Five Areas of Treatment for Low Back Pain
Our new colleague Robert Savala, MD has been a pain management specialist practicing in the Bay Area for 25 years. In the second of two posts, he discusses five strategies for medical treatment of low back pain (LBP).
When low back pain is severe and acute, supportive measures to control pain like medications, rest, chiropractic, and physical therapy are the mainstays of treatment. But when pain persists despite this “conservative care,” we turn to increasingly aggressive therapies.
The fact there are so many treatments for this condition reflects the fact that no single approach is reliably sufficient to cure this problem.
At present, we have five basic strategies for treating LBP: 1) Physical therapy/ chiropractic and changes of lifestyle, 2) medicines, 3) injections, 4) “other” and 5) surgery.
When talking about physical therapy and chiropractic, I focus on the importance of how we move our bodies and how it can affect our spine. Changes of behavior, stretching, traction, core stabilization, weight control, and spinal manipulations are the foundations of spine care. Having a trained professional guide and support you in building strength and healthy habits is critical, no matter what the next treatments may be.
Medicines are used to reduce pain by reducing inflammation, blocking pain signals, and suppressing hyperactive nerves. I have had my share of successes with medicine, but many patients are apprehensive about long-term effects and adverse reactions. And some patients just don’t respond adequately to treatment.
Injection therapies essentially rely on corticosteroids to relieve pain. Like cortisol (one of our body’s natural pain relievers), steroids are powerful anti-inflammatories but have many side effects on soft tissue and bone. Most doctors agree that long-term use of these substances can lead to a host of complications and limit their use.
The fourth area for pain management I call the “other.” These forms of treatment have a limited role in care and are usually employed when all other options have failed. Typically focused on reducing sensation, they include spinal cord stimulation, intrathecal infusion therapies, and other neuroablative techniques looking to destroy nerve endings.
Many patients come to me in the hopes of preventing our fifth option: surgery. Certainly, surgical procedures have an important role in treating spinal stenosis and instability of the spine—but to address pain from the discs, facet, and sacroiliac we don’t actually repair these structures but rely on removing tissue and fusing the spine. Many of us know individuals who had back surgery that didn’t help or even made them worse off. The serious concerns about surgery make many LBP sufferers rightfully anxious about these procedures.
Now let’s discuss the emerging role of regenerative medicine for the treatment of LBP.
Regenerative medicine techniques are the sole therapies that attempt to reduce pain by actually restoring the health of the targeted tissue. It seeks to stimulate a normalization of the tissue environment, the reduction of inflammation, and the reversal of tissue breakdown. I believe that back pain is particularly suited for this therapy.
One of regenerative medicine’s greatest appeals is the relative safety of harnessing the “body’s own pharmacy” to heal discs and overcome one of the major barriers to the disc healing itself: Because of the poor blood flow and anoxic environment of the spinal discs, a cascade of degeneration leads to progressive breakdown. To overcome this, we can inject these discs directly with growth factors derived largely from the platelets.
Platelets, which exist in our blood, are important in the formation of blood clots. Nature has packed these platelets full of growth factors so that, where there is injury and bleeding, as the clot degrades, thousands of different proteins are released, stimulating local tissue healing. To create Platelet-Rich Plasma (PRP) we draw a person’s blood, concentrate it, extract the platelets, and inject the solution using local anesthesia and light sedation in an outpatient procedure.
Mounting evidence demonstrates the effectiveness of PRP in stabilizing degenerative processes and promoting tissue repair. Importantly, these studies fail to find serious risks like tumor formation or adverse systemic reactions. This makes sense, given that the body’s own substances are being used to aid healing.
Recently, small studies have shown that even a single injection into a disc and facet joint can lead to a reduction of pain within a month of injection. Most studies show a gradual reduction in LBP continuing for at least 3 months. One 2017 study of patients receiving PRP into their discs showed that on follow-up, after an average of 6.5 years, 70% of patients showed significant reductions in pain and improvement with function without a single serious complication.
Unlike steroids—whose effects diminish with time, and are associated with negative systemic responses—the pain-relieving effects of PRP injection seem to advance over the months.
Of course, identifying the proper administration of the injections to the right structures is paramount in the success of treatment. Here at the Stone Clinic, we combine these procedures with physical therapy in an effort to solidify the results, help people regain life activities, and help them become stronger, faster, and fitter. Because, as Joseph Pilates said, “ You are only as old as your spine.”