What You Should Know About Treating Cancer Pain.
You don’t have to accept pain.
People who have cancer don’t always have pain. Everyone is different. But if you do have cancer pain, you should know that you don’t have to accept it. Cancer pain can almost always be relieved.
The key messages we want you to learn from this booklet are:
- Your pain can be managed.
- Controlling pain is part of your cancer treatment.
- Talking openly with your doctor and health care team will help them manage your pain.
- The best way to control pain is to stop it from starting or keep it from getting worse.
- There are many different medicines to control pain. Everyone’s pain control plan is different.
- Keeping a record of your pain will help create the best pain control plan for you.
- People who take cancer pain medicines as prescribed rarely become addicted to them.
- Your body does not become immune to pain medicine. Stronger medicines should not be saved for “later.”
Please see the referenced on-line booklet at http://www.cancer.gov/cancertopics/coping/paincontrol/page2 for more information.
What Is Back Pain?
Back pain is an all-too-familiar problem that can range from a dull, constant ache to a sudden, sharp pain that leaves you incapacitated. It can come on suddenly—from an accident, a fall, or lifting something heavy—or it can develop slowly, perhaps as the result of age-related changes to the spine. Regardless of how back pain happens or how it feels, you know it when you have it. And chances are, if you don’t have back pain now, you will eventually.
What Are the Risk Factors for Back Pain?
Although anyone can have back pain, a number of factors increase your risk. They include:
Age: The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain becomes more common with age.
Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine.
“Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise is good for the disks that cushion the vertebrae, the individual bones that make up the spine.
Diet: A diet high in calories and fat, combined with an inactive lifestyle, can lead to obesity, which can put stress on the back.
Heredity: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that affects the spine, have a genetic component.
Race: Race can be a factor in back problems. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine—also called the lumbar spine—slips out of place.
The presence of other diseases: Many diseases can cause or contribute to back pain. These include various forms of arthritis, such as osteoarthritis and rheumatoid arthritis, and cancers elsewhere in the body that may spread to the spine.
Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when this involves twisting or vibrating the spine, can lead to injury and back pain. An inactive job or a desk job may also lead to or contribute to pain, especially if you have poor posture or sit all day in an uncomfortable chair.
Cigarette smoking: Although smoking may not directly cause back pain, it increases your risk of developing low back pain and low back pain with sciatica. (Sciatica is back pain that radiates to the hip and/or leg due to pressure on a nerve.) For example, smoking may lead to pain by blocking your body’s ability to deliver nutrients to the disks of the lower back. Or repeated coughing due to heavy smoking may cause back pain. It is also possible that smokers are just less physically fit or less healthy than nonsmokers, which increases the likelihood that they will develop back pain. Smoking also increases the risk of osteoporosis, a condition that causes weak, porous bones, which can lead to painful fractures of the vertebrae. Furthermore, smoking can slow healing, prolonging pain for people who have had back injuries, back surgery, or broken bones.
What Are the Causes of Back Pain?
It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:
Mechanical problems: A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disk degeneration, which simply means that the disks located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured disks, which are also called herniated disks.
Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis. Less commonly, back pain may be caused by more severe injuries that result from accidents or falls.
Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, a curvature of the spine that does not usually cause pain until middle age; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. Although osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, a condition of widespread muscle pain and fatigue.
Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the disks that cushion the vertebrae, which is called diskitis. Tumors also are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.
Although the causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.
Can Back Pain Be Prevented?
One of the best things you can do to prevent back pain is to exercise regularly and keep your back muscles strong. All may help you avoid injury and pain. Exercises that increase balance and strength can decrease your risk of falling and injuring your back or breaking bones. Exercises such as tai chi and yoga—or any weight-bearing exercise that challenges your balance—are good ones to try.
Eating a healthy diet also is important. For one thing, eating to maintain a healthy weight—or to lose weight, if you are overweight—helps you avoid putting unnecessary and injury-causing stress and strain on your back. To keep your spine strong, as with all bones, you need to get enough calcium and vitamin D every day. These nutrients help prevent osteoporosis, which is responsible for a lot of the bone fractures that lead to back pain. Calcium is found in dairy products; green, leafy vegetables; and fortified products, like orange juice. Your skin makes vitamin D when you are in the sun. If you are not outside much, you can obtain vitamin D from your diet: nearly all milk and some other foods are fortified with this nutrient. Most adults don’t get enough calcium and vitamin D, so talk to your doctor about how much you need per day, and consider taking a nutritional supplement or a multivitamin.
Practicing good posture, supporting your back properly, and avoiding heavy lifting when you can may all help you prevent injury. If you do lift something heavy, keep your back straight. Don’t bend over the item; instead, lift it by putting the stress on your legs and hips.
When Should I See a Doctor for Pain?
In most cases, it is not necessary to see a doctor for back pain because pain usually goes away with or without treatment. However, a trip to the doctor is probably a good idea if you have numbness or tingling, if your pain is severe and doesn’t improve with medication and rest, or if you have pain after a fall or an injury. It is also important to see your doctor if you have pain along with any of the following problems: trouble urinating; weakness, pain, or numbness in your legs; fever; or unintentional weight loss. Such symptoms could signal a serious problem that requires treatment soon.
Which Type of Doctor Should I See?
Many different types of doctors treat back pain, from family physicians to doctors who specialize in disorders of the nerves and musculoskeletal system. In most cases, it is best to see your primary care doctor first. In many cases, he or she can treat the problem. In other cases, your doctor may refer you to an appropriate specialist.
How Is Back Pain Diagnosed?
Diagnosing the cause of back pain requires a medical history and a physical exam. If necessary, your doctor may also order medical tests, which may include x rays.
During the medical history, your doctor will ask questions about the nature of your pain and about any health problems you and close family members have or have had. Questions might include the following:
● Have you fallen or injured your back recently?
● Does your back feel better—or hurt worse—when you lie down?
● Are there any activities or positions that ease or aggravate pain?
● Is your pain worse or better at a certain time of day?
● Do you or any family members have arthritis or other diseases that might affect the spine?
● Have you had back surgery or back pain before?
● Do you have pain, numbness, or tingling down one or both legs?
During the physical exam, your doctor may:
● watch you stand and walk
● check your reflexes to look for slowed or heightened reflexes, either of which might suggest nerve problems
● check for fibromyalgia by examining your back for tender points, which are points on the body that are painful when pressure is applied to them
● check for muscle strength and sensation
● check for signs of nerve root irritation.
Often a doctor can find the cause of your pain with a physical and medical history alone. However, depending on what the history and exam show, your doctor may order medical tests to help find the cause.
Following are some tests your doctor may order:
Traditional x rays use low levels of radiation to project a picture onto a piece of film (some newer x rays use electronic imaging techniques). They are often used to view the bones and bony structures in the body. Your doctor may order an x ray if he or she suspects that you have a fracture or osteoarthritis or that your spine is not aligned properly.
Magnetic resonance imaging (MRI)
MRI uses a strong magnetic force instead of radiation to create an image. Unlike an x ray, which shows only bony structures, an MRI scan produces clear pictures of soft tissues, too, such as ligaments, tendons, and blood vessels. Your doctor may order an MRI scan if he or she suspects a problem such as an infection, tumor, inflammation, or pressure on a nerve. An MRI scan, in most instances, is not necessary during the early phases of low back pain unless your doctor identifies certain “red flags” in your history and physical exam. An MRI scan is needed if the pain persists for longer than 3 to 6 weeks or if your doctor feels there may be a need for surgical consultation. Because most low back pain goes away on its own, getting an MRI scan too early may sometimes create confusion for the patient and the doctor.
Computed tomography (CT) scan
A CT scan allows your doctor to see spinal structures that cannot be seen on traditional x rays. A computer creates a three-dimensional image from a series of two-dimensional pictures that it takes of your back. Your doctor may order a CT scan to look for problems including herniated disks, tumors, or spinal stenosis.
Although blood tests are not used generally in diagnosing the cause of back pain, your doctor may order them in some cases. Blood tests that might be used include the following:
● Complete blood count (CBC), which could point to problems such as infection or inflammation
● Erythrocyte sedimentation rate (also called sed rate), a measure of inflammation that may suggest infection. The presence of inflammation may also suggest some forms of arthritis or, in rare cases, a tumor.
