Back Pain/Slipped disc/ Sciatica Pain

Back pain is a disease of modern times. All of us will have low backache at some point of time. Most of the people who experience low backache for first time get better in 2-6weeks. However chronic backache or recurrent backache requires special management.
Back pain could be caused due to
1. Wrong posture or prolonged sitting
2. Wear & tear of spine called degeneration
3. These changes can occur in disc, facets joints, ligaments
4. Injuries to spine

Neurogenic pain is caused when herniated disc finches the nerve. This may cause damage the nerve and cause weakness & numbness in legs.
Spondylosis
Spondylosis is a term referring to degenerative osteoarthritis of the joints between the centra of the spinal vertebrae and/or neural foraminae. If this condition occurs in the zygapophysial joints, it can be considered facet syndrome. If severe, it may cause pressure on nerve roots with subsequent sensory and/or motor disturbances, such as pain, paresthesia, or muscle weakness in the limbs.
Slipped disc
The inter-vertebral discs are protective cushion-like shock-absorbing pads between the two bones of the spine called vertebrae. These discs are soft gel filled pads bounded by few layers of membrane called lamella. These discs do not actually “slip,” they may split or rupture (Slipped Disc is a misnomer). Following this rupture the gel escape into the surrounding tissue. The leaking jellylike substance can produce pressure on the spinal cord or on a single nerve root and cause pain either around the damaged disc or anywhere along the area controlled by that nerve. This condition is also known as a herniated disc, ruptured disc, prolapsed disc, or, more commonly, slip disc or slipped disc.
1. Frequently electric shock-like pain or burning pain. associated with some numbness, tingling sensations and sometime some muscle weakness.
2. Sciatica is a frequently used term both by doctors and by patients. It is a symptom and not a disease. Sciatica is defined as any pain that is starting in the low back and is going towards the legs. Sciatica is a non-specific term like fever.
3. Slipped disc is one of the most common cause of sciatica. Apart from conservative therapy all other forms of treatment aim at decompressing the nerve roots. These can be done by taking the disc out by surgery or by decompressing the foramen and disc by different interventions.
Sciatica
Sciatica is a set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body. Pain can be severe in prolonged exposure to cold weather. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms often differs, depending upon the underlying cause of the symptoms and pain levels
Diagnosis
You may be asked for simple tests and MRI scan to reach diagnosis. Treatment modalities include bed rest, back brace, medication, physical therapy and exercise. Epidural steroid injections, facet join injections, trigger joint injection and rarely surgery.

Treatment
Treatment depends on cause of back pain Spondylosis, facet joint arthritis - Treated with facet joint injection, Radiofrequency ablation of medial branch, intramuscular stimulation(IMS) of paraspinal muscles etc.
Muscular pain- treated with IMS trigger point injection, exercises
Slipped disc and sciatica—
When the cause of sciatica is due to a prolapsed or herniation of lumbar disc — 90% of disc prolapses resolve with MINIMAL intervention like transforaminal epidural injection, Like percutaneous disc decompression, ozone necleolysis.

Procedure: Transforaminal epidural injection
Epidural gluco-corticoid injections are commonly given to patients with leg and/or back pain to relieve such pain and improve mobility without surgery. These steroid injections buy time to allow healing to occur and/or as an attempt to avoid surgery after other conservative (non-surgical) treatment approaches have failed.
During a trans-foraminal injection, a thin needle is inserted into the epidural space through the bony opening of vertebral column from where a nerve root exits. (See Figure 1, Neuroforamen). The drug is delivered exactly in the area where disc is compressing nerve and causing inflammation.


The procedure is performed with the patient lying on their belly using fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radio-opaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed (See Figure 2). This technique allows the cortisone medicine to be placed closer to the irritated nerve root. The exposure to radiation is minimal.


Indications include disc herniations, Lumbar canal stenosis, vertebral fractures, Cancer tumor compressing epidural space, Herpes zoster pain etc. Patients with disc herniations and leg pain attains maximal improvement in 6 weeks. Interestingly, long-term success rates for trans-foraminal epidural glucocorticoid injections ranged from 71% to 84%.


Therapeutic Rationale – why steroids?


Structures (pain generators) like nerves/discs are accessible to neural blockade.


Surgery of these structure may fail to cure and may worsen painful spinal conditions.


Degenerative processes of the spine and the origin of spinal pain is complex.


The effectiveness of a large variety of therapeutic interventions used to manage chronic spinal pain has not

been demonstrated conclusively.


There is increasing evidence supporting the use of interventional techniques in managing spinal pain.



The objective


To deliver corticosteroid close to the site of pathology.


Trans Foraminal Epidural Steroid Injection (TFESI) – more specific & targeted to site of pathology


Interlaminar injections are very effective in cervical (neck) area


In many cases MRI shows disc bulge but patients are pain free.


Decrease size of disc means Decrease symptoms?


It is not always the case, as compression may continue in spite of resolution of the symptom.


It's also well described in many studies that asymptomatic individuals present with disc herniations that

are evident on CT / MRI scans.



Multiple mechanisms to explain radicular pain

Nerve damage of various nature (Partial axonal damage, Neuroma formation, Focal demyelination, Intraneural edema), Impaired microcirculation, Chemical irritation, Inflammation. The Steroid acts to reverse all these. Xraypics of lumbar and cervical epidurals