chronic pain and even short courses (5 days) have been linked to addiction and abuse potential.
- Nerve Blocks- These injections are done with a solution of a sugar analogue that connects to a specific receptor on the nerve and “resets” the nerve. Painful nerves tend to be swollen, dilated, tender, and leak substances that can cause further abnormal nerve function, breakdown to surrounding joints and soft tissue, and even depression and anxiety. The nerves being treated have been firing incorrectly for some time and want to go back to firing incorrectly even after being treated. Therefore, a series of injections is recommended, ideally at first every 1-2 weeks. Most patients get immediate relief of pain after the injections. A few hours to few days of relief is expected after the first set, with a 15-20% improvement each time- lasting longer and a return to a new baseline with less pain. It is usually planned to do 3 sets and reassess to see if you are responding as would be expected.
- “Sweet” Caudal epidural- an epidural is an injection in the space surrounding your spinal cord and can be done a few ways. We use a different solution (see above) and a different technique. Many times, not just one nerve is involved so we use a technique that can treat multiple nerves at one time. An area in your low back is exposed. US is used for guidance. There is a small injection for anesthetic, followed by the injection for the epidural. The injectate is a combination of dextrose, a very dose low dose of steroid (equivalent of a credit card at bottom of the empire state building- the equivalent of a regular dose that is used in a traditional epidural), and a small amount of anesthetic. The dextrose helps with neurogenic inflammation and pain. The low dose steroid can help modulate inflammation and improve healing, but without the side effects of higher doses. The injection takes about 15 minutes. We have found this to be very helpful for a variety of causes of low back pain.
- Platelet Lysate (PL) Caudal Epidural- Platelet lysate is made from your blood. It’s made in our Regenexx certified lab. Platelets slowly release their growth factors in a timed-release fashion to help healing. However, there are times when the physician wants all the growth factors contained in platelets immediately available to the area to prompt healing. In addition, there are areas of the body where using Platelet Rich Plasma (PRP) may cause too much inflammation. As a result, our physicians use the Regenexx Platelet Lysate Procedure to crack open the platelets to allow all the growth factors to be immediately available to your body. This is same procedure as a Sweet Caudal epidural but with a different product.
- PRP with a PL caudal epidural- using your own body’s blood we do a combination of PRP, a slow release of growth factors in to the areas that stabilize and support your spine, ie: ligaments, fascia, muscles, and joints. This helps treat these areas to better support the areas that are broken down and causing nerve irritation, pain, and dysfunction. The PL epidural is treating the nerve pain.
Many times, your insurance will cover some of these treatments but this varies due to each plan, and many times are there are stipulations on when you can do what, requirements, prior authorization. You can check with your insurance about coverage. PRP and PL are not currently covered by insurance companies. These are not experimental. We not only have studies supporting these treatments, we have years of experience, and hundreds of patients who have benefited greatly from these treatments, avoided surgery, and have better quality of lives. There are no hoops to jump through or regulations if you choose to go this route, and it is recommended by your doctors.