A Guide To Minimally Invasive Treatment Options for Chronic Back Pain

What’s in this Guide?

What is chronic pain?
When to see a doctor for chronic pain
Treatment options for chronic pain
What are minimally invasive treatments?
When is minimally invasive treatment less helpful?
When is minimally invasive treatment more helpful?
Spinal cord stimulation
Intrathecal pain pump
Regenerative medicine

What is chronic back pain?

Back pain, and most other forms of pain, can be divided into three categories:

Acute Pain
Subacute Pain
Chronic Pain

Acute pain is defined as pain that has been present for less than 6 weeks. The reason 6 weeks is an important number is because approximately 80% of back pain will resolve on its own. Almost always, acute back pain does not require minimally invasive or surgical treatment and patients and physicians should focus on controlling one’s symptoms,i.e., controlling pain while the body heals.

Subacute pain is defined as pain that has been present for 6 to 12 weeks. The subacute pain period represents a transition phase. While most patients will experience resolution of their pain before the end of the subacute period, some patients will go on to develop chronic pain. Just as with acute pain, minimally invasive and/or surgical therapy is usually not necessary for subacute pain, and treatment should focus on pain management while the body heals.

Chronic pain is defined as pain that has been present for longer than 12 weeks. It is abnormal for pain to last longer than 12 weeks; therefore, once pain has become chronic, further evaluation is necessary to understand why the body is still sending pain signals. Chronic pain is unlikely to resolve on its own and usually requires treatment. Contrary to popular belief, back surgery is usually not required to alleviate chronic pain as minimally invasive treatments (discussed in detail in the next section) have dramatically improved over the last 20 years and now provide superior pain relief with fewer risks when compared to back surgery. However, there are special cases (discussed below) where back surgery still remains the gold standard treatment option.

When to see a doctor for chronic pain

If you’re experiencing severe back pain that is limiting your ability to function (you can’t go to work or you can’t get out of bed) or you’re experiencing any of the following red flag symptoms, then you need to see a doctor.

New muscle weakness in arms or legs
Severe back pain following trauma (car accident or fall)
New loss of bowel or bladder control
You’re currently being treated for cancer
New or progressive numbness in arms or legs

Any of the above findings could indicate a severe underlying spinal abnormality like cancer, infection, a severely pinched nerve from a herniated disc (that could eventually lead to permanent paralysis), or a compression fracture. Just remember…severe pain, especially if it comes on quickly, is usually a warning sign from your body to your brain that something may be seriously damaged. If you’re unable to see your primary care doctor or go to an urgent care, a PainTheory patient coordinator can provide you with a free consultation.

Treatment options for chronic pain

Treatment options for chronic pain largely fall into 7 buckets. This article will mainly discuss “minimally invasive” treatment options for chronic pain, but you can see the categories of treatment options listed below.

Conservative Home Therapy: Rest, ice, over-the-counter medications, CBD, etc.
Non-Invasive Alternative Therapies: Acupuncture, massage therapy, cupping, chiropractic manipulation, etc.
Mental Health Therapies: Cognitive behavioral therapy (CBT), Pain neuroscience education (PNE), etc.
Traditional Minimally Invasive Therapies: Injections, nerve ablations, certain implants, etc.
Emerging Minimally Invasive Therapies: Platelet rich plasma (PRP), stem cell therapy, etc.
Surgery: Laminectomy, spinal fusion, etc.
Prescription Medication Management: Oral opioids, muscle relaxers, etc.

Determining the right treatment option varies from patient to patient and depends on numerous other factors such as duration and severity of the pain, degree to which pain is limiting the patient’s life, success of other treatment options, the patient’s work and lifestyle constraints, and willingness to try other therapies.

However–barring certain red flag symptoms–a basic rule of thumb that should be followed when determining the correct treatment option is to start with conservative, non-invasive therapies, and reserve surgery and oral opioid therapies as options of last resort.

