When evaluating patients for back pain, first we assess if the pain is acute or chronic in nature. Acute pain typically is due to trauma or overuse of the back area. Chronic pain is typically pain that lasts for several months and persists despite treatment. The next step in approaching patients with back pain is identifying what we call “the pain generator”; the source of pain. Common pain generators in the back are muscles, facet joints, discs and SI joint. Identifying the pain generator is essential since treatment is different for each pain generator.
Diagnosing back pain can be accomplished by history, physical examination, imaging (X-ray, CT scan, MRI) and/or nerve conduction study. These tests are essential to characterize the pain before treating it.
Clinical presentation of back pain differs based on the affected area that generates the pain. Muscle pain is described as cramps and spasms involving the muscle itself and can radiate around the affected area. Facet pain generator is produced by instability and arthritis of the facet joints, which are small joints in the back of the spine that allows mobility and stability of the spine. Facet pain is described as deep aching, nagging pain that is localized to the affected spine area back that is a lot worse with sitting, standing and activity and improves with laying down.
Disc pain is caused by herniation, tear or bulging of the disc and at times pushes on the nerve root. Typically pain is described as back or neck pain, that is deep aching, at times sharp radiating down one or more extremities. It can be associated with numbness, tingling sensations and/or weakness in that extremity. Pain is usually worse in the morning when waking up and better when leaning forward.
The sacroiliac (SI) joint is a large joint that forms between the sacrum (the base of the spine) and the pelvic bone. It is usually held together with large ligaments and tissue. Any instability in the back or gait can result in pain generated from this joint. Typical SI pain is described as a deep aching and at times burning pain over the buttocks that is a lot worse when standing and walking and better when sitting and lay down. The pain at times can radiate into the groin area down the buttocks area, but rarely below the knees.
Treatment of back pain is dependent on the pain generator. Muscle pain (spasms) is treated with muscle relaxant, trigger point injections, physical therapy, and/or TENS unit. Facet pain responds better to anti-inflammatories, opiates, physical therapy, facet cortisone injections and/or dorsal median branch block (a very small nerve that supplies each facet joint) and radiofrequency. Disc pain can be treated with anti-inflammatories, opioids, certain antidepressants and anticonvulsants, epidural steroid injections, spinal cord stimulator and/or surgery. SI joint pain can be difficult to treat with medications, however anti-inflammatories and opioids can be used. Steroid injections into the joint and nerve block with radiofrequency are very effective in treating this pain.