Since the severity of back pain varies so much from patient to patient, there are several treatments to choose from.
Analgesics are typically injected or applied topically (directly to the skin). They are more affective when injected, but this is not a practical way of taking them on a routine basis. The topical administration is limited in how much the drug penetrates the skin. The most common application is with the Lidoderm patch. This patch is applied on the affected skin and releases lidocaine, which “numbs” the skin. Because of their short-acting action, they are more often used for diagnostic purposes than for therapeutic purposes.
Muscle relaxants are thought to work on the secondary muscle spasm that accompanies pain. They also have been known to minimize the anxiety that sometimes comes along with pain, which exacerbates or amplifies pain. They also may help you sleep. Like narcotics, they are potentially addictive and should be administered with caution.
Antidepressants work by increasing the amount of norepinephrine or serotonin in the synapses of nerves. These are neurotransmitters that help mediate the communication between nerves in the brain. These medications have a subtler and less predictable effect on pain, and typically relief is delayed by as long as several weeks. Antidepressants are used for leg pain more than back pain, or for back pain when there is a superimposed element of depression. In general, the efficacy of antidepressants is much less predictable than other medications.
Antiseizure medications are being used with increasing frequency. Originally used for seizure disorders, they stabilize nerve cell membranes and make the nerves less “excitable.” In my experience, their effect, like with the antidepressants, is difficult to predict. They are most effective for neuropathy (pain or numbness arising from a diseased nerve).
An epidural injection is the administration of a liquid steroid outside the dura (the tough membrane that covers the nerves). The injection is most effective when administered under the guidance of a fluoroscope, which is an X-ray machine that shows the tip of the needle just before injection. This injection is typically given directly into the back. Most pain management doctors will not administer an epidural injection more than three times in a six-month period.
This is the administration of either or both a steroid and an analgesic to the facet joint. The injection can be into the joint (intra-articular) or into the vicinity of the nerve that innervates the joint (medial branch block). These injections can be either therapeutic (to make the pain better) or diagnostic (to find out if that facet is causing pain).
Morphine Intrathecal Pump
This is a device that is implantable into the back. It delivers medicine (usually morphine) into the spinal fluid that bathes the nerves. Morphine helps with pain and helps the patient avoid other side effects of narcotics, such as lethargy and constipation. Its use is limited to some extent by tolerance, as is the case with other narcotic delivery methods. The narcotic is delivered to the patient at a programmable rate, which can be adjusted to control the pain.
Here are some take-home points if you are considering surgery to remedy your back pain:
1. Surgery is much more effective in improving leg symptoms than back symptoms.
2. The success of surgery is more dependent on doing the right surgery than on doing the surgery right.
3. Surgery is rarely “needed” and should be viewed as an option.
4. Make sure your surgeon explains what will happen if you don’t have surgery.