Steps to getting treatment for Chronic Spinal (Cervical, Lumbar and Thoracic) Pain
There exists a standard of care when it comes to treating chronic spinal pain. Each of the steps listed below is pretty standard across the board, age is not a factor in these steps.
You first start to experience pain in one part of your spine. This goes on for a period of time and can be the result of some trauma and something you are not even aware of. How long do you wait before seeking treatment? So much depends on the individual. Everyone has a definite threshold for pain, so that always comes into play. Only to be used as a guideline, if after 10 days and you do not see any improvement in your situation, you are almost ready for the first step. If you feel the situation is getting worse, than go directly to step 1 and get started. But please, for many a peace of mind is very important. In those cases start step 1 now.
Step 1 – Your Primary Care Doctor
Visit to your primary care, who may or may not send you for xrays to check for fractures and standard alignment of the spine. Your PCP may prescribe some anti inflammatory medications, and muscle relaxers. If the problem has existed for more than a week or so or may prescribe short term pain medications on a temporary basis. Depending on the results of these treatments, the next step may be started.
Step 2 - The Specialists
Depending on your insurance coverage, you may or may not require pre approval or referrals to see either a board certified orthopedic doctor or a neurosurgeon who specializes in the Spine.
Consult with Spine surgeon or physiatrist includes examination of your spine, reflexes, discussion of where the pain is located to help rule in and out areas that may be of concern. You may be given a prescription for an MRI. A Magnetic Resonance Imaging study shows the soft tissue of the spine, as well as the hydration of the discs between the vertebra, and the alignment of the spine. It can show if there are areas of compression of either the spinal canal or the exits for the nerve roots as they pass through the foramen between each vertebra. Additional diagnostic tests may be order. One could be an EMG Electromyography procedure to assess the health of muscles and the nerve cells that control them (motor neurons). As with each step, a review of your progress may determine the following action.
Step 3 – The Beginning of Conservative Treatments
For so many, a referral for physical therapy ( usually 6 weeks or so in duration.) could be setup. The therapist report back to your doctor in terms of progress, good or bad. For many, this could be the end of any additional steps or actions. This does not mean you are fine and can go back to doing anything you want. More than likely you will have a set of exercises and restrictions which you need to follow.
For those that still need more help, there are many other conservative treatments available.
Additional Diagnostic tests
Epidural Spinal Injections
Trigger Point Injections
UltraSound / Tens
Pain management specialist
If none of the conservative treatments provide you with improvement and your MRI indicates a problem that needs to be addressed surgically, you may be scheduled for surgery.
Other testing that may or may not be done, based on the exam and findings on the MRI.
CAT scan - computer aided tomography- this is done to look at the bony structures of the spine. Vertebra and other bony overgrowth, as well as the canals through which the nerve roots pass.
Myelogram or CT/Myelogram - this test is done to see if there is compression of the nerve roots and to check the severity of it.
Discogram or discography- this is done to determine if there is fluid leaking from a disc with an annular tear. An annular tear, depending on the severity can cause the disc material to leak outside of the disc.
Consult with pain management if surgery is not warranted.
You may again be asked to return to physical therapy for more exercises and core strengthening. Even when physical therapy is discontinued, it is very important to continue the exercises given to you during PT since they continue to strengthen weakened muscles and help to protect your spine from further injury.
You may also be scheduled for a series of injections- this is done if there are findings on the studies and exams that show areas of concern. These injections serve two purposes, the first being that it helps to determine if a suspected area of concern is in fact the source of your pain, and there is also a therapeutic component . In many cases, the medications in the injections soothe inflamed tissue in the spine and can relieve pain. You may find that if the first injections do not relieve the pain , that the doctor suggests that you have more injections but a different type. This is also to determine if an area is in fact a pain generator, and to see if there is any therapeutic benefit to the injections. If they do not work, after usually two in a series, the doctor may determine not to continue them.
RFA - radio frequency ablation- this is a procedure done to burn the nerves in the facet joints when the facet joints are believed to be the cause of pain. It involves a heated electrode which is inserted into the facet joint and the nerves are heated for a short time, and burned. This relieves the pain in the effected areas. It may be done at several levels if necessary and is usually done at 6 month to 1 year intervals when successful. This procedure can be performed multiple times if necessary.
EMG is a test done to check the condition of the nerves as they travel from the brain to any area of the body. The test is done to check the speed of the nerves ability to transmit the signals and to determine if there is damage to those nerves.
TENS TENS is transcutaneous electrical stimulation. It is a machine that is commonly used in PT to help ease muscle spasms and for some eases pain.
Medications may be trialed- however there is a sequence to those medications. Usually the starting medications include things like prescription based anti –inflammatory medications ( such as Voltaren , naproxen or ibuprofen), muscle relaxants ( tizanadine, Relafen, baclofen and others)- possibly some nerve pain medications such as Topamax, Lyrica, or Neurontin (gabapentin), anti- depressants used off label work wonders for neuropathic pain, and you may be trialed on a medication for pain such as tramadol /Ultram. It is important that you give each new medication a proper trial……….it can take a few days to several weeks before you see the benefit of a medication so it is imperative that you wait at least two weeks, preferably a month and at least one dosage adjustment before saying that a medication is not helping. This applies to all medications that are new to you, but especially with some of these particular medications. They take some time to build to a therapeutic level so you may not see a big benefit for a week or more after each dosage adjustment or introduction to your treatment plan.
