The Lumbar Spine Puzzle: Interventional Pain Management

The Lumbar Spine PuzzleFlorida Pain Center of Naples solution for lumbar spine problems recognizes that the body is one interconnected machine, not a collection of individual parts and pieces. The lumbar spine is a crucial piece in our musculoskeletal puzzle. Structures such as the hip, knee, ankle, and foot are all controlled by spinal nerves in the low back, and a problem in the lumbar spine can create problems at any point in the lower-body chain. Many problems can occur in the lumbar spine. Some of the more common include arthritis, foraminal stenosis, pinched nerves, disc problems, and spondylolysis. We will review some lumbar spine problems as well as some traditional and interventional solutions.

First, let us look at the structure of the spinal column. The Spinal column, or backbone, is made up of vertebrae, stacked one on top of the other, with an intervertebral disc between each level to provide cushion and absorb shock. The cervical spine makes up the neck area and consists of seven vertebrae (C1–C7). C1 is at the very top of the spine. The cervical spine is followed by the thoracic spine (T1–T12), the lumbar spine (L1–L5), and the sacrum (S1–S5) and the coccyx (four fused vertebrae commonly known as the tailbone). The posterior (back) part of these vertebrae are the spinous processes (which you can feel if you run your fingers down your back), and on either side of these, connecting one vertebra to the next, are finger-joint-sized articulations called the facet joints. So, the five vertebrae of the lumbar spine have a total of ten facet joints. The spinal canal is a tunnel that runs down the middle of the column and houses the spinal cord, which has many nerves that transmit muscle commands and sensory information throughout the body and to the brain. The spinal column also has small holes where the nerves exit and branch off to other parts of the body. There is one at each level. One hole is called a foramen. The plural is called foramina. Any of these structures in the lumbar spine can become damaged or diseased in some way and lead to pain, discomfort, even disability.

Let us start with foraminal stenosis. When the spine is healthy, these nerves easily traverse the tunnel as described above, properly transmitting sensory information from each part of the body to the brain. When the spine is not healthy, however, this can disrupt the flow of information. The disc, that cushion between the spine bones, can bulge, or the spine joints can get arthritis, causing the foramen to narrow. This narrowing of the tunnel is called foraminal stenosis, and this can cause the nerves to get pinched. The pressure from a pinched nerve can cause muscle tightness, weakness, numbness, tingling, or pain in that nerve’s specific distribution. For instance, if there is foraminal stenosis in the lumbar spine level where the nerves branch into your leg and down to your toes, you could experience numbness (or one of the other sensations mentioned) all the way down in your big toe. Tingling in your fingers or tightness in the biceps muscle, for example, could be from foraminal stenosis in the level of the cervical spine where the nerves branch into your arm muscles and fingers. At times, the following methods to alleviate the symptoms and pain may be needed. However, we prefer to exhaust all other options, such as over-the-counter medications, chiropractic, physical therapy, and other available methods. Laser spine surgery can open the hole, but this surgery can have major side effects and can have serious implications, such as damage to the thoracodorsal fascia. A spinal fusion is another way to surgically treat stenosis, but the mention of a fusion should be your red flag to seek other opinions. Why?

Adjacent segment disease (ASD) can happen, which means that the levels above and below the fusion can get damaged over time. Additionally, surgery is often performed after diagnosing the problem solely based on findings on an MRI. An MRI indicating stenosis isn’t enough to appropriately diagnose that stenosis as the cause of back pain, and because of this, if you have foraminal stenosis, you really shouldn’t put all your trust in an MRI. Patients may or may not have back pain with foraminal stenosis, though they may have pain in another location, such as the knee or shoulder. Research also shows that physical therapy and chiropractic is as effective as surgery in relieving stenosis. The interventional pain management approach to foraminal stenosis utilizes nonsurgical solutions to treat it before it progresses. One of many solutions is injections of medications performed in-office that can reduce the swelling (inflammation) into the foramen and around the nerve can help manage the problem and keep it under control. Nerve root, and medial branch block injections can be done to determine if a specific spinal nerve root is the source of pain. We can also perform Lumbar Transforaminal Steroid Injections, which provide relief from foraminal stenosis, along with spinal stenosis and sciatica. It works by reducing inflammation and swelling to alleviate pressure on the spinal nerve. Blocks also can be used to reduce inflammation and pain.

Spinal Instability and Degenerative Joint Disease can cause havoc to ensue when it goes unnoticed and untreated. Like with any joint, when a damaged facet joint in the spinal column is left untreated and even unidentified, instability can set in, leading to pain, swelling, and more advanced diseases, such as degenerative joint disease (DJD). This can then lead to severe foraminal stenosis (see above). The surgical approach for severe DJD might be a fusion. A spinal fusion involves installing hardware, such as plates and screws, to bolt the vertebrae together, rendering them immovable and oftentimes disrupting the normal curves throughout the entire spinal column. It’s a limiting, irreversible procedure that can cause adjacent segment disease in the vertebrae above and below, and it should only be considered in the most extreme cases. Our approach would be to have you exhaust all other conservative methods available, including chiropractic and physical therapy. Our next step is to perform facet joint injections: an injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief.

