Back pain can be caused by radiculopathy, a term described by our pain management physicians at Spinal Diagnostics & Regenerative Medicine as an irritated or pinched nerve as it exits the spine. This opening is called the neural foramen. The nerve can be compressed by a bulging disc, an enlarged facet joint, or settling from degenerative disc disease. Bone spurs can also form, all of which can put pressure on the nerve. The diagram below shows a torn annulus with the contents on the nerve.

Patients will complain of back pain and spasm, as well as pain that radiates through the lower buttock down the leg into the foot. This pain is described as burning and numb. Severe cases will cause weakness in the leg or foot as well. The second diagram below shows your where the pain is based on what nerve is being affected.

Radiculopathy is diagnosed by history, physical exam, and imaging. EMG and nerve conduction studies may also be performed to provide objective information of potential nerve damage. Off loading the spine with weight loss, core strengthening, and back bracing can provide relief. Minimally invasive treatments such as epidural steroid injections are very effective for mild to moderate conditions. Sometimes the compression is too severe and requires surgical correction.

Patients will ask, “Why not just have surgery?” As a pain physician I see two major reasons: adjacent level disease and postoperative fibrosis of the nerve roots.

When you fuse a segment of the spine, that previously mobile segment is now rigid and results in altered normal forces above and below the fusion. Even with a perfect surgery, these forces accelerate the degenerative process across those areas leading to earlier breakdown. This is adjacent level disease. If you’re 80 years old this is not as concerning as if you’re 40 years old. The 40 year old has many years left and will likely need a revision along the way. You may need surgery, just be aware of this phenomenon.

The next is postoperative fibrosis. A perfect surgery can still result in patients laying a bed of scar at the surgical site and encasing the their nerve root in scar. This can tether the root in place, and with movement results in repetitive pulling on the nerve instead of sliding like it normally does. Again, you may need surgery, and have a perfect surgery performed, but still lay scar.

For these two reasons I believe a strong effort at conservative therapy is worth trying and remaining devoted to over the long term .

Degenerative disc disease is a condition of the spine that is the result of the intervertebral disc drying up, becoming thinner and perhaps “bulging.”  This is another type of arthritis of the spine (much like facet disease).  This condition can affect nerve roots and cause a radiculopathy as well as cause neck pain that is poorly defined and may radiate to the low back, hips, buttocks and legs.

Discs in the spine serve as both shock absorbers and spacers that lie between the bones of the spine. They have a fibrous outer ring called the annulus and a jelly middle called the nucleosus pulposis. The outer ring is constructed like a tire with alternating criss-crossing fibers. Over time these radials can snap, and the disc begins to bulge.

The outer portion of the disc has pain fibers while the inside does not. As the disc degenerates it starts to expose the outer pain fibers to the inner jelly middle, which is full of inflammatory mediators. Once that occurs, the disc itself can become painful and is now known as discogenic pain. This can be treated with epidural steroid injections, physical therapy, core strengthening, and back bracing. Surgery has been performed for discogenic pain but the results have been less than optimal.  In addition, approximately 70% of herniated discs will resolve on their own in one years time.  If there is a significant and severe strength deficit or bowel and bladder issues, this may be an indication to proceed straight to surgery.

When you fuse a segment of the spine, that previously mobile segment is now rigid and results in altered normal forces above and below the fusion. Even with a perfect surgery, these forces accelerate the degenerative process across those areas leading to earlier breakdown. This is adjacent level disease. If you’re 80 years old this is not as concerning as if you’re 40 years old. The 40 year old has many years left and will likely need a revision along the way. You may need surgery, just be aware of this phenomenon.

A perfect surgery can still result in a bed of scar at the surgical site and encasing the nerve root in scar. This can tether the root in place, and with movement results in repetitive pulling on the nerve instead of sliding like it normally does. Again, you may need surgery, and have a perfect surgery performed, but still lay scar.

For these two reasons I believe a strong effort at conservative and interventional therapy is worth trying to help alleviate symptoms.

There is no specific cause of arthritis rather than genetics, age, and “wear and tear.”  This is typically treated with NSAIDS, PT, and steroid injections.  If there is an underlying disease process like rheumatism or ankylosing spondylitis, treatments targeted at the underlying cause is warranted while we treat the effects of the condition.

A trigger point is a localized area of muscle damage that remains in spasm and causes localized pain as well as referred pain. This condition is diagnosed by history and physical exam. You can sometimes feel a nodule in the body of the muscle and identify it on ultrasound as well. This condition can be treated with a simple injection as well as deep tissue massage. Some patients find immediate and long lasting relief while others have repeated episodes over time. This usually indicates a deeper problem that is causing the repeated cycle of spasm and pain.

This is a condition that is characterized by a “slip” of one of the bones of the spine over another. It can be caused later in life due to degenerative changes or earlier from a defect in the pars interartcularis. Excessive extension, such as back bends that gymnasts perform, can cause this defect. This can also develop over time due to degenerative processes.
Many patients can live with this condition without even knowing it. However, as the slip becomes severe, it can put pressure on the nerves and spinal cord. This is called spinal stenosis, or a narrowing of the spinal canal. This can be treated with conservative techniques such as physical therapy, core strengthening, and bracing. Epidural steroid injections and medications can be very helpful as well. Sometimes symptoms are too severe and it may progress over time. Surgical stabilization is then needed.
Patients with a grade 2 or larger spondylolisthesis who fail conservative treatment do well with surgery. At that level of slip there is usually such profound stenosis that they can’t be managed conservatively. This is why it is important to establish your severity early to assess a realistic prognosis.