OTC Use of over the counter remedies- ice, heat, rest, walking, topical over the counter pain rubs all contribute to the over all pain relief, so continue to use them, every day if necessary, but especially during days that the pain is higher than normal. Staying physically active- even if it is just walking, do it, several times a day, even short distances will help your muscles to stay stronger, and to keep your spine from worsening. The WORST thing that you can do is to stay in bed, or become inactive. Modify your activities, since this is a chronic condition that you are facing, you are going to have to learn to modify your activities and how you do things. Don’t make the mistake that using pain medications in whatever form you are given them to try to compensate so that you can continue doing what you did prior to your injury. This sets you up to fail in many ways.
Opiate medications at some point, it may become necessary to add an opiate to your other medications. It is vitally important that if and when this happens, you follow the exact prescribing directions of your physician. Some medications work better than others, depending on your particular metabolism, and what is causing your pain. However, there are several things that you need to remember- the first is- you have survived this long into this journey without opiates, not necessarily functioning at your best otherwise you wouldn’t be here, but you have managed so far and it is important to have the pain treated however,you have a long time to continue to live, so look at using the least amount of medication that you can get by with, because at some point, as you age, your condition will worsen. If you go too high on medications early on, you leave yourself no where to go once they become no longer effective. All of us, at some point after being on medications for some time, will find that the current dosage is not as effective as it once was. This may mean that you require a dosage adjustment. Again, less is more when it comes to managing the pain.
Set realistic objectives when it comes to your pain levels and what you can live with. If you are reporting that your pain levels un-medicated are at a 8, then a realistic goal is a reduction of 50% using pain medications and other modalities. This is the goal that almost all PM doctors use when treating pain.
Use ALL of the other modalities, because each” tool “ that you use regularly adds to your PM toolbox and together they add up to more efficient and better overall pain control. Use your breakthrough medications if you are given them sparingly. Not for every single pain flare. Try ice, heating pads, hot showers, stretching, biofeedback, guided imagery, swimming or just plain resting for a bit to deal with flares first. If those don’t work, call your doctor and ask him what else you can do to ease the pain.
-There are two types of opiates used to treat chronic pain. When someone is new to taking opiates, the usual course is to use what is called IR immediate release medications- hydrocodone, Percocet, oxycodone ( no Tylenol) , morphine or dilaudid. These medications release all of their medication within an hour of ingestion and then the blood levels slowly fall over the course of the next 4-8 hours, depending on your metabolism. At some point, your doctor may add something called an ER extended release medication. These medications typically are dosed every 8-12 hours with one being dosed once a day, as well as patch versions of some medications. These medications for the most part are exactly the same as the ones that are immediate release , however they are made to release the medication over a set time interval. If the dosing schedule is 12 hours, then for those 12 hours, you will have constant levels of medications in your system. What you may not feel is the onset of the medication as you did with the immediate release or short acting versions of the same medication. This is NORMAL and does not mean that the medication is not working.
Always as I mentioned earlier, give any new medication or change to your medication dosage at least two weeks , preferably a month before calling and telling your doctor that it doesn’t work. A newly added medication may require at least one dosage adjustment, maybe more, so be patient.
Never take more medication than you are allotted per day. NO matter what. Call your doctor if the pain is out of control. If he feels that your taking extra is okay, he will tell you.
Proper use of breakthrough medications- they are not to be taken on a regular basis. They are there for those days when you do something that causes your pain to suddenly spiral out of control. Try the other modalities but if the pain does not settle down soon, then it is time to take the break through meds. However, every little increase in pain does not require the treatment to be reaching for the pill bottle. Doing so only raises your baseline medication dosage so after a short time, your body will signal that the pain is escalating, when in fact it is trying to convince you to take those extra meds. Doing this adds to creating what some call tolerance issues when it is not that at all, it is simply adding to your baseline pain medication dose that your body has become acclimated to.
SCS - Spinal cord stimulation- Sooner or later , for many of us facing chronic back pain, you may find that you are asked to consider the spinal cord stimulator trial or permanent implant. It may not be for all of us, but for those who have nerve related pain, it is most likely coming up during your treatment. I suggest that you do tons of research into them, the various models out there, talk to patients who have them and who had them removed as well. All of that being said, there is no reason NOT to at least go for the consult. Ultimately, it is the decision of the patient whether or not to go ahead with the trial, and the permanent implant, but a well educated patient is his/her own best advocate when it comes to treatment options.
Pain Pump this is the end of the road for many of us when it comes to the treatment of chronic pain . The spinal cord stimulator and the pain pump are both implanted devices that are meant to interrupt the pain signals or to deliver the medications we need directly into the spinal fluid.
Not everyone can deal with the idea of having a medical device implanted permanently in their bodies, but at some point, many of us will find ourselves facing the possibility of having to make this decision.
The treatment of any chronic condition is a journey, much of which is trial and error until we can find a combination of modalities that works for us, but remember that there is still the rest of our lives to deal with this , so if you can keep your medication dosages as low as you can early on, you save yourself more heartache down the road and leave more options available for those years when our conditions will worsen.
One last thing, it can take weeks and even months or years while the doctors we pay to treat us are working with us to come up with a plan that reduces the amount of pain, yet allows us to function at the best level that we individually can. Be patient, and work with your doctor, form a partnership. You will find that you have a caring physician who wants to see you do well, and he or she will have a patient that they feel is trustworthy and reliable.
Step 4 – Aggressive Actions
This could be surgery. It is not within the scope of this thread to go into any details regarding the various spinal surgeries, pros/cons, risks, outcomes and more.
written by former Spine-Health Moderator - Sandi