Part 2 of 2 Low Back Pain: What to Do - Who to See
Dr. Keley John Booth, MD shares insights from an Interventional Pain Specialists perspective on low back pain treatment options
Neurosurgeons & Orthopedic Spine Surgeons
Some of my surgeon colleagues will be appalled that I would discuss neuro and orthopedic surgeons under the same heading. For the purposes of patients seeking more information, it is not likely to offer much value to dissect the differing surgical perspectives when addressing a topic as general as low back pain.
It is my opinion that all too often, primary care physicians refer patients to surgeons with unconfirmed diagnoses and limited use of other less invasive and less costly treatment options. Turns out, it isn’t just my opinion!
A recent medical journal article published in The Spine Journal in 2018 concluded:
“Evidence-based medical interventional treatments for patients with LBP are not being taken advantage of before spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists.”
This is one of the reasons I advocate for any patient suffering back pain unresponsive to conservative therapy to undergo evaluation by an Interventional Pain Specialist. Spine pain specialists, such as myself, are uniquely suited to provide rapid and specific diagnosis of the source of the pain (aka “pain generator”). Subsequently, after a proper evaluation and diagnosis, non-surgical treatment options have the potential to provide significant relief of low back pain and ultimately the recovery of function for most patients.
It may come as a surprise to patients reading this, but there is no standard definition for a “Pain” doctor. The backgrounds, training, qualifications, and specialties of professionals referring to their field of focus as Pain Medicine or “Pain” doctors often vary wildly between practitioners. General (non-subspecialty trained) doctors, Family Medicine doctors, Internal Medicine doctors, Psychiatrists, Neurologists, and even some retired surgeons consider themselves practicing in this area of focus. Usually, a Pain doctor or Pain Medicine doctor designation indicates a focus on the medical and medication management of patients’ chronic pain generally, not specifically for low back. This designation most often is used by practitioners providing chronic opioid medication management, but not always. Typically, you will need to be referred out for more comprehensive evaluation and/or treatment options for your pain condition. These providers don’t usually provide interventional treatments such as nerve blocks, nerve stimulators, epidurals, and other advanced treatment modalities.
Interventional Pain Management Specialists
This designation is often used for those medical doctors that focus on the multi-modal treatment of spine related pain disorders and particularly low back pain, sciatica, sciatic nerve pain, spinal stenosis, degenerative disc disease, facet arthropathy, spondylosis, herniated discs, bulging discs, neuroforaminal stenosis, among others. Many Interventional Pain Specialists, such as myself, also provide therapy for major joint related pain such as for knee osteoarthritis as well as hip, shoulder, and sacroiliac joint disease. In my case, I also provide comprehensive medical management and medication optimization which includes conservative chronic opioid management. Another specialty feature is the oversight of the spine and joint related care of patients including physical therapy, medications, and pre or post-surgical care follow up as necessary. Many patients find our ability to provide advanced levels of interventional care a major advantage of working with specialists in this area, however there are a relatively limited supply of medical professionals with this extensive training and background.
The vast majority of Interventional Pain Specialists are Anesthesiologists. From the very beginning of our training, Anesthesiologists are trained to provide relief of pain utilizing the most advanced techniques to provide spinal and regional procedures to provide pain relief. The requirements to become a Board-Certified Anesthesiologist are rigorous and require training for a minimum of four years after graduation from medical school. The other subspecialties that may obtain some of the specialized training and experience in this field include Physical Medicine doctors (Physiatrists), Interventional Radiologists, and rarely Neurologists.
Often, there can be the development of behavioral manifestations of pain commonly including anxiety, depression, or both. A Psychiatrist may be a valuable addition to a multi-disciplinary team treating the most complex chronic low back pain cases. Their knowledge and experience with anti-depressants, anti-anxiety treatments, and counseling can be an invaluable addition for selected patients. Typically, Psychiatrists are not willing and may not be experienced in managing the comprehensive aspects of evaluation, diagnosis, and interventional treatment of low back pain.
