Low back pain is one of the most common maladies known to the human race. Neck pain is very common as well. There are many reasons for low back pain and neck pain. Perhaps the most difficult task with neck or low back pain is to identify the actual pain generator. There are people with spines that look terrible on MRI and x-ray who have minimal pain and conversely, there are patients with perfect appearing spines who have a great deal of pain. The process of identifying the pain generator in a complicated case may take a great deal of clinical skill, patience and time.
Theories of Low Back Pain and Neck Pain
There are many sources of back and neck pain. Far too often, other factors of pain are not taken into consideration. Patients may have an episode, or repeat episodes of back pain and perhaps leg or arm pain. They often have an MRI and this scan reveals a disc protrusion (also called “bulge” or “herniation”). The disc protrusion is most often blamed for the patient’s pain. However, the disc may have been protruded for many years before the episode of pain.
Disc pathology, or injuries, certainly can cause pain. However, a disc protrusion may not cause any pain at all. Since the MRI has had widespread use since the late 1980’s, there were tens of thousands of reports from radiologists who either scanned the spine of a patient, or were scanning the abdomen or pelvis of a patient, and noticed a massive disc herniation. The radiologists questioned the patient about back and leg pain to only find out the patient had neither current pain nor any history of back pain and leg pain. This discovery lead to a change in the theories of spine related pain.
The older theory of disc protrusion related pain is a mechanical compression theory (“pinched nerve”). This theory follows the idea that the disc was injured, and the injury produced a herniation, which compressed the spinal nerve root as it passed by the disc. This compression would then cause back pain and pain, numbness, tingling, electrical sensations or any combination, radiating down the leg.
The problem with this theory is the tens of thousands of patients with massive disc herniations that have been seen on MRI on patients have never had symptoms don’t seem to fit into the mechanical compression theory. Neurophysiologists came up with a new theory a few years ago. This theory is that chemical inflammation produces the pain instead of mechanical compression. This theory follows the idea that when the disc is acutely injured, it is inflamed and it releases chemical byproducts of inflammation. The inflamed disc material is near the nerve and inflames the nerve. Many surgeons at the time refuted this concept by stating that the surgical procedures are designed to decompress that nerve and this is what obtains the desired results. The neurophysiologists countered by indicating surgical decompression didn’t always work and when it did, the key point was the inflamed disc fragment was removed from the nerve, thus reducing chemical inflammation. Furthermore, and most importantly, there were tens of thousands of patients with compressed nerves from large disc herniations that never experienced pain. The neurophysiologists added that inflamed nerves probably tolerate compression less than normal, non-inflamed nerves.
So, today, significant back pain and leg pain is managed with conservative care and sometimes with powerful anti-inflammatory medication, and more time is allowed for the nerve to calm before surgical intervention is considered. A common expression today in spine care is “We treat the patient, not the film”. This indicates the changes in reliance upon the film for the diagnosis. The clinical exam is still the most important determining factor for the diagnosis.
Similar scenarios occur in neck pain. The major difference from low back pain is that the spinal cord stops in the upper lumbar spine, but it exists in the neck and mid back. This is a significant complicating factor. A large disc protrusion in the neck, or cervical spine, can compress the spinal cord. There are unique symptoms produced by spinal cord compression. There are other signs of cord compression that are silent. This makes an evaluation by a spine specialist necessary.
While the disc is capable of generating pain by itself, there are many other structures that can cause pain. Back pain can come from the joints in the spine that guide movement called the facet joints. The facet joints can become inflamed and they can become arthritic. Both of these conditions can cause pain. The facet pain can lead to muscle contraction, which further compresses the facet joint, which in turn creates more pain, which then causes the muscles to contract, and this can turn into a pain-muscle tightness cycle. It is important to note that normal appearing facet joints on X-ray and MRI can still generate pain.
Tendons and Fascia
The connective tissue, known as fascia, can become too tight and painful. The muscles can also become too tight, or chronically inflamed and cause pain. The muscles can be too weak and cause low back pain but that is another topic. We often hear of tendinitis in other regions of the body, but it can occur in the spine as well and anyone who has experienced tendinitis knows it causes pain. Some patients have localized low back pain and a small branch off the spinal nerve root is inflamed and problematic. This small branch is known as the posterior, or dorsal, rami. This can cause back pain and dysfunction of the back muscles.
