Marc Darrow, MD, JD.
Many times I will see a patient in my office who has been recommended to some type of spinal surgery to relieve back pain. This person has tried many treatments and remedies to avoid the need for surgery, mostly conservative care measures that have not helped that failed them to reduce back pain. I see these people, in many cases, as the last chance, in their thinking, for a non-surgical option to finally treat back pain that has plagued them for years.
There are many options to explore when seeking treatment for your back pain. Most people I see have tried the majority if not all of these standard chronic back pain treatments.
Treating back pain with medications:
For most, medication use started on their own with over the counter Non-steroidal anti-inflammatory drugs (NSAIDs) therapy. As pain worsened and this person had to seek medical care, the pain medications increased to possibly include:
- Painkillers including opioids.
- COX-2 Inhibitors (Non-steroidal anti-inflammatory drugs).
- Muscle relaxants therapy.
- Anti-seizure medications.
- Anti-Depressants therapy
Patients are for the most part dissatisfied with their back pain management when the primary treatment is pharmacology.
A paper from 2018 (1) revealed something you may already know. Patients are for the most part dissatisfied with their back pain management when the primary treatment is pharmacology. These people do not want to be treated with medicine, they are looking for alternative therapies for healing their body. This is what the authors of the paper wrote: “Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of low back pain, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy.”
pharmacotherapy is typically not seen as a long-term answer for many people. The reasons are simply, there is doubts about effectiveness and safety.
An April 2023 study (2) reviewed the data of 22238 patients on six medicines or medicine classes: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants for the treatment and management of acute, sub-acute, or chronic back pain.
- The researchers found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic low back pain compared to placebo.
Acute low back pain medications
- For acute low back pain, they found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high-certainty evidence for no evidence of difference between paracetamol and placebo.
- For safety, they found very low- and high-certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate-certainty evidence that muscle relaxants may increase the risk of adverse events.
Chronic low back pain medications
- For chronic low back pain, they found low-certainty evidence that NSAIDs and very low- to high-certainty evidence that opioids may provide a small effect on pain.
- For safety, they found low-certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low-certainty evidence that opioids may increase the risk of adverse events.
Back pain can be divided into three large classifications.
Axial or mechanical back pain.
Back pain can be divided into three large classifications. The most common condition is known as axial, or mechanical back pain. It is estimated that 90% of low back pain is of this nature and stems from soft tissue sprains and strains and disc herniation from lifting, bending, or wear and tear.
This pain can run the gamut from a very sharp to a dull ache. It may occur all the time, or it may come and go. It also varies in intensity from very mild to extremely severe. One patient may report that his/ her lower back is only sore when having been seated for a long time, or after working in the garden. Another patient may report severe, debilitating pain and need assistance to walk or stand, or even to get up from a sitting position. While one patient is perfectly straight, the other is bent over and locked in a crooked posture. The one thing that is common in these conditions is that the pain is restricted to the lower back area.
This most common type of problem, mechanical back pain, is completely non-specific with regards to the injured structure or structures. Generally, the pain gets worse with certain activities or positions. It is usually relieved by rest or changing positions. Note, extended bed rest may aggravate this type of problem.
This condition responds extremely well to conservative care. At times, spinal manipulation alone is the “miracle” affording immediate relief. More often, the injury involves more than just a misalignment of a vertebrae or of your pelvis, nerves, muscles, tendons, ligaments and skin can all have an influence on the degree of discomfort. And each of these may need to be addressed to attain relief.
If you have multiple episodes of this type of pain, you will want to engage yourself in a rehabilitation program to help resolve the underlying causes of the problem. Here, the diagnosis goes farther than just finding out what is causing the pain, but additionally centers on what weakness or restriction you have that ultimately causes you to have an episode. Here again, we function much like a “coach”, finding the cause(s) and helping to direct you towards ways of avoiding and limiting future bouts with pain.
Referred back pain.
The most common type of back pain is known as referred pain. Here, patients complain of having an achy, dull type of pain that seems to move around. The discomfort comes and goes and varies in intensity. This achy pain starts in the low back area and commonly spreads into the groin, buttocks and upper thighs.
The treatment options here are similar to those used in treating axial pain. Diagnostic and therapeutic measures are aimed at correcting abnormalities in the muscles, ligaments and small joints of the spine.
The last type of back pain is known as radicular pain. In this case, the pain is described as deep and usually constant. It follows the nerve down the leg and is often accompanied by numbness or tingling and muscle weakness. The most common example of this type of problem is the sciatic pain that radiates along that sciatic nerve – down the back of the thigh and calf into the foot. This type of pain is caused by injury to a spinal nerve. Some of the possible causes of this are a disc protrusion or bulge, arthritic changes or a narrowing of the opening through which the nerve exits.
