What you need to know about your back pain

Back and spine pain is debilitating. Its

impact is real and constant. And, it can have

devastating effects on the quality of your

life. At SpineCARE, we’ve developed a deep

understanding of back and spine pain by

caring for and treating thousands of patients.

If you are experiencing chronic back or spine pain, whether from injury, disease or

previous treatment, we can provide the optimum solution and relief. Our goal is to

reduce or eliminate your pain through targeted diagnosis and treatment. Our team of

experienced specialists begins with the most conservative treatment approach, which

often means therapy rather than surgery.

Pain management and relief is a journey. We travel it together with our patients until we

reach the desired destination and best outcome.

We have prepared this booklet to help you understand why your back or spine is hurting

and what options we can provide to help you regain your highest level of functioning

and well-being. We’ve also included basic information on the anatomy of your back and

spine.

We encourage you to take an active role in your journey to a more pain-free life. Asking

questions and exploring options will help us develop a personalized treatment plan that

is best for you.

Introduction

INTRODUCTION

Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help 1

CHAPTER 1: The Anatomy and Structure of Your Back 2

Spinal Column • Disc • Spinal Canal 2

Spinal Cord • Peripheral Nerves • Epidural Space • Facet Joints • Sacrum 3

Abnormal Anatomy 4

Herniated Discs • Degenerative Disc Disease 4

Spinal Stenosis • Facet Arthropathy • Sacroiliac Dysfunction/Sacroiliitis 5

CHAPTER 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain 6

Basic Spine X-rays: • Computed Tomography (CT) 6

Magnetic Resonance Imaging (MRI) • Other Imaging Techniques 7

CHAPTER 3: Conservative Therapies: The Starting Point for Treating Your Pain 8

Physical Therapy 8

Chiropractic Care • Acupuncture 10

CHAPTER 4: Interventional Pain Procedures: The Next Step in Treating Your Pain 11

Diagnostic Procedures 11

Therapeutic Procedures 12

CHAPTER 5: Surgical Options and Lifestyle Changes 15

Options for Spine Surgery 16

Preparing for Surgery, Ensuring a Successful Outcome 17

CHAPTER 6: Understanding and Managing Your Medications 22

NSAIDs (Non-steroidal anti-inflammatory drugs) 22

Muscle Relaxants • Neuropathic Medications 23

Opioid Medications 24

This booklet was written by the physicians at SpineCARE.

Table of Contents

Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help

1

Back and spine pain is debilitating. Its

impact is real and constant. And, it can have

devastating effects on the quality of your

life. At SpineCARE, we’ve developed a deep

understanding of back and spine pain by

caring for and treating thousands of patients.

If you are experiencing chronic back or spine pain, whether from injury, disease or

previous treatment, we can provide the optimum solution and relief. Our goal is to

reduce or eliminate your pain through targeted diagnosis and treatment. Our team of

experienced specialists begins with the most conservative treatment approach, which

often means therapy rather than surgery.

Pain management and relief is a journey. We travel it together with our patients until we

reach the desired destination and best outcome.

We have prepared this booklet to help you understand why your back or spine is hurting

and what options we can provide to help you regain your highest level of functioning

and well-being. We’ve also included basic information on the anatomy of your back and

spine.

We encourage you to take an active role in your journey to a more pain-free life. Asking

questions and exploring options will help us develop a personalized treatment plan that

is best for you.

Introduction

INTRODUCTION

Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help 1

CHAPTER 1: The Anatomy and Structure of Your Back 2

Spinal Column • Disc • Spinal Canal 2

Spinal Cord • Peripheral Nerves • Epidural Space • Facet Joints • Sacrum 3

Abnormal Anatomy 4

Herniated Discs • Degenerative Disc Disease 4

Spinal Stenosis • Facet Arthropathy • Sacroiliac Dysfunction/Sacroiliitis 5

CHAPTER 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain 6

Basic Spine X-rays: • Computed Tomography (CT) 6

Magnetic Resonance Imaging (MRI) • Other Imaging Techniques 7

CHAPTER 3: Conservative Therapies: The Starting Point for Treating Your Pain 8

Physical Therapy 8

Chiropractic Care • Acupuncture 10

CHAPTER 4: Interventional Pain Procedures: The Next Step in Treating Your Pain 11

Diagnostic Procedures 11

Therapeutic Procedures 12

CHAPTER 5: Surgical Options and Lifestyle Changes 15

Options for Spine Surgery 16

Preparing for Surgery, Ensuring a Successful Outcome 17

CHAPTER 6: Understanding and Managing Your Medications 22

NSAIDs (Non-steroidal anti-inflammatory drugs) 22

Muscle Relaxants • Neuropathic Medications 23

Opioid Medications 24

This booklet was written by the physicians at SpineCARE.

