Lower Back Pain Resources
Low back pain is a very common health problem worldwide and a major cause of disability – affecting performance at work and general well-being. Low back pain can be acute, sub-acute, or chronic. Though several risk factors have been identified (including occupational posture, depressive moods, obesity, body height and age), the causes of the onset of low back pain remain obscure and diagnosis difficult to make. Back pain is not a disease but a constellation of symptoms.
Low back pain affects people of all ages, from children to the elderly, and is a very frequent reason for medical consultations. The lifetime prevalence of low back pain is estimated at 60% to 70% in industrialized countries, with a one-year prevalence of 15% to 45%. Prevalence increases and peaks between the ages of 35 and 55.
As the world population ages, low back pain increases due to the deterioration of the intervertebral discs and the development of arthritic degeneration.
Low back pain is the leading cause of disability and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments. Several studies have been performed in Europe to evaluate the social and economic impact of low back pain. In the United Kingdom, low back pain was identified as the most common cause of disability in young adults, with more than 100 million workdays lost per year.
In the United States, an estimated 149 million workdays are lost every year because of low back pain, with total costs estimated to be US$ 100 to 200 billion a year (of which two-thirds is due to lost wages and lower productivity).
Pain from the lumbar spine can present in several ways. Pain can radiate to the buttocks or legs. To a lesser degree, pain can also be referred to the upper back, buttock, or posterior thighs. It is important to evaluate patients with spinal origin pain for cord impingement (myelopathy), radiculopathy, and dangerous underlying causes such as cancer, fractures, and osteomyelitis. As such, identifying the underlying pain generator and accompanying symptoms is essential in creating a differential diagnosis for low back pain.
The lumbar spine is comprised of five bones called vertebrae. Our vertebrae help to provide mobility and stability to your spinal column and also serve as an attachment point for muscles and ligaments. The five lumbar vertebrae increase in size as they descend and are aligned on top of one another in a centered alignment, allowing those vertebrae to carry the larger load transmitted from the head down. These larger vertebrae are also responsible for supporting our muscles and bones during movement. Given such, this region of our spine accounts for many of our most basic activities, including balance and the generation of locomotion (walking and running, etc.)
Above and below each vertebra is an intervertebral disc. The disc serves as the shock absorber between the vertebrae, and takes the load burden from 50% of our body. The back of the vertebra, the intervertebral disc, and the anterior longitudinal ligament form the anterior border of the spinal canal. Defects from these locations can contribute to a contact with exiting nerve roots. Diagnoses include herniated disc with impingement, spinal stenosis, foraminal stenosis, to name a few. The cervical, thoracic, and lumbar spine have their own directional curve. The lumbar spine bends forward, titled lumbar lordosis. This forward curve keeps the discs and muscles in proper alignment, and distributes weight evenly. The lumbosacral joint connects the lumbar spine to the sacrum.
The lumbar spine also serves as an attachment point for muscles. Muscles such as the latissimus, iliospoas, and multifidus muscles attach at various points of the these bones. These movements are performed by the muscles attached in the low back, and may vary depending on strength and flexibility. The most common causes of chronic low back pain are split with 40% or so from the lumbar facet joints and 40% from the lumbar intervertebral discs. 15% or so are from the sacroiliac joint (discussed under buttock pain), and the remaining 5% are from multiple less frequent causes.
Muscle sprain / strain is a common cause of low back pain. Such disorders are self-limiting and usually improve in days to a few weeks. There are conditions which muscle spasm may not improve on their own and may require treatment. When assessing pain from the low back, one of the first questions to ask is ‘does it radiate’. If the answer is ‘no’, then the pain is considered axial low back pain (non-radiating low back pain). The most common causes would be facet joint related pain, pain from the intervertebral discs (also known as discogenic pain), and the sacroiliac joint.
If the pain is radiating into the leg, it is more likely to be related to nerve impingement, which can happen for several reasons. The two most common causes would be a nerve impingement are secondary to a herniated disc or bony overgrowth on the nerve, and the second would be spinal stenosis. When it comes to chronic, non-radiating low back pain, determining the cause of pain starts with the patient history, physical exam findings, if any, and imaging studies such as X-rays or MRI’s.
Intervertebral discs may bulge or herniate and unfortunately prone to degeneration. Degenerative disc disease may start with an initial injury and progress to degeneration, or secondary to over-use or and age-related or genetic condition. Associated disc bulges or herniations may cause nerve irritation or impingement resulting in pain and symptoms as described in our section on radiating pain.
The lumbar medial branch nerve block is performed to confirm that a facet joint is the source of your pain, and therapeutically as well, to decrease pain in the region. The medial branch block is performed by placing less than 0.5 cc of a local anesthetic (numbing agents such as Lidocaine) with or without a small amount of steroid on the nerve.
The diagnostic portion of the procedure is determined by the effects of the local anesthetic. If the pain is improved by 80% within minutes of the procedure, then it is diagnostic for facet joints mediated pain. The physiologic action of the local anesthetic is for several hours to a day after the block. Therefore, the most important period diagnostically is the amount of pain relief you achieve over this period. The small amount of steroid may provide a prolonged therapeutic pain relief, however, if the first several hours after the block do not provide relief, it is less important diagnostically.
For your lumbar medial nerve block you have the option to receive medications to relax you. Most patients do not need anesthesia (twilight) because the 25 gauge needles are very thin. The risks are very low and these can be discussed with your physician prior to the procedure.
Using fluoroscopy (real-time x-ray), the physician will guide the needle into the proper area of your cervical spine. Once the needle is positioned near the medial branch nerve, a small amount of the medication is injected onto the medial branch nerve. The entire procedure typically takes less than 10 minutes.
You will be given a pain diary to fill out to document the amount of relief you have from the injection.
Non-Radiating Low Back Pain
To determine treatment options for low back pain that does not radiate, the first step is to come to a differential diagnosis. When it comes to chronic low back pain, or pain that lasts more than 6 months, the most common diagnoses are facet joint mediated pain or pain stemming from the intervertebral discs.
- Degenerative disorders of the lumbar spine
- Lumbar Facet Mediated Pain
- Radiofrequency Ablation
- Degenerative Disc Disease & Discogenic Pain
- Interventional Pain Management Options For DDD
- Spondylolisthesis
- Spondylolisthesis Treatment Options
- Vertebral Compression Fractures
- Vertebral Augmentation-Kyphoplasty and Vertebroplasty
- Minimally Invasive Lumbar Decompression
Degenerative disorders of the spine typically develop over time from over-use, abnormal wear and tear, repeated heavy lifting, or continued bad positioning. Such abnormal wear and tear over time may cause micro-traumas that can weaken soft tissues of the low back. Traumas such as falls, or acceleration deceleration movements such as whiplash are sudden in onset and may present immediately or days to weeks later.
Other findings include:
• Spondylosis is a generalized term to refer to injury to the posterior elements (the joints, spinous process, or ligaments. Lumbar facet osteoarthritis is a common degenerative disorder which would fall into this category.
• Discogenic Pain is pain stemming from the intervertebral discs. This pain typically does not radiate and has correlating imaging on the MRI which shows damage to the discs.
• Osteophytes are bony overgrowths. An osteophyte may irritate or impinge a spinal nerve causing inflammation and pain. Ostephytes that do not contact neural tissue may be asymptomatic as well.
• Radiculitis is pain described as electric or shooting pain in the distribution of a nerve. Disc herniation and osteophyte formation are common causes of radiculitis.
The spine’s joints are called facet joints or zygapophyseal joints. These joints are located on the posterolateral aspect of the lumbar spine and allows us to flex, extend, and rotate. Each facet joint receives nerve supply from the medial branch nerve from the vertebral level above and below the joint. The lumbar facets joins are relatively small, ~1.5cm diameter, and covered in a fibrous capsule. The medial branch nerve is a small sensory branch off the spinal nerve roots that innervates the facet joint. The nerve supplies sensory information from the joint and sends that information to the spinal cord and brain.