● C-reactive protein (CRP), another blood test that is used to measure inflammation, may indicate an infection or some forms of arthritis.
● HLA-B27, a test to identify a genetic marker in the blood that is more common in people with ankylosing spondylitis (a form of arthritis that affects the spine and sacroiliac joints) or reactive arthritis (a form of arthritis that occurs following infection in another part of the body, usually the genitourinary tract).
It is important to understand that medical tests alone may not diagnose the cause of back pain. Often, MRI scans of the spine show some type of abnormality, even in people without symptoms. Similarly, even some healthy pain-free people can have elevated sed rates.
Only with a medical history and exam—and sometimes medical tests—can a doctor diagnose the cause of back pain. Many times, the precise cause of back pain is never known. In these cases, it may be comforting to know that most back pain gets better whether or not you find out what is causing it.
What Is the Difference Between Acute and Chronic Pain?
Pain that hits you suddenly—after falling from a ladder, being tackled on the football field, or lifting a load that is too heavy, for example—is acute pain. Acute pain comes on quickly and often leaves just as quickly. To be classified as acute, pain should last no longer than 6 weeks. Acute pain is the most common type of back pain.
Chronic pain, on the other hand, may come on either quickly or slowly, and it lingers a long time. In general, pain that lasts longer than 3 months is considered chronic. Chronic pain is much less common than acute pain.
How Is Back Pain Treated?
Treatment for back pain generally depends on what kind of pain you experience: acute or chronic.
Acute Back Pain
Acute back pain usually gets better on its own and without treatment, although you may want to try acetaminophen, aspirin, or ibuprofen to help ease the pain. Perhaps the best advice is to go about your usual activities as much as you can with the assurance that the problem will clear up. Getting up and moving around can help ease stiffness, relieve pain, and have you back doing your regular activities sooner. Exercises or surgery are not usually advisable for acute back pain.
Chronic Back Pain
Treatment for chronic back pain falls into two basic categories: the kind that requires an operation and the kind that does not. In the vast majority of cases, back pain does not require surgery. Doctors will nearly always try nonsurgical treatments before recommending surgery. In a very small percentage of cases—when back pain is caused by a tumor, an infection, or a nerve root problem called cauda equina syndrome, for example—prompt surgery is necessary to ease the pain and prevent further problems.
Following are some of the more commonly used treatments for chronic back pain.
Hot or cold: Hot or cold packs—or sometimes a combination of the two—can be soothing to chronically sore, stiff backs. Heat dilates the blood vessels, both improving the supply of oxygen that the blood takes to the back and reducing muscle spasms. Heat also alters the sensation of pain. Cold may reduce inflammation by decreasing the size of blood vessels and the flow of blood to the area. Although cold may feel painful against the skin, it numbs deep pain. Applying heat or cold may relieve pain, but it does not cure the cause of chronic back pain.
Although exercise is usually not advisable for acute back pain, proper exercise can help ease chronic pain and perhaps reduce the risk of it returning. The following four types of exercise are important to general physical fitness and may be helpful for certain specific causes of back pain:
The purposes of flexion exercises, which are exercises in which you bend forward, are to (1) widen the spaces between the vertebrae, thereby reducing pressure on the nerves; (2) stretch muscles of the back and hips; and (3) strengthen abdominal and buttock muscles. Many doctors think that strengthening the muscles of the abdomen will reduce the load on the spine. One word of caution: If your back pain is caused by a herniated disk, check with your doctor before performing flexion exercises because they may increase pressure within the disk, making the problem worse.
With extension exercises, you bend backward. They may minimize radiating pain, which is pain you can feel in other parts of the body besides where it originates. Examples of extension exercises are leg lifting and raising the trunk, each exercise performed while lying prone. The theory behind these exercises is that they open up the spinal canal in places and develop muscles that support the spine.
Stretching: The goal of stretching exercises, as their name suggests, is to stretch and improve the extension of muscles and other soft tissues of the back. This can reduce back stiffness and improve range of motion.
Aerobic exercise is the type that gets your heart pumping faster and keeps your heart rate elevated for a while. For fitness, it is important to get at least 30 minutes of aerobic (also called cardiovascular) exercise three times a week. Aerobic exercises work the large muscles of the body and include brisk walking, jogging, and swimming. For back problems, you should avoid exercise that requires twisting or vigorous forward flexion, such as aerobic dancing and rowing, because these actions may raise pressure in the disks and actually do more harm than good. In addition, avoid high-impact activities if you have disk disease. If back pain or your fitness level make it impossible to exercise 30 minutes at a time, try three 10-minute sessions to start with and work up to your goal. But first, speak with your doctor or physical therapist about the safest aerobic exercise for you.
A wide range of medications are used to treat chronic back pain. Some are available over the counter. Others require a doctor’s prescription. The following are the main types of medications used for back pain.
Analgesic medications are those designed specifically to relieve pain. They include over-thecounter acetaminophen (Tylenol1) and aspirin, as well as prescription narcotics, such as oxycodone with acetaminophen (Percocet) or hydrocodone with acetaminophen (Vicodin). Aspirin and acetaminophen are the most commonly used analgesics; narcotics should only be used for a short time for severe pain or pain after surgery. People with muscular back pain or arthritis pain that is not relieved by medications may find topical analgesics helpful. These creams, ointments, and salves are rubbed directly onto the skin over the site of pain. They use one or more of a variety of ingredients to ease pain.
Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that relieve pain and inflammation, both of which may play a role in some cases of back pain. NSAIDs include the nonprescription products ibuprofen (Motrin, Advil), ketoprofen (Actron, Orudis KT), and naproxen sodium (Aleve). More than a dozen others, including a subclass of NSAIDs called COX-2 inhibitors, are available only with a prescription.
All NSAIDs work similarly by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.2
2Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People age 65 and older and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.
Side effects of all NSAIDs can include stomach upset and stomach ulcers, heartburn, diarrhea, and fluid retention; however, COX-2 inhibitors are designed to cause fewer stomach ulcers. For unknown reasons, some people seem to respond better to one NSAID than another. It’s important to work with your doctor to choose the one that’s safest and most effective for you.
Muscle relaxants and certain antidepressants have also been prescribed for chronic back pain, but their usefulness is questionable. If the cause of back pain is an inflammatory form of arthritis, medications used to treat that specific form of arthritis may be helpful against the pain.
Traction: Traction involves using pulleys and weights to stretch the back. The rationale behind traction is to pull the vertebrae apart to allow a bulging disk to slip back into place. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released, the stretch is not sustained and back pain is likely to return. There is no scientific evidence that traction provides any long-term benefits for people with back pain.
Corsets and braces
Corsets and braces include a number of devices, such as elastic bands and stiff supports with metal stays, that are designed to limit the motion of the lumbar spine, provide abdominal support, and correct posture. Although these may be appropriate after certain kinds of surgery, there is little, if any, evidence that corsets and braces help treat chronic low back pain. In fact, by keeping you from using your back muscles, they may actually cause more problems than they solve by causing lower back muscles to weaken from lack of use.
Developing a healthy attitude and learning to move your body properly while you do daily activities, particularly those involving heavy lifting, pushing, or pulling, are sometimes part of the treatment plan for people with back pain. Other behavior changes that might help pain include adopting healthy habits, such as exercise, relaxation, and regular sleep, and dropping bad habits, such as smoking and eating poorly.
Injections: When medications and other nonsurgical treatments fail to relieve chronic back pain, doctors may recommend injections for pain relief. Following are some of the most commonly used injections, although some are of questionable value.
Nerve root blocks
If a nerve is inflamed or compressed as it passes from the spinal column between the vertebrae, an injection called a nerve root block may be used to help ease the resulting back and leg pain. The injection contains a steroid medication or anesthetic and is administered to the affected part of the nerve. Whether the procedure helps or not depends on finding and injecting precisely the right nerve.
