What is the best approach for back pain relief?  What does the research prove?

First, let’s look at the options.  Pain meds, NSAIDS, epidural steroid injections, lower back surgery and exercises.  There are lots of different options under each of these umbrellas also. 

In addition to these primary options you have belts, devices, and supplements. We are going to focus on pain meds, NSAIDS, injections, surgery, and exercise because these approaches have been researched extensively over the past three decades. There is a wealth of information in the medical literature that allows us to draw clear conclusions as to what works and what doesn’t.

So…what works best?

The pharmaceutical industry has you convinced you need a pill or an injection.  The medical device industry has you sold on a surgery or a belt or some type of apparatus to magically make your pain disappear. The physical therapy industry tells you to exercise and stretch.  The chiropractors tell you all that’s needed is weekly “adjustments.”

Is any of this true though?  What is the best back pain treatment?  What works best for the majority of people the majority of the time?

There is only one way to answer this question.  We have to look at the medical literature.  We have to look at high level medical research that determines if any of these treatments are effective for lower back pain.

Answering this question any other way is unacceptable.  The reason being, any other source of information is simply trying to sell you on buying into their method…so they can make money.  It’s that simple.

Lower back pain treatment is BIG business.  $100 billion per year big.  All the advertisements for drugs, injections, and surgery are to make boat loads of money. How well these interventions work is not as important as CONVINCING you how well they work. 

If you think the answer to your back pain is a pill, an injection, or a surgery then you’re going to try any or all of these treatment approaches.  Likely repeatedly over the course of years and years.

When there is big money to be made, the effectiveness of the treatment is irrelevant.  Only the perception matters.

To make an informed decision regarding what treatment is best for YOUR back you have to consider the facts.  Not advertisements disguised as facts.  Not misinformation.

We are going to take a look at each lower back pain treatment tactic from a medical literature view. Simply…does it work or not? If it works, how well does it work?

PAIN MEDS

How effective are opioid pain meds for lower back pain relief?  Not very. There is no evidence that opioids speed up return to work in injured workers or improve function in those with acute lower back pain. (1)

For acute, severe lower back pain that is seriously affecting your ability to function these drugs may be considered.  The important thing is understanding how to use them and how long to use them for. 

Opioid pain killers are not the cure for lower back pain, not by a long shot.  They can be a decent tool when used correctly though.  Using these drugs correctly means only taking them for one or two weeks and only using them as a tool to stay active and keep moving.  That’s it.  The potential for serious problems arise when narcotic pain killers are taken for months and years.  Unfortunately that’s how these drugs have been used for people with lower back pain.  As a primary treatment approach opposed to a tool for a short period.

Pain medication is intended to be used acutely, for short periods.  Thanks to the pharmaceutical industry opioid pain medication is now used like it’s as harmless as drinking a glass of water.  This is a topic for another time.  Let’s focus on pain medication’s effectiveness for managing lower back pain.

It’s not effective.  At least the way it’s currently used is not effective.  If used to reduce severe pain related to injury it can be effective.  If used to reduce pain following surgery it’s effective.  If used for one or two weeks it’s effective.  When used for months and years it’s not effective.  In fact there is compelling evidence that opioid pain medication can actually INCREASE pain.  How this is possible will be discussed in a future article.  Just know it happens.  

Getting off opioid pain medication has been PROVEN to reduce pain in several studies.  Opioid pain medication used to manage chronic lower back pain for long periods is detrimental in many ways.  It is a terrible approach that results in more harm than good.  More people die each year in the United States because of overdose from prescription pain medication compared to deaths from all illegal drugs combined.  Think about that for just a minute.  There are more deaths every year caused by prescription pain medication compared to all illegal drugs combined.

If you underwent surgery or have severe back pain you may need to use opioid pain medication for a week or two.  That’s it.  These drugs are effective when used to reduce severe, acute pain.  They will allow you to stay mobile and active when pain is at it’s worst.  Do not use these drugs for more than one month.  Research shows this is when the brain begins to change in response to the drugs.  This is when dependency can start to develop.  Once this happens it more difficult to quit using the drugs, people think they need them.  It’s best to never get to this point.

Most people with mechanical, musculoskeletal lower back pain do NOT need opioid pain medication at all.  If you feel you do, use these drugs for short periods only.

NSAIDS

Are NSAIDS effective? .  For acute onset lower back pain NSAIDS can be an effective tool, if used correctly.  These drugs should be used short-term, for one or two weeks following acute onset of lower back pain.  They should not be used for months and years. 

