Most patients with spinal pain do not have any serious or significant underlying problem. We now understand the 70% of patients experiencing spinal pain will have “non-specific spinal pain” were we simply do not know exactly where the pain is arising from. A recent review of the major medical literature was published in the Lancet Medical Journal in March 2018. This concluded that most neck and back pain is not due to a specific underlying problem but is a complex process due to genetic, lifestyle, environmental and psychological issues. In only a small number of patients will an identifiable source of the pain be found.
Red Flags – Serious Conditions
It is of course important to be sure that there is no serious underlying pathology such as infection or tumour. In most situations your history (story) and examination will suggest that there may be a more serious cause of the spinal pain.
I will look for “red flags” such as a history of cancer, recent trauma to the spine, symptoms suggestive of more generalised disease such as weight loss, reduced appetite or temperatures. The character of the pain can also assist in identifying patients who may have more serious pathology. Severe unremitting and progressive pain can suggest a serious structural problem.
Patients with numbness, weakness or bowel or bladder disturbance may have spinal cord or nerve compression. In these situations, I will recommend urgent assessment and investigation often including an MRI scan and blood tests.
Specific Spinal Pain
Thirty percent of patients presenting to my clinic will have a specific cause of the pain. For example inflammatory joint conditions such as rheumatoid arthritis or ankylosing spondylitis can cause back pain. In this situation I will refer you to a rheumatologist and you may require treatment with medication for inflammatory arthritis.
There are certain structural problems such as spondylolysis and spondylolisthesis which can cause back pain and may require treatment. However, in many situations these conditions are actually asymptomatic. If we do identify a specific cause of the pain then there may be a specific treatment that can be offered.
Non specific spinal pain
The majority of patients who attend my clinic will have non-specific spinal pain. This means that no identifiable cause for the pain can be found and this occurs in the majority of patients. An MRI scan will often show incidental degenerative changes or radiological findings which are probably not the cause of your pain. We now understand that many individuals will have signs of disc degeneration and wear and tear on their MRI scan but have no significant symptoms. The relationship between wear and tear and back pain is unclear.
In the past there was the perception that this degeneration caused back pain and many surgeons offered operations such as spinal fusion or disc replacement. These procedures met with very variable success and in recent years NHS and NICE (The National Institute for Health and Care Excellence) do not feel that these procedures are cost-effective or clinically useful and they are not therefore offered routinely to patients with back pain. In very selected situations a small number of patients may undergo spinal surgery for back pain, but the outcome of these procedures is very variable and not routinely recommended currently. I do not offer spinal fusion for back pain currently as I feel that it is ineffective for most patients.
When we are certain that there is no serious, specific or structural cause of the spinal pain then we can conclude that the pain is non-specific and must be managed rather than cured.
The mainstays of management are simple analgesia such as paracetamol or an anti-inflammatory such as naproxen. Stronger medication such as opioid based drugs are not recommended by NICE as they have limited clinical usefulness and are highly addictive.
There is excellent evidence that lifestyle changes such as standing more than sitting and walking more than driving can be effective in improving spinal health. Physical activity is generally felt to be beneficial and should not be avoided. Once we understand the pain is not due to any serious problem then patients should not avoid the pain but should continue to move and exercise as much as possible. In fact, it is felt to be counter-productive not to exercise as this the de-conditions the spinal muscles and makes the situation worse.
Recent studies suggest that core strengthening exercises such as Pilates or yoga will have a positive benefit as well.
Long-term spinal pain is a problem that needs to be managed rather than cured. Some patients find it difficult to accept that the pain cannot be fixed. However chronic back and neck pain must be considered similar to conditions such as diabetes or high blood pressure which cannot be cured but can be managed.
In some situations, cognitive behavioural therapy can change how we think about the pain and there is moderate evidence that for some patients this can be helpful.
Arm and Leg Pain (Sciatica and Brachalgia)
Some patients may have radiating pain to the arm or leg. This is usually called brachalgia or sciatica. In most cases it is due to a trapped nerve. The nerve can be impinged by a disc prolapse, a bony spur or rarely a ganglion cyst. In patients with persistent arm or leg pain for more than several weeks investigation is required to determine the cause of the symptoms.
Slipped discs, bulging discs, herniated discs and disc prolapse all mean the same thing. This is where a disc presses on a nerve and causes pain to radiate down the leg or the arm. Some patients may also experience numbness or weakness and if there is loss of power in the limb then more urgent investigation may be required. An MRI scan will usually confirm the diagnosis.
If the pain in the arm or leg is due to a slipped disc then in 70 to 80% of cases this will get better after 2 to 3 months.
Bony spurs and spinal stenosis
Some patients with pain in the arm or leg will have nerve compression due to bony overgrowth causing narrowing of the spinal canal or the nerve foramina. This will also be confirmed on MRI scan. In these situations, symptoms are less likely to get better spontaneously.
Synovial cysts are a rare cause of sciatica usually in the lumbar spine. The cyst arises from the facet joint and is very similar to a ganglion found at the back of the wrist. The cyst presses on the nerve root and causes similar symptoms to a disc prolapse. Occasionally the cyst will rupture and the patient will get better but more usually surgical excision of the cyst is required.
Management of Nerve Pain
In the majority of patients with arm or leg pain due to nerve compression symptoms will usually settle spontaneously after 2 to 3 months. During this period is important to keep moving and active.
Oral analgesia such as paracetamol or co-codomol may be helpful. NICE guidelines indicate that anti-inflammatories such as brufen, nurofen or naproxen are useful intermittently. Nerve tablets such as pregabalin, amitriptyline or gabapentin can be useful but the evidence for their effectiveness is variable and they often have many side effects.
If the pain persists at a high level then I can offer injections. Only a small number of anaesthetists carry out cervical nerve root and epidural injections but we can arrange onward referral for these to be performed.
In the Ulster Clinic we can offer lumbar nerve root injections or epidural injections. These can be quite effective and provide pain management for 2 to 3 weeks. They tend to work best in patients who have had relatively short-lived symptoms and are likely to get better continuously.
In my experience patients who have had symptoms for longer than 2 to 3 months are less likely to recover spontaneously and may have to consider surgery.