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Spine – Neck & Low Back Conditions
Most people will experience at least one or two episodes of acute neck or lower back pain in their lifetimes. However, chronic, recurrent pain is not normal and not something you just have to live with. Several potential contributors to chronic neck and back pain include soft tissue strain, core muscle deconditioning, and degenerative disc disease manifestations. Determining the sources of a particular patient’s spine symptoms is paramount to formulating an effective treatment program.
Evaluating a patient with neck or back pain involves a physical examination to determine their pain patterns and what anatomic structures are responsible. Diagnostic imaging such as X-ray and MRI are often valuable for evaluating structural anatomy such as intervertebral discs, nerve roots, and facet joints.
Fortunately, most patients with chronic neck and low back pain can be effectively treated with non-surgical modalities. Commonly effective treatments include physical therapy and injection therapy.
The Intervertebral Disc
In one way or another, many painful conditions of the spine are related to dysfunction of the intervertebral disc. Intervertebral discs are the soft, compressible structures between the vertebrae, the spinal column’s bones. The discs provide shock absorption and flexibility to the spine. An intervertebral disc is made up of a tough outer ring called the annulus fibrosis, primarily composed of collagen fibers. Contained within the center of the annulus fibrosis is a soft jelly-like center called the nucleus pulposis, made up of proteoglycans and water. In addition to encircling the nucleus pulposis, the annulus fibrosis connects the vertebrae, contributing to the overall stability of the spinal column. The nucleus pulposis provides cushioning between the vertebrae.
Degenerative Disc Disease
As we age, disc degeneration commonly occurs as our discs desiccate or “dry out” due to fragmentation of the proteoglycan molecules. As discs lose water content, they shrink and lose their cushioning properties, often leading to spine stiffness. Any disc can degenerate, but the most common discs to degenerate in the lumbar spine are L4-5 and L5-S1. Disc degeneration can be considered an expected part of the aging process. Although not all degenerative discs are necessarily symptomatic, degenerative disc disease and its manifestations can play a role in several painful spine conditions. Understanding these effects can allow the formulation of effective treatment strategies.
Disc Herniations
A disc herniation occurs when the exterior margin of the disc pushes outward beyond its normal boundaries. Disc herniations can occur as an acute event such as lifting a heavy object or developing gradually over time with wear and tear. In either case, it is not unusual for some level of degenerative disc disease to pre-exist, weakening the disc, making it more susceptible to herniation.
Disc herniations can be classified as disc protrusions, disc extrusions, or disc sequestrations. A disc protrusion is a herniation that involves 25% or less of the disc circumference, and the farthest edge of the herniation measures smaller than the herniation’s origin at its base.
A disc extrusion is a herniation where the nucleus pulposis squeezes through a weakness, fissure, or tear in the annulus, but the soft material is still connected to the disc by a thin stalk.
Disc sequestration occurs when the nucleus of an extrusion completely separates from the disc and becomes free-floating in the spinal canal.
Disc herniations can cause pain in several different ways. If the displaced disc material physically compresses a nearby nerve root, this can lead to pain in the neck, arm, back, or leg. For low back herniations, these leg symptoms are often referred to as sciatica since they involve dysfunction of the sciatic nerve, the largest nerve traveling down into the lower extremity. Nerve compression can also result in weakness or numbness in the upper or lower extremities with a disc herniation in the neck or low back, respectively.
But even if the disc is not physically pressing on a major nerve, just the presence of the displaced nucleus material that the body considers a foreign invader can trigger an immune response, bringing painful inflammation to the area.
Disc Bulge
A disc bulge is another abnormal disc shape wherein a larger part of the disc displaces beyond its normal boundaries. While there is less than 25% focal displacement of the disc in a disc herniation, a disc bulge exists when the generalized displacement involves 25% or more of the circumferential border. Even though a bulge involves a larger disc area, it tends to extend shorter distances outward and is less often associated with clinical symptoms.