Table of Contents

Understanding Your Back and Spine Pain: Why You Hurt and How We Can Help

1

2 3

Before we can discuss the causes, diagnosis, and treatment of back pain, it is important to understand

the basic structure of the back. The back is comprised of a variety of tissues, including bones, muscles,

joints, discs and nerves. All these parts work together to keep us upright, balanced and active.

Spinal ColumnThe spine forms the axis of our body. It is a bony structure

that starts at the base of the skull and runs all the way down

to the tailbone. The spine is comprised of individual bones

called vertebra (see figure 1) that are stacked on top of each

other to form a column, generally known as the spinal column

(see figure 2). The spinal column tapers off and ends with the

tailbone or coccyx. The vertebrae are named based on their

location in the spinal column. There are seven vertebral bones

in the neck called cervical vertebrae, 12 vertebral bones in the

mid-back called thoracic vertebrae and five vertebral bones

in the lower back called lumbar vertebrae. The vertebrae are

connected by ligaments, which are bands of collagen fibers

that connect bone to bone. Ligaments act to reinforce and

stabilize the spinal column while allowing limited mobility.

DiscEach vertebra is separated from the one below it by fibrous tissue

called a disc (see figure 3). Discs space out the vertebral bones, allow

movement of the spinal column, and act as shock absorbers during

activity. The discs are comprised of an outer and an inner layer. The

outer layer is made up of fibrous tissue and cartilage and surrounds

an inner gelatinous layer. The fibrous tissue distributes pressure evenly

across the disc while the gelatinous layer cushions external forces.

Spinal CanalStacking the vertebral bones on top of each other results in the formation

of a tube inside the spinal column (see figure 1). This empty cylindrical

space, called the spinal canal, contains and protects the spinal cord

and its supporting structures.

Chapter 1: The Anatomy and Structure of Your BackSpinal CordThe spinal cord is a collection of nerve tissue that connects the brain to

the rest of the body. All the nerves in our body originate from the spinal

cord. In turn, the spinal cord sends information to and from the brain

about the body. The spinal cord is covered by three different layers

of tissue and bathed in a special liquid called the cerebrospinal fluid.

(See figure 5). The spinal cord, in turn, gives rise to nerves that travel

all over the body. These nerves split off from the spinal cord and leave

the spinal canal through holes called vertebral foramen. The origin of

each nerve from the spinal cord is named the nerve root (see figure 3).

Peripheral NervesNerves exit on either side of the spinal column and travel throughout the body, including down the arms,

hands, legs and feet. Once the nerves leave the spinal column they are renamed peripheral nerves. These

nerves are responsible for the sensation and motion of our body.

Epidural SpaceThe epidural space is the area between the outermost layer of the spinal cord and the inside bony surface of

the spinal canal. The epidural space contains nerves branching off the spinal cord, blood vessels and fatty

tissue. This is a common site for interventions aimed at treating back pain.

Facet JointsFacet joints are the joints that form between the vertebral bones when they

are stacked on top of each other to construct the spinal column (see figure

4). They are located on the outer left and right side of the spinal column all

along the spine. These joints allow flexion, extension and rotation of the

spine. They also stabilize the spine and limit certain types of movements.

SacrumThe sacrum (see figure 2) forms the base of the spinal column and ends

with the tailbone. It is a triangular structure comprised of five vertebrae that

are fused together (unlike the vertebrae that make up the rest of the spinal

column). The sacrum sits wedged between the right and left hipbones.

The joints formed by the sacrum and the hipbones are known as the right

and left sacroiliac joints (see figure 4).

Figure 1Vertebral bone

Nerve Root

Spinal Canal

Spinal Cord

Vertebral Body

Figure 2Spinal column schematic: neck to sacrum

CervicalSpine

Sacrum

ThoracicSpine

LumbarSpine

((

((

Nerve Root

Vertebrae

Discs

Sacrum

Figure 3Spinal column and sacrum lateral (side) view

Figure 4Spinal column and sacrum posterior (back)) view

Spinal Cord

Nerve Root

Facet Joints

SacroiliacJoints

2 3

Before we can discuss the causes, diagnosis, and treatment of back pain, it is important to understand

the basic structure of the back. The back is comprised of a variety of tissues, including bones, muscles,

joints, discs and nerves. All these parts work together to keep us upright, balanced and active.