As we age, or secondary to repetitive use, injury, and trauma (such as falls or whiplash), the facet joints can develop damage, or wear and tear, and cause pain. The median branch nerve is responsible for sending these signals. The results of these events can ultimately lead to arthritis, as we can happen in other joints of our body.
Facet joint pain can be secondary to back pain and may radiate (travel) into the hips, buttocks, and posterior thighs. While arthritis is commonly detected by x-ray or MRI, the presence of arthritis/facet hypertrophy (increased joint size) does not always mean it is the cause of low back pain. The joints also serve as the posterolateral wall of the spinal canal. When joints get damaged and the cartilage lost, the articulating bones starts to rub against eachother, causing inflammation, and eventual hypertrophy of the joint. When this joint becomes hypertrophied and compress the spinal nerves and cause spinal stenosis and/or foraminal stenosis.
Figure 2. The facet joint anatomy. A. The DRG and nerve root B. The medial branch nerve C. The superior articular facet from the level below D. The superior articular facet from the level above the nerve root.
What is the Lumbar Radiofrequency Ablation Procedure?
The lumbar radiofrequency ablation, or RFA, is a low risk outpatient procedure used to treat chronic pain from the facet joints. The procedure is performed with special needles percutaneously (through the skin), placed over the lumbar medial branch nerves. The nerves for the facet joints are ablated (destroyed) using radiofrequency energy. The nerves are ‘burnt’ using heat generated through radiofrequency waves and special needles that have a tip that heats. These nerves are only responsible for the transmission of pain, so there are usually no other negative effects from eliminating these nerves.
The pain relief from the procedure should be approximately 6-9 months. Unfortunately, these small sensory nerves can regenerate, and the pain can return. At that time the decision can be made to repeat the procedure.
Who is a candidate?
Radiofrequency ablation is a treatment option for patients who have experienced substantial pain relief after the diagnostic portion of the medial branch block injection and have a return of pain. The medial branch block is typically performed twice to confirm the source of pain and to give the patient the best opportunity to improve.
The Lumbar Radiofrequency Ablation Procedure
The procedure is performed in the outpatient setting under fluoroscopy. You do not need anesthesia for the procedure, however, many patients request a relaxing medication or sedation for the procedure and that is an option if requested.
When in the procedural room, you will be laying on your stomach. The fluoroscopy unit is used to visualize the bony landmarks to identify where the medial branch nerves travel.
The skin area is numbed using a local anesthetic. Your physician guides the RFA needle into the proper area of your lumbar spine. Once the needles are positioned in the appropriate area near the medial branch nerve, the radiofrequency generator is used to make sure that only the nerves that transmit pain are contacted. Once this is verified, local anesthetic is placed, and then the nerves are ablated with the special needles and heat.
Our physicians have pioneered a technique to maximize the area of the lesion that is created in the nerve.
We believe the success of our procedure is related to the technique utilized. The radiofrequency ablation is an operator dependent procedure and success is based on accuracy of needle placement. This technique has been adopted by many practitioners and have learned it through the Spine and Pain Institute of NY’s Youtube page, which has been viewed over 250,000 times.
Two-Needle Technique for Lumbar Radiofrequency Medial Branch Denervation: A Technical Note. Chapman KB, Schirripa F, Oud T, Groenen PS, Ramsook RR, van Helmond N. Pain Physician. 2020 Sep;23(5):E507-E516. PMID: 32967401.
Lumbar (low back) degenerative disc disease (DDD) is a common condition in aging adults. The intervertebral discs serve as the spine’s shock absorbers and, as we age, discs gradually dry out, losing strength and resiliency. In most people, these changes are gradual. In fact, many of our patients don’t know they have degenerative disc disease.
Disc degeneration is a normal part of aging, and usually is not a problem. However, DDD can cause discs to lose height and become stiff. When disc height is lost, nerve impingement, bone and joint inflammation, and resultant pain can occur.
Disc degeneration typically causes pain that is relegated to the low back or possible buttocks, unless part of the degenerated disc is impinging on a nerve. The pain is typically worsened with sitting or standing for extended periods and made better with moving around.
Intervertebral Discs
Our Lumbar intervertebral discs serve several functions; they along with the vertebral bodies absorb and distribute stress and weight changes the spine incurs during activity and movement. The discs also allow shifts in pressure absorption as our spine bends. Species are required so to survive, as we need to have a portion of our spine give way to let us make these movements.
Our discs are composed of an outer layer or annular fibrosis; a tough substance that retains the inner disc cushioning material, the nucleus pulposus. The nucleus is avascular and does not contain nerves in the normal state. If the tough, outer annulus fibrosis is compromised, the disc can bulge, and if there is a rupture in the annulus, the disc can herniate.
There nucleus pulposus contains a soft, jelly like substance which provides much of the shock absorbing characteristics mentioned. Once there is damage to the outer layers of the disc, such as an annular tear or disc herniation, the nucleus pulposus starts to lose hydration, begins to contract, and nerve and blood vessels start to grow into the disc. This is the underlying process which leads to findings on the MRI of a thinner, darker colored disc.
Diagnosis
Our practice combines our expertise and advanced diagnostic technology to ensure a correct diagnosis. The diagnostic process includes:
• Medical history. The physician asks you questions about your symptoms, their severity, and treatments you have already tried.
• Physical examination. You are carefully examined for limitations of movement, problems with balance, and pain. During the exam, the doctor looks for loss of reflexes, muscle weakness, loss of sensation or other signs of neurological injury.
• Diagnostic tests. Most physicians start with x-rays, which helps to rule out other problems such a tumor or infection. The films also reveal loss of disc space between the vertebrae. This test can be followed by an MRI which gives a picture of the soft tissue of the spine.
• In some cases, a test called Discography confirms the diagnosis. Discography involves injecting contrast dye into the affected disc (or discs) to create a clearer image and temporarily replicate symptoms.
Nonoperative Treatment
The good news is that most cases of lumbar degenerative disc disease do not require surgery. Many different nonsurgical treatments help relieve symptoms. These include:
• Medications, such as an anti-inflammatory to reduce swelling and pain, muscle relaxants to calm spasm, and occasionally narcotic painkillers to alleviate acute pain.
• Cold/heat therapy, especially during the first 24-48 hours.
• Spinal injections (i.e. epidural) may help relieve low back and leg pain.
• Physical therapy, which may include gentle massage, stretching, therapeutic exercise, bracing, or traction to decrease pain and increase function.
• Chiropractic or alternative therapy (i.e. acupuncture).
In conjunction with these treatments, our staff will educate you about healthy posture and proper body mechanics.
The intervertebral disc is innervated by several places. The anterior and lateral portions of the disc are found to be cause innervated through the sympathetic nervous system. The posterior portion of the disc is supplied by the sinuvertebral nerve. The vertebral body itself receives innervation from a nerve called the basivertebral nerve.
Epidurals/blocks/Intercept
Treatments for discogenic pain have not fared well over time. Standard interventional treatments could include a lumbar medial branch block to rule out the facet joints as the source of pain. If negative, an epidural injection may be an option for subacute cases or for short term relief of symptoms, however an epidural injection as a treatment has been shown limited results on long term outcomes with disc related pain.
After many failed attempts at treating disc related low back pain, a new procedure has been introduced and is showing long-term benefit in a subcategory of patients suffering from discogenic low back pain, called the Interacept procedure.
Surgical Treatment
If symptoms of lumbar DDD persist, despite nonoperative treatments, further diagnostic tests may be necessary. Tests may include a CT scan, MRI, Myelogram, and possibly Discography. If your surgeon discovers that one or more intervertebral discs are damaged, and causing pain or other symptoms (e.g. weakness in muscles), surgery may be necessary. The surgical procedure likely will include a discectomy (removal of the damaged disc) and interbody fusion (fusing together the vertebrae above and below the disc space).
