By Andrew Cole, MD, Veritas Health Advisory Medical Board
Lower back pain that lasts for over three months is considered to be chronic and usually requires professional medical intervention. Chronic lower back pain may be managed by nonsurgical and/or surgical methods. Treatment usually aims to improve function, reduce pain, and manage neurological signs and symptoms, such as numbness, weakness, and other abnormal sensations.
A combination of nonsurgical and/or minimally invasive options are usually tried first. If no relief and/or progression of pain is experienced, surgery may be considered. Several newer, upcoming treatments are being researched and may help bridge the gap between nonsurgical and surgical treatments for lower back pain.
Treatment of chronic back pain usually starts with nonsurgical methods. A few examples include:
- Oral medications. Both over-the-counter and prescription pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants may help provide pain relief. Sometimes, opioids may be prescribed for a short duration.
- Physical therapy and exercise. Exercises and physical therapy specifically aimed to treat the underlying cause can be effective in relieving chronic back pain. These therapies help stabilize the back and keep the muscles and joints well-conditioned, providing long-term pain relief.
- Lifestyle changes. Committing to certain lifestyle modifications, such as staying active, quitting smoking, and reducing weight in overweight individuals are an integral part of managing lower back pain. Practicing mindfulness training and/or meditation can also be effective in reducing chronic pain.
Sudden flare-ups of pain may be managed by ice and heat therapy, topical medications, and/or therapeutic massages.
Minimally Invasive Treatments
Injection techniques or certain implanted devices may be useful in inhibiting the transmission of pain signals from the underlying source to the brain. Common treatments include:
- Lumbar epidural steroid injections. Epidural steroid injections deliver steroids directly into the spinal epidural space that surrounds the spinal cord and nerve roots. Steroids help decrease inflammation and reduce the sensitivity of nerve fibers to pain, generating fewer pain signals.
- Radiofrequency ablation. Radiofrequency ablation is used to treat back pain stemming from the vertebral facet joints or the hip’s sacroiliac joints. A part of the pain-transmitting nerve is heated with a radiofrequency needle to create a heat lesion. This resulting lesion prevents the nerve from sending pain signals to the brain.
- Spinal cord stimulation. Spinal cord stimulation directs mild electrical pulses through a small, implanted device. These impulses interfere with pain messages, preventing them from reaching the brain.
Injection treatments are usually considered after nonsurgical methods are tried for several weeks with no pain relief. These treatments may not be used in certain conditions, such as infections or specific drug allergies.
Surgery is usually indicated when lower back pain is associated with worsening leg weakness and/or numbness or gait coordination problems despite trying several nonsurgical treatments.
Surgery to relieve nerve root pressure may include:
- Removing parts of herniated or degenerated discs
- Trimming overgrown bone around facet joints and/or nerve roots
- Sectioning all or a part of the vertebral lamina (posterior part of the vertebra) to provide more space for the compressed spinal cord and/or nerve roots
Newer techniques allow surgeries to be performed with less invasive procedures, using small incisions, minimal tissue damage, and faster recovery.
For a surgery to be successful, it is essential that the patient has a structural condition that is known to be responsive to surgical intervention. Additionally, the patient must be evaluated for psychological wellness and the presence of persistent habits such as the use of tobacco or other drugs.
Several new treatments are being studied in preclinical and clinical trials with promising outcomes for chronic lower back pain. A few oral and injection therapies are discussed below.
Oral medications such as tanezumab and melatonin have shown to improve back pain when combined with other pain-relieving drugs. Botulinum toxin injections may temporarily numb or weaken nerves and muscles that cause lower back pain.
Regenerative medicine aims to promote healing of damaged and/or degenerated tissues and typically includes:
- Platelet-rich plasma (PRP) therapy. PRP is a concentration of platelets suspended in a small amount of plasma from the patient’s own blood. PRP contains several growth factors that help promote tissue healing and growth of new tissue. PRP injections have shown to regenerate and repair degenerated discs. PRP therapy may also help reduce pain stemming from the sacroiliac and/or facet joints.
- Stem cell therapy. Stem cells have the ability to develop into other types of cells and can perform several functions. These cells can help regenerate disc tissue, stop disc degeneration, reduce inflammation, and promote healing.
Very few large, randomized, and controlled trials have established the efficacy of these treatments. More robust research is needed to establish the long-term safety and effectiveness of regenerative therapy in managing chronic lower back pain.
Living with chronic back pain may give rise to fatigue, anxiety, and/or depression over time. It is important to consult a medical professional to get an accurate diagnosis of the underlying cause of back pain. A chronic pain specialist physician can help formulate a treatment plan to try and provide long-term benefits.
Dr. Andrew Cole has 30 years of experience specializing in spine and joint pain management. Dr. Cole has held numerous medical appointments throughout his career, and recently served as the Executive Director of Rehabilitation & Performance Medicine Enterprise for Swedish Health Services and as Medical Director of Ambulatory Musculoskeletal Services for Swedish Medical Group.
He has held several academic faculty positions, such as Clinical Professor at the University of Washington School of Medicine and Clinical Preceptor at Midwestern University. He has been an active researcher of spine pain rehabilitation, lecturing nationally and internationally, and writing journal articles and book chapters on the topic. Dr. Cole is also the editor and co-author of 11 textbooks.
Dr. Cole founded a nonprofit organization, Community Based Rehabilitation International, which delivers rehabilitation solutions to Caribbean nations. He serves as a member of Veritas Health’s Medical Advisory Board.