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Shots Aren’t Best of Back Pain Treatments
Dr. David Lipschitz
Steroid injections for back pain increase the risk of fractures.
Many patients with chronic back pain who do not respond to conservative measures
are referred to a pain specialist. Following a careful workup to identify the
abnormality causing the pain, local steroid injections are often recommended.
Although such treatment is thought to be relatively safe, a study published in
the Journal of Bone and Joint Surgery showed that every steroid injection increased
the risk of a fracture in that area by 21 percent. The researchers analyzed outcomes
in 3,450 patients with back pain who received at least one steroid injection
and compared their outcomes to 3,000 back pain patients who never received an
injection. Those treated with injections had a significantly higher risk of vertebral
Steroids cause bone weakness; they impair bone integrity, leading to a greater
risk of a fracture. While these findings will lead to more caution about local
steroid injections, they still should be used where appropriate — but as
infrequently as possible.
So what are the causes of back pain and what are the principles of its treatment?
Sudden back pain occurs after serious injuries, from lifting heavy objects or
from inappropriate posture. Chronic back pain can occur because of narrowing
of the spinal canal (spinal stenosis), herniation or degeneration of disks between
the vertebra, osteoarthritis of the spinal joints or an abnormality called spondylolisthesis,
where one vertebra slides either forward or backward over the one below.
Osteoporosis can weaken bone sufficiently that minor injury can collapse a vertebra
or collapse could occur spontaneously.
Muscle spasm is a major cause of severe pain in the back. Often associated with
stiffness, the pain can be overwhelming and is felt in the low back and buttocks.
Frequently the pain is mistakenly thought to come from the hip.
Pain also occurs because of nerve irritation that leads to pain radiating down
the leg and below the knee. This is often called sciatica. Nerve damage can also
cause numbness, tingling and burning, most frequently felt in the feet.
Not every person who arrives at the doctor’s office with significant back
pain needs an immediate X-ray or imaging studies. However, testing must be done
if the damage to nerves is severe enough to cause significant weakness or loss
of sensation. Impaired bowel or bladder function is another serious finding.
Depending on the diagnosis, immediate surgery could be needed to prevent further
and permanent nerve damage.
Bed rest is recommended for an acute flare-up of back pain. During this time,
adequate pain medications should be prescribed, as should muscle relaxants to
reduce spasms. Because it is easier to prevent than to relieve pain, medication
should be taken on a schedule. Acetaminophen (generic Tylenol) is always prescribed
first. While it may by itself not be sufficient for adequate relief, it acts
synergistically, making a second and stronger pain medication more effective.
Bed rest should be limited to two days, after which physical therapy should begin.
In combination with analgesics, the vast majority of patients will receive a
great deal of relief, and no further treatment will be needed. Many patients
are helped greatly by chiropractic care, and there is evidence that acupuncture
can be as effective as most other modalities.
If pain becomes more severe or does not respond to the initial treatment, X-rays
should be obtained and, if needed, a referral to a back surgeon arranged, to
determine whether surgery is needed. A decision to operate requires someone with
a great deal of training and the identification of a specific abnormality that
is highly likely to be corrected by surgery.
If surgery is not a consideration, referral to a pain specialist should be considered.
While local injections will, in the future, be used more judiciously, local pain
patches and nerve stimulation could be prescribed.
A pain team should always be involved in a decision to prescribe narcotics. Appropriate
counseling from a team of professionals, a contract to assure that no one else
prescribes narcotics and close supervision are needed to assure good pain control
with a minimal chance of abuse.
These days much can be done to help patients with back pain. Seeking care from
the appropriate experts is the key to better outcomes with the fewest adverse
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