Conquer Back and Neck Pain - Walk It Off! (27 page)

There is a class of treatments for back pain that is based upon killing the sensory nerves in your back. These nerves are responsible for sending pain sensation from the facet joints, ligaments, and discs in your back to your brain. The rationale for destroying these nerves is to stop the source of the pain. The first method to be developed in this class was facet rhizotomy, a method that uses a long, thin knife to cut the nerves to the facet joints. The method was the rage in Australia, which is where it was developed. It was soon apparent to Australian doctors that it did not work and was dangerous, so the procedure’s popularity declined faster than its meteoric climb.

Coincidentally, as I was writing this section I received an e-mail requesting my opinion concerning what was the correct choice for a patient. The patient was in his 50s and was continuing to have pain following a micro-discectomy. One physician had recommended revision spine surgery and another had recommended an IDET procedure with a 75 percent chance of a good result. My reply was that IDET is a method of destroying the nerve endings in the peripheral layers of a painful disc to relieve back pain. The clinical studies show that it is relatively safe procedure, but the results are not much better than letting the condition heal on its own. It is also an expensive procedure.

In addition to having the pain nerves in your back cut (rhizotomy) and burned (IDET), you can have them electrocuted (percutaneous facet rhizotomy), frozen (cryoablation), and now poisoned, no less, with Botox! Thankfully I have not heard of a method of hanging the nerve.

Electrocuting the nerves by percutaneous facet rhizotomy has been proven to be no better than placebo in a well-designed, controlled clinical trial. Botox has been shown to give short-term relief compared to placebo in a small trial. The procedure is rigorous, requiring multiple injections under fluoroscopy, is potentially dangerous and expensive, and I would not recommend it.

I do not mean to be facetious when discussing these various attempts at destroying the pain nerves in your facet joints or discs to relieve back pain, but none of them has passed rigorous Level I trials showing efficacy compared to placebo or long-term efficacy as determined by meta-analysis (page 108). I have not encountered people who have had these types of procedures who feel that they helped for a long period of time. I do not recommend any of them because of lack of efficacy, potential danger, and high cost.

I have already discussed the rationale for epidural steroid injections in the chapter on disc herniation. There is Level I evidence for the short-term efficacy and safety for the use of epidurals for disc herniation, but not for spinal stenosis. The majority of patients for whom I have prescribed epidurals have had enough pain relief from their disc herniation to be able to stop taking narcotics and sleep through the night. It is a relatively safe treatment, but it’s expensive. I do not recommend more than three epidurals in a six-month period. I think that the lifetime total number of epidurals should be limited to six. Too many epidurals can lead to chronic holes in the dural sac containing the nerves and scarring around the nerves. If the nerve continues to be irritated after six epidural steroid injections, it is my opinion that you should consider surgery to relieve the impingement on the nerve.

Epidurals are administered in the middle of your back, where the steroid is injected into the epidural space in the central spinal canal at the level of the disc herniation. They can also be placed from the side into the channel through which a specific nerve is traveling, which is the trans-foraminal approach. Either way, they should be performed with the use of a fluoroscopy machine so that the doctor can see exactly where the injection is going. I think epidurals provide better and faster pain relief and are safer than giving steroids by mouth, although they are much more expensive than oral steroids (see page 58 for a complete description of epidural injections).

Immobilization with corsets and braces has been an old-time mainstay for treatment of acute and chronic back pain. There is no data to authenticate their use. I find that older deconditioned individuals with a component of mechanical back pain from spondylolisthesis, vertebral fractures, and scoliosis seem to benefit from a corset or brace, and they are the only patients who will wear them. Some people find they are helpful in relieving acute attacks of low-back pain. I have gotten away from prescribing cervical collars for acute neck pain. I think patients actually get over acute attacks of neck pain sooner if they keep moving. When neck pain is preventing a person from getting to sleep, I do recommend a soft collar.

There is a class of treatments in which stimulation of skin sensation through heat, ice, light touch, tickling, and vibration stimulates the release of your own painkillers, the endorphins. None of these methods will relieve pain if you are taking narcotics or muscle relaxants, because these medications deplete and block the action of your endorphins. Skin stimulation also works because the brain gives precedence to skin sensation over pain sensation from deep ligamentous structures like painful discs and facet joints. Acupuncture, Transcutaneous Neural Stimulation (TENS), Rolfing, and light massage are some of the modalities that fall into this category.

After two days of unaccustomed lifting and bending while cleaning up my yard after Hurricane Wilma, I experienced backache that was keeping me from falling asleep. My wife gave me
cosquillitas
(means “little tickles” in Spanish) on my back, and within a few minutes the backache and muscle spasm subsided and I was able to fall asleep. Don’t laugh; try it sometime when you are having an attack of back pain. It really works!
Cosquillitas
work in the same way as acupuncture, and are arguably a lot less expensive, less painful, and more fun than getting stuck with acupuncture needles!

There are a lot of treatments out there from which to choose for your back pain. Most of them have not passed the test of Level I evidence-based medicine or the test of time. Some are safe, effective, and inexpensive, and you can do them yourself (aerobic exercise). Some are just the opposite: dangerous, ineffective, and expensive (facet rhizotomy), and should be avoided. Using the information I have given you in this chapter, you can access the Web and find out for yourself which treatments are good and which ones do not seem right. You should then discuss them with your doctor and find out what she or he thinks about the treatment and whether it is right for you.

Failed back syndrome (FBS) refers to persistent or recurrent symptoms following previous back surgery. The original surgery may have failed to relieve the pain, or it only relieved it for a period of time and then the original pain recurred, or a different pain occurred.

