Patients with back pain have no shortage of minimally invasive treatment options, many of which are offered by pain specialists in Cleveland Clinic’s Department of Pain Management. The diverse interventions are aimed at restoring function and alleviating pain, even in patients with complex causes of back pain.
When conservative measures (such as oral pain medications and physical therapy) fail to adequately relieve back pain, or if red-flag signs (e.g., weakness) are present, referral for evaluation by a pain specialist should be considered. So says Shrif J. Costandi, MD, staff physician in the Department of Pain Management.
“Back pain can have nonmalignant and malignant causes,” says Dr. Costandi, “and the specific therapy must be matched to the cause.” Below is a rundown of interventions considered by Dr. Costandi and his colleagues based on the underlying cause of back pain.
Facet arthropathy is a common cause of axial back pain. If it’s suspected, temporary relief from medial branch blocks can confirm the diagnosis (medial branches are nerves that supply the facet joints and cause pain), at which point pain specialists can proceed to radiofrequency ablation (RFA) of involved nerves for long-term relief. “The average duration of relief from RFA is usually six to nine months,” notes Dr. Costandi.
When radiculopathy is the cause of back pain, epidural steroid injections — either interlaminar or transforaminal — can be effective interventions to facilitate physical therapy and early return to work.
Pain emanating from the sacroiliac (SI) joint can be managed by SI joint steroid injections and physical therapy to strengthen core muscles. If SI joint injections provide relief but the effect is temporary, RFA of the lateral sacral branches may be offered.
Discogenic pain is confirmed with provocative discography, which also identifies the disrupted discs. Two new treatments offered for discogenic pain are biacuplasty and fibrin sealant injections (via the Biostat® System). Biacuplasty with the TransDiscal™ System is a minimally invasive procedure that applies radiofrequency heat through probes to the annulus of the disc to destroy painful nerve fibers. Changes in collagen fibers induced by biacuplasty may also improve disc stability. Fibrin sealant is a biologic tissue that, when applied to a disrupted disc, seals the disruption, restores disc height and encourages tissue repair. The Department of Pain Management is participating in clinical studies of the fibrin sealant; results from data analysis are promising, Dr. Costandi says.
For postlaminectomy syndrome, or persistent pain after spinal surgery, pain relief and improved function may be provided by a multidisciplinary approach that combines injections, physical therapy, psychological support and optimal medical management. If this is insufficient or provides only temporary relief, the patient may be a candidate for a trial of spinal cord stimulation. If the trial improves function and reduces pain and medication requirements, permanent implantation of the spinal cord stimulator is considered. An emerging option under study at Cleveland Clinic and just a few other centers worldwide is dorsal root ganglion stimulation, in which only the dorsal root ganglia at the exiting nerve roots are stimulated (vs. the entire dorsal sensory column of the spinal cord), allowing for more sophisticated stimulation and coverage.
For pain from spinal stenosis, if conservative management is inadequate, the first option is epidural steroid injections plus physical therapy. Decompression surgery has traditionally been considered next-line therapy, but an outpatient procedure called mild® (minimally invasive lumbar decompression) is now available. Objective improvements in standing time and walking distance have been recorded in studies of mild at Cleveland Clinic. “Patients who could barely stand for 10 minutes were up and moving around for several hours following mild,” says Dr. Costandi. “Some patients can walk a mile or two after being able to walk only 200 or 300 feet. Many can drop their canes, too.”
For intractable back pain, delivery of opioids and local anesthetics to the cerebrospinal fluid through an intrathecal pump may be tried as a last option.
Back Pain of Malignant Origin
Vertebral compression fractures can have nonmalignant (osteoporosis) as well as malignant causes. Painful fractures can be treated with kyphoplasty, a minimally invasive procedure in which cement is injected into the vertebral body to restore vertebral height and reduce pain.
Pain from vertebral metastases may be managed by a novel technique using the OsteoCool™ System, which employs water-cooled radiofrequency probes to ablate malignant bone tissue. OsteoCool therapy is an option for patients in whom radiotherapy and opioids provide inadequate relief. “Patients’ pain levels and disability scores were improved significantly,” notes Dr. Costandi.
Choice and Collaboration Are Key
The ability to choose from many interventions is key to successful individualized back pain management, says Dr. Costandi. So is collaboration. “We refer patients to physical therapy to supplement most medical interventions. If there is any psychological component, our patients are seen by a pain psychologist for behavioral modification or stress-coping techniques. A multidisciplinary approach is the best way to deal with chronic pain.”
Dr. Costandi sees patients at Cleveland Clinic’s main campus and the Richard E. Jacobs Health Center in Avon. He can be reached at 216.444.8455.