Facet joint injections
The facet joints are those where the vertebrae connect to one another, keeping the spine aligned. Although arthritis in the facet joints themselves is rarely the source of back pain, the injection of anesthetics or steroid medications into facet joints is sometimes tried as a way to relieve pain. The effectiveness of these injections is questionable. One study suggests that this treatment is overused and ineffective.
Trigger point injections
In this procedure, an anesthetic is injected into specific areas in the back that are painful when the doctor applies pressure to them. Some doctors add a steroid medication to the injection. Although the injections are commonly used, researchers have found that injecting anesthetics or steroids into trigger points provides no more relief than “dry needling” (inserting a needle and not injecting a medication).
Complementary and alternative treatments
When back pain becomes chronic or when medications and other conventional therapies do not relieve it, many people try complementary and alternative treatments. Although such therapies won’t cure diseases or repair the injuries that cause pain, some people find them useful for managing or relieving pain. Following are some of the most commonly used complementary therapies.
Spinal manipulation refers to procedures in which professionals use their hands to mobilize, adjust, massage, or stimulate the spine or surrounding tissues. This type of therapy is often performed by osteopathic doctors and chiropractors. It tends to be most effective in people with uncomplicated pain and when used with other therapies. Spinal manipulation is not appropriate if you have a medical problem such as osteoporosis, spinal cord compression, or inflammatory arthritis (such as rheumatoid arthritis), or if you are taking blood-thinning medications such as warfarin (Coumadin) or heparin (Calciparine, Liquaemin).
Transcutaneous electrical nerve stimulation (TENS)
TENS involves wearing a small box over the painful area that directs mild electrical impulses to nerves there. The theory is that stimulating the nervous system can modify the perception of pain. Early studies of TENS suggested it could elevate the levels of endorphins, the body’s natural pain-numbing chemicals, in the spinal fluid. But subsequent studies of its effectiveness against pain have produced mixed results.
This ancient Chinese practice has been gaining increasing acceptance and popularity in the United States. Acupuncture is based on the theory that a life force called Qi (pronounced chee) flows through the body along certain channels, which if blocked can cause illness. According to the theory, the insertion of thin needles at precise locations along these channels by practitioners can unblock the flow of Qi, relieving pain and restoring health.
Although few Western-trained doctors would agree with the concept of blocked Qi, some believe that inserting and then stimulating needles (by twisting or passing a low-voltage electrical current through them) may foster the production of the body’s natural pain-numbing chemicals, such as endorphins, serotonin, and acetylcholine.
As with acupuncture, the theory behind acupressure is that it unblocks the flow of Qi. The difference between acupuncture and acupressure is that no needles are used in acupressure. Instead, a therapist applies pressure to points along the channels with his or her hands, elbows, or even feet. (In some cases, patients are taught to do their own acupressure.) Acupressure has not been well studied for back pain.
A type of massage, rolfing involves using strong pressure on deep tissues in the back to relieve tightness of the fascia, a sheath of tissue that covers the muscles, that can cause or contribute to back pain. The theory behind rolfing is that releasing muscles and tissues from the fascia enables the back to align itself properly. So far, the usefulness of rolfing for back pain has not been scientifically proven.
Depending on the diagnosis, surgery may either be the first treatment of choice—although this is rare—or it is reserved for chronic back pain for which other treatments have failed. If you are in constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function at your job, or to perform daily activities, you may be a candidate for surgery.
In general, two groups of people may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disk, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement. People in the second group are those with only predominant low back pain (without leg pain). These are people with diskogenic low back pain (degenerative disk disease), in which disks wear with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.
Some of the diagnoses that may need surgery include:
Herniated disks: In this potentially painful problem, the hard outer coating of the disks, which are the circular pieces of connective tissue that cushion the bones of the spine, are damaged, allowing the disks’ jelly-like center to leak, irritating nearby nerves. This causes severe sciatica and nerve pain down the leg. A herniated disk is sometimes called a ruptured disk.
Spinal stenosis: Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord and spinal nerves run. It is often caused by the overgrowth of bone caused by osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but also to numbness in the legs and the loss of bladder or bowel control. Patients may have difficulty walking any distance and may have severe pain in their legs along with numbness and tingling.
Spondylolisthesis: In this condition, a vertebra of the lumbar spine slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause not only low back pain but also severe sciatica leg pain.
Vertebral fractures: These fractures are caused by trauma to the vertebrae of the spine or by crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back pain, but it may also put pressure on the nerves, creating leg pain.
Diskogenic low back pain (degenerative disk disease): Most people’s disks degenerate over a lifetime, but in some, this aging process can become chronically painful, severely interfering with their quality of life.
Following are some of the most commonly performed back surgeries:
For herniated disks:
Laminectomy/diskectomy: In this operation, part of the lamina, a portion of the bone on the back of the vertebrae, is removed, as well as a portion of a ligament. The herniated disk is then removed through the incision, which may extend two or more inches.
Microdiskectomy: As with traditional diskectomy, this procedure involves removing a herniated disk or damaged portion of a disk through an incision in the back. The difference is that the incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disk through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar. It appears to take about the same amount of time to recuperate from a microdiskectomy as from a traditional diskectomy.
Laser surgery: Technological advances in recent decades have led to the use of lasers for operating on patients with herniated disks accompanied by lower back and leg pain. During this procedure, the surgeon inserts a needle in the disk that delivers a few bursts of laser energy to vaporize the tissue in the disk. This reduces its size and relieves pressure on the nerves. Although many patients return to daily activities within 3 to 5 days after laser surgery, pain relief may not be apparent until several weeks or even months after the surgery. The usefulness of laser diskectomy is still being debated.
For spinal stenosis:
Laminectomy: When narrowing of the spine compresses the nerve roots, causing pain or affecting sensation, doctors sometimes open up the spinal column with a procedure called a laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the spine and removes the lamina and any bone spurs, which are overgrowths of bone that may have formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.
Spinal fusion: When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal fusion, two or more vertebrae are joined together using bone grafts, screws, and rods to stop slippage of the affected vertebrae. Bone used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.
Although the surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body. With donor bone, there is a slight risk of disease transmission or tissue rejection, which happens when your immune system attacks the donor tissue. In recent years, a new development has eliminated those risks for some people undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate bone generation, eliminating the need for grafts. The proteins are placed in the affected area of the spine, often in collagen putty or sponges.
Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.
For vertebral osteoporotic fractures:
Vertebroplasty: When back pain is caused by a compression fracture of a vertebra caused by osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and inject a cement-like mixture called polymethylacrylate into the fractured vertebra to relieve pain and stabilize the spine.3 The procedure is generally performed on an outpatient basis under a mild anesthetic.
3Used only if standard care, rest, corsets and braces, and analgesics fail.
Kyphoplasty: Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine following fractures caused by osteoporosis. Kyphoplasty is a twostep process. In the first step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the second step, he or she injects polymethylacrylate to repair the fractured vertebra. The procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.
For diskogenic low back pain (degenerative disk disease):
Intradiskal electrothermal therapy (IDET): One of the newest and least invasive therapies for low back pain involves inserting a heating wire through a small incision in the back and into a disk. An electrical current is then passed through the wire to strengthen the collagen fibers that hold the disk together. The procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDET is debatable.
Spinal fusion: When the degenerated disk is painful, the surgeon may recommend removing it and fusing the disk to help with the pain. This fusion can be done through the abdomen, a procedure known as anterior lumbar interbody fusion, or through the back, called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is successful in about 60 to 70 percent of cases. Fusion for low back pain or any spinal surgeries should only be done as a last resort, and the patient should be fully informed of risks.
Disk replacement: When a disk is herniated, one alternative to a diskectomy, in which the disk is simply removed, is removing the disk and replacing it with a synthetic disk. Replacing the damaged one with an artificial one restores disk height and movement between the vertebrae. Artificial disks come in several designs. Although doctors in Europe had performed disk replacement for more than a decade, the procedure had been experimental in the United States until the Food and Drug Administration approved the Charité® artificial disk for use in 2004.
Our physicians and medical team are experts in the diagnosis and treatment of back pain. We can help you navigate the complex choices and treatment options and help you get your life back.
What is Central Pain Syndrome?