I have found that the most common reason for failed back-pain surgery is that the patient was not prepared for the original surgery before it was performed. People who are on high doses of painkillers and who are deconditioned will experience little relief from spine surgery for back pain. Because of this they are difficult to mobilize and impossible to rehabilitate following surgery. Often the original source of pain was magnified by the pain medication they were taking before surgery, and the surgical procedure made the pain even worse. I suspect that if these patients had been weaned off of pain medications and rehabilitated before the surgery, the majority would have obtained enough relief from their original problem to avoid the surgery all together.

Scar tissue is also a cause of failed back syndrome. Scar formation is a normal healing process following any surgery on the body. Most scars on our skin are not painful unless a nerve is injured and forms a neuroma (enlargement of the end of a cut nerve, which may be painful or may not). The same is true for spine surgery. It is rare to see an injured nerve as the cause of failed back surgery. Scarring around the spinal nerves following surgery is rarely the cause of the pain. The exception is when the scar tightly attaches a spinal nerve to an adjacent disc or facet joint. When this happens the nerve can be repeatedly stretched by abnormal motion in the degenerated unstable disc. One of the rationales for performing spinal fusion is to prevent this from happening by immobilizing the abnormal disc space.

Another thing that I have seen blamed on scar tissue as the reason for failed back surgery is that a partially cut ligamentum flavum (the yellow ligament between the lamina which is cut in every laminectomy) can bunch up and compress or stretch a spinal nerve. This is a common cause for failed micro-discectomy where portions of the ligament are cut but not completely removed. The entire cut portion of the ligament is removed during a standard discectomy so that retained ligament is not a problem following this procedure.

There are several other reasons why failed back syndrome can occur following disc excision. I have surgically removed a fragment of disc the size of your thumb and was sure there were no more fragments to remove. On closer inspection, I have found another fragment of disc the same size as the first one! This happens more often than you would think. When a disc herniation is composed of several large fragments, there is reported to be a 25 percent risk of a recurrent disc herniation at the same site at a later date. This happens no matter how carefully the first surgery was performed. Fortunately, most disc herniations are not large and/or fragmented and are associated with less than a 5 percent risk of re-herniation following surgical removal.

Discs can herniate on the opposite side at the same level as the first disc excision and at other levels (remember the example of the young doctor who had disc herniations at three different levels at different times).

Normally patients have immediate relief of leg and arm pain following a disc excision. If the same pain persists immediately following surgery, then a retained disc fragment should be suspected. Retained fragments of disc can usually be detected with another MRI scan. If the extremity pain goes away for a period of time but then recurs in the same distribution and character as before, a recurrent disc herniation at the same site as before should be suspected. However, when the pain is in a different distribution than that experienced before the surgery, a disc herniation should be suspected at a different level than was operated upon.

Following disc excision in the low back, the disc space can continue to narrow and cause spinal stenosis. The most common level for this to occur at in the low back is at the L5-S1 disc space. The disc excision provides relief of the stabbing pain and numbness down the leg to the bottom and side of the patient’s foot. Removing the disc herniation relieves the symptoms from the compressed S1 nerve root. As the disc continues to degenerate and narrow, the L5 nerve root becomes entrapped in its passageway nearby. The patient then begins to experience a diffuse aching sensation down the same side of both legs while walking, but the pain is relieved by sitting, which is classical neurogenic claudication from spinal stenosis (see page 75). The pain may radiate to the top of the foot rather than the side and bottom of the foot prior to the disc surgery. I try to prevent this from happening by enlarging the passageways for the nerves (foramenotomy) when I perform a disc excision. It is hard to do this through a small incision, which is one reason I think a standard incision rather than a micro-incision is a better way to remove a disc herniation (see page 61).

Approximately 20 percent of people will experience chronic mechanical low-back pain following removal of a herniated disc. In fewer than 5 percent of people these symptoms will become so disabling as to warrant being labeled as failed back syndrome and require a spinal fusion for relief. It does not seem wise to perform a spinal fusion on everyone who undergoes a disc excision in order to prevent only 5 percent from having a second operation. When I explain this to my patients who are about to have a disc excision, they agree — no fusion.

Six weeks following an L5-S1 disc excision, one of my patients was still complaining of leg pain and still had a strongly positive straight-leg-raising test (see page 51). She also complained that she could not sleep because of the pain. I suspected a recurrent disc herniation and ordered a new MRI scan with contrast dye. Much to my amazement, she had a tumor at the L4-5 level, but the old disc herniation at L5-S1 was gone compared to her original MRI scan. There was no sign of a tumor on her original MRI scan, which had been performed without contrast dye. A neurosurgeon colleague of mine removed her benign tumor, resulting in excellent long-term relief. She definitely had two problems, an L5-S1 disc herniation and a tumor at the L4-L5 level of her spine. I do not know if both problems were causing her pain or whether the disc herniation was asymptomatic (see
Chapter 5
) and only the tumor was causing the pain. This case illustrates another reason for failed back syndrome, missed diagnosis or multiple diagnoses.

There are also several ways that failed back syndrome can occur following surgery for spinal stenosis. Remember from
Chapter 6
on spinal stenosis that there are five places at each level of the lumbar spine where a nerve can be entrapped. A single or several nerves may be entrapped at several levels and sites at the same time. Sometimes it is very difficult to detect all of the places of nerve entrapment at the time of surgery. Failure to decompress all of the sites of entrapment can be a reason of failed back syndrome. This can be avoided by using a high-quality MRI scan to identify all of the places of entrapment prior to surgery (see discussion on closed MRI in
Chapter 5
, page 52). The first surgery may be adequately performed, with the patient experiencing relief of pain and resuming walking normally, only to have the symptoms of spinal stenosis recur. When this sequence of symptoms occurs, the spinals stenosis has either recurred at the same level or affected another level of the spine. This occurs in fewer than 5 percent of cases, and I do not know of any way to prevent it from happening.