Many procedures are performed using minimally invasive techniques, which can help speed your recovery. Of course, if surgery is necessary, your surgeon will clearly explain the recommended procedure and the benefits and risk.
Conclusion
While lumbar degenerative disc disease is a natural part of aging, it does not mean you have to live with low back pain. We can help you return to a healthy, pain-free and active life. For most patients this is accomplished with nonsurgical treatments. But, even if surgery is needed, be assured we will discuss all procedure risks and benefits and provide you with the best possible care. Severe pain related to the discs currently is the one of the more difficult causes of pain to treat, from conservative therapies, interventional therapies, and surgically.
In addition to treating, your practitioner at The Spine and Pain Institute of New York are deeply committed to patient education. By helping you understand the cause of your condition, we can help you eliminate risk factors and instill spine healthy habits for a lifetime. While you are under our care, our medical staff will provide you with excellent information to help you recover, minimize risk factors, and stay healthy.
Symptoms of Spondylolisthesis
Most patients with spondylolisthesis have no symptoms. When symptoms do occur, they may include the following:
Pain in the low back, thighs, and/or legs — especially after exercise — that radiates into the buttocks Muscle spasms Leg pain or weakness Tight hamstring muscles Irregular gait (walking pattern)
Types of Spondylolisthesis
Isthmic spondylolisthesis (51%) is the most common type. It occurs as the result of spondylolysis, a condition that leads to small stress fractures (breaks) in the part of the spinal bone called the pars interarticularis. Most cases actually develop before age 9 and are asymptomatic (no pain).
• Degenerative spondylolisthesis (25%) is the second most common form of the disorder. From age and activity, degenerative changes occur to the spinal structures, especially the discs. When the discs and joints of the spine wear down, they are less able to resist movement by the vertebrae.
• Traumatic spondylolisthesis (<3%) in which an injury leads to a spinal fracture or slippage.
• Pathological spondylolisthesis (<3%) results when the spine is weakened by disease — such as osteoporosis, an infection, or tumor.
• Dysplastic (Congenital) spondylolisthesis (21%) results from abnormal bone formation in utero (womb). In this case, the abnormal arrangement of the vertebrae puts the vertebrae at greater risk for slipping.
• Post-surgical spondylolisthesis
• Grading of Spondylolisthesis
Most spine physicians use the Meyerding Grading System to classify slips. This is a relatively easy system to understand. Slips are graded on the basis of the percentage that one vertebral body has slipped forward over the vertebral body below.
Grade I: 1-24% of the vertebral body has slipped forward over the body below
Grade II: 25-49% slip
Grade III: 50-74% slip
Grade IV: 75%-99% slip
Generally, Grade I and Grade II slips do not require surgical treatment and are treated non-operatively. Grade III and Grade IV slips may require surgery if the spine is unstable and pain is unrelenting.
Diagnosis
Imaging is necessary to diagnose spondylolisthesis. Simple x-rays of the low back are usually adequate to show a vertebra out of place. However, computed tomography (CT) or magnetic resonance imaging (MRI) provides detailed images and may be needed to more clearly see the spinal structures involved.
Spondylolisthesis is a common finding on imaging studies and its presence does not necessarily mean that you need surgery. A simple x-ray can be performed to determine if the effected levels are stable.
Nonsurgical Treatment
Nonsurgical treatment for mild spondylolisthesis is successful in about 75% of cases. Nonsurgical treatment may combine the following:
The patient may be advised to temporarily avoid aggressive activities such as sports. Additionally, you may be prescribed anti-inflammatory medication or analgesic pain medications depending on symptoms. A brace or back support may also be prescribed to help stabilize the lower back and reduce pain.
Injections
Spondylolisthesis pain may originate in different places. Nerve impingement causes pain to radiate (travel) down the legs. Nerve impingement can be caused by a degenerated disc possibly damaged during vertebral slip, or from facet joint stress also attributable to the spondylolisthesis.
Pain caused by stress on the facet joints can be helped with medial branch block injections, and pain from the pressure on the nerves may be helped from intermittent epidural steroid injections. Patients that respond to lumbar medial branch blocks may benefit from a radiofrequency procedure for longer term pain relief.
Surgery
Surgery may be necessary if the vertebra continues to slip or if pain is not relieved with nonoperative treatment and interferes with daily activities. Surgery is successful in relieving symptoms in 85-90% of people with severe symptomatic spondylolisthesis.
Laminectomy and fusion
The most common surgical procedure used to treat spondylolisthesis is called a laminectomy and fusion. In this procedure, the compressed spinal canal is widened by removing or trimming the laminae (roof) of the vertebrae. This is done to create more space for the nerves and relieve pressure on the spinal cord. The surgeon may also need to remove all or part of the vertebral disc (discectomy) and then also fuse vertebrae together. If fusion is done, various devices (like screws or interbody cages) may be implanted to enhance fusion and to support the unstable spine.
The vertebrae of the spine can be viewed as bricks that help to hold your body upright. As you grow older, the strength or density of these bricks may diminish. Osteoporosis is a common metabolic bone disease that affects millions of people over age 50. Osteoporosis causes bones to lose their density or strength putting vertebral bones at greater risk for compression fracture. Osteoporosis is the most common cause of fracture. The World Health Organization (WHO) defines osteoporosis as a T-score below -2.5 on DEXA scan
There are over 700,000 vertebral compression fractures (VCF) a year in the US and is responsible for approximately 70,000 hospitalizations annually, as well as a financial burden on the health care system. The most commonly affected patient group is the elderly, with 25% of affected patients over the age of 70, and 50% over the age of 80.
A vertebral compression fracture (VCF) can be caused by vertebral stress such as from a fall or lifting a heavier object. Sometimes the patient doesn’t remember how or when the fracture happened. IT is estimated that 25% of VCF are painful enough for a patient to seek medical attention.
If you suffer a sudden onset of mid or low back pain, it is important to obtain a simple x-ray to determine if you have a vertebral compression fracture, especially if you are at risk for osteoporosis.
VCF Symptoms
In addition to pain, other signs and symptoms include:
• Loss if height (one of the reasons many older people seem to shrink as they age)
• Kyphosis (or humpback)
• Loss of balance (which increases the risk of falling)
• Neurological symptoms such as numbness, tingling, or weakness*
*Weakness increases the risk of falling and breaking bones
Diagnosis
Our comprehensive diagnostic process includes:
Medical history
Your doctor will talk to you about your symptoms, their severity, and what treatments you have already tried. The pain is usually in the region of the fractured vertebrae and occasionally it can cause pain to travel in the distribution of a local nerve (ie around the ribcage or down the leg).
Physical examination
You are carefully examined for movement limitations, balance problems, and pain. During the exam, the doctor will evaluate loss of extremity reflexes, muscle weakness, loss of sensation, or other signs of a neurological problem. Patients may have focal tenderness to palpation of the spinous process and/or local kyphosis (forward curvature of the spine).
Diagnostic tests
X-ray is a common test that can quickly show if a vertebra is fractured. In an elderly patient presenting with sudden onset severe back pain an x-Ray should be considered to evaluate for fracture. In the rare event there is concern about spinal cord damage, a CT scan or myelography is performed. Myelography involves injecting contrast dye into the spinal column to visually enhance the spinal cord and nerve roots.
Identification of a fracture on x-ray does not mean that the fracture is new/recent or causing the pain. An MRI without contrast of the region of the spine with the fracture can confirm if the fracture is recent by visualizing inflammation in the fracture. Old fractures are much less likely to show this finding.
Within the differential diagnosis is metastatic cancer to the spine or multiple myeloma. A fracture may be an initial presentation of these diseases, and for that reason, a biopsy is typically performed when performing a kyphoplasty. Metastatic cancer to the spine must be considered and ruled out. The following variables should raise suspicion fractures above T5 atypical radiographic findings failure to thrive and constitutional symptoms younger patient with no history of fall.