The midback or thoracic spine can be a source of pain. The common causes are muscle strain, rib sprains, postural muscle weakness and pain, and disc injuries. The quality of pain of these injuries presents similarly to the neck and the low back.
There is a relatively newly identified thoracic pathology known as thoracic epidural arteriovenous malformation (T.E.A.M.). This particular form of thoracic arteriovenous malformation was identified by neurosurgeon, Robert S. Bray, Jr., MD, of D.I.S.C. Sports and Spine in Marina del Rey and Newport Beach, CA. T.E.A.M. patients may present as constant thoracic pain and aching and may have developed balance difficulties. A special method of imaging T.E.A.M. was developed at Mink Radiologic Imaging. This imaging method is required to confirm a possible case of T.E.A.M. The management of T.E.A.M. will be discussed on a case-by-case basis.
Management of Spine Pain
The staff at the Soft Tissue Center serves many roles in spine care. We often serve as the first stop for the patient, so the entire diagnostic work-up is completed. This includes a history and a thorough clinical examination. This may be followed up with x-rays, MRI, CT scans, spect bone scans, and nerve studies (EMG and/or nerve conduction velocity studies) as indicated. The next step is to recommend either:
1) conservative care to decrease pain and improve function,
2) refer the patient for a combination of pain management and conservative care,
3) refer the patient for a neurosurgical consultation.
We are also sought for second and third opinions because our reputation is one for allowing enough time to hear the entire history and perform a thorough clinical examination. We can also review the previously performed tests and make our recommendations. Sometimes, we may concur that a case appears to be surgical especially in the presence of a progressive neurologic deficit or unrelenting pain. Other cases may need a brief trial of a combination of conservative methods. The opposite may be true as well. For example, a patient may have had an injury to his/her neck. Conservative care may have been recommended by another facility. Our second or third opinion evaluation may reveal that the patient has signs of spinal cord compression, and we may recommend the patient to be evaluated immediately by a neurosurgeon (signs of spinal cord compression are often silent and are determined by the presence of pathological reflexes during an examination and correlating clinical symptoms).
The Soft Tissue Center often provides post-operative spine care to reduce pain, improve function and improve range of motion using soft tissue mobilization. Naturally, soft tissue mobilization is gently rendered in the early stages of post-operative rehabilitation.
Neurosurgeons often refer patients to the Soft Tissue Center for pain following a surgical procedure. The neurosurgeon would state that the surgical procedure was successful (i.e. the microdiskectomy resolved the patient’s pain that was referred down their leg or arm, but the neck or back still hurt. The patients commonly viewed this as a failed surgery, although technically the procedure was successful. The surgical procedure decompressed the inflamed nerve root, but the soft tissue structures may still be too tight, inflamed, or fibrosed (have scar tissue). The muscles in the back or hip, or in the upper back and neck, may have these conditions and cause low back pain or neck pain. While the surgeon reduced the herniated disk, or bone spur, the soft tissue structures were not changed. Once the patient received soft tissue mobilization, the pain improved, range of motion improved, function improved and the patient then viewed the surgery as a good outcome. The neurosurgeons were happy also. This common scenario applies to microdiskectomies, microforaminotomies, one and two-level fusions with or without instrumentation, hemi-laminectomies, and laminectomies. Again, post-operative soft tissue mobilization is a common procedure.
Strengthening of the back or neck extensor muscles can provide long-lasting benefit of the oft forgotten component of core strengthening. The strengthening of the back muscles can often reduce pain and improve a sense of strength and confidence in patients. This method of back and neck strengthening is known as MedX. The MedX system tracks every treatment session including range-of-motion and force generated by the patient and this data is stored on the MedX computer. This data is compared to age and sex-matched normal values and provides a basis of comparison for future tests.
Acupuncture also serves a role in controlling pain from various forms of back and neck pain. Acupuncture also can help post-op pain. It is also an excellent choice from post-anesthesia nausea.
The doctors at the Soft Tissue Center can be your first step and help guide you through the process of diagnosis and the treatment plan whether the plan is rehabilitation with our group or if we need to refer you to another specialist for co-management of your spine pain.