Central pain syndrome is a neurological condition caused by damage to or dysfunction of the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. This syndrome can be caused by stroke, multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson’s disease. The character of the pain associated with this syndrome differs widely among individuals partly because of the variety of potential causes. Central pain syndrome may affect a large portion of the body or may be more restricted to specific areas, such as hands or feet. The extent of pain is usually related to the cause of the CNS injury or damage. Pain is typically constant, may be moderate to severe in intensity, and is often made worse by touch, movement, emotions, and temperature changes, usually cold temperatures. Individuals experience one or more types of pain sensations, the most prominent being burning. Mingled with the burning may be sensations of “pins and needles;” pressing, lacerating, or aching pain; and brief, intolerable bursts of sharp pain similar to the pain caused by a dental probe on an exposed nerve. Individuals may have numbness in the areas affected by the pain. The burning and loss of touch sensations are usually most severe on the distant parts of the body, such as the feet or hands. Central pain syndrome often begins shortly after the causative injury or damage, but may be delayed by months or even years, especially if it is related to post-stroke pain.
Is there any treatment?
Pain medications often provide some reduction of pain, but not complete relief of pain, for those affected by central pain syndrome. Tricyclic antidepressants such as nortriptyline or anticonvulsants such as neurontin (gabapentin) can be useful. Lowering stress levels appears to reduce pain.
What is the prognosis?
Central pain syndrome is not a fatal disorder, but the syndrome causes disabling chronic pain and suffering among the majority of individuals who have it.
What is Complex Regional Pain Syndrome?
Complex regional pain syndrome (CRPS) is a chronic pain condition. The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the injury, which gets worse rather than better over time. CRPS most often affects one of the arms, legs, hands, or feet. Often the pain spreads to include the entire arm or leg. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. Doctors aren’t sure what causes CRPS. In some cases the sympathetic nervous system plays an important role in sustaining the pain. Another theory is that CRPS is caused by a triggering of the immune response, which leads to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected area.
Is there any treatment?
Because there is no cure for CRPS, treatment is aimed at relieving painful symptoms. Doctors may prescribe topical analgesics, antidepressants, corticosteroids, and opioids to relieve pain. However, no single drug or combination of drugs has produced consistent long-lasting improvement in symptoms. Other treatments may include physical therapy, sympathetic nerve block, spinal cord stimulation, and intrathecal drug pumps to deliver opioids and local anesthetic agents via the spinal cord.
What is the prognosis?
The prognosis for CRPS varies from person to person. Spontaneous remission from symptoms occurs in certain individuals. Others can have unremitting pain and crippling, irreversible changes in spite of treatment.
What is Diabetic Neuropathy?
Diabetic neuropathy is a peripheral nerve disorder caused by diabetes or poor blood sugar control. The most common types of diabetic neuropathy result in problems with sensation in the feet. It can develop slowly after many years of diabetes or may occur early in the disease. The symptoms are numbness, pain, or tingling in the feet or lower legs. The pain can be intense and require treatment to relieve the discomfort. The loss of sensation in the feet may also increase the possibility that foot injuries will go unnoticed and develop into ulcers or lesions that become infected. In some cases, diabetic neuropathy can be associated with difficulty walking and some weakness in the foot muscles. There are other types of diabetic-related neuropathies that affect specific parts of the body. For example, diabetic amyotrophy causes pain, weakness and wasting of the thigh muscles, or cranial nerve infarcts that may result in double vision, a drooping eyelid, or dizziness. Diabetes can also affect the autonomic nerves that control blood pressure, the digestive tract, bladder function, and sexual organs. Problems with the autonomic nerves may cause lightheadedness, indigestion, diarrhea or constipation, difficulty with bladder control, and impotence.
Is there any treatment?
The goal of treating diabetic neuropathy is to prevent further tissue damage and relieve discomfort. The first step is to bring blood sugar levels under control by diet and medication. Another important part of treatment involves taking special care of the feet by wearing proper fitting shoes and routinely checking the feet for cuts and infections. Analgesics, low doses of antidepressants, and some anticonvulsant medications may be prescribed for relief of pain, burning, or tingling. Some individuals find that walking regularly, taking warm baths, or using elastic stockings may help relieve leg pain.
What is the prognosis?
The prognosis for diabetic neuropathy depends largely on how well the underlying condition of diabetes is handled. Treating diabetes may halt progression and improve symptoms of the neuropathy, but recovery is slow. The painful sensations of diabetic neuropathy may become severe enough to cause depression in some patients.
What are the signs and symptoms of depression?
People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of symptoms vary depending on the individual and his or her particular illness.
Signs and symptoms include:
- Persistent sad, anxious, or “empty” feelings
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Irritability, restlessness
- Loss of interest in activities or hobbies once pleasurable, including sex
- Fatigue and decreased energy
- Difficulty concentrating, remembering details, and making decisions
- Insomnia, early-morning wakefulness, or excessive sleeping
- Overeating, or appetite loss
- Thoughts of suicide, suicide attempts
- Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.
What illnesses often co-exist with depression?
Other illnesses may come on before depression, cause it, or be a consequence of it. But depression and other illnesses interact differently in different people. In any case, co-occurring illnesses need to be diagnosed and treated.
Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.3,4 PTSD can occur after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat. People experiencing PTSD are especially prone to having co-existing depression.
In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than 40 percent of people with PTSD also had depression 4 months after the traumatic event.5
Alcohol and other substance abuse or dependence may also co-exist with depression. Research shows that mood disorders and substance abuse commonly occur together.6
Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease. People who have depression along with another medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression.7 Treating the depression can also help improve the outcome of treating the co-occurring illness.8
What causes depression?
Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors.
Depressive illnesses are disorders of the brain. Longstanding theories about depression suggest that important neurotransmitters—chemicals that brain cells use to communicate—are out of balance in depression. But it has been difficult to prove this.
Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain involved in mood, thinking, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has occurred. They also cannot be used to diagnose depression.
Some types of depression tend to run in families. However, depression can occur in people without family histories of depression too.9 Scientists are studying certain genes that may make some people more prone to depression. Some genetics research indicates that risk for depression results from the influence of several genes acting together with environmental or other factors.10 In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Other depressive episodes may occur with or without an obvious trigger. http://www.nimh.nih.gov/health/publications/depression/what-is-depression.shtml
What are Temporomandibular Joint and Muscle Disorders (TMJ)?
Temporomandibular joint and muscle disorders, commonly called “TMJ,” are a group of conditions that cause pain and dysfunction in the jaw joint and muscles that control jaw movement. Some estimates suggest that TMJ disorders affect over 10 million Americans; the conditions appear to be more common in women than men.
Causes and Symptoms
Trauma to the jaw or temporomandibular joint plays a role in some TMJ disorders but in most cases, the exact cause of the condition is not clear. A variety of symptoms may be linked to TMJ disorders. Pain in the chewing muscles and/or jaw joint is the most common symptom; others include jaw muscle stiffness; limited movement or locking of the jaw; painful clicking, popping or grating in the jaw joint when opening or closing the mouth; and a change in the way the upper and lower teeth fit together.
For most people, discomfort from TMJ disorders will eventually go away with little or no treatment. Some, however, develop significant, long-term problems. Simple steps that may help ease symptoms temporarily include eating soft foods, applying ice packs, and avoiding extreme jaw movements like wide yawning and gum chewing. Short term use of over-the-counter or prescription pain medicines and learning techniques to reduce stress may also provide relief. Even if symptoms become significant and persistent, most people still do not need aggressive types of treatment. http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/default.htm
What Is Fibromyalgia?
Fast Facts: An Easy-to-Read Series of Publications for the Public
Fibromyalgia is a disorder that causes muscle pain and fatigue (feeling tired). People with fibromyalgia have “tender points” on the body. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them.
People with fibromyalgia may also have other symptoms, such as:
● Trouble sleeping
● Morning stiffness
● Painful menstrual periods
● Tingling or numbness in hands and feet
● Problems with thinking and memory (sometimes called “fibro fog”).
A person may have two or more coexisting chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.
What Causes Fibromyalgia?