We will write additional articles on the 7 buckets of treatment for chronic pain, but the remainder of this articles will cover “minimally invasive” treatments for chronic pain.

What are minimally invasive treatments?

Minimally invasive treatments use techniques to significantly decrease the size of surgical incisions. Often, minimally invasive treatments are performed through a needle (no incision required) and use only local anesthesia or moderate sedation (twilight anesthesia). The purpose of minimally invasive treatments (examples include epidural steroid injection (ESI) and radiofrequency nerve ablation) are to decrease pain and reduce, if not eliminate, recovery times after the procedure. Minimally invasive procedures are typically performed in-office and patients usually go home 1 hour after their procedure.

Epidural Steroid Injection (ESI): Mixture of long acting local anesthetic and anti-inflammatory steroid are injected into the epidural space. Inflamed spinal nerve roots which cause pain syndromes such as sciatica are coated with the anti-inflammatory cocktail leading to significant pain relief in appropriately selected patients. The physician uses real-time [wiki]fluoroscopy[/wiki] to ensure appropriate positioning of the needle within the epidural space. Epidural steroid injections are used to treat patients who are diagnosed with a [wiki]radiculopathy[/wiki] (back pain that radiates or shoots into the arms or legs).

Although there are minimally invasive treatments for acute and subacute pain, the majority of minimally invasive treatments aim to treat chronic pain, i.e., pain that has been present for longer than 12 weeks and is therefore unlikely to resolve on its own. When performed on the right patient by a skilled physician, patients with chronic pain usually achieve greater than 50% pain relief. Not uncommonly do patients experience complete resolution of their painful symptoms. Before we review each of the minimally invasive treatments for chronic pain (spinal cord stimulation, etc.), first we must discuss an equally, if not more, important topic: which patients are unlikely to benefit from minimally invasive treatment?

When is minimally invasive treatment less helpful?

Acute or Subacute Pain

Over 80% of american’s will experience back pain at some point during their life. If we were able to freeze time right now and assess every person experiencing back pain, only 1 person out of 100 would be experiencing pain due to a serious underlying medical condition like cancer. Put another way, the vast majority of back pain is not life threatening, although it can be highly life limiting. Let’s go back to our time freeze scenario for one additional important point. Of all the people experiencing back pain right now, 80% will experience resolution of their symptoms within 1 month.

As the above statistics show, the majority of patients will experience relief with conservative therapies alone (exercise, physical therapy, and OTC pain medication) which are discussed in a separate article. Here are the scenarios where your back pain will almost certainly resolve on its own; therefore, minimally invasive treatment is usually unnecessary:

Back pain has only been present for 1-2 weeks;
You haven’t tried conservative therapy; or
The pain is not severely impacting your daily activities.

MEDICAL INSIGHT

There is one major exception to the above rule…no matter how long your back pain has been present (it could be less than 1 day), if the pain is so severe that you can’t do activities that you’d be able to do any other day like walk, get out of the car, or transition from standing to lying, then seek medical help. Severe debilitating pain, especially if bedridden, can lead to serious downstream medical problems such as blood clots (deep vein thrombosis), lung collapse (atelectasis), and pneumonia. Sometimes severe pain, especially when it comes on quickly, can be related to a spinal compression fracture or insufficiency fracture.

When surgery is required

First and foremost, surgery should be thought of as a last ditch effort to solve back pain. Back surgery is different than minimally invasive treatment in that surgery often requires large surgical incisions that take months to heal. Spinal fusion is an example of a back surgery that requires significant recovery prior to returning to full function.

In fact, surgery is only used when a patient is experiencing both pain and muscle weakness. Back pain alone (in the absence of true muscle weakness) is rarely an indication for back surgery.

Muscle weakness is defined as a lack of muscle strength within a muscle and is a red flag symptom that requires immediate medical attention as the weakness can become permanent (paralysis) if left untreated. Muscle weakness is often related to severe pinching of a spinal nerve which must be fixed surgically with a decompression procedure (laminectomy, discectomy, fusion).

