Managing low backache and other spinal pains – perspective of a Pain Physician
Low backache and Neck pain are among the commonest debilitating conditions in modern society. Such pains while commonly responsible for absence from work can cause disability, impaired gait, loss of sleep and appetite, anxiety, depression and other sufferings.
Most acute episodes of back pain (strains, sprains and muscle spasms) are self-limited with progressive symptomatic improvement and complete resolution in a couple of weeks. The present guidelines to manage acute low back pain stress on staying active and discourage bed rest, analgesics like paracetamol or other NSAIDS if necessary and spinal manipulation for pain relief. However one in three sufferers have continuous, moderate pain three months after the acute episode when it is called chronic or persistent back or neck pain. Some patients experience recurrent episodes of back or neck pain, which is similar to exacerbation of a chronic problem.
Chronic back pain presents a diagnostic challenge. Due to the small region in sensory cortex of the brain dedicated to the back, precise localization of the pain is difficult. This explains why the complaint of back pain suggests a potentially large number of problems, musculoskeletal and otherwise. Pain may originate from spinal structures such as facet joints, vertebral periosteum, intervertebral discs etc as well as from paravertebral muscles, abdominal or pelvic organs. Also scientific evidence suggests that psychological illnesses can contribute to the cause of chronic back pain problems.
Pain Medicine is a discipline of medicine concerned with the study of pain as well as prevention, evaluation, treatment and rehabilitation of persons in pain. The role of Pain Physician lies in the proper assessment of the chronic pain condition in order to pinpoint its cause and its management by interventional pain procedures if not responding to conservative management. The interventional pain procedures are minimally invasive procedures (injections), mostly done on day care basis which are meant to either deposit a drug (local anaesthetic / steroid) near the pain generator, ablation of nerves or implantation of intrathecal pumps or spinal cord stimulators. Interventional pain procedures are used for not only for therapeutic pain relief but also to confirm the diagnosis.
The management of chronic low back and neck pain is multidisciplinary. Apart from a Pain Physician, a multidisciplinary chronic pain management team comprises of Physical medicine professional for physical therapy and a Psychologist for managing the psychological comorbidity. As the causes of low back pain and neck pain are diverse, such patients will need extensive evaluation and at times diagnostic blocks might be needed to confirm the origin of pain from particular structures in the back.
A plan for pain management is made which is individualized for each patient addressing the various factors responsible for the origin of pain, be it physical, functional restoration, social or psychological. The goal of the pain management includes reconditioning, reducing pain, improving function, sleep and mood. Throughout the focus is more on self management of pain and enable patients to become active participants in the management of their illness. The Radiofrequency ablation of nerves and Neuromodulation techniques such as implantable pumps and spinal cord stimulators have made it possible to provide long term pain relief by modulating the pain signals travelling to the brain thereby reducing pain perception.
The chronic back and neck pain management should therefore be seen as a process rather than a quick fix measure involving a multidisciplinary approach, utilizing education, medications and interventions, physical, occupational and behavioural therapy for alleviating pain and other related sufferings.