The causes of fibromyalgia are unknown. There may be a number of factors involved. Fibromyalgia has been linked to:
● Stressful or traumatic events, such as car accidents
● Repetitive injuries
● Certain diseases.
Fibromyalgia can also occur on its own.
Some scientists think that a gene or genes might be involved in fibromyalgia. The genes could make a person react strongly to things that other people would not find painful.
Who Is Affected by Fibromyalgia?
Scientists estimate that fibromyalgia affects 5 million Americans 18 or older. Between 80 and 90 percent of people diagnosed with fibromyalgia are women. However, men and children also can have the disorder. Most people are diagnosed during middle age.
People with certain other diseases may be more likely to have fibromyalgia. These diseases include:
● Rheumatoid arthritis
● Systemic lupus erythematosus (commonly called lupus)
● Ankylosing spondylitis (spinal arthritis).
Women who have a family member with fibromyalgia may be more likely to have fibromyalgia themselves.
How Is Fibromyalgia Treated?
Fibromyalgia can be hard to treat. It’s important to find a doctor who is familiar with the disorder and its treatment. Many family physicians, general internists, or rheumatologists can treat fibromyalgia. Rheumatologists are doctors who specialize in arthritis and other conditions that affect the joints or soft tissues.
Fibromyalgia treatment often requires a team approach. The team may include your doctor, a physical therapist, and possibly other health care providers. A pain or rheumatology clinic can be a good place to get treatment.
What Can I Do to Try to Feel Better?
There are many things you can do to feel better, including:
● Taking medicines as prescribed
● Getting enough sleep
● Eating well
● Making work changes if necessary.
What is Headache?
There are four types of headache: vascular, muscle contraction (tension), traction, and inflammatory. The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and, at times, disturbed vision. Women are more likely than men to have migraine headaches. After migraine, the most common type of vascular headache is the toxic headache produced by fever. Other kinds of vascular headaches include “cluster” headaches, which cause repeated episodes of intense pain, and headaches resulting from high blood pressure. Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles. Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection. Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by inflammation, including those related to meningitis as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth.
Is there any treatment?
When headaches occur three or more times a month, preventive treatment is usually recommended. Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Regular exercise, such as swimming or vigorous walking, can also reduce the frequency and severity of migraine headaches. Drug therapy for migraine is often combined with biofeedback and relaxation training. One of the most commonly used drugs for the relief of migraine symptoms is sumatriptan. Drugs used to prevent migraine also include methysergide maleate, which counteracts blood vessel constriction; propranolol hydrochloride, which also reduces the frequency and severity of migraine headaches; ergotamine tartrate, a vasoconstrictor that helps counteract the painful dilation stage of the headache; amitriptyline, an antidepressant; valproic acid, an anticonvulsant; and verapamil, a calcium channel blocker.
What is the prognosis?
Not all headaches require medical attention. But some types of headache are signals of more serious disorders and call for prompt medical care. These include: sudden, severe headache or sudden headache associated with a stiff neck; headaches associated with fever, convulsions, or accompanied by confusion or loss of consciousness; headaches following a blow to the head, or associated with pain in the eye or ear; persistent headache in a person who was previously headache free; and recurring headache in children. Migraine headaches may last a day or more and can strike as often as several times a week or as rarely as once every few years. http://www.ninds.nih.gov/disorders/headache/headache.htm
What is Multiple Sclerosis?
An unpredictable disease of the central nervous system, multiple sclerosis (MS) can range from relatively benign to somewhat disabling to devastating, as communication between the brain and other parts of the body is disrupted. Many investigators believe MS to be an autoimmune disease — one in which the body, through its immune system, launches a defensive attack against its own tissues. In the case of MS, it is the nerve-insulating myelin that comes under assault. Such assaults may be linked to an unknown environmental trigger, perhaps a virus.
Most people experience their first symptoms of MS between the ages of 20 and 40; the initial symptom of MS is often blurred or double vision, red-green color distortion, or even blindness in one eye. Most MS patients experience muscle weakness in their extremities and difficulty with coordination and balance. These symptoms may be severe enough to impair walking or even standing. In the worst cases, MS can produce partial or complete paralysis. Most people with MS also exhibit paresthesias, transitory abnormal sensory feelings such as numbness, prickling, or “pins and needles” sensations. Some may also experience pain. Speech impediments, tremors, and dizziness are other frequent complaints. Occasionally, people with MS have hearing loss. Approximately half of all people with MS experience cognitive impairments such as difficulties with concentration, attention, memory, and poor judgment, but such symptoms are usually mild and are frequently overlooked. Depression is another common feature of MS.
Is there any treatment?
There is as yet no cure for MS. Many patients do well with no therapy at all, especially since many medications have serious side effects and some carry significant risks. However, three forms of beta interferon (Avonex, Betaseron, and Rebif) have now been approved by the Food and Drug Administration for treatment of relapsing-remitting MS. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. The FDA also has approved a synthetic form of myelin basic protein, called copolymer I (Copaxone), for the treatment of relapsing-remitting MS. Copolymer I has few side effects, and studies indicate that the agent can reduce the relapse rate by almost one third. An immunosuppressant treatment, Novantrone (mitoxantrone), is approved by the FDA for the treatment of advanced or chronic MS. The FDA has also approved dalfampridine (Ampyra) to improve walking in individuals with MS.
One monoclonal antibody, natalizumab (Tysabri), was shown in clinical trials to significantly reduce the frequency of attacks in people with relapsing forms of MS and was approved for marketing by the U.S. Food and Drug Administration (FDA) in 2004. However, in 2005 the drug’s manufacturer voluntarily suspended marketing of the drug after several reports of significant adverse events. In 2006, the FDA again approved sale of the drug for MS but under strict treatment guidelines involving infusion centers where patients can be monitored by specially trained physicians.
While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some patients. Spasticity, which can occur either as a sustained stiffness caused by increased muscle tone or as spasms that come and go, is usually treated with muscle relaxants and tranquilizers such as baclofen, tizanidine, diazepam, clonazepam, and dantrolene. Physical therapy and exercise can help preserve remaining function, and patients may find that various aids — such as foot braces, canes, and walkers — can help them remain independent and mobile. Avoiding excessive activity and avoiding heat are probably the most important measures patients can take to counter physiological fatigue. If psychological symptoms of fatigue such as depression or apathy are evident, antidepressant medications may help. Other drugs that may reduce fatigue in some, but not all, patients include amantadine (Symmetrel), pemoline (Cylert), and the still-experimental drug aminopyridine. Although improvement of optic symptoms usually occurs even without treatment, a short course of treatment with intravenous methylprednisolone (Solu-Medrol) followed by treatment with oral steroids is sometimes used.
What is the prognosis?
A physician may diagnose MS in some patients soon after the onset of the illness. In others, however, doctors may not be able to readily identify the cause of the symptoms, leading to years of uncertainty and multiple diagnoses punctuated by baffling symptoms that mysteriously wax and wane. The vast majority of patients are mildly affected, but in the worst cases, MS can render a person unable to write, speak, or walk. MS is a disease with a natural tendency to remit spontaneously, for which there is no universally effective treatment.
What is Occipital Neuralgia?
Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Typically, the pain of occipital neuralgia begins in the neck and then spreads upwards. Some individuals will also experience pain in the scalp, forehead, and behind the eyes. Their scalp may also be tender to the touch, and their eyes especially sensitive to light. The location of pain is related to the areas supplied by the greater and lesser occipital nerves, which run from the area where the spinal column meets the neck, up to the scalp at the back of the head. The pain is caused by irritation or injury to the nerves, which can be the result of trauma to the back of the head, pinching of the nerves by overly tight neck muscles, compression of the nerve as it leaves the spine due to osteoarthritis, or tumors or other types of lesions in the neck. Localized inflammation or infection, gout, diabetes, blood vessel inflammation (vasculitis), and frequent lengthy periods of keeping the head in a downward and forward position are also associated with occipital neuralgia. In many cases, however, no cause can be found. A positive response (relief from pain) after an anesthetic nerve block will confirm the diagnosis.
Is there any treatment?
