The easiest way to think about treatment for spine problems is to group them into categories, aside from doing nothing (believe or not, this is an option for some benign problems): medications, physical medicine and surgery.
We will discuss medications and physical medicine below. Keep in mind that 85% of back pain resolves in four weeks and it is a small percentage of patients who need treatment at all. For those we almost always start with non-operative or conservative treatments.
The first line of defense for pain is usually Tylenol (acetaminophen) or aspirin. Sometimes this is sufficient but if not then the next line of defense is the non-steroidal anti-inflammatories (NSAID’s). The best examples are Ibuprofen or Aleve, which are available over the counter. There are a number of similar NSAID’s that can be prescribed but these aren’t usually and more effective.
Always make sure that you are able to take these medications and that they don’t interfere with something you are already taking, such as Coumadin or some high blood pressure medications.
If the pain is too great then the next option is narcotics. These are all derivatives of morphine, which comes from opium. These are called opioids and include Vicodin (generic – hydrocodone), Percocet (generic – oxycodone), Dilaudid (generic – hydromorphone), and Oxycontin (long acting oxycodone) to name a few. Although they can be very effective they all have side effects and the potential for physical dependence and addiction. If the pain is severe enough to use these medications then a full evaluation by your primary care provider and potentially a referral to spine specialist is in order.
There are a few other medications that are commonly used such as muscle relaxants, which are fancy sedatives and can make you very sleepy. There are two drugs that are now used commonly for sciatic (leg) pain from nerve involvement. These are Neurontin (gabapentin) and Lyrica (pregabalin). These are actually anti-seizure medications and are used for their effect on nerve cells. In the brain they can prevent seizures and for pain they effect the pain nerve cells.
Oral steroids, like prednisone, are sometime used for their very potent anti-inflammatory properties and for their positive effect on nerve cells. The effects are often temporary but can help in an acutely painful episode. Steroids like cortisone can also be injected into the spine in different ways so that they have their effect right at the problem area.
For some people with chronic, long-standing pain, anti-depression medications may be recommended. These can sometimes help in combination with other medications. People with chronic pain are often depressed from the changes that occur in the brain, not to mention the effects that chronic pain can have on your life and relationships.
Physical medicine is a broad category but includes everything that is not a medication or surgery.
The most obvious is physical therapy. There are two types of physical therapy, passive and active.
Passive therapy is anything that the therapist does to you and active therapy is anything that you do yourself. Passive therapy includes massage, heat or ice packs, ultrasound, TENS unit (transcutaneous electrical nerve stimulation) spinal traction and therapist-assisted stretching.
Active therapy is more like a overall fitness program that aims to strengthen and stretch your back and leg muscles.
In general, passive modalities are more useful for acute back pain while active therapy is more effective for returning patients back to good functioning. There is pretty good evidence that a good structured, active, exercise based program is as effective for low back pain as is spinal fusion.
Chiropractic manipulations can sometimes be helpful for acute, short-term problems but have not been proven effective for all spinal problems. Most chiropractors will do a careful medical history and physical exam that should identify any really worrisome problems that require further medical attention.
There are a number of exercise programs that are similar in their approach to active physical therapy that some people believe are helpful for maintaining good back health. Yoga and Pilates are the most common. Although they lack good scientific evidence for effectiveness, common sense informs us that staying healthy and fit is a good idea. Once an acute episode has resolved these types of programs may help maintain the improvement.
We include acupuncture in this category. There is no good scientific evidence to prove this is useful but our doctors' decades of patient experience tells them that many patients find acupuncture useful.
It is generally a harmless treatment provided the needles that are used are clean. The worse that can happen otherwise is that you are some money and it didn’t work.
Braces can sometime help you through an episode but will not prevent future episodes or injury. Putting on a brace will not allow you to do things that you might not do without the brace.
Massage alone may feel good while it is being performed but there is no evidence of long term benefit compared to other treatments or that this should be a mainstay of treatment for back pain. Most insurers won’t pay for this type of treatment but it could give you short term relief.