An option is to not treat the compression fracture. And if there is no pain that may be a valid option. However, in the patient population most affected by vertebral fracture is the elderly. And in the elderly severe pain can lead to secondary complications related to the disability from the pain. Muscle wasting, pneumonia, blood clots, and mental changes are complications that lead to a finding that one procedure out of fourteen performed will save a life.
Nonsurgical Treatment
Most compression fractures can be treated with pain-relieving medication, activity modification, and bracing. Osteoporotic patients, who are not taking medication to control osteoporosis, may be prescribed a drug and supplement regimen to prevent disease progression.
Bracing limits fracture movement and immobilizes the spinal region affected. While braces are not always comfortable or fashion-forward, bracing can help reduce pain. Brace use is discontinued when x-rays show the fracture is stable and healed.
Surgical Treatment
Vertebroplasty and kyphoplasty are minimally invasive surgical procedures performed to treat vertebral compression fractures. Sometimes, treatment involves spinal instrumentation and fusion.
Vertebroplasty and kyphoplasty are similar, but different procedures. Both procedures involve injecting orthopedic cement into the fracture. A primary difference between these procedures is kyphoplasty uses a balloon, which is inflated, to create a cavity for the orthopedic cement. Kyphoplasty can help restore lost vertebral body height caused by a compression fracture.
Our doctors prefer to use vertebroplasty as there is no need for general anesthesia.
A severe compression fracture may require spinal instrumentation and fusion. Instrumentation (i.e. screws, rods) and fusion (bone graft) joins two or more vertebrae together, stops movement, and stabilizes the spine.
A Treatment for Vertebral Compression Fractures
Vertebral augmentation is a general term used to describe either a kyphoplasty or a vertebroplasty. These procedures involve the injection of a type of a polymer called polymethylmethacrylate (PMMA) into a fractured vertebral bone. PMMA is colloquially known as ‘bone cement’. The bone cement interdigitates into the bone to and from the heat forms a solid. This material is also used in procedures such as joint replacements to secure the implant within the bone. The difference between kyphoplasty and vertebroplasty is that a kyphoplasty involves the creation of a cavity within the fractured bone. This can be performed with an inflatable balloon device, or with other instruments.
The procedure involves guiding a special needle under fluoroscopic guidance (real time x-ray) into the vertebral compression fracture. Once the needle is in the bone, a cavity is created for the cement. The PMMA is then injected through a needle into the bone to stabilize the fracture and hopefully eliminate the pain. In many instances, the pain relief may be immediate. In cases where pain persists, the fracture may have caused a change in the anatomy. And this structural change is causing pain for other reasons, such as stress on the facet joints.
At the Spine & Pain Institute of NY these procedures are be performed with light anesthesia in an outpatient setting. General anesthesia is not needed, and the patient will be discharged home the same day, barring unforseen complications.
Potential complications
Vertebroplasty and kyphoplasty are generally considered safe, low-risk procedures. However, in some instances, serious complications may occur. These complications include infection, bleeding, and side effects from cement (PMMA) leaking, which may result in pain, tingling, numbness, or weakness. Rare complications include pulmonary embolism from cement particles traveling to the lung, spinal stenosis from cement leaking into the epidural space, nerve root or spinal cord damage resulting in paralysis (extremely rare). The kyphoplasty and vertebroplasty is a very rewarding procedure for pain physicians as it can take patients out of severe pain in a quick, low risk manner. Although not all patients improve with the treatment, knowing the underlying cause of the fracture was not a malignancy.
Discogram
The discogram procedure, also called provocative discography, is used to help accurately diagnose discogenic pain (pain coming from the disc). The decision to proceed with discography is made when it is unclear if pain is coming from the discs, or which disc is causing pain. An MRI demonstrates the disc anatomy, but does not tell if the damaged disc is causing pain. This procedure gives the physician an anatomical view of the disc by using injected contrast agent, allowing defects caused as tears and degeneration to be visualized. Just as importantly, the procedure gives evidence to whether or not the patient has concordant pain (the same pain the patient has at home) and if the disc is the source of the patient’s pain.
The results of this test determine the appropriate course of further treatment. Surgeons commonly send patients for this procedure to make their surgery more precise in both the lumbar and cervical spine. Ask your surgeon about discography prior to spinal fusion.
How is discography performed?
Discography, an invasive procedure, is performed under fluoroscopy (live-time x-ray) in a sterile environment. This procedure requires you to be fully alert, as you need to identify the characteristics of your pain. Prior to the procedure an antibiotic may be administered through your IV line.
You will be positioned on laying down with pillows for support and comfort. The affected area of your spine will be cleaned with an antiseptic solution, and the skin numbed using an anesthetic.
Under fluoroscopic guidance, a contrast agent is injected into the center of selected discs through a small needle. The contrast enhances the disc’s anatomical characteristics and may spread outside the disc if abnormal. As each disc is injected with contrast, you are asked to describe your symptoms, such as the intensity and type of pain experienced. When discography replicates your symptoms, it is called a positive discogram. If symptoms are not replicated, it is a negative discogram. Discography can be uncomfortable, although symptoms are temporary. The procedure may take 30-45 minutes, depending on the number of discs examined.
What happens after the procedure?
You may experience some discomfort, or pain, for a short period after the procedure. If your pain becomes intense, please contact us so we can quickly help you to be more comfortable.
The images from the procedure as well as the information obtained from the procedure will be forwarded to your surgeon. The hope is that the results of the discogram allow you to have a smaller surgery or avoid a surgery that may not help, or to diagnose the disc as the source of the pain.
The MILD (Minimally Invasive Lumbar Decompression) procedure
The spinal cord lies in the spinal canal which is meant to provide protection for the sensitive neurological structures. This complex structure composed of multiple structures that can degenerate or overgrow over time; these include hypertrophy of the ligamentum flavum, facet joint arthritic changes, and bulging intervertebral discs, all of which can lead to a narrowing of the spinal canal.
Then the central spinal canal narrows, impingement on the spinal canal can become asymptomatic, however as the canal narrows further, patients may develop symptoms of neurogenic claudication.
Neurogenic claudication is described as progressively worsening pain in the buttocks and legs that worsens with standing or walking and is relieved with forward flexion and sitting.
In combination with patient symptomatology, radiologic evidence often used to define spinal stenosis is a canal area of less than 100 mm2.
The ligamentum flavum (LF) is a short, thick ligament that connects the laminae of adjacent vertebrae in the spine. In other words, the lamina is the bony covering of the spinal canal. The LF consists of 80% elastin fibers and 20% collagen fibers. This high percentage of elastin fibers is what responsible for the ligament’s yellow color and flexible nature. As we age and years of stretching, these ligaments can overgrow secondary to repeated use mechanism and injuries, and lead to ligamentum flavum hypertrophy. The ligament can become quite thick, and according to current literature, may contribute up to 85% of the induced narrowing of the spinal canal. At each intersegmental level the ligamentum flavum is a paired structure being represented symmetrically on both sides.
Figure 1. (a) drawing of the normal anatomy of the ligamentum flavum. (B) Normal ligamentum flavum (arrows) on axial T2 scans. (c) Severe hypertrophy of the ligamentum flavum on sagittal T2 (arrows).
Traditionally, if a patient has failed conservative therapy, such as medications and epidural steroid injections, patients really were left with the option of decompressive surgery. Commonly a laminectomy is performed, which is an open, operative procedure in which the lamina (bone that covers the back of the spine) is removed and the ligament is dissected out under direct visualization. In worse conditions, further decompression is required, which requires hardware is required to stabilize spine.
Introducing a new treatment for Spinal Stenosis secondary to ligamentous hypertrophy:
The MILD (Minimally Invasive Lumbar Decompression) procedure is designed to treat lumbar spinal stenosis secondary to ligamentum flavum hypertrophy. This treatment for spinal stenosis is a safe therapeutic option to relieve pressure on the spinal nerves to reduce lower back and leg pain and increase mobility.