Facet Joint Dysfunction
While the intervertebral discs connect each vertebra of the spine in the front of the spinal cord, the facet joints are the structures that connect those same bones of the spinal column in the back. There are two facet joints for each intervertebral disc level. The facet joints can become pain generators if they are injured by acute trauma or degenerative disc disease. A common cause of acute facet joint injury is the forceful hyperflexion and hyperextension of the spine that can occur with acceleration-deceleration mechanisms such as during automobile collisions. Distractive forces can damage the ligaments supporting the facet joints, while the cartilage surfaces can be traumatized by forceful compression. This damage can lead to joint instability and painful inflammation. With degenerative disc disease, the articular cartilage of facet joints can degenerate when excessive loads are shifted onto them as the discs in the front collapse and squash down.
Neuropathic Pain
Neuropathic pain develops when there is inherent dysfunction within the nerves themselves. Neuropathic dysfunction may involve large, major nerve branches or the millions of small-fiber nerves distributed throughout the body’s soft tissue. Small-fiber nerves can be damaged by an acute stretch injury accompanying soft tissue trauma. Or they can be damaged by wear and tear over time. While other more vascular tissues like skin and muscle can heal themselves quite readily, nerve tissue is not amenable to spontaneous regeneration and repair. This lack of healing can lead to chronic nerve dysfunction and pain.
SPINE – Neck & Low Back Treatment
Physical Therapy
Physical therapy can be a beneficial part of effectively treating painful neck and lower back conditions. Physical therapists can use various modalities to help reduce soft tissue irritation and muscle spasm. Tight muscle groups can be treated with a stretching program. The weakness of core muscles in the trunk may also lead to poor support and additional stress on the spine. Specific strengthening exercises can address underlying muscle imbalance. Physical therapy alone may be sufficient to treat relatively simple neck and low back conditions. However, more complex cases may benefit from a multi-modal approach using other non-surgical methods such as targeted injection therapy.
Pain Management Injections
Traditional pain management involves injecting pain-generating pathologic anatomic structures with corticosteroid solution. Corticosteroids are anti-inflammatory drugs that can reduce painful inflammation for sustained periods. While corticosteroids do not “fix” the problem, physicians can use them to help patients with an underlying degenerative condition get through occasional, painful flare-ups. With imaging guidance, corticosteroids can be injected directly into or around the anatomic structure responsible for the pain. Common types of injections are epidural injections and facet joint injections. While corticosteroid injections can effectively relieve painful symptoms in some patients, there are concerns about potential local and systemic adverse effects, particularly with repeat use. These potential downsides are why newer regenerative injection therapies are attractive for many patients.
Regenerative Injection Therapy
Regenerative injection therapy (RIT) is a newer type of treatment using orthobiologics. These are non-pharmacologic, natural substances that can reduce inflammation and stimulate healing. Examples of orthobiologics include dextrose, concentrated platelets, and bone marrow aspirate concentrate (BMAC). This approach is relatively new and part of a growing trend to develop therapeutic modalities that are safer and more effective than traditional injection methods.
Dextrose is a natural, simple carbohydrate, and it is the exclusive fuel consumed by neurons or nerve cells in the brain and central and peripheral nerves. In therapeutic use, dextrose injection therapy (DIT) has been shown to reduce neurogenic inflammation, which is the inflammation that occurs within the nerve tissue itself. By mitigating chronic nerve irritability, neuropathic pain can be treated directly. This is the basis of perineural injection treatment (PIT), where the physician places multiple, small injections within the soft tissue along painful, sensory nerve pathways. The pain-relieving properties of dextrose have two different effects. There is sometimes an immediate, short-term relieving effect of dextrose, similar to what one experiences with a local anesthetic injection. But with repeat administration over a period of time, this pain relief converts to a long-term steady-state condition of the nerves being treated.
Bone marrow aspirate concentrate contains cellular and non-cellular components that our bodies continuously manufacture for tissue maintenance, homeostasis, and repair. These elements include marrow cells, platelets, cytokines, and plasma proteins. Bone marrow can be harvested through a special needle from one of the large marrow-producing bones, such as the ilium of the pelvis. The aspirated marrow fluid is then concentrated and injected into or around anatomic structures identified as pain generators in the spine. Commonly targeted structures are the epidural space, nerve roots, and facet joints. The goal of regenerative injection therapy is to naturally stimulate the body’s own healing capacity to reduce painful inflammation, improve flexibility and restore function.
Since first integrating regenerative injection therapy into his practice in 2015, Dr. Meier has been collecting clinical follow-up results, which indicate a high level of patient satisfaction for a treatment approach that is preferable to surgery in many cases.
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