NSAIDS are well documented to increase your risk of having a heart attack or a stroke, even if you don’t have a heart condition.  If you do have an underlying heart condition the risk is greater.  Taking NSAIDS for longer periods of time and taking larger dosages increases the risk of heart attack or stroke.  Kidney failure has been associated with NSAID use, these drugs should not be taken if you have kidney disease.  NSAIDS also cause GI bleeding and stomach ulcers.  All of these side effects increase with age. 

If you decide to use an NSAID to manage your back pain take the lowest dose possible that provides pain relief.  Don’t take the drug for more than two weeks.

EPIDURAL STEROID INJECTIONS

Is an epidural for lower back pain the answer?  Epidurals are an especially popular treatment approach for people with lower back pain.  Especially if you have sciatica or spinal stenosis.  Do they work? 

When compared to not having an epidural there is no statistical difference in pain or disability levels in people with sciatica or spinal stenosis.  There is some evidence showing that epidural steroid injections may reduce radicular leg pain (sciatica) sooner compared to not having an injection. 

A couple months out there is no difference in leg pain compared to not having an injection though.  There is some compelling evidence showing a correlation between epidural steroid injections and chronic lower back pain and disability.  The succinct answer is NO, epidurals don’t work too well.  Everybody has a story about the family member or friend that had an epidural and their back pain or sciatica magically disappeared.  Hopefully this happens for you.  When looked at objectively in large scale studies it’s simply not the case though.

If you are considering an epidural steroid injection to treat your lower back pain it’s important you understand how successful these injections typically are. People often expect an injection to magically make their pain disappear, all of their pain.  Truth be told, this is rarely the case.  If these injections are “successful” they usually offer modest short-term pain relief.  In the papers that determine the success or lack thereof, modest short-term pain relief is considered successful.

That said, the first thing to know is that a complete resolution of your lower back pain is unlikely following an injection.  Second, if you do experience pain relief it will be short-term.  Pain relief will not be permanent.  If pain relief is realized it is generally accepted that 3 weeks of relief is the average.  This is why multiple injections every year, year after year are required.  They do NOT address the cause of your symptoms.  They only address the symptom (pain). Treating low back pain with an injection is essentially a bandaid.  There is nothing wrong with this, sometimes you need a bandaid.  The take-home point is not to confuse a bandaid with a cure.

When epidural steroid injections are compared to injecting saline (salt water) under the skin, there is no difference in pain reduction.  Think about that.  You can inject a drug into the area where the nerve root is or you can inject salt water under the skin, nowhere near the nerve root.  And there is no difference in outcome.  Is the steroid even doing anything?

So, when should an injection be considered?  According to the medical literature injections are most successful when administered to people who have radicular leg pain.  This is a medical term that describes leg pain that is a result of nerve root irritation at a specific spinal segment.  Basically the nerve is irritated where it exits the lumbar region to travel into the leg.  The worst symptoms are thus experienced in the leg.  This condition is often referred to as sciatica.  Sciatica or radicular pain can be caused by a disc herniation or spinal stenosis (narrowing of the canal that houses the spinal cord or narrowing of the opening where the nerve root exits).  

The group of people who benefit the most from epidural steroid injections are those who have radicular pain caused by a disc herniation.  Those with radicular pain that can not be directly attributed to a disc herniation do not usually realize as much pain relief compared to those with a clear disc herniation that correlates with clinical symptoms.  It’s not uncommon for a person to have a left side disc herniation but have right leg radicular pain.  An epidural steroid injection in this type of case is usually not successful because the disc herniation is not correlated with the clinical symptoms.

Sciatic pain or radicular pain responds best to epidural steroid injections when:

• Radicular pain has been present for less than 3 months
• Radicular pain is a result of a disc herniation
• The disc herniation present correlates with the clinical symptoms

Even when radicular pain is a result of disc herniation and an injection is done, the long-term outcome is no better compared to exercise.  

Basically when the correct criteria are met an injection offers short-term pain relief.  When assessed 6 months, one year, and two years down the road there is no difference in pain relief or ability to function compared to if you had an injection or not.

 So while an injection MAY offer short-term, modest pain relief it does not improve pain relief or function over the long-term.  So when should you consider an injection?

• If your sciatic pain has been present for less than 3 months and can be directly attributed to a herniated disc.
•  If you require fast, short-term relief.
•  If you’re basically unable to sleep or complete your regular every day activities because of severe leg pain.

Even if you meet these criteria an injection will likely result in modest, short-term pain relief.

Epidural steroid injections used to treat people with spinal stenosis and radicular pain have actually been correlated with increased pain and disability. The relationship is one of correlation, not causation.  Big difference here.  But when looked at over the course of time, people with spinal stenosis who have epidural steroid injections have more pain and disability compared to those with spinal stenosis who do NOT have the injections.  