The minimally invasive spine surgery utilizes fluoroscopy to visualize the treatment field. The procedure relieves spinal stenosis symptoms by removing redundant ligaments to reduce pressure and crowding inside the spinal canal. Additionally, there are also multiple safety checks that your physician will implement to ensure an optimal outcome. The entire procedure is accomplished through a straw-sized tube. Therefore, there is minimal disturbance to the surrounding tissues and allows for a speedy recovery. The procedure is performed using specialized mild devices and a local anesthetic with conscious (‘awake’ or ‘light’ as opposed to ‘general’) sedation.
The Mild procedure to treat spinal stenosis restores space (relieve pressure on nerves) in the spinal canal while maintaining the natural supporting structure of bone and muscle in the spine. This structural stability is accomplished by locating and removing only those portions of tissue and bone that compress the spinal nerves and cause pain.
What you can expect with mild
• Minimally invasive procedure through a tiny incision, requiring no stitches.
• Local anesthetic or light sedation is typically used.
• Fast procedural time, usually performed in less than 1 hour.
• Out-patient, same day procedure.
• Often return to work and resume light daily tasks within a few days.
• Minimal scar secondary to small access cannula.
• No implants left behind.
Lumbar Spinal Stenosis Recovery
Almost all Mild lumbar spinal stenosis surgery patients are able to return home the same day. Unlike major back surgery, mild procedure patients generally return to their typical routine within a few days. Rehabilitation following the Mild spinal stenosis procedure is also usually much faster and easier than that of open surgical procedures.
Clinical studies have proven the Mild decompression procedure for spinal stenosis to be a safe, low-risk treatment with no reported major complications for those seeking relief from lower back and leg pain and increased mobility. In addition, complication rates for the mild procedure are lower and recovery times faster than other surgical procedures for treating lumbar spinal stenosis.
Not Burning Bridges
The Mild procedure patients are not hindered from receiving additional back surgery in the future, should it be deemed necessary. And if the mild procedure does not give the patient the relief of symptoms that they are looking for then surgery can still be performed in the future. In fact, patients requiring further back surgery may potentially be healthier due to their increased mobility and physical function following the mild procedure for lumbar spinal stenosis.
Schedule a visit
Our physicians are among the most experienced in this procedure not only in the area but in the country and lecture and teach the procedure nationally and internationally. The Spine and Pain Institute of New York is a center selected by Vertos, the manufacturer of the mild device as one of the originals research centers. If you wish to learn more about the Mild procedure or any other procedures feel free to call our offices to schedule an appointment.
Lower Back Pain Radiating To The Legs
Evaluation of a patient experiencing pain radiating to the legs starts with a thorough patient history, physical exam, and review of pertinent imaging studies such as X-rays or MRI’s. If it is deemed that the pain is spinal in origin, the two common causes are Herniated Discs in the Lumbar Spine & Lumbar Spinal Stenosis.
As previously mentioned, the disc forms part of the anterior border of the epidural space, along with the vertebral bodies. Then there is damage to the outer layer (annular fibrosis) of the disc, the integrity of the disc can be lost. This can lead to bulging of a disc, which is analogous to a bulge on a car tire. A disc bulge occurs secondary to a weakening of the annulus, and the pressure from the inner contents pushing outward. While a bulge often does not cause symptoms itself, if it is significant enough or near a nerve root, it may cause radicular pain. This is a less often cause of a sciatica type pain.
If the tough, outer annulus fibrosis ruptures, the nucleus pulposus can exit through the defect and enter the epidural space, this is known as a disc herniation. Disc herniations can range in their symptomatology. Disc herniations can occur acutely with trauma or an inciting event, or may be a gradual progression, starting with an annular tear, to a bulge, to a herniation. Symptoms can range from asymptomatic, to causing pain in the low back, or radiating pain if a nerve is impinged.
Sciatica is a symptom meaning pain felt in one or both legs.Sciatica pain can be severe and debilitating. A first line of treatment is over-the-counter and non-interventional low back treatments. While pain can be severe, the natural course for disc herniation is for the bulge or herniation to be resorbed – or pull back into a more normal position between the upper and lower vertebral bodies. Usually, pain improves over weeks to months. Alternatively, pain may persist.
Our body’s natural response to injury is to attempt to heal or correct the problem is inflammation. We see this in our body all the time, from a sprained ankle or knee, or a simple cut in our skin. Inflammation is our body’s natural system to heal itself. Inflammation is a process by which our body sends cells and nutrients to an area or to fend off any foreign substances. A herniated nucleus pulposus in the epidural space is recognized as a foreign material in that space and the inflammatory response is our attempt to remove this material.
Our spinal cord ends at approximately the L1-2 and below that region the spinal canal is filled with cerebrospinal fluid and contains the spinal nerve roots. This allows for slightly more give than in the cervical spine
When a lumbar disc bulges or herniates, nerve roots may become irritated and possibly impinge on nerve roots and cause radiating (travels) pain in specific areas of the legs based on what nerve was irritated. Severe spinal cord impingement can cause symptoms throughout the body and legs and may be a surgical emergency. Signs and symptoms of cord impingement range from being asymptomatic to loss of bowel or bladder function and paralysis.
Figure 3. Evidenced based dermatome map of Lee et al. This is in contrast to the popularly used Keegan et al. where dermatomes were parallel in nature. Blank regions indicate areas of major variability and overlap. The S3,4, and S5 supply the perineum but were not shown for clarity.
When Pain Does Not Improve
Treatments
Initial conservative efforts include over-the-counter medications such as anti-inflammatories and Tylenol. Physical therapy, chiropractic manipulations, and home exercises are common conservative care modalities that be utilized to assist in improvement. It is important to understand that it is not uncommon for a disc to naturally resorb – pull back into normal position within the upper and lower vertebral bodies. Pain and related symptoms may diminish. Often in the management of disc herniations it is a pain physician’s role to assist in the healing process, in essence ‘buying time’ to allow one to heal on their own. However, sometimes the pain does not resolve with treatment, and becomes persistent, or may worsen.
Epidural Injection
An epidural injection is a common treatment to relieve pain associated with a nerve impingement. The goal of the epidural is to relieve the pain that radiates into the legs, and also hopefully the back pain. An epidural injection is performed using fluoroscopic guidance — a fluoroscopy unit is similar to real-time x-ray. Using fluoroscopy, a very small needle is guided as close to the disc herniation as possible.
The needle enters the epidural space and a very small amount of saline and steroid is injected into the space. Because the needle is precisely placed within the irritated area, only a small amount of medication is needed. Steroid is the strongest anti-inflammatory medication and our hopes is that this medication would facilitate improvement. The amount of pain and symptom relief a patient experiences depends on the susceptibility of the underlying pathology to the effects of the injected medications. Many patients experience pain relief from minutes to days after a procedure, however there are times the response does not reach clinical effect.
Lumbar stenosis is a narrowing of the spinal canal in the lower part of the spine. This narrowing places pressure on the spinal cord and/or nerves. While some patients are born with this narrowing, most cases of lumbar stenosis occur in patients over the age of 50 and are the result of aging and “wear and tear” on the spine.
Many patients with lumbar stenosis remain symptom-free until other conditions further compress the spinal canal. Other conditions that can cause compression include:
• Calcification (the ligaments of the spine thicken and harden)
• The formation of osteophytes (bony growths on bones and joints)
• Bulging or herniated discs
• The slipping of one vertebra onto another (called spondylolisthesis)
• Trauma (such as from an accident)
Symptoms
The symptoms of lumbar spinal stenosis include:
• Low back pain that eases when bending forward or sitting.
• Pain, weakness, or numbness in the legs, calves or buttocks.
• Burning sensations, tingling, and pins and needles in the involved extremity, such as a leg.
