Spinal back and neck pain is a big healthcare issue in the United States, accounting for the most common cause of work related disability and 15 billion dollars in yearly healthcare costs. Additionally, there are 14 billion dollars in yearly indirect costs related to lost wages. Despite these costs, the likelihood of chronicity and recurrence is high. With such economic impact and mediocre prognosis, it’s clear that more effective approaches are needed. The 4 pillars of effective chronic spine care, tailored physical and manual therapy, appropriate medical management, effective interventional care and minimally invasive surgical solutions, may make a difference for some patients as well as helping clinicians to avoid common pitfalls.
The first pillar, tailored physical or manual therapy, is important in the early course of the patient’s pain. PT is not one size fits all. It has been shown that some patients may benefit more from conditioning therapy, like Pilates or aerobics, than from passive exercises. Some patients with back pain may suffer from segmental instability, meaning that a portion of their spine may not resist motion well. In these cases core strengthening should be the focus of physical therapy. In other patients, pain may be exacerbated and relieved by opposite motions. Extension may relieve pain and flexion may aggravate it. This is called a directional preference. These patients may benefit more from mechanical diagnosis and therapy, a unique form of PT that requires patients to perform end stage range of motion exercises in a posture that relieves pain. Additionally, patient satisfaction rates from manual therapies, usually chiropractic manipulation, run high. Some chiropractors are also experts at posture training, a specialized form of therapy designed to combat the mechanical stress of poor posture.
The second pillar in effective spine care is appropriate medical management of chronic pain. While narcotics and anti-inflammatories are key in the treatment of acute exacerbations, they can have significant side effects if taken chronically. Narcotics may lead to dependence and addiction, while anti-inflammatories can have effects to the stomach or kidneys. Alternative medications can reduce the potential for these side effects. Cymbalta, an antidepressant, has recently been cleared by the FDA for use in patients with chronic back pain. Lyrica and Neurontin, both anti-convulsants, seem to be effective in treating neuropathic pain, such as radiculopathy. The use of these drugs should be determined based on the over-riding complaints; back/neck pain or radiculopathy (usually intense leg or arm pain). Note that these alternative medications themselves may possess side effects. Some chronic patients have skin hypersensitivity as a result of chronic pain. Recent data suggests that analgesic patches, such as a 5% Lidoderm® patch may be effective in relieving back pain in these patients. Lastly, spinal cord stimulation may serve as an alternative to chronic use of narcotics in treating patients who have failed most other therapies.
Effective interventional pain management is the third pillar in chronic spinal care. Patients are usually referred for interventional pain management when other therapies have not succeeded. The most commonly performed interventional pain procedure, the epidural steroid injection, may not always be what is needed. A careful history and physical can determine what the patient’s pain generator might be. A neck pain patient involved in a restrained motor vehicle accident is more likely to suffer from a cervical facet injury. A younger patient with disc herniation probably has discogenic back pain. An older patient with similar symptoms probably has pain originating from the lumbar facet joints. If the patient has had a lumbar fusion or has given birth several times, the sacroiliac joints may be the cause of pain. In these cases, an epidural injection may not be the best option. Also, there would be little basis for repeating an ineffective epidural injection. Alternative, targeted procedures may be more effective. These might include facet blocks, median branch blocks and discography. Performing the appropriate procedure is important so that patients are not unnecessarily deemed treatment failures when they might not have had the right treatment to begin with.
As a last resort, surgery may be required to treat chronic spinal pain. The first 3 pillars are very important prior to referring a patient to surgery because with tailored physical and manual therapy, appropriate medical therapy and effective pain management patients may never need to be referred to surgery. If it comes down to surgery though, it’s important to perform surgery in a way that maximizes rehabilitation potential and recovery by maintaining spinal stability and motion. That is the 4th pillar. A conventional spinal discectomy surgery requires the surgeon to incise fascia, dissect and incise posterior spinal muscles, remove facet joints and cut ligaments to access the disc. These structures are critical biomechanically to the stability of the spine. Therefore, much of the recovery associated with surgery is due to the surgery itself. Affecting stability may also lead to biomechanical problems in the future. The common alternative, fusion, restricts motion in the treated segment and may lead to hypermobility and accelerated degeneration in the adjacent spine. Commonly practiced forms of minimally invasive surgery are less damaging but really are only mini versions of the original procedures. The incisions and dissections are smaller, but the same structures are affected. Percutaneous surgery, often with the use of an endoscope, can achieve the same surgical goals without the collateral effects on stability and motion. Recovery and rehabilitation is quicker and the results are similar to other surgical techniques in properly selected patients.
Chronic spinal pain is a huge economic burden and there is a high recurrence rate. By adhering to these four pillars of effective care: tailored physical and manual therapy, appropriate medical management, effective interventional care and minimally invasive surgical solutions, providers may be able to have a greater impact on outcomes and patient satisfaction rates.
