Treating Low Back Pain – What really works?

Author: Dr. Nitin Khanna, MD

Back pain leads to a significant amount of time off work for employees at a substantial cost to employers and the society at large. The main goal in treating patients suffering from this pervasive health issue is to facilitate their return to work in a safe and expeditious manner.

The first and most critical step in treating patients complaining of back pain is to make an accurate diagnosis and identify the source of their pain. There are many possible pain generators -- the patient’s symptoms may emanate from their intervertebral disc, facet joint, fracture of the vertebral body, muscle, or even the sacroiliac joint. In over 90% of patients, we are able to make the diagnosis based on the patient’s history and a thorough physical exam. X-rays are then used to confirm this diagnosis. In most cases, an MRI is not necessary and tends to be overutilized.  

The next step after making a comprehensive and accurate diagnosis is to institute a targeted treatment plan to address the pain generator. For the majority of patients, a treatment plan involving modified work duty, anti-inflammatory medications, and physical therapy is sufficient, and no further treatment is necessary.

Facet injections and radiofrequency ablations are occasionally beneficial, but tend to offer short-term relief. However, in some cases these can be very useful in determining the pain generator, thereby facilitating physical therapy. A common misconception is that epidural injections are effective in the treatment of low back pain. In reality, there is no data to support the use of epidural injections for the treatment of low back pain.

Surgical intervention is recommended in only a small proportion of patients, and should be considered only after a long course of non-operative treatment. Good surgical outcomes for patients with low back pain are strongly correlated with careful patient selection, excellent surgical technique, and early and aggressive postoperative rehabilitation. While micro-discectomy’s typically provide predictable outcomes, spinal fusions have yielded less than perfect results. However, fusion operations do work in properly selected patients. Some of the newer, minimally-invasive spine fusion techniques are an advance from a post-operative morbidity standpoint, but have not demonstrated a significant improvement in clinical outcomes. The newer motion-sparing, artificial disc replacement options are also exciting, but clinical data does not suggest that they offer any improvement over fusion. The future seems bright for significant advancement in these areas.

Early and aggressive postoperative rehabilitation is critical to ensuring successful surgical outcomes. We recommend rehab starting at 2-weeks post-op, followed by work conditioning for 3-weeks, if needed, starting at 3 to 4 months post-op. By doing so, our patients are typically able to return to work full-duty within 5 to 6 months. Depending on light-duty availability, many patients are able to return to work much sooner.

A comprehensive spine-care system is critical to delivering optimal care for patients with low back pain. The treating team must be proficient in making an accurate diagnosis and must also be knowledgeable about entire spectrum of spine-care options to recommend an appropriate treatment modality for each patient.

Dr. Nitin Khanna is a Board certified and Fellowship trained Spine surgeon. Dr. Khanna completed his Spine Fellowship from the prestigious RUSH Presbyterian Hospital in Chicago. He completed his Orthopaedic and Spine training at the world renowned Washington University in St. Louis. He can be reached at Spine Care Specialists at 219-924-3300.