• Bladder and bowel problems (in severe cases).
• Although rare, very severe cases can also cause significant loss of function or even paraplegia.
Diagnosis
The physicians at our practice care about your health. That is why we will use a combination of techniques and sophisticated technology to help make an accurate diagnosis:
• Medical history. We will talk to you about your symptoms, how severe they are, and what treatments you have already tried.
• Physical examination. You will be carefully examined by one of our spine specialists for limitations of movement, problems with balance, pain, loss of reflexes in the extremities, muscle weakness, loss of sensation, and other signs of spinal cord injury.
• Diagnostic tests. Generally, we start with plain x-rays, which allow us to rule out other problems such as tumors and infections. CT scans and MRIs give us three-dimensional views of the spine and can help detect osteophytes and herniated discs. With some patients we may order a myelogram. This is a test that involves injecting a liquid dye into the spinal column to show where the pressure on the nerve is occurring.
Non-Operative Treatment
Most cases of lumbar stenosis are successfully treated with non-surgical techniques such as pain medications and anti-inflammatory medications. Severe pain may also be treated with corticosteroids that are injected into the lower back (i.e. epidural steroid injections). Depending on the extent of nerve involvement, some patients may need to temporarily restrict their activities. However, most patients only need to rest for a brief time. Physical therapy exercises will also be prescribed to help strengthen and stabilize the spine as well build endurance and increase flexibility.
If these non-surgical measures do not work, we will discuss further options. There are a number of procedures and surgical techniques that we can be used to treat this condition. The goal of each of these treatments is to widen the spinal canal and relieve the pressure by removing the cause of compression.
Interventional Pain Management Options
Treatment for spinal stenosis from an interventional pain standpoint after conservative treatments is an epidural steroid injection. This can be repeated several times a year if there is adequate pain relief. If the epidurals do not help enough, further options are considered. There are two interventional pain procedures that can be used to treat some types of spinal stenosis. One is an indirect decompression of the ligamentum flavum, called the MILD procedure, and one is an interspinous spacer called Vertiflex, which is placed between the spinous processes to life the vertebrae.
Surgical Treatment
The most common surgery for lumbar stenosis is called a decompressive laminectomy in which the laminae (roof) of the vertebrae are removed, creating more space in the spinal canal for the nerves. If only a portion of the laminae need to be removed, it is called a laminotomy. If there are herniated or bulging discs, these may also be removed (this is called a discectomy) to increase canal space. Sometimes the foramen (the area where the nerve roots exit the spinal canal) may also need to be enlarged. This procedure is called a foraminotomy.
For those patients who need surgical repair on more than one level, or who have significant spinal instability, spinal fusion may be required in addition to the decompression surgery. This traditionally involves taking a small piece of bone (usually from the hip) and grafting it onto the spine. Spinal implants (called instrumentation) such as screws and rods are used to support the spine and provide additional stability while the fusion is healing.
The MILD (Minimally Invasive Lumbar Decompression) procedure
The spinal cord lies in the spinal canal which is meant to provide protection for the sensitive neurological structures. This complex structure composed of multiple structures that can degenerate or overgrow over time; these include hypertrophy of the ligamentum flavum, facet joint arthritic changes, and bulging intervertebral discs, all of which can lead to a narrowing of the spinal canal.
Then the central spinal canal narrows, impingement on the spinal canal can become asymptomatic, however as the canal narrows further, patients may develop symptoms of neurogenic claudication.
Neurogenic claudication is described as progressively worsening pain in the buttocks and legs that worsens with standing or walking and is relieved with forward flexion and sitting.
In combination with patient symptomatology, radiologic evidence often used to define spinal stenosis is a canal area of less than 100 mm2.
The ligamentum flavum (LF) is a short, thick ligament that connects the laminae of adjacent vertebrae in the spine. In other words, the lamina is the bony covering of the spinal canal. The LF consists of 80% elastin fibers and 20% collagen fibers. This high percentage of elastin fibers is what responsible for the ligament’s yellow color and flexible nature. As we age and years of stretching, these ligaments can overgrow secondary to repeated use mechanism and injuries, and lead to ligamentum flavum hypertrophy. The ligament can become quite thick, and according to current literature, may contribute up to 85% of the induced narrowing of the spinal canal. At each intersegmental level the ligamentum flavum is a paired structure being represented symmetrically on both sides.
Figure 1. (a) drawing of the normal anatomy of the ligamentum flavum. (B) Normal ligamentum flavum (arrows) on axial T2 scans. (c) Severe hypertrophy of the ligamentum flavum on sagittal T2 (arrows).
Traditionally, if a patient has failed conservative therapy, such as medications and epidural steroid injections, patients really were left with the option of decompressive surgery. Commonly a laminectomy is performed, which is an open, operative procedure in which the lamina (bone that covers the back of the spine) is removed and the ligament is dissected out under direct visualization. In worse conditions, further decompression is required, which requires hardware is required to stabilize spine.
Introducing a new treatment for Spinal Stenosis secondary to ligamentous hypertrophy:
The MILD (Minimally Invasive Lumbar Decompression) procedure is designed to treat lumbar spinal stenosis secondary to ligamentum flavum hypertrophy. This treatment for spinal stenosis is a safe therapeutic option to relieve pressure on the spinal nerves to reduce lower back and leg pain and increase mobility.
The minimally invasive spine surgery utilizes fluoroscopy to visualize the treatment field. The procedure relieves spinal stenosis symptoms by removing redundant ligaments to reduce pressure and crowding inside the spinal canal. Additionally, there are also multiple safety checks that your physician will implement to ensure an optimal outcome. The entire procedure is accomplished through a straw-sized tube. Therefore, there is minimal disturbance to the surrounding tissues and allows for a speedy recovery. The procedure is performed using specialized mild devices and a local anesthetic with conscious (‘awake’ or ‘light’ as opposed to ‘general’) sedation.
The Mild procedure to treat spinal stenosis restores space (relieve pressure on nerves) in the spinal canal while maintaining the natural supporting structure of bone and muscle in the spine. This structural stability is accomplished by locating and removing only those portions of tissue and bone that compress the spinal nerves and cause pain.
What you can expect with mild
• Minimally invasive procedure through a tiny incision, requiring no stitches.
• Local anesthetic or light sedation is typically used.
• Fast procedural time, usually performed in less than 1 hour.
• Out-patient, same day procedure.
• Often return to work and resume light daily tasks within a few days.
• Minimal scar secondary to small access cannula.
• No implants left behind.
Lumbar Spinal Stenosis Recovery
Almost all Mild lumbar spinal stenosis surgery patients are able to return home the same day. Unlike major back surgery, mild procedure patients generally return to their typical routine within a few days. Rehabilitation following the Mild spinal stenosis procedure is also usually much faster and easier than that of open surgical procedures.
Clinical studies have proven the Mild decompression procedure for spinal stenosis to be a safe, low-risk treatment with no reported major complications for those seeking relief from lower back and leg pain and increased mobility. In addition, complication rates for the mild procedure are lower and recovery times faster than other surgical procedures for treating lumbar spinal stenosis.
Not Burning Bridges
The Mild procedure patients are not hindered from receiving additional back surgery in the future, should it be deemed necessary. And if the mild procedure does not give the patient the relief of symptoms that they are looking for then surgery can still be performed in the future. In fact, patients requiring further back surgery may potentially be healthier due to their increased mobility and physical function following the mild procedure for lumbar spinal stenosis.
Schedule a visit
Our physicians are among the most experienced in this procedure not only in the area but in the country and lecture and teach the procedure nationally and internationally. The Spine and Pain Institute of New York is a center selected by Vertos, the manufacturer of the mild device as one of the originals research centers. If you wish to learn more about the Mild procedure or any other procedures feel free to call our offices to schedule an appointment.