Treatment is generally symptomatic and includes massage and rest. In some cases, antidepressants may be used when the pain is particularly severe. Other treatments may include local nerve blocks and injections of steroids directly into the affected area.
What is the prognosis?
Occipital neuralgia is not a life-threatening condition. Many individuals will improve with therapy involving heat, rest, anti-inflammatory medications, and muscle relaxants. Recovery is usually complete after the bout of pain has ended and the nerve damage repaired or lessened.
What is Peripheral Neuropathy?
Peripheral neuropathy describes damage to the peripheral nervous system, which transmits information from the brain and spinal cord to every other part of the body.
More than 100 types of peripheral neuropathy have been identified, each with its own characteristic set of symptoms, pattern of development, and prognosis. Impaired function and symptoms depend on the type of nerves — motor, sensory, or autonomic — that are damaged. Some people may experience temporary numbness, tingling, and pricking sensations, sensitivity to touch, or muscle weakness. Others may suffer more extreme symptoms, including burning pain (especially at night), muscle wasting, paralysis, or organ or gland dysfunction. Peripheral neuropathy may be either inherited or acquired. Causes of acquired peripheral neuropathy include physical injury (trauma) to a nerve, tumors, toxins, autoimmune responses, nutritional deficiencies, alcoholism, and vascular and metabolic disorders. Acquired peripheral neuropathies are caused by systemic disease, trauma from external agents, or infections or autoimmune disorders affecting nerve tissue. Inherited forms of peripheral neuropathy are caused by inborn mistakes in the genetic code or by new genetic mutations.
Is there any treatment?
No medical treatments exist that can cure inherited peripheral neuropathy. However, there are therapies for many other forms. In general, adopting healthy habits — such as maintaining optimal weight, avoiding exposure to toxins, following a physician-supervised exercise program, eating a balanced diet, correcting vitamin deficiencies, and limiting or avoiding alcohol consumption — can reduce the physical and emotional effects of peripheral neuropathy. Systemic diseases frequently require more complex treatments.
What is the prognosis?
In acute neuropathies, such as Guillain-Barré syndrome, symptoms appear suddenly, progress rapidly, and resolve slowly as damaged nerves heal. In chronic forms, symptoms begin subtly and progress slowly. Some people may have periods of relief followed by relapse. Others may reach a plateau stage where symptoms stay the same for many months or years. Some chronic neuropathies worsen over time, but very few forms prove fatal unless complicated by other diseases. Occasionally the neuropathy is a symptom of another disorder.
What Is Spinal Stenosis?
Spinal stenosis is a narrowing of spaces in the spine (backbone) that results in pressure on the spinal cord and/or nerve roots. This disorder usually involves the narrowing of one or more of three areas of the spine: (1) the canal in the center of the column of bones (vertebral or spinal column) through which the spinal cord and nerve roots run, (2) the canals at the base or roots of nerves branching out from the spinal cord, or (3) the openings between vertebrae (bones of the spine) through which nerves leave the spine and go to other parts of the body. The narrowing may involve a small or large area of the spine. Pressure on the lower part of the spinal cord or on nerve roots branching out from that area may give rise to pain or numbness in the legs. Pressure on the upper part of the spinal cord (that is, the neck area) may produce similar symptoms in the shoulders, or even the legs (see figs.1, 2, and 3).
Who Gets Spinal Stenosis?
This disorder is most common in men and women over 50 years of age. However, it may occur in younger people who are born with a narrowing of the spinal canal or who suffer an injury to the spine.
What Structures of the Spine Are Involved?
The spine is a column of 26 bones that extend in a line from the base of the skull to the pelvis (see fig. 1). Twenty-four of the bones are called vertebrae. The bones of the spine include 7 cervical vertebrae in the neck; 12 thoracic vertebrae at the back wall of the chest; 5 lumbar vertebrae at the inward curve (small) of the lower back; the sacrum, composed of 5 fused vertebrae between the hip bones; and the coccyx, composed of 3 to 5 fused bones at the lower tip of the vertebral column. The vertebrae link to each other and are cushioned by shock-absorbing disks that lie between them.
The vertebral column provides the main support for the upper body, allowing humans to stand upright or bend and twist, and it protects the spinal cord from injury. Following are structures of the spine most involved in spinal stenosis (see figs.1, 2, 3, and 7).
- Intervertebral disks. Pads of cartilage filled with a gel-like substance that lie between vertebrae and act as shock absorbers.
- Facet joints. Joints located on the back of the main part of the vertebra. They are formed by a portion of one vertebra and the vertebra above it. They connect the vertebrae to each other and permit backward motion.
- Intervertebral foramen (also called neural foramen). An opening between vertebrae through which nerves leave the spine and extend to other parts of the body.
- Part of the vertebra at the back portion of the vertebral arch that forms the roof of the canal through which the spinal cord and nerve roots pass.
- Elastic bands of tissue that support the spine by preventing the vertebrae from slipping out of line as the spine moves. A large ligament often involved in spinal stenosis is the ligamentum flavum, which runs as a continuous band from lamina to lamina in the spine.
- Narrow stem-like structures on the vertebrae that form the walls of the front part of the vertebral arch.
- Spinal cord/nerve roots. A major part of the central nervous system that extends from the base of the brain down to the lower back and that is encased by the vertebral column. It consists of nerve cells and bundles of nerves. The cord connects the brain to all parts of the body via 31 pairs of nerves that branch out from the cord and leave the spine between vertebrae.
- A thin membrane that produces fluid to lubricate the facet joints, allowing them to move easily.
- Vertebral arch. A circle of bone around the canal through which the spinal cord passes. It is composed of a floor at the back of the vertebra, walls (the pedicles), and a ceiling where two laminae join.
- Cauda equina. A sack of nerve roots that continues from the lumbar region, where the spinal cord ends, and continues down to provide neurologic function to the lower part of the body. It resembles a “horse’s tail” (cauda equina in Latin).
What Causes Spinal Stenosis?
The normal vertebral canal (see fig. 4) provides adequate room for the spinal cord and cauda equina. Narrowing of the canal, which occurs in spinal stenosis, may be inherited or acquired. Some people inherit a small spinal canal (see fig. 5) or have a curvature of the spine (scoliosis) that produces pressure on nerves and soft tissue and compresses or stretches ligaments. In an inherited condition called achondroplasia, defective bone formation results in abnormally short and thickened pedicles that reduce the diameter (distance across) of the spinal canal.
Acquired conditions that can cause spinal stenosis are explained in more detail in the sections that follow.
Spinal stenosis most often results from a gradual, degenerative aging process. Either structural changes or inflammation can begin the process. As people age, the ligaments of the spine may thicken and calcify (harden from deposits of calcium salts). Bones and joints may also enlarge: when surfaces of the bone begin to project out from the body, these projections are called osteophytes (bone spurs).
When the health of one part of the spine fails, it usually places increased stress on other parts of the spine. For example, a herniated (bulging) disk may place pressure on the spinal cord or nerve root (see fig. 6). When a segment of the spine becomes too mobile, the capsules (enclosing membranes) of the facet joints thicken in an effort to stabilize the segment, and bone spurs may occur. This decreases the space (neural foramen) available for nerve roots leaving the spinal cord.
Spondylolisthesis, a condition in which one vertebra slips forward on another, may result from a degenerative condition or an accident, or, very rarely, may be acquired at birth. Poor alignment of the spinal column when a vertebra slips forward onto the one below it can place pressure on the spinal cord or nerve roots at that place.
Aging with secondary changes is the most common cause of spinal stenosis. Two forms of arthritis that may affect the spine are osteoarthritis and rheumatoid arthritis.
- Osteoarthritis is the most common form of arthritis and is more likely to occur in middle-aged and older people. It is a chronic, degenerative process that may involve multiple joints of the body. It wears away the surface cartilage layer of joints, and is often accompanied by overgrowth of bone, formation of bone spurs, and impaired function. If the degenerative process of osteoarthritis affects the facet joint(s) and the disk, the condition is sometimes referred to as spondylosis. This condition may be accompanied by disk degeneration, and an enlargement or overgrowth of bone that narrows the central and nerve root canals.
