Surgery for spinal conditions is always a last resort, and a course of action that we recommend only after all nonsurgical therapies have been exhausted without results, or if permanent neurological damage is immanent unless we perform surgery. Even though we are a surgical practice, we send more patients for nonsurgical treatments than we recommend for surgery, year after year, in keeping with these principles.
Nonsurgical treatments that we commonly recommend are listed below.
The human body has a remarkable ability to heal itself if given the chance. Since many spinal conditions can be the result of repetitive stress on the spine and its joints, it is very important to take a break from activities that may exacerbate your condition for at least 4-6 weeks. During this period of time, we often recommend the same restrictions that we recommend for our postoperative patients; that is, no bending, twisting, or lifting over 10-20 pounds of weight. For lumbar disc herniations, for example, studies have shown that approximately over 80% of patients will improve within 6 weeks with activity restrictions and medical management alone.
Medications that we commonly prescribe for spinal conditions fall into four broad categories: nonsteroidal anti-inflammatories, steroidal anti-inflammatories, muscle relaxants, and narcotic analgesics.
Nonsteroidal anti-inflammatories, or NSAIDSs, such as ibuprofen (Motrin) and naprosyn (Aleve) are generally useful in patients with arthritis that affects any part of the body, and the spine is no exception. Pain from spinal conditions often arises from inflammation of the muscles and the joints of the spine, as well as inflammation of the nerves coming from it. We often recommend a 4-6 week trial of NSAIDs, and encourage continued use of NSAIDs if significant pain relief is achieved. As NSAIDs can commonly cause gastrointestinal side effects such as ulcer formation, we recommend over-the-counter H2 blockers such as famotidine (Pepcid) or ranitidine (Zantac) for patients who are sensitive to the effects of NSAIDs.
Steroidal anti-inflammatories have similar effects as NSAIDs but are more potent. We commonly prescribe a tapered “Medrol Dosepac” for patients in severe pain, and with much success. Since chronic steroid use can have serious side effects such as peptic ulcer disease, body weight redistribution, mood changes, muscle weakness, skin ulcerations, and suppression of the immune system, we tend to use steroids cautiously, and for short periods of time only.
At least a small part, and, in many instances, a large part of the pain that our patients experience can be attributed to muscle spasm, which is often described by patients as a burning, writhing pain that can radiate from the spine and into the arms and legs. When this is the case, muscle relaxants, such as cyclobenzaprine (Flexeril), methocarbamol (Robaxin), or diazepam (Valium) are extremely helpful.
Narcotic analgesics, such as hydrocodone (Norco, Vicoden) and tramadol (Ultram) are always a medical last resort for managing pain from spinal conditions. This is because they have a relatively high potential for tolerance and addiction. We tend to use these for short periods only, and typically defer the management of patients using long-term narcotics or strictly regulated narcotics such as oxycodone (Percocet) to pain management specialists.
External Orthoses (Braces)
We commonly cervical collars and thoracic or lumbar braces after cervical and lumbar surgery, though they can also be instrumental in avoiding surgery for patients with a degree of spinal instability. We typically advise patients to use a collar or brace whenever they are engaged in upright activities that may exacerbate their pains. Because prolonged use of a collar or brace can cause deconditioning of the muscles of the neck and back, we typically limit the use of orthoses to 2-3 months, unless absolutely necessary.
Physical therapy can be separated into active and passive regimens. Active physical therapy tends to focus on muscle strengthening, while passive physical therapy has the goal of stretching and relaxing muscles, while widening the neural foramina through which nerve roots travel. We tend to prescribe passive physical therapy for most patients, and typically prescribe heat, traction, and massage for at least 6-8 weeks. This type of regimen has been extremely successful for patients with cervical disc herniations, and moderately successful in patients with lumbar disk herniations.
We generally prescribe active physical therapy for patients who have persistent weakness in spite of maximal medical and surgical management.
Injections involve the injection of steroids and analgesics (such as Lidocaine) into specifically targeted areas of the spine. In an epidural injection, the steroid/analgesic compound placed near a nerve root in order to decrease inflammation in it. In a facet injection, a joint called the facet is injected in order to relieve pain and inflammation caused by arthritis in that joint. Both interventions are typically performed by a pain management specialist, who may perform them at regular intervals for several months, depending on the situation.
These types of injections can be useful in controlling a patients’s while his or her body goes on to heal itself over a 6-8 week period. They are useful not only as a therapy, but also as a diagnostic measure for patients who may have several levels of spinal disease, but only a few levels of symptomatic disease. If, for example, a patient’s pain is improved after an injection at a certain level, we can be confident that that level is a pain generator, and will be more apt to perform an operation at that level than another, asymptomatic level.