The following are some questions physicians are asked most frequently about back and neck pain diagnoses and treatment.  Other questions may occur to you as you talk to your physician or other health-care provider.

Q: Why is my back or neck pain worse in the morning?
A: If your pain involves your intervertebral discs, it can worsen in the morning after lying down for the night. This is because your discs now have a chance to rehydrate (absorb fluids) and enlarge after being compressed from the weight of your body all day. This swelling tends to irritate any compressed nerve that is causing you pain.

Similarly, if muscle pain is involved, the muscles can stiffen overnight, resulting in painful movement in the morning as the stiffness is worked out. 

Q: Why does my doctor tell me to rest for several days instead of doing something more to find out what is wrong with my back?
A: There are a few reasons why it is better to rest your back for a while, treat the pain symptomatically with analgesics, and hope the pain goes away by itself. First, the International Association for the Study of Pain (IASP) Back Pain in the Workplace taskforce found that 50 percent of all back pain will go away after a week of rest. Even more striking, 90-95 percent of pain complaints will go away within a month, according to the IASP report. The discomfort itself actually helps you get better by forcing you to stop doing things that aggravate the condition causing the pain. And this helps in the healing process.  However, there is also evidence that lying down for more than 4 days is associated with a worse outcome than gradually increasing activity after a few days of rest.   So the best strategy is to rest for a few days, using analgesics such as NSAIDs to relieve the pain, and then to increase your activities gradually.

Q: I'm not sure I understand how a  "continuum of care" applies to me. Can you give me an example?
A: A continuum of care is a course of treatment that begins with the simplest treatment options and then progresses to stronger more potent therapy if the condition, in this case pain, fails to respond.  For example, if you have a radiating back pain that did not begin with a traumatic injury such as an accident, here is what your continuum of care might look like, depending upon response to treatment:

·         Typically the first treatments would be physical therapy, medications and stretching exercises.  (See medications and physical therapy.)

·         If the pain persists, a thorough diagnostic workup would be in order. This might include a history and physical examination, X-rays, assessment of medications and, possibly, flexion/extension studies, a computerized tomography (CT) scan of the affected and a Magnetic Resonance Imaging (MRI) scan.

·         While medications and physical therapy continue, in the case of nerve-related pain, a series of three epidural steroid injections might be the next course of treatment.  In the case of muscle pain, trigger point therapy, using injections, might be followed by icing and stretching exercises.  In either case, the injections should be continued only if effective, and repeated steroid injections (more than three in a six-month series) should be avoided.

·         At this point, you and your physician should evaluate whether you need to expand your therapy to include other options. A multi-disciplinary approach that coordinates different treatments, such as appropriate use of different types of medications, physical therapies and psychological therapies, will, in general, improve your chances of recovery.

·         If the comprehensive approach indicated above is not effective, further evaluation of the three divisions of the spine (anterior, vertebral body and disc, spinal cord structures with its nerves and posterior – facets, ligaments, muscles) may be considered. Appropriate therapies at this stage may be spinal cord stimulation, spinal narcotics, or lysis (breaking up) of the adhesions (scar tissue, or a similar binding of tissues to nerves).

Continuum of care also must consider treatment of the emotional problems, such as depression and anxiety, that are often triggered by chronic pain.  These problems worsen pain by interfering with your body's own pain control mechanisms; if not managed right away, they will interfere with the effects of treatment and your ability to recover from painful conditions.  Your physician may treat these conditions with medications, or refer you to an appropriate mental health professional for counseling and medication treatment.  It is very important that you treat these problems right away, not delay treatment in the hope that these problems will just "go away".  (See psychosocial section.)

Q: Which local anesthetic is best to use for injections and blocks?
A: There is no ‘best' local anesthetic. The anesthetic used depends upon the situation.  Anesthetics vary by how long they last so the choice depends upon how long it will take for the procedure to be performed.

Q: Why do you use dye in certain diagnostic procedures?
A: Dye provides a way to contrast how fluid is flowing or spreading in the area injected. If there is no flow, then these are probable areas of obstruction that may be causing your pain. The dye or contrast agent shows up as opaque, or dark, on an X-ray screen. If you have an allergy to iodine or other contrast materials, be sure to tell your physician prior to the test.

Q: What will be injected?
A:  The injected agent depends on the procedure being performed. In the caudal neuroplasty technique (also know as the Racz technique), the injected materials may include a non-ionic contrast medium, Wydase, a normal saline solution, a local anesthetic, a steroid, and perhaps a hypertonic saline that will also work to decrease inflammation.  In the epidural steroid injection procedure, the injected materials may include a steroid, or a steroid with a local anesthetic, and perhaps a normal saline solution.

Q: What will happen during the procedure?
A: Much depends on the type of procedure and where on your body it is taking place.

·         If the problem is on the posterior (back) side of the spine, then it could be a facet joint, and you probably will receive an injection such as those described above. If appropriate, you may undergo RFTC of the sensory nerve. RFTC is short for Radio Frequency Thermal Coagulation. This is a procedure done to relieve pain by destroying part of the sensory nerve going to a specific joint.

·         If the purpose of the procedure is to break up scar tissue, a caudal neuroplasty may be performed.  Surgery also is an option for posterior spine problems. 

