Selecting the Most Appropriate Nonsurgical Lumbar Approaches

For a patient with lumbar back pain, radiating leg pain or weakness, or other back-related problems, an effective treatment may appear to be elusive. Oftentimes, nonsurgical approaches may be successful. However, a team of experts at a dedicated spine center is needed to truly match the right treatment method to the needs of each individual patient.

Diagnosing lumbar pain begins with a thorough review of the patient’s medical history and a careful physical examination. Primary care physicians can then provide first-line treatments for lumbar pain, and they can prescribe initial medications, including various nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and neurostablizers. But, if the drugs have not provided the patient comfort and the pain is still unresolved after 4 to 6 weeks, then referral to nonoperative specialists may be necessary, preferably to a spine specialty team who can offer the full spectrum of care for the lumbar spine.

Specialists on the Duke neurospine team agree that nonsurgical treatments, including pharmacotherapies, are the most common interventions for referred patients. However, older patients with comorbidities may be challenging to treat because of possible issues related to polypharmacy.

Physical Therapy

Physical therapy is often a good starting point, says Carolyn Keeler, DO, who oversees several approaches to back pain. Strengthening exercises with attention to core muscles are a large part of the regimen.

“Often we see improvement in mobility and pain in about 6 weeks,” she explains.

Sometimes therapy alone is enough, but sometimes it is just a temporary measure if the patient has a sedentary lifestyle or is obese. “One spine may be supporting the weight of 2 or 3 people,” says Rowena Mariano, MD, an interventional neurospine specialist at Duke. “Sometimes this explanation is a wake-up call for patients in pain.”

Medications

The most common medications used for lumbar spine issues at the outset are NSAIDs (eg, ibuprofen, naproxen). “These can be hit or miss, so patients might try different drugs, and they are prescribed a short dose to avoid long-term side effects of these medications,” says Mariano. Acetaminophen may also be an appropriate choice, but Mariano explains that care should be taken to avoid overdose if narcotics are concurrently prescribed that also contain acetaminophen.

Muscle relaxants can work against spasms or tightness around the spine. Nerve-stabilizing medicines also work for nerves that are overfiring, Mariano explains.

Therapies depend on the particular condition. For example, numbness and tingling may respond better to nerve stabilizers. But, if the pain has a burning feel and the patient is taking a nerve stabilizer, then NSAIDs may work better, she says.

Evidence-Based Acupuncture

Acupuncture is also a well-accepted treatment for back pain. Keeler and Mariano are both trained in acupuncture, and they use it as an adjunct treatment. The Agency for Healthcare Quality and Research has released evidence-based reports that show acupuncture was superior to no treatment in improving pain intensity, disability, functioning, well being, and range of motion immediately after treatment.

Acupuncture can be used for lumbar pain and, in select patients, for sciatica. Acupuncture needles are sometimes placed in the region of the spine nearest to the point of pain and can add local relief for patients where they are tender, Mariano says. Other points on the body are known to be effective acupuncture points for relieving pain, Keeler says.

However, insurance coverage for acupuncture can be a limiting factor.

Injections

If physical therapy and standard medications aren’t effective, spinal interventional procedures may be appropriate. Most commonly, epidural steroids are injected to deliver powerful anti-inflammatory effects to the region associated with the patient’s symptoms.

Epidural injections can reduce inflammation within the spine and the epidural space just outside the sac that holds the spinal fluid.

"If people have back pain associated with a shooting pattern of pain, which is common in sciatica, we can inject near the nerve roots for herniated discs and spinal stenosis, or inject the spinal facet joints for pain referred from the joints," Mariano comments. Injections are also used for sacroiliac-related pain.

Mariano says other treatments for lumbar pain are also available such as lumbar sympathetic nerve block, which is used for people with chronic regional pain syndrome.

Duke’s diversified team provides comprehensive nonoperative care with assistance of behavioral pain management and other forms of supportive care, Keeler says. A full set of surgical options is also available at Duke. Patients who come to Duke for lumbar care at the Duke Spine Center have access to all of the specialists, including neurosurgeons, orthopaedists, pain specialists, physiatrists, and psychologists. To refer a patient, call 844-790-2013.