If your physician determines disc herniation(s) and excessive ligamentous tissue inside the spinal canal are causing your low back and leg pain, a newer non-surgical option for you may be the Superion indirect decompression (Vertiflex Inc., Carlsbad, CA, USA) procedure. The Superion indirect decompression is a completely reversible, minimally invasive technique approved by the FDA to treat lumbar spinal stenosis. It is comfortably performed in the outpatient setting with minimal sedation. In another words, you can safely go home on the same day after this procedure and start to feel relief.
Symptomatic lumbar spinal stenosis presents most commonly after the age of 65, as do comorbidities that can make even a smaller open spinal surgery and anesthesia riskier. These compounded with the risks associated with hospitalization and recovery after spine surgery. The minimally invasive approaches to interspinous stabilization make it possible to treat localized symptomatic stenosis in a broader group of patients that do not want or cannot, have general anesthesia or extensive lumbar surgery.
How is Superion indirect decompression procedure performed?
After making a small incision, a tiny titanium spacer is placed between the narrowed segment(s) behind the spinal canal. When fully deployed, the letter H-shaped spacer is secured to create leeway for the exiting spinal nerves without removing any bones, unlike the traditional surgical decompression, which often requires a long and painful recovery from a large incision(s) and permanent hardware installation to fuse an unstable spine.
The Superion indirect decompression procedure is demonstrated in the animation below:
What are the results?
The 5 year, multi-centered, randomized-controlled trial testing the effectiveness of the Superion indirect decompression procedure demonstrated 84% of the participants reported a significant and sustained back (66%) and leg (75%) pain reduction. More importantly, there were dramatic improvements in disability, satisfaction, function, and greatly decreased opioid medication needs. Additionally, the pain relief and functional gains were again observed in the post-market research. Furthermore, a head to head study showed that Superion indirect decompression out-performed the conventional laminectomy at 12 and 24 months.
Ask your physician at the Spine and Pain Institute of New York if Superion Indirect Decompression System is right for you. Schedule your appointment today.
What is Intracept?
For a subset of patients with axial, non-radiating low back pain that is not related to the facet joints, there is a new procedure with very promising outcomes. Our intervertebral discs are surrounded by the vertebral body on their top and bottom surfaces. Where the vertebral body meets the disc is called the endplate. When the endplate becomes degenerated, nerve fibers and blood vessels can grow into the disc. A finding on MRI of a degenerated endplate is called a Modic change. Patients that present with axial low back pain and Modic changes are a candidate for this therapy.
The Intracept procedure is an outpatient procedure that uses a needle to perform radiofrequency ablation of the basivertebral nerve in the vertebral body. The basivertebral nerve is the nerve that provides sensory information from the vertebral body to the spinal cord and brain. Applying radiofrequency energy heats tissue to the point of tissue of nerve ablation, in turn decreasing pain transmission from the degenerated endplates and discs. Intracept is a low risk outpatient procedure with a relatively limited recovery period.
Recent studies have shown that the interverterbral disc is innervated by the basivertebral nerve through the vertebral endplate. As such, pain from disc degeneration is transmitted through the endplate and the basivertebral nerve. This causes an inflammatory response in the endplate, which appears as Modic changes in the vertebral endplates seen on MRI.
Figure 1. Innervation of the disc. (a) Anatomy of the Basivertebral nerve with a Sinuvertebral nerve in the normal disc. (b) Pathologic disc.
Prospective Randomized Trial with 5-year Results
A clinical trial was published which prospectively randomized 225 patients with chronic LBP to Intracept treatment demonstrated impressive improvements in pain relief and just as importantly, improvement in function. These improvements were seen shortly after the procedure and were maintained at the 2-year and 5-year mark. 30% of patients reported no back pain at the 5-year mark and narcotic use was stopped in over 60% of the patients.
Data from the two Level I randomized controlled trials would suggest that in approximately 80% of patients, two vertebral bodies are treated, which constitute one vertebral motion segment. In the remaining patients, 1 or 2 additional vertebral bodies are treated for a total of 2-3 vertebral motion segments. And finally, the Food and Drug Administration (FDA) required evidence that the intraosseous BVN does not regenerate and that the vertebrae return to pre-treatment strength after a period of normal healing. A standard which it passed.
Candidates for Intracept Procedures
To qualify for the procedure, you must have chronic low back pain for more than 6 months and have failed conservative therapy such as physical therapy and interventional pain procedures such as medial branch blocks and epidural injections. The procedure is FDA approved levels for the L3-4, L4-5, or L5-S1 levels (although it has been performed off label at other locations). Patients must show evidence on MRI of type 1 or type 2 Modic changes, including inflammation, edema, endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointense signals (type 1) or changes to the vertebral body marrow, including replacement of normal bone marrow by fat, and hyperintense signals (type 2).
Patients who are not candidates for the procedure are:
Patients without Modic changes on MRI or with Modic 3 changes (end-stage sclerosis). Patients with severe osteoporosis, scoliosis, skeletally immature patients (generally <18 years of age), patients with implantable technology such as pacemakers, defibrillators, or spinal cord stimulators, or other electronic implants. Additional contraindications are severe cardiac or pulmonary compromise, active systemic or local infection, or those that are pregnant
The Intracept Procedure
The procedure can be performed with without, or with minimal anesthetic in the outpatient setting under fluoroscopic guidance. After local anesthetic is placed, the following steps are performed:
1. Under fluoroscopic guidance, the Intracept introducer cannula is advanced through the pedicle into the vertebral body, and a curved cannula is then placed through the cannula to access the region where the basivertebral nerve is located.
2. The radiofrequency probe is then inserted through the curved path to the common location of the nerve. Radiofrequency energy is used to generate heat which lesions the basivertebral nerve. After which, the probes are removed, and a bandage placed.
Ask your physician at the Spine and Pain Institute of New York about the Intracept procedure to learn more, and if you are a candidate for this groundbreaking therapy, which thus far as shown impressive results across multiple outcome measures.
Failed Back Surgery Syndrome: Post-Laminectomy Syndrome
Very often our hope is to use interventional procedures to delay or avoid surgery, however there are many times that surgery cannot be avoided or is necessary. Underlying pain is the most common driving force for one to undergo surgery. Unfortunately, surgery may correct an underlying condition, but pain may not always improve or potentially return in the future. It is not uncommon to have surgery on your neck and continue to have pain in the neck and/or radiating pain to the arms. Sometimes the pain can be severe and debilitating.
Pain Treatment Options
Unfortunately, a sub-population of patients who have spinal surgery continue to have pain. If one continues to have pain after surgery, there are still options available.
The first step is epidural injections, which provides adequate pain relief for many patients. In addition, there are different ways to administer an epidural injection to ensure it pain-relieving medication is precisely injected. Depending on the type of your surgery, certain injections may be more appropriate and effective than others.
Other causes of pain may be pain secondary to the facet joints. Facet joint pain responds favorably to medial branch blocks and potentially provides long term pain relief. Sometimes the sacroiliac joints (behind the pelvis) become irritated and generate pain.
Sometimes, the implanted spinal instrumentation causes pain and may be relieved with an anesthetic and steroid injection.
When injections do not provide adequate long-term pain relief, spinal cord stimulation or dorsal root ganglion stimulation (neuromodulation) may be considered. Several studies prove that spinal cord stimulation is more effective in relieving pain that repeat surgery. Advances in neuromodulation technology enable this device to be effective in the treatment of low back and leg pain. To see testimonials from patients who have used dorsal root ganglion stimulation for their pain, visit our Youtube page below.
DRG-S for Low Back Pain and Leg Pain
Effective treatment for chronic low back pain (LBP) is considered the ‘holy grail’ of neuromodulation. Spinal Cord Stimulation (SCS) was introduced in 1967 to treat chronic pain. Over the years it has shown mixed results for LBP, with limited improvements in pain and function, and loss of efficacy over time. Dorsal root ganglion stimulation (DRG-S) was developed as a treatment for nerve-related pain syndromes and has proven to be superior to SCS for complex regional pain syndrome (CRPS), which typically affects the hands or feet.