Unfortunately, severe pain during muscle contraction leading to decreased range of motion is often misinterpreted as muscle weakness. Remember, pain alone (in the absence of muscle weakness) rarely if ever requires surgical intervention as it can almost always be treated with a minimally invasive procedure that not only alleviates pain but carries far fewer risks. For this reason, it is very important to distinguish true muscle weakness (related to severe nerve damage) from false muscle weakness (caused by severe pain during muscle contraction).

True muscle weakness is not, in and of itself, a painful process…one simply cannot activate a particular muscle group regardless of whether they experience pain during the action. For example, with foot drop (video below), the ankle muscles do not activate; therefore, one foot flops or appears to drag behind the other as the patient walks. In contrast, when pain is limiting motion, the muscle activates normally; however, the action (for example, lifting your arm above your head) cannot be completed due to extreme pain during the motion. In essence, the pain becomes so unbearable the action is stopped.

In some cases, patients can experience both true muscle weakness and pain that limits motion at the same time. If you are at all uncertain whether you are experiencing muscle weakness, consultation with a physician is recommended. If you don’t have a primary care physician or you simply want answers as soon as possible, you can talk to a patient coordinator now.

Video: This video shows a patient experiencing right sided foot drop. Notice how his right foot is floppy and how it appears as though his right foot would not clear uneven pavement. If you were to ask this patient to “stand on his heels”, his right foot would stay flat on the ground while his left foot would make a “V” shape.

Additional red flag symptoms, which require immediate medical attention (similar to true muscle weakness) because surgery could be required are:

RED FLAG SYMPTOMS

Inability to control your bowl/bladder or numbness along both inner thighs (cauda equina syndrome)
Pain that started after trauma such as a fall or car accident (compression fracture)
Pain associated with a throbbing sensation in your abdomen (abdominal aortic aneurysm)
Back pain associated with a new fever, night sweats, or chills (discitis)
New or progressive weakness in the arms or legs (myelopathy)

If any of the previous scenarios describe you, it could be case that you have a severe underlying medical condition causing your pain, and prompt evaluation by a medical doctor is recommended.

However, if you’re not experiencing red flag symptoms and you’re not someone whose pain is likely to resolve with conservative treatment alone (discussed above), then read on, because you’re someone who’s likely to benefit from minimally invasive treatment strategies.

When is minimally invasive treatment more helpful?

If you’ve read through the above sections and determined that you don’t have red flag symptoms and your pain is unlikely to resolve on its own (scenarios where pain is likely to resolve on its own are detailed above), then you may stand to benefit from a minimally invasive treatment. In bullet format, here are the scenarios where your back pain is much less likely to resolve on it’s own:

When you’ve tried conservative therapy and are still in pain; or
Have been in pain for longer than 3 months; or
Have severe pain that is limiting your life.

If you fall into one of the three buckets above or you’ve been diagnosed with one of the following medical conditions then you are likely to be a candidate for a minimally invasive therapy. I have:

Failed back syndrome
Chronic sciatica unresponsive to other treatments
Chronic pain related to [wiki]degenerative disc disease
Chronic pain related to spinal stenosis
Chronic pain related to facet syndrome
Pain related to metastatic cancer (bone metastasis)
Intolerable side effects from oral opioid medications

Let’s now discuss some of the innovative, minimally invasive treatment options that exist for patients struggling with chronic pain. These treatment options have given hope and a sense of normalcy to those patients who previously had one option only…constant suffering.

Spinal Cord Stimulation

What is spinal cord stimulation (SCS)?

A spinal cord stimulator (SCS) is a small medical device, similar to a pacemaker, that uses electrical impulses to mask pain signals before reaching the brain.

Medical Insight
Spinal cord stimulation (SCS) results in meaningful pain relief for 50-70% percent of well-selected patients and has minor rates of complication (1).

Who is spinal cord stimulation good for?