·         If the problem is on the anterior (front) side of the spine, then a vertebroplasty may be performed or a discogram used to identify a potential disc problem. Other procedures for this type of problem include: IDET or Interdiscal electrothermocoagulation, a procedure whereby a disc is cauterized or heated to seal a rupture; or surgical stabilization or fusion. This is a surgical procedure using bone grafts, metal pins, screws and cages to stabilize an unstable back.

Q: What does it mean to perform a "block?"
A: Pain is caused by nerves and the sensation of pain is a sensory response to what is happening to those nerves. Temporary and more permanent nerve blocks are used to control pain. Sensory and sympathetic nerves may be temporarily blocked using an injection procedure, while a neurolytic nerve block is a more permanent measure that lesions, or "kills", the affected portion of the nerve and the feeling below it.

Q: How do you know where a nerve is just from looking at an X-ray, which only shows bones?
A:  Most standard X-rays cannot show soft tissue, only bone or other hard tissues.  However, along with the fluoroscope's fast generation of pictures, contrast dyes can help pinpoint problem areas. In addition, a Magnetic Resonance Imaging (MRI) scan can show soft tissues such as nerves, muscles and other connective tissue. Many of these more sophisticated "X-ray" devices are used to diagnose nerve and other soft tissue problems.

Q: Will I have too much radiation exposure from the fluoroscope in the epidural neuroplasty procedure?
A: While the amount of radiation from the procedure is important if you are pregnant, it is otherwise considered minimal. In fact, the amount of radiation you receive is roughly equivalent to sitting out in the sun or in front of the television set. This is very different than the amount of radiation you might receive undergoing a cancer treatment.

Q: What if I have allergies?
A: Be sure to inform your physician about your allergies so that appropriate alternative substances can be chosen. Often contrast agents containing iodine are used for X-ray procedures. Be sure to tell your health-care provider if you are allergic to shellfish or have had a reaction to radiographic "dyes." If this is the case, contrast materials could cause a life-threatening allergic reaction.

Q: When do I need which pain treatment?
A: The choice of a particular treatment option depends on where you are in your continuum of care (whether you have exhausted the simpler treatments), the advice of your physician, and, perhaps, consultations with other health-care professionals.

Q: How long do some of these procedures provide pain relief? Will they have to be redone and, if so, how often?
A: They all vary.  For example:

·         The neuroplasty techniques should provide relief for at least two to three months, but often provide relief for longer than a year.

·         A steroid injection can only be done for six to eight doses, and can last two to three weeks.

·         A spinal cord stimulator (SCS) is a more permanent technique that need only be done one to two times. An electrode placed over the afflicted sensory fibers on the spinal column is constantly stimulated to mask the sensation of pain.

·         An intrathecal drug infusion system can administer any drug into the intrathecal area. Its purpose will vary slightly depending upon the drug. Morphine, hydromorphone (Dilaudid), and other medications or a combination of medications can mask the pain response. Clonidine will reduce your pain receptor's response to the pain, while a local anesthetic will be infused to decrease nerve irritation.

·         For a disc problem, an IDET or RFTC or a discectomy may last several months or forever.

·         A facet joint problem can be treated with injections that last from several hours to two-three months. With RFTC lesioning, the procedure may provide relief for several months.  However, lesioning, or burning, the nerve too frequently can result in neuritis, a nerve inflammation.

Q: What is the success rate of the neuroplasty procedures?
A: While there is no published data, some specialists report anecdotally that IDET procedures have a success rate of over 60 percent and that lysis of adhesions (freeing the nerves from scars to relieve pain) have a more than an 80 percent success rate at three to six months, and a more than 50 percent success rate at 12 months.  These success rates have been confirmed in published, controlled studies, but such treatment choices must be discussed with your physician.       

Q: What are the risks of the procedure?
A: The inherent risks depend upon the procedure being performed and are the same for both inpatient and outpatient procedures.  However for most procedures the risk is minimal, which means adverse reactions are uncommon.  Prior to the procedure, you will fill out a consent form that lists possible risks associated with the procedure. This is due to the need for full disclosure. Keep in mind that some side effects, such as those arising from the use of a local anesthetic, are temporary and will wear off.  Other risks could include nerve damage that results in numbness, weakness or paralysis, drug interactions, bruising or infections. 

Q: Why are antibiotics used?
A: Antibiotics are used for steroid injections and other invasive procedures mentioned above to help reduce the chances of infection.

Q: What post-treatment care will I need?
A: Immediately after the procedure, you may require drugs for initial post-procedural pain. These may include narcotic medications and non-steroidal anti-inflammatory drugs (NSAIDs).  Mobility exercises that focus on flexion (bending) the spine may be needed for lumbar stabilization for the higher lumbar muscles and stretching exercises can help maintain flexibility of the freed-up nerves.

Q: Why do doctors ask me if I'm taking aspirin, NSAIDs (non-steroidal anti-inflammatory drugs) or blood thinners?
A: These medications can interfere with platelet formation, which in turn can inhibit blood clotting. If such medications are taken prior to spinal injection or surgical procedures, hemorrhaging (profuse loss of blood) and paralysis may occur.