As a healthcare consumer with spinal stenosis who is considering an epidural steroid injection this information should be completely transparent.  Now it is.  If you have spinal stenosis and don’t get any relief following an injection, know that you’re in the majority and this is normal.

LOWER BACK SURGERY

Should you consider lower back surgery?  Back surgery should only be considered if gross spinal instability is present and/or if there are hard neurological signs. 

Gross Spinal Instability

A tumor or fracture renders part of the spinal column unstable.  If this happens the spinal cord and nerve roots can be compromised, leading to difficulty with mobility and walking. 

Hard Neurological Signs

Hard neurological signs show up if the spinal cord or nerve roots are compromised.  Foot drop, bowel or bladder incontinence, and leg weakness are hard neurological signs.  Note that surgery is not being considered for lower back pain.  This is because the medical literature is very clear.  Surgery for back pain does not have a great track record. 

Surgery to address instability, spinal cord compression, and nerve root compression works.  It works to maintain or restore function by decompressing the spinal cord or nerves and stabilizing the spine.

If pain is your primary complaint don’t have back surgery. Back surgery is no more effective at reducing pain and disability compared to conservative care. Read the first sentence again.  This is a simple concept, but just because it’s simple does not mean it’s not important.  Back surgery fails time and again to reduce back pain and disability.  There are numerous side effects that come with back surgery.  Paralysis, death, increased chances of having another back surgery, and increased pain medication use are just a few.

If you have radicular leg pain, also commonly referred to as sciatica, a microdiscectomy MAY result in a reduction of leg pain sooner compared to not having surgery.

People with sciatica due to a herniated disc who have surgery compared to those who do not have surgery don’t have less pain or better function.  The people who have surgery to reduce leg pain don’t have less leg pain compared to those who do not have surgery.  Those who have surgery don’t have improved functional levels compared to those who don’t have surgery. Basically undergoing a microdiscectomy MAY result in short-term pain relief compared to not having surgery.  As time passes there is no benefit to having surgery compared to not having surgery if you have sciatica. (2)

A microdiscectomy can be done in a minimally invasive manner, resulting in minimal damage to the spinal musculature and surrounding tissues.  If you insist on having back surgery, this is your safest bet.  Still, if pain is the primary problem you’re not going to have any less pain six months down the road compared to if you did not have surgery.  If you have radicular leg pain that is so severe you are unable to function a microdiscectomy is an option.

In the presence of hard neurological signs a microdiscectomy SHOULD be considered.  A hard neurological sign is an impairment in motor, sensory, or reflex behavior.  Foot drop or marked weakness of specific leg muscles are hard motor neurological signs.  The motor impairments are what affect functional ability.  If you have foot drop or an inability to rise up on your toes on one side a nerve root could be compressed by a piece of disc.  If this is the case it is beneficial to remove the piece of disc compressing the nerve root.  

This allows the nerve to get the signal to the muscle again.  Like unkinging a hose.  This can ultimately lead to restored motor function.  With hard motor signs there are often sensory changes such as numbness along a nerve pathway in the leg.  Unless tested people don’t notice reduced reflexes.  

A microdiscectomy in this case is NOT to reduce pain.  It’s to restore nerve conduction so muscles innervated by the nerve are able to function properly.

Don’t EVER consider a lumbar fusion to reduce lower back pain.  The only time a lumbar fusion should be considered is to stabilize a grossly unstable spine.  A grossly unstable spine will be present following a traumatic accident that results in spinal fracture or if a spinal tumor has compromised the spinal column.  

Occasionally a severe spondylolisthesis may benefit from lumbar fusion.  A spondylolisthesis is another condition that results in gross spinal instability, it is fairly common and must be severe to necessitate fusion though.  When lumbar fusion is used to restore stability to a grossly unstable spine it’s effective.  When lumbar fusion is used as a treatment to address back pain the results are dire.

A study published in 2011 compared having a lumbar fusion to not having a lumbar fusion in people with chronic lower back pain.  There were 725 people who underwent spinal fusion for chronic low back pain and 725 people with chronic back pain who did NOT have surgery.  The results are staggering.

If you have lumbar fusion surgery you increase your odds of permanent disability by 5.5 times.  You increase your risk of death by 1.5 times.  Opioid pain medication use is increased by 41% following lumbar fusion surgery.  You miss 1140 days of work.  You have a 1 in 4 chance of having another back surgery.  A 3 in 4 chance of continued pain pill use.  You have a 3 in 4 chance of NEVER working again.

