Back Pain and Sciatica
DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of back pain.
Alternative NamesHerniated Disk; Sciatica
Medications and Alternative Treatments
The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). These agents block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Evidence suggests that short term use brings effective relief in patients with acute back pain. Their benefits for chronic back pain are less certain.
There are dozens of NSAIDs. The most common are the following:
Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:
Note on interactions: Of great concern is research suggesting taking NSAIDs with aspirin might reduce the benefits of aspirin or other heart protective drugs. Diabetics taking oral hypoglycemics may need to adjust the dosage if they also need to take NSAIDs because of possible harmful interactions between the drugs.
COX-2 Inhibitors (Coxibs)
Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors, or coxibs. They inhibit an inflammation-promoting enzyme called COX-2. Others, such as etoricoxib, are under investigation. Meloxicam (Mobicox) is a related drug known as a preferential COX-2 inhibitor.
Evidence is increasing that the coxibs are significantly less harmful to the gastrointestinal (GI) tract than common NSAIDs, but they still pose some risk. In an important 2003 study, Celebrex had a significantly better safety record in the GI tract than NSAIDs and had lower rates of ulcers even in patients who needed to also take aspirin prevent heart attacks. Another 2003 study also suggested that rofecoxib was safer for the GI tract than NSAIDs. Some early evidence also suggests that, like NSAIDs, they may be partially protective against colon cancer and possibly even Alzheimer's disease.
In spite of their potential promise, some researchers believe that inhibiting COX-2 may have some negative side effects over the long term. The effects of these drugs on the heart particularly require clarification. The following are possible adverse effects or complications:
Coxibs can interfere with other drugs taken concurrently. Patients taking anticoagulant drugs such as warfarin may experience a higher risk for bleeding with the use of these agents. The use of coxibs can interfere with many other drugs taken concurrently, including lithium, methotrexate, and many others taken for heart disease, high blood pressure, or epilepsy. Patients should discuss all other medications with their physician. Patients should discuss all other medications with their physician.
COX-2 inhibitors are also significantly more expensive than traditional NSAID, costing about $80 per month, compared to about $15 for an NSAID like naproxen. Although they pose a lower risk for ulcers than NSAIDs, this risk is small for most NSAID users, so choosing coxibs may be justified only in patients with evidence of GI bleeding. More research is needed.
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these agents.
Opioid Pain Relievers
Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of pain
There are two types of narcotics:
Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.
Injections of different substances are sometimes used to treat low back pain caused by nerve impingement. The injection is usually an epidural, which is directed into the spaces between the outer membrane of the spine and the vertebrae. None of these substances cure the problem.
A 2002 review of studies concluded that antidepressants may lessen pain severity in some patients, although they had little effect on daily functioning. Some experts suggest that treating people for depression who have both low back pain and depression may be even more beneficial and cost-effective than back treatments. Certain antidepressants, called tricyclics, can even be effective painkillers in non-depressed people with chronic back pain. They include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomill). It should be noted that tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.
A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) are sometimes used for patients with acute low back pain. Evidence as reported in a major 2003 review supported their effectiveness in relieving non-specific low back pain, but experts in the study warned that these drugs should be used cautiously, since their effects occur in the brain, not the muscles. They also added that more comparison studies are needed to determine if they are more effective then common pain relievers. For example, a 2003 study of patients in the emergency room reported no additional pain relief when Flexeril was added to ibuprofen. Patients also experienced a number of central nervous system side effects. Drowsiness and other side effects are common. Some of these drugs, such as Soma, can be addictive and do little more than produce sleep. Of further concern, in some people the tensed back muscles may be protecting the damaged disc or vertebrae, in which case muscle relaxants could be harmful.
Tumor-Necrosis Factor (TNF) Modifiers. TNF modifiers interfere with specific components of tumor-necrosis factor, a powerful immune factor that is important in the inflammatory process and may play role in nerve dysfunction and pain that occurs in sciatica. In one early study, one of these agents, infliximab (Remicade), was associated with significant improvement in sciatica. More research is warranted.
Lidocaine Patch. Lidocaine, a local anesthetic, is available in patch form (Lidoderm) and has been used specifically for herpes zoster pain. Early studies are suggesting that it may provide significant relief for people who suffer from low back pain with very few adverse effects, even with continuous use of four patches a day. If further studies support its benefits, the patch could prove to be an important treatment
NO-NSAIDs. NO-NSAIDs are drugs that combine NSAIDs and nitric oxide (NO), a substance that enhances blood flow to the stomach and increases levels of protective mucus and bicarbonate. These agents show particular promise in providing pain relief and reducing the risk for GI problems and warrant additional investigation.
There have been claims for a number of herbal and so-called natural remedies for relief of back pain. Most herbal remedies that are effective contain active ingredients, just as standard medications do, that relieve pain, relax muscles, or increase circulation. In such cases, they are also likely to have similar side effects. For example, in one trial, the herbal pain reliever white willow bark (Assaliz) was as effective as the COX-2 drug rofecoxib (Vioxx). Willow bark contains the active ingredient found in aspirin and so, theoretically, may have the same adverse effects as NSAIDs. A German study on pain management reported that herbal products containing black current leaf or oils, evening primrose, and borage may be useful and safe for pain due to inflammation. According to another German study, harpagophytum (a South African herb commonly called devil's claw or grapple plant) may be useful for back pain.