While a few of these cases will require surgery, most respond to conservative care. Here the care will consist of multiple therapies, all designed to reduce inflammation, balance your posture, strengthen supporting structures, attain normal motion and improve the health of the nerve that is involved.
In all types of back pain, your health habits play an important role. For example, there are certain foods that are high in the fats that cause more inflammation. Limiting intake of these animal fats and increasing your intake of the good fats that reduce inflammation may play an important role in your healing. Smoking is another health concern. Statistically, smokers are slow healers with respect to back pain.
An important part in prevention is keeping these back muscles active and in good tone.
One of the most important areas in chronic back pain management is the strength of your abdominal wall and your pelvic floor. There are three major abdominal muscles, each with small subdivisions. Any weakness in one of these sections can be the root cause of a chronic back problem. Weakness in these structures causes your back muscles to tighten and shorten. This adversely affects the lower back on the small joints and discs.
Exercise, Yoga and Physical Therapy
Many people can find success with Exercise, Yoga and Physical Therapy as treatment options for chronic back pain. Many do not. Why? Many people I see are athletes who are very familiar with the importance of building the core muscles for body posture. Despite this knowledge and an understanding of the need to exercise, they are here visiting me with constant lower and mid-back spasms and a radiating dull pain.
Physical therapy is a treatment that works by strengthening muscle and retraining muscles to be more effective. To do this physical therapy requires the muscle to get stronger through resistance training. If the tendon attachment to the bone is weak and stretched out, the necessary resistance will be very difficult to achieve. Our treatments help to strengthen this attachment and are explained below.
This is not to say yoga is not an effective treatment. A January 2022 paper (3) investigated the effect of a stretch and strength-based yoga exercise program on neuropathic pain due to lumbar disc herniation. Here is the author’s opinion: ” lumbar disc herniation with neuropathic pain influences treatment outcomes negatively. Most yoga poses include the parameters of spinal training and help reduce pain and disability in patients with low back injuries. We hypothesized that yoga positively affects both lumbar disc herniation and neuropathic pain by increasing mobilization, core muscle strength, and spinal and hamstring flexibility.”
The patients in this study were taught yoga for 1 hour twice weekly for 12 weeks. Neuropathic pain, low back pain, disability, and function were measured blind before and at the 1-, 3-, and 6-month follow-ups. The “analysis showed a statistically significant difference in neuropathic pain, patient global assessment, low back pain, disability, and function in favor of the yoga group at post-treatment. The between-group effect sizes were moderate at 6-months follow-up. It was determined that the selected stretch and strength-based yoga exercise could be a promising treatment option for neuropathic pain due to low back pain.” For some this can be a helpful treatment. Yoga can help with stress and sleep. For others advancements in pain relief can be made, but as I will discuss below, those advancements can be lost as spinal ligaments and tendons continue to weaken and any gains in posture and pain relief can be lost.
Spinal injections therapy- Platelet Rich Plasma Therapy, Cortisone, Epidural and Transforaminal steroid injection, Bone Marrow Aspirate, Prolotherapy and Botox
Platelet Rich Plasma Therapy or more commonly referred to as PRP treatments are injections given into the area of spine to strengthen the spinal ligament attachments and help restore stability and prevent the vertebrae or the bones from slipping out of place causing herniated discs. The treatments are made from healing and growth factors found in your blood. These healing and growth factors are collected from a standard blood draw in the arm. The collected platelets are then concentrated and injected into the injured area of the back to stimulate healing and regeneration to the soft tissue structures that stabilize the spine. We do not inject into the spinal canal or directly into the discs with this therapy.
Orthopedics alternative treatments
Injecting directly into the disc was discussed in a 2019 paper (4) suggesting this treatment as a possible future therapy once more studies were assessed. The researchers wrote: “PRP has great potential to stimulate cell proliferation and metabolic activity of IVD cells in a laboratory setting. Several animal studies have shown that the injection of PRP into degenerated IVDs is effective in restoring structural changes (IVD height) and improving the matrix integrity of degenerated IVDs as evaluated by magnetic resonance imaging (MRI) and histology. The results of this basic research have shown the great possibility that PRP has significant biological effects for tissue repair to counteract IVD degeneration. Clinical studies for evaluating the effects of the alternative treatments injection of PRP into degenerated IVDs for patients with discogenic LBP have been reviewed. Although there was only one double-blind randomized controlled trial, all the studies reported that PRP was safe and effective in reducing back pain. While the clinical evidence of tissue repair of IVDs by PRP treatment is currently lacking, there is a great possibility that the application of PRP has the potential to lead to a feasible intradiscal therapy for the treatment of degenerative disc diseases. Further large-scale studies may be required to confirm the clinical evidence of PRP for the treatment of discogenic LBP.”