If you DON’T have lumbar fusion surgery you have a 2.5 times greater chance of returning to work.  You only miss 316 days of work.

The study concludes;

“Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy is associated with significant increase in disabil­ity, opiate use, prolonged work loss, and poor return to work status.” (3)

If you want to be disabled and addicted to pain medication go ahead and have a lumbar fusion for your low back pain.  Seriously.  If you never want to work again have a lumbar fusion.  This gives you 3 in 4 odds of never retiring to work.  If you want to live an active life WITHOUT pain stay away from lumbar fusion surgery for pain relief.  

Remember, fusion surgeries are indicated to stabilize a grossly unstable spine. If this is you, a fusion should be considered.  If you’re like most people and have back pain without any unstable fractures or spinal tumors DO NOT consider spinal fusion.

Even if you return to work, aren’t addicted to pain medication, and don’t have another surgery…the outcome following lumbar fusion is no better compared to if you never had the surgery! Even if you have a good outcome, without any complications that are VERY common, you won’t have less pain or better function compared to if you never had the surgery. (4) (5)

LOWER BACK EXERCISES

Are lower back exercises effective?  For 90% of people with lower back pain, yes.  Lower back exercises reduce pain, improve function, and reduce the chances of future lower back pain. 

The medical literature has shown this to be the case again and again for the past two decades.  For most people with lower back pain exercise is more effective at reducing pain and improving function compared to drugs, injections, or surgery. 

Numerous medical research studies have compared exercise to drugs, injections, and surgery.  And exercise is always better or just as good, without the side effects these other treatment options come with.  Because of better results with less potential for side effects exercise should be the primary focus. 

You need to know what exercises to do, how often to do them, how to do them, etc.  The Crush Back Pain website provides all of this information for you.

You need to have a basic understanding of how well each of these lower back pain treatment approaches works.  Then you’ll be able to make the best possible decision for YOUR back.  Opposed to blindly going along with what you are told to do.  And hoping it works.  Then trying the same thing again, and hoping it works.  Then trying something else.  And hoping it works.

KNOW what works.  KNOW what to expect.  Then make your decision.  This will save you TIME, MONEY, and FRUSTRATION opposed to the standard trial and error approach.

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REFERENCES

1. BMJ. 2015 Jan 5;350:g6380.  Opioids for low back pain. Deyo RA1, Von Korff M2, Duhrkoop D3.
2. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review.  Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC.    
3. Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study. Nguyen, Trang H. MD, PhD^*; Randolph, David C. MD, MPH^*; Talmage, James MD^†; Succop, Paul PhD^*; Travis, Russell MD^‡
4. Ann Rheum Dis. 2010 Sep;69(9):1643-8. Epub 2009 Jul 26. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Brox JI1, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O.  
5. Spine J. 2013 Nov;13(11):1438-48. doi: 10.1016/j.spinee.2013.06.101. Epub 2013 Nov 5. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Mannion AF, Brox JI, Fairbank JC
6. Spine (Phila Pa 1976). 2013 Feb 15;38(4):279-91.  Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial.  Radcliff K1, Kepler C, Hilibrand A, Rihn J, Zhao W, Lurie J, Tosteson T, Vaccaro A, Albert T, Weinstein J.
7. J Bone Joint Surg Am. 2012 Aug 1;94(15):1353-8.  The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial.  Radcliff K1, Hilibrand A, Lurie JD, Tosteson TD, Delasotta L, Rihn J, Zhao W, Vaccaro A, Albert TJ, Weinstein JN.     Eur Spine J. 2011 Apr;20(4):513-22. Epub 2010 Oct 15.  
8. Backstrom KM, Whitman JM, Fylnn TW. Lumba spinal stenosis- diagnosis and management of the aging spine. Man Ther. 2011; 16(4): 308-317.  
9. Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis. A randomized trial. Ann Int Med. 2015; 162: 465-473.
10. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. NEJM. 2013; 317(1): 11-21.
11. Fritz JM, Lurie JD, Whitman JM, et al. Association between physical therapy and long-term outcomes for individuals with lumbar spinal stenosis in the SPORT study. Spine J. 2014; 14(8): 1611-1621.
12. Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight year results of the Spine Parient Outcomes Research Trial (SPORT). Spine. 2015; 40(2): 63-76.
13. Phys Med Rehabil Clin N Am. 2014 May;25(2):471-89.e1-50.  Epidural steroid injections for radicular lumbosacral pain: a systematic review.  Shamliyan TA1, Staal JB2, Goldmann D3, Sands-Lincoln M3.

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