Because there are no government regulations of these products, neither the effectiveness nor safety of herbal products can be guaranteed.
According to a 2001 review of studies, only intensive programs that include both psychological and physical rehabilitation therapies were successful in reducing chronic low back pain and improving function. A number of effective approaches to low back pain--called collectively mind-body techniques--employ psychological, behavioral, or physical methods to promote relaxation and reduce stress. Although many may be helpful, evidence is lacking on the specific approaches that would be most successful and which patients would most likely benefit.
Stress Reduction. Stress reducing techniques, including relaxation methods and meditation, may be helpful. One study, for example, reported that meditation was beneficial in reducing pain and improving mood among chronic pain sufferers who had not responded to traditional care. Another found that after three weeks, patients who were in pain after back surgery had less discomfort and slept better after practicing relaxation imagery techniques while listening to music for 25 minutes a day.
Cognitive-Behavioral Therapy. Studies report that a course of cognitive-behavioral therapy helps reduce chronic back pain or at least enhances the patient's ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves and their approach to pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative and, to a degree, a manageable experience among many positive ones. In one study, therapists also taught relaxation techniques and methods to improve posture. The sessions were two and a half hours each week for 12 weeks. More research is needed.
Patient Education and Support Groups. A 2002 study reported that patients with chronic low back pain who participated in an expert-moderated e-mail support and discussion group had less pain and disability after 12 months. An Australian massive public-health campaign that educated patients and doctors about the importance of staying active and dispelled fears about long-term impairment from back pain dramatically reduced disability and worker compensation claims.
A number of well-conducted studies have supported that benefits of massage therapy for patients with chronic or acute back pain, especially when it is combined with exercise and patient education. In fact, one analysis in 2003 suggested it may reduce the costs of care. However, it is usually not covered by insurance.
Spinal Manipulation for Uncomplicated Acute Low Back Pain. Spinal manipulation may be useful for acute back pain that persists beyond two to three weeks. There are a number of variations, but one example of a spinal manipulation technique is the following:
Controversy exists over whether on-going manipulations after a first visit work any better for relieving pain than simply gradually resuming normal activity. Some patients consider spinal manipulation to be highly effective for chronic low back pain as well. A major 2003 analysis, however, reported that current evidence did not support the benefits of spinal manipulation over general medical care or physical therapy for either acute or chronic back pain. (It was better than sham therapy, however.) A large study is underway to determine its value for both acute and chronic low back pain.
Chiropractic or Osteopathy. Spinal manipulations are typically performed by chiropractors, but osteopathic doctors also perform them.
Positive Emotional Effects. Both chiropractors and osteopaths offer verbal assurance and a precise treatment regimen. The direct physical connection through spinal manipulation reinforces the patient-practitioner relationship. The emotional effects of such connections may be as important for healing as the treatments themselves. Chiropractors offer a further psychological advantage, which is availability to their patients. Many medical doctors believe that because low back pain is self-limited and resolves the patient can wait for an appointment. A chiropractor, however, is more likely to see a patient promptly.
Adverse Effects. Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulations is low. It should be strongly noted, however, that serious complications (including stroke or spinal cord or neck injury) have been reported with manipulations of the neck. Although little research has been done on such complications, an English survey indicated that they are more frequent than commonly thought.
Some chiropractors overuse x-rays, particularly those of the full spine, which may have long-term harmful consequences.
Patients should also be aware that some chiropractors use alternative treatments that have not been proven or rigorously studied. All patients should require objective evidence on the benefits of their treatments.
Other Noninvasive Procedures
Vertebral Axial Decompression. Vertebral axial decompression (VAX-D) may reduce pain and improve function in patients with chronic low back pain, including sciatic pain that radiates down the leg. The patient lies face down on a special table, clutching hand grips and wearing a pelvic harness. Movable parts of the contraption exert a traction-like action that alternately decompresses the spine, then relaxes, over one-minute intervals. Each session lasts about 30 minutes, and 10 to 20 sessions on successive days are often required. The procedure is thought to alleviate pain and enhance healing by relieving pressure within the discs, promoting the in-flow of oxygen, fluids, and nutrients to the spinal column. Some evidence supports its benefits, with reported success rates of around 70%. It is not yet covered by most insurers, however, and more studies are needed to confirm its benefits.
Acupuncture. Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small pins or exerting pressure on certain "energy" points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation known as Teh Chi, which brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. In any case, it may be specifically helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who has acupuncture should be sure it is performed in a reputable location with experienced practitioners who use sterilized equipment.
Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) employs a small device delivers electrical stimulation to deep tissues and nerve pathways near the spine. It has shown some initial promise for relief of chronic back pain and may also improve mobility and sleep. Treatment sessions are conducted in the doctors office and last about 30 minutes. The device only became available in 2002, so experience is very limited. A correct pattern of stimulation appears to be important for optimal relief and needs to be determined.
Electric Nerve Stimulation. Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points. The standard procedure is to give 80 to 100 pulses per second for 45 minutes three times a day. The patients are barely aware of the sensation. Although a 2002 analysis of trials could find no direct evidence of benefit, small studies have reported some relief for chronic low back pain from either TENS or PENS. It is not known if these effects are long lasting. Neither approach is helpful for relief of acute low back pain in most patients.
Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax then the process is stopped. Discomfort is minimal. Small studies are reporting some help in relieving a number of condition the cause chronic pain, including low back pain.