- Rheumatoid Arthritis. Rheumatoid arthritis usually affects people at an earlier age than osteoarthritis does and is associated with inflammation and enlargement of the soft tissues (the synovium) of the joints. Although not a common cause of spinal stenosis, damage to ligaments, bones, and joints that begins as synovitis (inflammation of the synovial membrane which lines the inside of the joint) has a severe and disrupting effect on joint function. The portions of the vertebral column with the greatest mobility (for example, the neck area) are often the ones most affected in people with rheumatoid arthritis.
Other Acquired Conditions
The following conditions that are not related to degenerative disease are causes of acquired spinal stenosis:
- Tumors of the spine are abnormal growths of soft tissue that may affect the spinal canal directly by inflammation or by growth of tissue into the canal. Tissue growth may lead to bone resorption (bone loss due to overactivity of certain bone cells) or displacement of bone.
- Trauma (accidents) may either dislocate the spine and the spinal canal or cause burst fractures that produce fragments of bone that penetrate the canal.
- Paget’s disease of bone is a chronic (long-term) disorder that typically results in enlarged and abnormal bones. Excessive bone breakdown and formation cause thick and fragile bone. As a result, bone pain, arthritis, noticeable bone structure changes, and fractures can occur. The disease can affect any bone of the body, but is often found in the spine. The blood supply that feeds healthy nerve tissue may be diverted to the area of involved bone. Also, structural problems of the involved vertebrae can cause narrowing of the spinal canal, producing a variety of neurological symptoms. Other developmental conditions may also result in spinal stenosis.
- Ossification of the posterior longitudinal ligament occurs when calcium deposits form on the ligament that runs up and down behind the spine and inside the spinal canal (see fig. 7). These deposits turn the fibrous tissue of the ligament into bone. (Ossification means “forming bone.”) These deposits may press on the nerves in the spinal canal.
What Are the Symptoms of Spinal Stenosis?
The space within the spinal canal may narrow without producing any symptoms. However, if narrowing places pressure on the spinal cord, cauda equina, or nerve roots, there may be a slow onset and progression of symptoms. The neck or back may or may not hurt. More often, people experience numbness, weakness, cramping, or general pain in the arms or legs. If the narrowed space within the spine is pushing on a nerve root, people may feel pain radiating down the leg (sciatica). Sitting or flexing the lower back should relieve symptoms. (The flexed position “opens up” the spinal column, enlarging the spaces between vertebrae at the back of the spine.) Flexing exercises are often advised, along with stretching and strengthening exercises.
People with more severe stenosis may have problems with bowel and bladder function and foot disorders. For example, cauda equina syndrome is a severe, and very rare, form of spinal stenosis. It occurs because of compression of the cauda equina, and symptoms may include loss of control of the bowel, bladder, or sexual function and/or pain, weakness, or loss of feeling in one or both legs. Cauda equina syndrome is a serious condition requiring urgent medical attention.
How Is Spinal Stenosis Diagnosed?
The doctor may use a variety of approaches to diagnose spinal stenosis and rule out other conditions.
- Medical history. The patient tells the doctor details about symptoms and about any injury, condition, or general health problem that might be causing the symptoms.
- Physical examination. The doctor (1) examines the patient to determine the extent of limitation of movement, (2) checks for pain or symptoms when the patient hyperextends the spine (bends backwards), and (3) checks for normal neurologic function (for instance, sensation, muscle strength, and reflexes) in the arms and legs.
- X ray. An x-ray beam is passed through the back to produce a two-dimensional picture. An x ray may be done before other tests to look for signs of an injury, tumor, or inherited problem. This test can show the structure of the vertebrae and the outlines of joints, and can detect calcification.
- MRI magnetic resonance imaging). Energy from a powerful magnet (rather than x rays) produces signals that are detected by a scanner and analyzed by computer. This produces a series of cross-sectional images (“slices”) and/or a three-dimensional view of parts of the back. An MRI is particularly sensitive for detecting damage or disease of soft tissues, such as the disks between vertebrae or ligaments. It shows the spinal cord, nerve roots, and surrounding spaces, as well as enlargement, degeneration, or tumors.
- Computerized axial tomography (CAT). X rays are passed through the back at different angles, detected by a scanner, and analyzed by a computer. This produces a series of cross-sectional images and/or three-dimensional views of the parts of the back. The scan shows the shape and size of the spinal canal, its contents, and structures surrounding it.
- A liquid dye that x rays cannot penetrate is injected into the spinal column. The dye circulates around the spinal cord and spinal nerves, which appear as white objects against bone on an x-ray film. A myelogram can show pressure on the spinal cord or nerves from herniated disks, bone spurs, or tumors.
- Bone scan. An injected radioactive material attaches itself to bone, especially in areas where bone is actively breaking down or being formed. The test can detect fractures, tumors, infections, and arthritis, but may not tell one disorder from another. Therefore, a bone scan is usually performed along with other tests.
Who Treats Spinal Stenosis?
Nonsurgical treatment of spinal stenosis may be provided by internists or general practitioners. The disorder is also treated by specialists such as rheumatologists, who treat arthritis and related disorders; neurologists, who treat nerve diseases and pain medicine specialists who treat both arthritic and nerve disorders with nonsurgical and interventional procedures. Orthopaedic surgeons and neurosurgeons also provide nonsurgical treatment and perform spinal surgery if it is required. Allied health professionals such as physical therapists may also help treat patients.
What Are Some Nonsurgical Treatments for Spinal Stenosis?
In the absence of severe or progressive nerve involvement, a doctor may prescribe one or more of the following conservative treatments:
- Nonsteroidal anti–inflammatory drugs (NSAIDs), such as aspirin, naproxen, ibuprofen, or indomethacin, to reduce inflammation and relieve pain.1
- Analgesics, such as acetaminophen, to relieve pain.
- Corticosteroid injections into the outermost of the membranes covering the spinal cord and nerve roots to reduce inflammation and treat acute pain that radiates to the hips or down a leg.
- Anesthetic injections, known as nerve blocks, near the affected nerve to temporarily relieve pain.
- Restricted activity (varies depending on extent of nerve involvement).
- Prescribed exercises and/or physical therapy to maintain motion of the spine, strengthen abdominal and back muscles, and build endurance, all of which help stabilize the spine. Some patients may be encouraged to try slowly progressive aerobic activity such as swimming or using exercise bicycles.
- A lumbar brace or corset to provide some support and help the patient regain mobility. This approach is sometimes used for patients with weak abdominal muscles or older patients with degeneration at several levels of the spine.
1Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People age 65 and older, as well as those with any history of ulcers or gastrointestinal bleeding, should use NSAIDs with caution.
What Are Some Alternative Therapies for Spinal Stenosis?
Alternative (or complementary) therapies are diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Some examples of these therapies used to treat spinal stenosis follow:
- Chiropractic treatment. This treatment is based on the philosophy that restricted movement in the spine reduces proper function and may cause pain. Chiropractors may manipulate (adjust) the spine to restore normal spinal movement. They may also employ traction, a pulling force, to help increase space between the vertebrae and reduce pressure on affected nerves. Some people report that they benefit from chiropractic care. Research thus far has shown that chiropractic treatment is about as effective as conventional, nonoperative treatments for acute back pain.
- This treatment involves stimulating certain places on the skin by a variety of techniques, in most cases by manipulating thin, solid, metallic needles that penetrate the skin. Research has shown that low back pain is one area in which acupuncture has benefited some people.
More research is needed before the effectiveness of these or other possible alternative therapies can be definitively stated. Health care providers may suggest these therapies in addition to more conventional treatments.
Minimally Invasive Lumbar Decompression MILD. This procedure involves removing excess tissue around the spine in order to increase the space for the spinal nerves, resulting in decreased pain. Please see http://www.vertosmed.com for more information. Your physicians at Blue Ridge Pain Management can perform this same day procedure.
When Should Surgery Be Considered and What Is Involved?
