Understand Low back pain : Lumbar Disc Pain

Lumbar spines are composed of few structures which may cause low back pain. Spinal pathology usually involves few of those structures – not only one structure- making the diagnosis of low back pain sometimes tricky.

Conservative spinal treatment like Physical therapy, Chiropractor adjustments, Acupuncture sessions, Massage sessions, Meditation are not targeted treatments, meaning, same treatment may tackle all these structures at the same time.

The pattern of pain complaints and good physical examination assist to establish a “Differential Diagnosis” meaning, list of possible causative structure by order of possibility being the “The main generator of Pain”.

Interventional Pain Injections are targeted injections directed to a specific structure/s. These directed blocks have both diagnostic and therapeutic purpose. If you target a specific structure and got a good relief, so this structure is part of the pain process. If pain relief was 70-80%, so that structure is the main generator of pain and needs to be tackled to get the most pain relief. If you get pain 20-30% pain relief from targeting that structure, though it would be a pain generator but it is probably not the “main generator of pain”. Tackling that minor generator of pain is not essential but would also help to add more relief to patient if tackling the main generator is not giving enough relief.

There are few patterns of low back pain that help in diagnosis and tailoring a treatment plan;

INTERNAL DISC PAIN: Vertebral disc is a structure that lies between each two vertebrae acting as a cushion and shock absorbent to minimize stress and impact on vertebral bones. More pressure is emphasized on disc with bending forwards and lifting heavy objects. Vertebral disc pathology usually starts as gradual degenerative process from wear and tear or sometimes starts as a sudden pain or popping feeling due to traumatic event like car accident or lifting heavy object. Most gradual non accident degenerative disc disease start as purely discogenic pain then advanced to other patterns as condition gets worse.

Purely internal discogenic pain usually presents as an Axial pain,

1) limited to low back pain, on one or both sides,

2) Comes and goes with physical activity, lifting weights, repetitive bending, patient is pain free among painful bouts,

3) usually not shooting down the legs,

4) not accompanied by numbness and tingling down the leg,

5) gets better with rest, NSAIDs as needed, and moderation of activities.

Radicular (Sciatic) Pain: As disc pathology gets worse, disc material is squeezed out outside disc boundaries causing disc bulge and may pinch on nerve roots causing radicular (sciatic) pain down one or both legs that may be accompanied with numbness and tingling down the legs. The disc material might leak outside the disc causing chemical irritation and inflammation of the nerve root at that level. Each nerve root supplies specific muscles and skin zone. Muscle weakness or sensory changes in such zones can pinpoint the related causative nerve root.

After trying conservative treatment with no significant help, patient might try fluoroscopy guided Interventional Pain Injections or procedures. Physician usually start with,

Interlaminar Epidural Steroid Injection (IL-ESI): A steroid injection +/- local anesthetic is injected straight in the middle of the back into the spine where medicine goes directly to affected disc and spread to get nerve roots on both sides. This shot usually good for purely internal disc pain or in case of bilateral radicular (sciatic) pain down both legs.

Transforaminal Epidural Steroid Injection (TFESI): when patient has a radicular pain. A nerve block of steroid +/- local anesthetic is injected to target specific nerve roots. It provides both diagnostic and therapeutic purposes. Each lumbar nerve root supply specific muscles and skin sensory area in the leg. The radicular pain pattern may help doctor to predict which nerve roots are affected but TFESI helps to confirm the diagnosis and helps with pain relief.

Minimally Invasive Micro-Endoscopic Discectomy: is a minimally invasive procedure with a small skin opening to introduce a fine instrument to punch out piece of isolated bulging disc causing a pinch on a nerve to relief pressure on that nerve and eliminate radicular pain.

All above procedures are usually performed at an ambulatory same day surgical center. Above procedures usually take about 3 minutes, 5 minutes, and 45 minutes respectively.

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