Research has shown PRP to be effective in healing and treating degenerative disc disease (DDD) by addressing the problems of spinal ligament instability and by stimulating the regeneration of the discs indirectly (although discs were not directly injected, they showed an increase in disc height).(5)
Research showed that PRP therapy is able to recover the mechanical properties of denatured (worn-down) discs, thereby providing a promising effective therapeutic modality.(6) Although I don’t typically consider Degenerative disc disease to be a major player in neck or back pain, I do treat these areas daily. From my exam, it is typically not the discs that are the issue, but the ligaments at their connection to bone that cause the pain. This is called an enthesopathy. And typically, it is easy to heal with PRP. Please be very careful to not have surgery for areas that can heal with PRP. As you will read, areas in MRIs that show anatomical issues, may not be the pain generator.
In 2019 we published our study on the effectiveness of PRP treatments for the patient for chronic low back pain. The study appears in the journal Cogent Medicine.(7)
This research gives an insight into what level of treatment success we can have with certain back pain conditions and how many PRP treatments the patient should expect towards achieving their treatment goals.
Let’s get to our study:
In our research, Treatment of Chronic Low Back Pain with Platelet-Rich Plasma Injections, we wrote:
- 67 patients underwent a treatment of one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
- Patients who received two treatments received injections an average 24 days apart and patients who received three treatments received injections an average 20.5 days apart.
- Baseline and post-treatment outcomes of resting pain, active pain, lower functionality scale, and overall improvement percentage were compared to baseline and between groups.
- Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief. These same patients experienced improvements in resting pain and functionality score, yet these results were not statistically significant.
- Patients who received a series of two and three treatments experienced significant decreases in resting pain and active pain and reported 46.17% and 54.91% total overall improvement respectively. In addition, they were able to perform daily activities with less difficulty than prior to treatment.
Transforaminal steroid injections are injected into the spine in the space between the spinal cord and the vertebrae. This treatment is designed as an anti-inflammatory measure to reduce pressure on the nerves that may come from inflammation from a herniated disc or spinal instability. Many doctors do not believe this is the best treatment option for patients with long standing back pain as will be demonstrated in the research below.
A June 2021 study (8) compered PRP injections to Transforaminal steroid injection. Here are the results: “Transforaminal steroid injection is extensively used as a treatment in cases of herniated disc, but it is associated with complications. In comparison, platelet-rich plasma (PRP) injection has been used in musculoskeletal disorders and could be another option . . . (for) patients who suffer from radicular pain due to lumbar disc herniation.” In this study the researchers substituted PRP for steroid, administered the injection in the same way and recorded that the PRP provided similar results. The authors concluded: “The results showed similar outcome for both transforaminal injections using PRP and steroid in the treatment of lumbar disc herniation, suggesting the possible application of PRP injection as a safer alternative.”
Medicine is showing that PRP can be among effective alternative therapies.
In December 2023, the Mayo Clinic offered this assessment for the use of regenerative medicine (9) for degenerative spinal disease.
“Regenerative medicine is a novel biotechnology targeting mechanical, degenerative, and inflammatory conditions believed to cause pain. Preparations including platelet-rich plasma, mesenchymal stem cells (adipose tissue and bone marrow aspirate concentrates), and growth factors are derived from an autologous donor. The goal of intervention through guided injection of the regenerative media is to reduce inflammation and reverse the degenerative cascade in hopes of restoring normal cellular composition (physiologic homeostasis) and anatomical function to improve pain and function.”
This study reviewed limited research supporting the use of platelet-rich plasma injections for facet joint arthropathy and sacroiliac joint pain compared to traditional steroid treatments, as well as the use of platelet rich plasma or mesenchymal stem cells for lumbar discogenic and radicular pain.
“Current evidence to support regenerative medicine for spine-related pain is limited. Although several studies demonstrated a reduction in pain, many of these studies had a small number of participants and were case series or prospective trials. Regenerative medicine treatments lack evidence for the treatment of spine-related pain. Large randomized controlled trials are needed with consistent study protocols to make further recommendations.”
References for this article
1 Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, Seneviwickrama M, Briggs AM, Wluka AE. Patients’ perceived needs for medical services for non-specific low back pain: a systematic scoping review. PLoS One. 2018 Nov 8;13(11):e0204885.
2 Cashin AG, Wand BM, O’Connell NE, Lee H, Rizzo RR, Bagg MK, O’Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2023(4).
3 Yildirim P, Gultekin A. The Effect of a Stretch and Strength-Based Yoga Exercise Program on Patients with Neuropathic Pain due to Lumbar Disc Herniation. Spine. 2022 Jan 11.