Facet Joint Arthritis and Other Facet Problems: The facet joints, those finger-joint-sized articulations on either side of the spinous processes on the back of the spine, can, like any other joint, become injured from trauma or develop arthritis from cartilage breakdown due to wear and tear or other issues. Facet joints allow for and limit to a certain degree, movement in the spine. When you bend backward, these joints become compressed, and when you bend forward, they open up. Rotation in the lumbar spine, however, is limited to about 12 degrees in either direction, compared to about 40 degrees in the thoracic spine 90 degrees in the cervical spine. When damage or arthritis occurs, facet joints can become chronically painful and uncomfortable, especially with movement. Facet cysts can also develop when a facet joint gets arthritic and swollen. A facet cyst is simply a fluid-filled expansion of the covering of the joint (called the capsule). The joint can balloon out in a few common places, and one of those can put pressure on the nerves in the spinal canal, causing pain in the spine or anywhere along the branch of the affected nerve (e.g., in the leg if the cyst is in the lumbar, or lower, spine). Again, one method we can perform facet joint injections: an injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief. That then allows us to diagnose the issue and the next best procedure for pain relief.

Disc Problems (Herniated, Bulging, Torn, or Degenerated): There are four common types of disc problems that can occur in the lumbar spine. A herniated disc is when the outer covering of the structure breaks open, letting the inner gel herniate out. A bulging disc is when the outer covering doesn’t completely break open, but the fibers are stretched and weak, leading the inner gel to cause bulging. A torn disc is when the outer covering gets a tear that doesn’t result in a herniation or bulge but does cause pain due to ingrown nerves or the disc leaking nasty chemicals on the associated spinal nerve. Finally, a degenerated disc is one that has collapsed due to few living cells inside, causing a lack of production of the chemicals that usually plump up the disc. The surgical solution for lumbar disc problems depends on the disc problem. Generally, disc surgeries include either back fusions or disc replacement. In both cases, the damaged disc tissue is removed. With the fusion, the vertebrae are then bolted together with hardware to make them immobile, which can lead to adjacent segment disease (ASD) and other problems. With the disc replacement, the idea is that it should have fewer side effects than a lumbar fusion; however, research has shown that abnormal motion with the artificial-disc device can lead to ASD, and other side effects of the device include wear-and-tear ions in the blood from the breakdown of the metal or plastic device, ongoing pain, and revision surgeries. However, as a last resort and all other methods are exhausted, this may be necessary for a normal quality of life. In interventional Pain Management, we recognize and “properly” diagnose the different disc-injury types and help guide you to determine what options are the best and in which order you should exhaust them. A pinched lumbar nerve can cause pain or numbness anywhere along the route that nerve branch supplies, including the butt, hip, and knee. Pain may or may not exist in the low back. So, a pinched nerve can cause problems in and of itself, but it’s important not only to treat the pinched nerve but also whatever caused the problem (e.g., stenosis, disc bulge, etc.).

It is important to understand that chronic knee pain, for example, could be due to a pinched nerve, or other problem in the lumbar spine, especially if it’s accompanied by low-back pain. However, if a pinched lumbar nerve is presenting as knee pain without back pain, it is easy for your doctor to diagnose knee pain based only on MRI findings of the knee (e.g., arthritis, meniscus tears, and so on that can just be normal wear and tear with age, not a major source of pain). Therefore, we find it so important to examine the musculoskeletal system as a whole unit rather than in parts and pieces. The surgical approach to a pinched nerve depends on the cause of the pinched nerve. If it is a disc bulge, for example, it could be a discectomy and graft and/or a lumbar fusion (see “Disc Problems” in this report). If it’s foraminal stenosis, it could be a laser surgery to enlarge the foraminal opening where the nerve is being pinched (see “Foraminal Stenosis” in this report). Unfortunately, even knee replacements, for example, are a possibility if the pinched nerve is presenting as chronic knee pain and surgery is recommended based primarily on knee MRI findings rather than an examination of the full musculoskeletal system. Treatment could be precise image-guided injections, and the key is using nonsurgical methods first and to thoroughly and “accurately” diagnose the source of the pain and the why behind it. Drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids may be recommended for short term relief, but all come with their side effects and shortcomings. NSAIDs come with a long and growing list of dangerous side effects, such as sudden-death heart attacks, stroke, and GI bleeding, and addiction and overdose due to prescription opioids have reached epidemic proportions in the U.S.

We have many more options to help diagnose and treatments not listed here for your best outcome. Our goal is to treat the body as a system and to find the why behind your pain, give you as much relief and as many options as possible to help you live a happy, pain-free life.

Florida Pain Center
(239) 659-6400
730 Goodlette Rd North, #200
Naples, FL 34102

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