As utilization of DRG-S increased, so did our understanding of its underlying mechanisms of action. One such mechanism of action is a result of the stimulator device sending inhibitory signals into the spinal cord. Based on this principle, the team at the Spine & Pain Institute of NY pioneered the treatment of low back pain with DRG-S at the T12 spinal level1. Their publication on a case series of patients using DRG-S at the T12 level for intractable low back pain was better than previous studies with other forms of neurostimulation for low back pain.
The study included patients who had failed extensive treatments and included several patients who had multiple spinal surgeries. They reported not only excellent pain relief, but also great improvements in physical function and psychological testing that were not previously seen with neuromodulation therapy. The results of the study are shown on the right, here, and below. In our clinical experience, these results are readily reproducible and have been maintained over time.
After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2.
After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2.
To better understand this complex subject, which for many may be challenging to fully grasp, the major points have been illustrated in this animated graphic. Since that time, the team has expanded the use of DRG-S by placing additional leads at S1 along with T12 as an off-label treatment for low back and associated leg pain. Our results continue be superior to our doctor’s experiences with other forms of neurostimulation for similar pain conditions. Our doctors have collectively published over 20 articles in peer reviewed medical journals on DRG-S and are considered thought leaders and pioneers of DRG-S therapy. While results from our practice with DRG-S are quite impressive and have been published and shared with the medical community, the team also recorded patient testimonials to further illustrate the great improvements seen with this therapy. The testimonials can be accessed on our Youtube page.
Multiple studies have published positive results using DRG-S therapy for low back pain. For instance, DRG-S was utilized at the L2 level to treat discogenic low back pain following failed back surgery. The graphic below shows the changes in patient reported survey scores used to measure treatment response before and after DRG-S therapy in each study. Collectively, improvements with DRG-S therapy in VAS (visual analog scale) which measures pain severity, ODI (Oswestry disability index) and SF-36 Physical which measure physical function, EQ-5 which measures quality of life, and SF-36 Mental which measures psychological improvements were consistent with or superior to prior spinal cord stimulation studies. If you are interested in learning more about DRG stimulation for low back pain and leg pain, or have failed other forms of neuromodulation, please feel free to reach out to our physicians at the Spine and Pain Institute of NY to learn more.
1. Chapman KB, Groenen PS, Patel K V., Vissers KC, van Helmond N. T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series. Neuromodulation Technol Neural Interface. 2020;23(2):203-212. doi:10.1111/ner.13047
2. Chapman KB, Groenen PS, Vissers KC, van Helmond N, Stanton‐Hicks MD. The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment. Neuromodulation Technol Neural Interface. Published online April 23, 2020:ner.13150. doi:10.1111/ner.13150
Splanchnic and Celiac Plexus Blockade
The celiac plexus is a web of nerve fibers that lies in the abdomen near the aorta. It is a relay station for the nerves that innervate the abdominal contents from the lower esophagus to part of the colon. The nerves are responsible for sending messages back and forth and innervate the intestines and are responsible for pain transmission. The nerves that innervate the abdomen come from the spinal cord and meet in several places to form their diffuse connections, and lie in a web like structure called a plexus.
The celiac plexus block is a procedure in which a long-acting local anesthetic is placed at the celiac plexus to block the transmission of pain from the abdomen. The celiac plexus block procedure is most frequently used in patients when other pain medications or other less invasive therapies are not effective. This type of pain may be caused by irritation, compression, or entrapment of the nerve bundles because of tumor invasion, fibrosis, or chronic inflammation resulting from chronic pancreatitis or Crohn’s disease, among others. Pain attributed to the pancreas is a common indication for a celiac plexus blockade.
The splanchnic nerves are the nerve fibers that connect the spinal cord to the celiac plexus. These nerves can also be blocked using a local anesthetic. The splanchnic nerves lie close to the side of the spine. These are groups of individual nerves, not a diffuse plexus. Thus, is possible to lesion (therapeutically burn) the splanchnic nerves with energy generated using radiofrequency.
A celiac plexus block procedure involves the use of fluoroscopic x-ray imaging (real time x-ray) for precise needle placement and injection of a long-acting analgesic block to manage pain. Celiac plexus blocks typically provide temporary relief with less risk. Longer pain relief can be obtained with a neurolytic agent.
Another option for abdominal pain control is spinal cord stimulation. This involves using electrical stimulation to modulate the transmission of nerve signals to and from the abdomen.
EDUCATIONAL RESOURCES
Kyphoplasty
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Discography
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Dorsal Root Ganglion Stimulation
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Spinal Cord Stimulator
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Facet Joint Syndrome
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Herniated Disc
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Lumbar Epidural
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Spinal Stenosis
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Lumbar Transforaminal Steroid Injection
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Lumbar Radiculopathy
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Complex Regional Pain Syndrome
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Lumbar Sympathetic Block
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Radio Frequency Ablation
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Medial Branch Block
This injection treats the pain of an inflamed nerve in your cervical spine. It relieves nerve swelling. If you have a herniated disc, spinal stenosis or some other problem that's pressing on a nerve, it may help you.
EDUCATIONAL RESOURCES
Celiac Plexus Block
This procedure temporarily disrupts the nerves of the celiac plexus. These nerves branch away from your spine. They connect to the organs in your abdomen. Pain signals caused by conditions such as pancreatitis or pancreatic cancer travel through these nerves on the way to your brain. A celiac plexus block can relieve your pain.
Our Philosophy
Pain is a complex problem that requires treatment and management by a pain medicine specialist. Millions of people suffer from headaches and nerve pain at great personal cost. If you find that you cannot safely control your pain with over-the-counter medications, or have failed to find relief from other treatments or practitioners, you should consider consulting with our pain management physicians. For most patients, interventional pain management procedures can treat or reduce pain, allowing the patients to regain function, and thereby improving their quality of life.
Let's live pain free.
Is Pain Management Right for You?
Depending on many factors, such as the type of pain and your general health, there are numerous options for treating your pain. Some patients are surprised to learn that a treatment that previously failed to provide relief may be effective when combined with a multi-treatment approach.
Our specialists treat complex pain issues. There are many different physical and neurological disorders that contribute to pain, and we treat all types of pain including:
Practice Policies
We are pleased you chose The Spine and Pain Institute of New York for the diagnosis, treatment and management of your pain. To acquaint you with our office policies, we provide the following information.
*If your insurance requires a referral for a visit to a specialist, you must obtain this referral from your Primary Care Physician prior to your visit.
INITIAL CONSULTATIONS
Please bring the following relevant information to your consultation.
Photo ID
Insurance Information
Referral*
Diagnostic Studies & Reports (MRI/X-Rays)
List of Medications
INSURANCE & BILLING
We accept most insurance programs and their subsidiaries. If we do not participate in your insurance plan, please contact Billing to find out if other arrangements are possible. Text us via Klara using the messaging option to the bottom right of this page! Just detail your concern or question, and a member of the team will reply via return text message or phone call. Insurance co-payments are due at the time of arrival. We accept cash, checks and credit cards.
APPOINTMENTS
If you are a new patient, please arrive 15 minutes prior to your appointment to allow time to register. If you are running late or need to reschedule, please contact us as soon as possible to make us aware. Unfortunately, if you are more than 30 minutes late for your appointment time, we will have to reschedule.
PROCEDURES
If you are scheduled for a procedure or plan on having one in the future, please read the attached important instructions to follow prior to a procedure.You will be called prior to your procedure and notified about the following information as well.
MEDICATIONS & REFILL REQUESTS
Please discuss your medication needs, including refill requests, with your provider at the time of your appointment. Medications should be taken only as prescribed. Please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave the office.
AFTER HOURS EMERGENCIES
Our regular phone lines are transferred to an answering service after normal business hours. Please proceed to the nearest emergency room for after-hours emergencies.