Evaluation, treatment, and management of physical therapy plays an integral role in the ongoing care of patients suffering from both acute or chronic low back pain. When utilized in conjunction with comprehensive interventional pain care, I have found that patients respond better over time to treatments and have the added benefit of reducing the likelihood of further injury and possibly slowing the development of pain associated with the aging degenerative spine. Reduction of muscle spasms, improving range of motion, strength, and balance are all potential benefits. In addition, physical therapy is often a critical part of recovering from musculoskeletal surgery for low back pain.
Chiropractic Evaluation and Treatment
Literally millions of people have sought care from Chiropractors and many have identified improvement in their back pain as a result. The primary challenge has been the significant variability of the methodologies involved in evaluation, diagnosis, and treatments utilized. The types of therapy and treatment provided between different practitioners can vary extensively for the same diagnosis. In my experience, Chiropractors that are open to working with other professionals in a collaborative manner offer the best opportunity for patients to improve their condition. The reality is that any specialist should be capable of recognizing the potential limitations of their chosen profession and you should be wary of those that are not prepared to share those potential limits with you. Let me be clear, no single profession or individual specialist is capable of treating every potential malady that causes low back pain. Rarely, a full complement of experienced, multi-disciplinary specialists are not able to find the definitive cause of your pain.
Acupuncture and Acupuncturists
Admittedly, I have had limited exposure to acupuncture in clinical practice. However, when I was in specialty training, a Pain Management attending physician performed a version of a Korean hand acupuncture for a chronic neck pain I was having. I was initially very skeptical as a proud student of scientifically based western medicine. To my surprise, I did receive some relief for 2 to 3 days. Hardly scientific, but when suffering pain that is slowing you down, it may be worth a try. High quality medical studies are extremely limited and techniques vary tremendously so it’s difficult to make any more specific recommendations. In my research, I did come across an interesting study titles: Battlefield acupuncture to treat low back pain in the emergency department. There were only 15 patients enrolled but they did find some improvement in numeric pain ratings among most patients.
As a treatment, massage appears to be most helpful in the short-term reduction of symptoms associated with low back pain such as muscle spasm. Many patients find this a useful adjunct to the other therapies discussed here. The largest limitation appears to be cost and access to quality establishments offer consistent services. If you find the right one and you have the time and can afford it – this can be a great way to spend an hour for your aching back. Just don’t expect a miraculous long-term resolution of your low back pain.
Self-Professed “Experts” in Low Back Pain
It goes without saying, if you follow the advice of non-professionals or those without an appropriate depth of knowledge and a clear understanding of their limitations, your results are likely to be limited. A general rule of thumb is that anyone that claims they have “just the thing” or a “miracle” cure for all your low back pain woes should be approached with caution. There is likely no oil, no rub, no one medication, no single herb, no one physical activity, no special brace, and no “trick” to curing your low back pain instantly. You are better off sticking with a medical professional’s advice should you have prolonged or persistent low back pain limiting your activities and quality of life.
There are thousands of books, millions of articles and research papers on the topic of low back pain. Given the shear amount of disability and cost associated with this condition, it is recognized as a huge public health concern. In addition, the occurrence on the rise and the scourge of back pain will continue into the foreseeable future. Considering the complexities of this topic, the potential impact on your life, your work, and those you love – you owe it to yourself to seek out a proper spine pain specialist. It is my professional opinion that the best medical provider to seek out is one that has an extensive array of non-invasive interventional, diagnostic, and therapeutic back pain treatment modalities. In addition to optimization of your medications and coordination with adjunct therapies such as physical therapy and chiropractic care as indicated, you have the potential to substantially improve your low back pain condition. As an Interventional Pain Specialist, I look forward to providing you the benefit of my extensive training and experience in the treatment of your pain whether sciatica, discogenic pain, radiating pain, degenerative spine disease, spinal stenosis, arthritis, or other causes. Don’t hesitate to contact us today, we look forward to getting you on the road to low back pain relief!