Spinal cord stimulation is best for patients who suffer from:

Chronic pain after back surgery termed “failed back surgery syndrome.”
Chronic pain after surgery is defined as pain that has not resolved 6 months after surgery.
Chronic pain that has not responded to other treatments.
Chronic pain is defined as pain that has been present for longer than 4 to 6 months and has failed to resolve with other treatments like medication management, injections, and physical therapy.
Patients who suffer from chronic pain that radiates from the back into one or both of the legs.
Patients that have radiating pain–or “radicular pain,” commonly known as “sciatica”–have a particularly high chance for treatment success

Other conditions that can be successfully treated with spinal cord stimulation are:

Arachnoiditis
Chronic Sciatica or Arm Pain
Complex Regional Pain Syndrome (CRPS)
Failed Back Surgery Syndrome (FBSS)
Multiple Sclerosis

Find out if spinal cord stimulation is a good fit for you with our quiz.

What is the process for getting a spinal cord stimulator?

Step 1: Evaluation by a medical doctor

If you have have chronic back pain that has failed multiple therapies or have persistent back pain after spine surgery (failed back surgery syndrome), discuss spinal cord stimulation with your interventional pain doctor. An interventional pain doctor specializes in using non surgical, minimally invasive procedures to reduce pain. If you are unsure if you’re a candidate for spinal cord stimulation or you don’t have an interventional pain doctor, you’re eligible for a free digital pain consultation today on PainTheory.

Step 2: Stimulator trial

Before a permanent spinal cord stimulator is inserted, a trial is performed to ensure adequate pain relief. At your physician’s office or surgery center, temporary leads are placed into the back (image 1). Unlike the long-term implant, the temporary leads have an external stimulator device that can be easily disconnected (image 2). Over the next 3 to 7 days you will be able to see if the SCS works for managing your pain.

Image 1

Thin wires are inserted under image guidance into the space near the spinal nerves (intrathecal space)

Image 2

The temporary wires are hooked to a temporary pulse generator that very closely resembles the implanted device

What defines SCS trial success?

Your pain is reduced by at least 50%.
You’re able to return to activities that matter to you.
Your need for pain medication is reduced.
You’re able to relax and sleep better.

Step 3: Implantation

If the trial run is successful, a minimally invasive procedure is performed to place a permanent stimulator. During the procedure, the lead wires along the back of the vertebrae are then connected to a pulse generator positioned just below the skin near the waistline (image). Most patients leave the day of or the morning after their procedure.

Image: pulse generator is positioned just beneath the skin near the waistline. The pulse generator is not visible to others but can be easily removed by an interventional pain doctor

Step 4: Recovery

The spinal cord stimulator is programmed before leaving the surgery center. Approximately 10 days after the procedure, the incision is checked to ensure adequate wound healing. Fine tuning of the device also occurs to ensure maximum pain relief.

Intrathecal Pain Pump

What is an intrathecal pain pump?

An intrathecal pain pump is a small medical device that delivers pain medications directly to the spinal cord. The pain pump consists of two parts: 1) the pump (reservoir) that holds pain medication, and 2) the medication tubing ([wiki]catheter[/wiki]) that carries pain medication to the spinal cord nerves.

MEDICAL INSIGHT

Because medication is targeted to areas of pain signaling – as opposed to oral medications that are distributed throughout the entire body – pain pumps can alleviate pain with less than 1% of the amount of oral medication.

Who are intrathecal pain pumps good for?

Pain pumps have been proven most successful for patients with:

Chronic pain (pain that has been present for years)
Failed back surgery syndrome
Cancer related pain
Complex regional pain syndrome
Chronic pancreatitis
Causalgia (burning pain related to peripheral neuropathy)
Arachnoiditis

Pain pumps can also help lessen [wiki]spasticity[/wiki] (muscle rigidity and spasms) caused by:

Cerebral palsy
Multiple sclerosis
Stroke
Traumatic brain injury
Spinal cord injury