It probably goes without saying that the best way of treating back pain or indeed neck pain is non-operative.
Surgery, although useful, has to remain the last option due to the collateral damage caused, the recovery time, the potential complications and the changes to the body’s mechanics.
This article is written by Andrew Quaile, Consultant Spinal and Orthopaedic Surgeon, Hampshire and Surrey.
I tell my patients that surgery is great fun for me as it puts petrol in my car and pays the mortgage, but would I do it to my wife, my mother or my sons. Certainly not, unless there was nothing else to do. We are not dealing, in the main, with cancers or infections and therefore surgery for pain control should be the last option. Pain from nerves is a different subject and less controversial from a surgical point of view.
The mainstay of treatment for back or neck pain is physical therapy. That can be Physiotherapy, Osteopathy or Chiropractic management. There are very vocal proponents of all three and more. It is better, in my view, to find a practitioner who listens to the problems carefully and develops a good relationship with the sufferer than to be worried about which is the best discipline. This sort of treatment is best to be individualised as we are all so very different. The basic thrust of management is to get on top of the symptoms by restoring the architecture to the correct position by some sort of manipulation and then holding it there with good muscle control, such as core stability. The general exercise programmes for this would be Pilates and the use of a fit ball. It is important to continue spinal exercises when the pain is improved to prevent recurrences rather than reacting to them once they have occurred. The horse has bolted then and it is too late.
The pain itself should be kept under control by pain killers, anti-inflamatories and perhaps anti-spasmodics to allow the physical therapy to proceed. The fear that people express is that ‘pain means damage is occurring’. In this context, that is not true. Damage implies a permanent injury to something. That is not happening. This is a situation where the pain can vary depending upon activity or other factors. The symptoms can therefore flare up but will settle. It is better, therefore, to keep the symptoms under control to allow physical therapy to proceed than worry about masking ‘damage’. The body needs exercise and movement to remain alive and keep joints and discs lubricated and supplied with nutrients. Patients often present in the downward spiral of pain and disability. It hurts and so they don’t move, leading to less muscle control and more pain. The result is the couch potato with a walking stick.
An alternative way of achieving pain control is by injection. These are either aimed at nerves, via caudal epidurals or nerve blocks, or at joints via facet blocks. Facet blocks can also be made more permanent via devices such as coblation or radio frequency probes. The idea generally is to achieve a ‘window of opportunity’ for a return to an exercise programme by damping down inflammation and therefore pain for a period of a few weeks. With luck, the natural healing processes and the physical therapy would have started to kick in before the injection wears off. I advise waiting for 7 to 10 days before returning to the physical programme. The two should therefore work in tandem.
A final comment is on timing. The longer pain is present the harder it is to remove as it becomes ‘learned’. Pain for three months becomes chronic and difficult to eradicate. The sooner a diagnosis is made and pain controlled the better for long-term recovery.