In many cases, the conditions causing spinal stenosis cannot be permanently altered by nonsurgical treatment, even though these measures may relieve pain for a period of time. To determine how much nonsurgical treatment will help, a doctor may recommend such treatment first. However, surgery might be considered immediately if a patient has numbness or weakness that interferes with walking, impaired bowel or bladder function, or other neurological involvement. The effectiveness of nonsurgical treatments, the extent of the patient’s pain, and the patient’s preferences may all factor into whether or not to have surgery.
The purpose of surgery is to relieve pressure on the spinal cord or nerves and restore and maintain alignment and strength of the spine. This can be done by removing, trimming, or adjusting diseased parts that are causing the pressure or loss of alignment. The most common surgery is called decompressive laminectomy: removal of the lamina (roof) of one or more vertebrae to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disk. Various devices may be used to enhance fusion and strengthen unstable segments of the spine following decompression surgery.
Patients with spinal stenosis caused by spinal trauma or achondroplasia may need surgery at a young age. When surgery is required in patients with achondroplasia, laminectomy (removal of the roof) without fusion is usually sufficient.
What Are the Major Risks of Surgery?
All surgery, particularly that involving general anesthesia and older patients, carries risks. The most common complications of surgery for spinal stenosis are a tear in the membrane covering the spinal cord at the site of the operation, infection, or a blood clot that forms in the veins. These conditions can be treated but may prolong recovery. The presence of other diseases and the physical condition of the patient are also significant factors to consider when making decisions about surgery.
What Are the Long-Term Outcomes of Surgical Treatment for Spinal Stenosis?
Removal of the obstruction that has caused the symptoms usually gives patients some relief; most patients have less leg pain and are able to walk better following surgery. However, if nerves were badly damaged before surgery, there may be some remaining pain or numbness or no improvement. Also, the degenerative process will likely continue, and pain or limitation of activity may reappear after surgery. NIAMS-supported researchers have published results from the Spine Patient Outcomes Research Trial (SPORT), the largest trial to date comparing surgical and non-surgical interventions for the treatment of low back and associated leg pain caused by spinal stenosis. The study found that for patients with spinal stenosis, surgical treatment was more effective than non-surgical treatment in relieving symptoms and improving function. However, the functional status of patients who received non-surgical therapies also improved somewhat during the study.
Pelvic Pain Overview
“Pelvic pain” is a general term used to describe pain that occurs mostly or only in the region below a woman’s belly button. This type of pain is a common reason women seek medical care. The pain can be steady, or it can come and go. Severe pain can interfere with daily living and quality of life. Many health problems can cause pelvic pain, yet the exact cause often is not known. Treatment depends on what triggers the pain, how intense the pain is, and how often the pain occurs. The NICHD conducts and supports research on many disorders that cause or are associated with pelvic pain. NICHD scientists are seeking to understand more fully why some women have pelvic pain, how pelvic pain affects functional abilities and quality of life, and which treatments are effective for pain-causing conditions.
For more information about this topic, select the Condition Information, Research Information, Clinical Trials, or Resources and Publications link in the menu on the left.
- Pelvic pain
Medical or Scientific Name
- Chronic pelvic pain
Pelvic pain has many possible causes, including:
- Adhesions, or tissue that grows between organs in the abdomen
- Endometriosis (pronounced en-doh-mee-tree-OH-sis)
- Painful bladder syndrome, also called interstitial cystitis (pronounced IN-tur-STISH-uhl siss-TY-tiss)
- Irritable bowel syndrome
- Pelvic floor disorders
- Uterine fibroids (pronounced YOO-ter-in FAHY-broidz)
- Vulvodynia (pronounced vuhl-voh-DIN-ee-uh)
Number of Women Affected
About 15% of women of childbearing age in the United States report having pelvic pain that lasts at least 6 months.
Pain occurs mostly or only in the region below a woman’s belly button. Women describe the pain they feel in many different ways. Severe pain can interfere with daily living and quality of life.
Treatments for pelvic pain include:
- Pain medication, such as pain relievers, muscle relaxants, and antidepressants
- Physical therapy
- Hormonal medications, such as birth control pills
What is Shingles?
Shingles (herpes zoster) is an outbreak of rash or blisters on the skin that is caused by the same virus that causes chickenpox — the varicella-zoster virus. The first sign of shingles is often burning or tingling pain, or sometimes numbness or itch, in one particular location on only one side of the body. After several days or a week, a rash of fluid-filled blisters, similar to chickenpox, appears in one area on one side of the body. Shingles pain can be mild or intense. Some people have mostly itching; some feel pain from the gentlest touch or breeze. The most common location for shingles is a band, called a dermatome, spanning one side of the trunk around the waistline. Anyone who has had chickenpox is at risk for shingles. Scientists think that in the original battle with the varicella-zoster virus, some of the virus particles leave the skin blisters and move into the nervous system. When the varicella-zoster virus reactivates, the virus moves back down the long nerve fibers that extend from the sensory cell bodies to the skin. The viruses multiply, the tell-tale rash erupts, and the person now has shingles.
Is there any treatment?
The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with antiviral drugs, which include acyclovir, valcyclovir, or famcyclovir. Antiviral drugs may also help stave off the painful after-effects of shingles known as postherpetic neuralgia. Other treatments for postherpetic neuralgia include steroids, antidepressants, anticonvulsants, and topical agents.
In 2006, the Food and Drug Administration approved a VZV vaccine (Zostavax) for use in people 60 and older who have had chickenpox. In March 2011, the FDA extended the approval to inlcude adults 50 to 59 as well. Researchers found that giving older adults the vaccine reduced the expected number of later cases of shingles by half. And in people who still got the disease despite immunization, the severity and complications of shingles were dramatically reduced. The shingles vaccine is a preventive therapy and not a treatment for those who already have shingles or postherpetic neuralgia.
What is the prognosis?
For most healthy people who receive treatment soon after the outbreak of blisters, the lesions heal, the pain subsides within 3 to 5 weeks, and the blisters often leave no scars. However, shingles is a serious threat in immunosuppressed individuals — for example, those with HIV infection or who are receiving cancer treatments that can weaken their immune systems. People who receive organ transplants are also vulnerable to shingles because they are given drugs that suppress the immune system.
A person with a shingles rash can pass the virus to someone, usually a child, who has never had chickenpox, but the child will develop chickenpox, not shingles. A person with chickenpox cannot communicate shingles to someone else. Shingles comes from the virus hiding inside the person’s body, not from an outside source.
What is Trigeminal Neuralgia?
Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that causes extreme, sporadic, sudden burning or shock-like face pain. The pain seldom lasts more than a few seconds or a minute or two per episode. The intensity of pain can be physically and mentally incapacitating. TN pain is typically felt on one side of the jaw or cheek. Episodes can last for days, weeks, or months at a time and then disappear for months or years. In the days before an episode begins, some patients may experience a tingling or numbing sensation or a somewhat constant and aching pain. The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. TN occurs most often in people over age 50, but it can occur at any age, and is more common in women than in men. There is some evidence that the disorder runs in families, perhaps because of an inherited pattern of blood vessel formation. Although sometimes debilitating, the disorder is not life-threatening.
The presumed cause of TN is a blood vessel pressing on the trigeminal nerve in the head as it exits the brainstem. TN may be part of the normal aging process but in some cases it is the associated with another disorder, such as multiple sclerosis or other disorders characterized by damage to the myelin sheath that covers certain nerves.
Is there any treatment?
Because there are a large number of conditions that can cause facial pain, TN can be difficult to diagnose. But finding the cause of the pain is important as the treatments for different types of pain may differ. Treatment options include medicines such as anticonvulsants and tricyclic antidepressants, surgery, and complementary approaches. Typical analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN. If medication fails to relieve pain or produces intolerable side effects such as excess fatigue, surgical treatment may be recommended. Several neurosurgical procedures are available. Some are done on an outpatient basis, while others are more complex and require hospitalization. Some patients choose to manage TN using complementary techniques, usually in combination with drug treatment. These techniques include acupuncture, biofeedback, vitamin therapy, nutritional therapy, and electrical stimulation of the nerves.
What is the prognosis?
The disorder is characterized by recurrences and remissions, and successive recurrences may incapacitate the patient. Due to the intensity of the pain, even the fear of an impending attack may prevent activity. Trigeminal neuralgia is not fatal.