What Can Go Wrong With the Spine

From University of California, San Diego, School of Medicine

Hello, my name is Douglas Chang; I'm the Chief of Physical Medicine and Rehabilitation in the Department of Orthopaedic Surgery at the University of California San Diego Medical Center. I want to talk to you about spine pain. Before we start that discussion however, I want to go over some of the anatomy of the spine. I have a plastic model here. There are a few components to the spine; first of all, there are bony segments, which are separated by little vertebral disks, which serve as rubbery cushions that give flexibility to the spine.

In the back of the spine are these small facet joints -- articulating joints that run up and down both sides of the spine. The spinal cord is depicted here in yellow, and that is the "information superhighway" that connects the brain to the rest of our bodies. At various levels, branches provide connections to our extremities, in this case the arms, to the vital organs, and down here, to the legs.

A handful of conditions represent things that can go wrong with the spine.
First, these disks are like jelly-filled donuts and they can get little tears, protrusions, or disk bulges; sometimes these disk herniations, or protrusions, are big enough to exert pressure and affect the nerve, and people experience burning pain running down the legs.
Another condition occurs because these facet joints have a tendency to develop osteophytes. I liken that to the mineral crust that develops in our plumbing pipe fixtures at home over decades.

Similar to our plumbing, if these bone spurs become too big, they can exert a mass effect on these nerves -- this time coming from behind, whereas before, the disks were exerting an effect from in front, causing the sciatic pain running down the leg.

Now, what can we do about spine pain?
The treatment of spine pain has just a handful of options.
There are medications that run the gamut from simple over-the-counter analgesics to opioids, and in-between are a few medications that are not often considered by many primary care physicians in the field, and I wanted to alert you to those agents. One is gabapentin, a neuropathic pain medication, and there is new research on antidepressants (such as duloxetine) for relief of painful neuropathic conditions.

In addition to medications, physical therapy is a recommended treatment for back pain and neck pain.
That involves strengthening the core, the stomach muscles, the back muscles, the bladder floor, and the diaphragm.
My patients will often go to physical therapy and the emphasis will not be so much on active conditioning of the spine and core, but on passive modalities, which I really frown upon. These are modalities such as electrical stimulation, laser light therapy, and so forth. I don't like the therapist to be spending too much time on those types of treatments.

Apart from physical therapy, conditioning, and medications, a couple of interventions are available, which are a bit more aggressive and can be quite effective in the treatment of spine pain.
A small, but nice body of literature points to the use of cortisone shots to these facet joint areas; that can be followed up with another process called radiofrequency ablation, a technique that is showing some promise in the treatment of nonradiating back pain, as well as neck pain.

Another form of injection involves epidural treatments, and these epidurals are similar to the epidurals that women might be given during labor and delivery; however, when the pain patients come in, we do these procedures with the addition of x-ray fluoroscopy, which helps localize our needle and gives us an additional degree of safety in performing this procedure.
The idea is to provide some cortisone, and perhaps a little bit of anesthetic, to these irritated nerve roots, to help cool down the swelling and remove sciatic, or radicular pain, running down the extremities (the legs and arms).
It is actually quite effective.

One avenue through which we can deliver the medication in an epidural is the inner laminar root (going between the lamina).
Another is a transforaminal approach, or a "selective nerve root approach," in which we come in at an oblique angle right around the nerve root tunnel.
A third approach is called the caudal approach, which is a small tunnel at the base of the sacrum, and above the coccyx.
A needle will go in about a quarter of an inch and deliver medication that will go up and down the disks and nerves and treat that pain.