January 13, 2021

Alternatives to spine surgery

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One or more of these nonsurgical treatments may give you relief from chronic back pain

Fewer than 5% of people with chronic back pain have surgery to treat the problem. If you’ve considered having surgery but your doctor said you are not a good candidate for that, there are other treatments that can relieve your chronic back pain. Eric P. Sturos, M.D., a physical medicine and rehabilitation doctor, explained these nonsurgical treatments for back pain and how they help.

What would rule someone out for surgery? 

There are many reasons why someone may be told that they’re not eligible for spine surgery, Sturos said. It’s not meant for short-term back pain, for example, or pain that is likely to get better with time. In the absence of persistent debilitating problems, muscle weakness or balance issues, someone with chronic back pain is likely better off with one or more types of conservative – nonsurgical – treatment. Generally, these alternatives to surgery fall into four categories: medications, physical therapy, injections, and integrative medicine.

Help for back pain

If you’re ready to tackle the root cause of your back and neck pain, this treatment guide can help.

Medication

While medications are not necessary, they can certainly be helpful.  The immediate tool is an over-the-counter medicine, such as acetaminophen (Tylenol) or ibuprofen (Advil or Motrin, for example).  For short-term pain this may be enough relief to prevent you from needing to see a doctor.

Medications generally “can be used in acute flares, when pain is preventing you from doing what you need to do on a day-to-day basis,” Sturos said. “If somebody is having pain that’s preventing them from doing their job, their daily activities, or preventing them from doing the things that they love,” then medications may be a good option to help them feel better while their body heals, so they can function. 

If over-the-counter medicines and/or time aren’t offering enough relief, another option is prescription medication. That may include non-steroidal anti-inflammatories (NSAIDs) at a higher dose or different formulation than what’s available over the counter. Muscle relaxers are another option, especially for pain at night, because a typical side effect is sleepiness. 

“Then there are prescriptions that can help nerve pain, or neuropathic pain medications,” Sturos said. These types of prescriptions can help with pain shooting down a person’s leg, commonly described as “sciatica” or more formally known as radicular pain, although this is an off-label use of these medications.  

Opioids comprise another class of pain medication, though Sturos is cautious about prescribing those, because of their risky side effect profile, limited benefit for chronic back pain and addictive nature, among other reasons.

But patients should not expect medication to completely solve their back problems. Nor should they expect to use medications long-term for this purpose. 

“People tend to get better from back pain, or back pain flares,” Sturos said. “If it’s an acute flare-up” of an on-and-off problem, “I find medications can be helpful in getting over that flare.” Chronic back pain may justify some medications for longer periods of time. But other nonsurgical chronic back pain treatments can be more effective for treating long-term pain, namely physical therapy exercises or other spine interventions, Sturos said.

Physical therapy

It’s very common for spine doctors to refer people with chronic back pain to physical therapy.

“The purpose of physical therapy is to help decrease pain and increase function, primarily through learning personalized strengthening exercises to do for their back and how to do them correctly,” Sturos said. Although the details depend on a person’s individual case, physical therapy is typically prescribed for six to eight weeks, with one to two in-person physical therapy visits each week and ultimately a transition to doing these exercises at home.

“Physical therapists are tremendous in the way they are able to tailor these exercises to that patient’s specific pain, and help them develop some sort of a home exercise program to perform on their own, both between sessions and once finished with the formal PT,” Sturos said. 

One of the main benefits of physical therapy for back pain is the increased core strength it provides, which helps to support the spine. This isn’t the quick and easy fix we’d prefer, but people get the best results if they learn the correct exercises, perform them correctly and maintain consistently on their own, long after their in-person sessions have ended. It can take several weeks to feel a significant change in muscle strength or see significant functional improvement with consistent exercise, Sturos said. 

Keeping up with appropriate physical therapy exercises over the long term, as maintenance, can also prevent or lessen future back pain flares, Sturos said.

Injections

There are many types of spine injections that can help with chronic back or leg pain. The two primary reasons for spine injections are to determine where the pain originates from (diagnostic injections) and to provide longer-term pain relief (therapeutic injections). These injections are typically performed using X-rays to accurately place the needle. Three of the more common procedures are epidural steroid injections, medial branch blocks/ablations, and joint injections (in the sacroiliac joint, hip, etc.). 

Epidural steroid injections can be beneficial in patients who have severe radiating pain down their legs,” Sturos said. The steroid is a strong anti-inflammatory medication and helps to decrease the inflammation, or calm the inflamed nerve that’s contributing to their pain. “If somebody has a disc herniation in their lumbar spine, for instance, the disc material may irritate a nearby nerve and result in severe pain down their leg. That’s where an epidural steroid injection can be beneficial.” These injections can knock out the acute pain and provide an anti-inflammatory effect for several months. Epidural injections can also be performed for diagnostic reasons at very specific levels to guide future treatments like surgery. 

Medial branch blocks/ablations are a series of procedures that are used primarily to diagnose and treat pain originating from the small facet joints in the back of the spine. This is commonly due to arthritis-type pain – the achy pain that comes from wear and tear, is worse with prolonged standing and that tends to affect older adults. The blocks simply anesthetize the presumed painful joints for diagnostic reasons and to help predict a person’s possible responses to an ablation. The ablation portion of the procedure “burns” the small nerves responsible for providing sensation from these small joints, preventing the painful messages from getting back to the brain. The effects of a medial branch ablation can result in months or even years of pain relief in some patients.  

Integrative medicine

Acupuncture, chiropractic manipulations, massage, myofascial release, meditation or mindfulness, yoga, tai chi, aerobic exercise – these are just some of the other nonsurgical, nonmedical strategies that can help ease back pain and should be at least part of the treatment plan, Sturos said. 

“A lot of my patients find a significant amount of benefit from any combination of these treatments,” he said.

He refers some patients to the Osher Center for Integrative Medicine at Vanderbilt. The Osher Center offers many holistic therapies aimed at easing pain, including massage, exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercises, progressive relaxation, electromyography biofeedback and cognitive behavioral therapy. 

If you have dealt with chronic back pain that’s not improving despite a combination of these treatments, another option is working with a psychologist who specializes in chronic pain, Sturos said. Research in recent years has repeatedly shown that people can affect their own pain perception, with education about their thought patterns, meditation and other cognitive training, which can give them some control over their pain.

When should you see a doctor about your back pain?

Your ability, or inability, to function is a better indicator of whether you should see a doctor than the amount of time that your back’s been hurting. 

So if a backache isn’t preventing you from going about your business, the best immediate strategy is to take some over-the-counter pain medicine if needed and give it a bit of time. But if this pain persists or you’re experiencing severe pain, weakness, numbness/tingling or trouble with balance, those are signs you should see a doctor soon. 

“If you’re unable to manage your pain or a typical flare is lasting longer than usual” Sturos said, “then it may be worth seeing a spine specialist as they have additional tools in their toolbox to help diagnose the pain, manage it, and ultimately improve your ability to function effectively.”

Small-size photo, a couple in bike helmets standing outdoors with their bikes.

Vanderbilt Physical Medicine and Rehabilitation’s Wilson County clinic is taking new patients who seek relief from back and neck pain, sciatica and other conditions involving the spine. Our specialists work together to create the best treatment for you. Download our treatment guide, and call for an appointment: 615-875-5100.