New options provide relief for back aches
By Patricia Anstett
Knight Ridder Newspapers

February 17, 2002

DETROIT -- Is your back still aching despite your best efforts to get rid of the pain with rest, gradual stretching exercises and medicine--for years the standard approaches for ailing backs?

There are millions like you.

Back pain, next to headache, is the most common cause of pain. About 31 million people have pain in the lower back alone. The older you are, the more overweight or out of shape you are, the more likely you are to have back pain.

For most people, there is good news. Eighty percent of back pain goes away after three months. "The other 20 percent is the problem child of medicine, and that's what is generating all the attention," said Dr. Dennis Dobritt, director of Tri-County Pain Consultants near Detroit.

What has emerged is a better understanding of what causes unresolved back pain and a few new or improved technologies to treat it. Several of the options are so new that doctors remain divided in assessing them.

"You've got to be the right patient and have the right diagnosis" to be a candidate for certain treatments, cautioned Dr. Shlomo Mandel, an orthopedic surgeon who heads the Center for Back Disorders in the Henry Ford Health System.

Here's a look at how doctors try to diagnose unresolved back pain and a summary of four options. Two, epidural steroid injections and spinal cord stimulators, have been around for years but now are improved.

The other two, nucleoplasty and intradiscal electrothermal therapy, are relatively new and promising, although there is debate as physicians await results about whether they offer significant advances.

One word of caution: "Be leery of anybody who tells you they'll take away your pain," said Dr. Gary Mason, direct of pain management at St. John Hospital in Detroit. "Our goal is to eliminate more than 50 percent of the pain."

To diagnose the problem, doctors first have to sort out the cause of your ailing back. "The body generates pain through different systems, and because of that, the medications and treatments used differ," Dobritt explained.

If a back aches and throbs, it's called inflammatory pain and typically responds best to anti-inflammatory medicines, narcotics or steroid injections, Dobritt said.

If back pain has a "stabbing shooting, tingling, electrical quality to it," it's called neuropathic pain, and it responds better with anti-convulsant, anti-depressant or local anesthetic injections and creams, he said.

A new test, discography, helps determine whether pain originates in the back's discs. They are the spongy tissue between the bones of the spinal column and with age may flatten, get less cushiony, tear or develop tiny leaks, thus pinching and compressing nearby nerves.

Discography works like this: With a patient lightly sedated, lying face down on a table, a doctor numbs a section of the spine and inserts a thin needle that shoots dye into the disc. An instrument also measures the pressure inside the disc. The dye illuminates under an X-ray, helping doctors spot tiny cracks in a disc. Any pain a person feels in the procedure also helps doctors pinpoint a pain source.

Some physicians prefer discography because it diagnoses a painful disc itself. Other doctors use magnetic resonance imaging tests because they show soft tissue and can identify a pinched nerve.

Following are the latest treatments:

Epidural steroid injection

Who it's for: People with chronic lower back pain or leg pain, particularly from sciatica, which inflames and compresses lower-back nerves and may cause one-side numbness.

What they are: Anti-inflammatory drugs, anesthetics and sometimes narcotic medicines are combined in a needle. Doctors may use one or more injections.

How they are done: The patients can lie down or sit up. The doctor makes an injection into the epidural space that surrounds the spinal cord and the fluid-filled sac around it.

"It's the best thing with the least risk of anything I can offer," said Dr. Louis Bojrab, a pain specialist with the Michigan Pain Institute at St. Joseph Mercy Hospital, in Ann Arbor, Mich.

How long it takes: A few minutes.

Recovery: A few minutes.

Results: Often effective in reducing or eliminating pain for a week or two and possibly much longer with minimal side effects.

Side effects: Less than 1 percent had headaches afterward, and about 10 percent had other pain complaints for 24 to 48 hours.

Costs: Several hundred dollars for each injection. Most insurance plans cover this technique.


Who it's for: For patients with mild-to-moderate disc bulges without tears. Many have sciatica, a condition caused by disc pain that radiates down the leg. Typically, this procedure is used for patients who have had epidural steroid injections that have not reduced the pain.

What it is: A treatment, federally approved in 2000, that removes disc material with a needle though a simple injection. The procedure creates channels that decompress or shrink a bulging disc, replacing surgery and eliminating the risk of scar tissue that can cause surgically induced back and leg pain.

How it's done: The patient receives light intravenous sedation and local anesthesia to numb the back. A fluoroscope, an X-ray machine connected to a TV monitor, shows the doctors where the needle reaches the disc. With the same entry point, a doctor threads a probe that takes out a small amount of the disc.

How long it takes: 20 minutes.

Recovery: People often leave for home within one hour of the procedure.

Results: Pain relief may be immediate or take up to two weeks. "Nucleoplasty is an elegant approach aimed at a simple problem," Bojrab said. "It makes the most anatomical sense. You take the volume out of the disc."

Side effects: Rare risk of infection.

Costs: $8,500

More information:
Intradiscal electrothermal therapy

Who it's for: Patients with disc cracks that extend to the outer wall of the disc and may leak toxic chemicals from inside of the disc.

What it is: A heat treatment, federally approved in 1999, that is much like nucleoplasty. The heat it delivers through a thin tube is applied to the disc's outer wall, causing the collagen in the wall to thicken and contract.

How it's done: The patient receives light intravenous sedation and local anesthesia to numb the back. A fluoroscope, an X-ray machine with a TV monitor, tells the doctors where the needle reaches.

The procedure is technically challenging--enough that respected physicians such as Dobritt often get referrals from other physicians who have trouble reaching pain points inside a disc. Sometimes he uses two entry points to heat each side of a disc.

How long it takes: 20 to 30 minutes. People go home within an hour.

Recovery: Patients typically wear rigid back braces for two months during recovery and avoid bending and prolonged sitting. Lasting pain relief may take a year to achieve.

Results: More than half a dozen studies reported in the last two years at national medical meetings show that 70 percent to 80 percent of patients report lasting pain relief and improved health.

Side effects: Pain may get worse before improving. Small risk of infection.

More information: ORATEC Interventions Inc., the developer of the IDET procedure, has a Web site at
Costs: About $8,800. Insurance may not cover it.

Spinal cord stimulation

Who it's for: People with neuropathic pain--burning, stabbing or tingling pain, particularly after previous back surgery. It doesn't work as well for patients with inflammatory disc pain, Dobritt said.

What it is: A battery-operated implantable device, like a heart pacemaker, that sends electrical signals to the spinal cord to blunt pain signals to the brain. Although the devices have been around for more than 20 years, recent advances have made the stimulators last as long as eight years before patients undergo another procedure to replace the battery.

How it's done: A doctor implants a device under the skin that sends mild electrical impulses to the spinal cord. Patients are lightly sedated and given intravenous and local anesthesia, to be awake to tell the doctor if the procedure provides a signal that effectively covers the pain site. The procedure takes two to three hours; patients recover for about an hour before going home.

Results: As much as 70 percent effective, Dobritt said. Typically, pain is reduced from severe to a tingling sensation, Dobritt said. Patients may experience procedure-related pain for as long as six weeks.

Risks: Rare but include bleeding, infection, headaches, pain, spinal cord injury, paralysis.

More information: You can obtain a patient information package from Medtronic, a leading firm that makes the stimulators and other pain devices, by calling 800-664-5111, ext. 855. Or visit
Costs: About $25,000; insurance coverage varies.

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