Pain and other symptoms originating in the spine can have a major affect on an individual’s everyday life. Chronic axial pain is estimated to cost the United States $100 billion per year with approximately 40 million sufferers. This estimate does not include chronic pain caused by malignancy.1 Low back pain specifically is estimated to have the highest burden on the American healthcare system with neck pain coming in at number four.2 In some estimates the prevalence of low back and neck pain within an individual’s lifetime is as high has 80%.
Pain in the low back can be attributed to many causes and tissue types. These causes include, spinal facet injury, muscle spasm, degeneration of the disc, herniation of the disc, spinal stenosis and referral from other sources such as the sacroiliac joint. Often an individual can have multiple causes at once. Common complaints include: stiffness, dull sensations, sharp sensations and radiation of pain often into the leg.
Interventional Medicine is a medical specialty that focuses on non-surgical procedures to assist in the medication of pain through injection and other minimally invasive techniques. In many cases, this specialty has played a pivotal role in the management and mediation of pain and discomfort. When addressing spinal pain, there are multiple treatment options dependent on symptoms and diagnosis. Included below are three procedures, which have shown to be effective for many individuals.
There are multiple treatment options for individuals suffering from chronic neck and low back pain. The most common options include physical therapy, chiropractic manipulative therapy, analgesics and anti-inflammatory medication. In some cases, surgical intervention is required to alleviate the pain and discomfort.
In cases where an individual’s pain is discogenic (caused by any injury to the intervertebral disc) or caused by an inflammatory response affecting the nerve root, the utilization of an epidural steroid injection (ESI) may be indicated. Epidural steroid injection is a procedure utilized to decrease inflammation and irritation within the spine. In an orthopedic setting an ESI can help with chronic low back, mid-back or neck pain. Among a variety of non-surgical procedures intended to treat axial pain, ESI is one of the most common.
The procedure is an image-guided injection containing a local anesthetic and corticosteroid. The anesthetic is used for short-term pain relief while the corticosteroid is meant to provide long-term relief. The solution is injected into the epidural space of the spinal cord, which is the outermost section of the spinal cord and contains the spinal nerve root.
An ESI can be administered in three types: caudal, interlaminar and transforaminal. The interlaminar approach is from the posterior and is administere
d between the lamina of the spinal segment above and below. It is reported to be the most common as it is can deliver the medication closest to the injury site. Transforaminal application is a more lateral approach that focuses on the space where the nerve root exits. It has been shown to use the least medication due to its specificity at an individual segment. Caudal approach is from the inferior portion and is used exclusively in the lumbar spine. It is considered to be the easiest of the three procedures but is the least specific and requires the most medication.3 In many cases an individual patient may receive multiple approaches based on their reaction to other procedures, ongoing symptoms and diagnostics performed.
In cases where an individual is experiencing facet pain, a Radiofrequency Ablation (RFA) may be the most effective option. The facet joint, also called the zygapophyseal joint, is the area on the posterior section of the spine, which is made up of the superior articular process and inferior articular process of the adjacent vertebrae. The joint allows for motion of the spinal column in flexion, extension, lateral flexion and rotation. When the facet joint is injured the adjacent nerve called the medial nerve detects the pain signal. The medial nerve innervation allows for pain signals to be sent to the brain and perceived by the individual.
Postmortem studies have indicated that the highest level of degeneration in the spine is located at the disc and facet joint.4 The facet joint can be injured in many ways and the symptoms that accompany that injury normally include: pain while standing or walking, pain with extension, local pain to the low back or neck, muscle spasm and mild or no radiation of pain.
A radiofrequency ablation is a procedure that involves a local anesthetic and insertion of a needle, from the posterior aspect, along the medial nerve, which innervates the facet joint. The terminal end of the insertion acts to denervate a section of the nerve thus eliminating the signal from the joint. The procedure can be effective for patients suffering from facet type symptoms throughout the spinal column.
In many cases, pain caused by injury within the spine can begin to cause problems outside the spinal column. It is not uncommon for disc or facet injury to accompany muscle pain. Prolonged tightness and muscle spasm can cause there to be trigger points within the muscle. A trigger point is an area of tenderness within a muscle that is caused by an adhesion or a collection of muscle fibers. This type of injury can cause pain to the touch and also refer pain to other areas throughout the body.
Common points of pain can be found at the trapezius muscle as well as other adjacent muscles to the spine. Although not limited to the axial region, these types of injuries can affect the function of the spine and put an individual at higher risk of spine related injury.
For these types of symptoms, trigger point injections (TPI) can be indicated. A TPI is a procedure, which targets the collection of fibers causing pain within the muscle with the intent of breaking the adhesion, and eliminating the pain. These types of injections can be therapeutic in nature and also diagnostic. The procedure can be used to identify when a certain pain pattern is caused by the trigger point or a radiculopathy from the spine.5
In any type of injury, it is critical that a clinician who is familiar with the mechanism and treatment options available examine each individual. Although multiple specialists perform these procedures it is advised to seek a specialist who is trained in Physical Medicine a
nd Rehabilitation (PM&R). As always, practitioners that are considering these procedures are advised to seek out the most recent literature and guidelines to assist in their clinical decision-making. Continued examination of the outcomes of the procedure is suggested to identify the best treatment options.
For more information please feel free to contact one of our Patient Care Coordinators today at 908-754-1960 or you may contact us online.
About the Authors
Joseph Mejia D.O., F.A.A.P.M.& R, is a graduate of University of Michigan and West Virginia School of Osteopathic Medicine. He is Board Certified in Physical Medicine & Rehabilitation and Sports Medicine. Dr. Mejia received his Fellowship Training in Interventional Pain Management from University of Medicine and Dentistry. He has advanced training in Regenerative Medicine and is the Medical Director and Partner of Performance Rehabilitation & Regenerative Medicine.
John F. Ellis, D.C. is a graduate of Logan Chiropractic College. He is a Board Certified Chiropractic Physician with licenses held in New Jersey and New Hampshire. His past research work involves human performance pertaining to orthopedic conditions. Dr. Ellis is a Chiropractic Physician at Performance Rehabilitation & Regenerative Medicine.
- Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012; 13:715-724.
- US Burden of Disease Collaborators. The state of US health, 1999-2010: Burden of diseases, injuries, and risk factors. JAMA 2013; 310:591-608.
- Manchikanti L et al. An update of comprehensive evidence-based guidelines for interven- tional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician 2013; 16:S49-S283.
- Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine (Phila Pa 1976). 1994;19(7):801–806.
- Adelmanesh, F. The Diagnostic Accuracy of Gluteal Trigger Points to Differentiate Radicular from Non-radicular Low Back Pain. The Clinical Journal of Pain. 2015 Oct 21