Spinal ColumnThe spine forms the axis of our body. It is a bony structure

that starts at the base of the skull and runs all the way down

to the tailbone. The spine is comprised of individual bones

called vertebra (see figure 1) that are stacked on top of each

other to form a column, generally known as the spinal column

(see figure 2). The spinal column tapers off and ends with the

tailbone or coccyx. The vertebrae are named based on their

location in the spinal column. There are seven vertebral bones

in the neck called cervical vertebrae, 12 vertebral bones in the

mid-back called thoracic vertebrae and five vertebral bones

in the lower back called lumbar vertebrae. The vertebrae are

connected by ligaments, which are bands of collagen fibers

that connect bone to bone. Ligaments act to reinforce and

stabilize the spinal column while allowing limited mobility.

DiscEach vertebra is separated from the one below it by fibrous tissue

called a disc (see figure 3). Discs space out the vertebral bones, allow

movement of the spinal column, and act as shock absorbers during

activity. The discs are comprised of an outer and an inner layer. The

outer layer is made up of fibrous tissue and cartilage and surrounds

an inner gelatinous layer. The fibrous tissue distributes pressure evenly

across the disc while the gelatinous layer cushions external forces.

Spinal CanalStacking the vertebral bones on top of each other results in the formation

of a tube inside the spinal column (see figure 1). This empty cylindrical

space, called the spinal canal, contains and protects the spinal cord

and its supporting structures.

Chapter 1: The Anatomy and Structure of Your BackSpinal CordThe spinal cord is a collection of nerve tissue that connects the brain to

the rest of the body. All the nerves in our body originate from the spinal

cord. In turn, the spinal cord sends information to and from the brain

about the body. The spinal cord is covered by three different layers

of tissue and bathed in a special liquid called the cerebrospinal fluid.

(See figure 5). The spinal cord, in turn, gives rise to nerves that travel

all over the body. These nerves split off from the spinal cord and leave

the spinal canal through holes called vertebral foramen. The origin of

each nerve from the spinal cord is named the nerve root (see figure 3).

Peripheral NervesNerves exit on either side of the spinal column and travel throughout the body, including down the arms,

hands, legs and feet. Once the nerves leave the spinal column they are renamed peripheral nerves. These

nerves are responsible for the sensation and motion of our body.

Epidural SpaceThe epidural space is the area between the outermost layer of the spinal cord and the inside bony surface of

the spinal canal. The epidural space contains nerves branching off the spinal cord, blood vessels and fatty

tissue. This is a common site for interventions aimed at treating back pain.

Facet JointsFacet joints are the joints that form between the vertebral bones when they

are stacked on top of each other to construct the spinal column (see figure

4). They are located on the outer left and right side of the spinal column all

along the spine. These joints allow flexion, extension and rotation of the

spine. They also stabilize the spine and limit certain types of movements.

SacrumThe sacrum (see figure 2) forms the base of the spinal column and ends

with the tailbone. It is a triangular structure comprised of five vertebrae that

are fused together (unlike the vertebrae that make up the rest of the spinal

column). The sacrum sits wedged between the right and left hipbones.

The joints formed by the sacrum and the hipbones are known as the right

and left sacroiliac joints (see figure 4).

Figure 1Vertebral bone

Nerve Root

Spinal Canal

Spinal Cord

Vertebral Body

Figure 2Spinal column schematic: neck to sacrum

CervicalSpine

Sacrum

ThoracicSpine

LumbarSpine

((

((

Nerve Root

Vertebrae

Discs

Sacrum

Figure 3Spinal column and sacrum lateral (side) view

Figure 4Spinal column and sacrum posterior (back)) view

Spinal Cord

Nerve Root

Facet Joints

SacroiliacJoints

4 5

Abnormal Anatomy

Now that we have an idea of the normal anatomy of the back, we can touch on abnormalities that

can be the source of back pain. It is important to remember that these abnormalities can occur

at any level of the spine and cause symptoms anywhere from the neck downward.

Herniated DiscsThe fibrous tissue between the vertebrae can slip, bulge or rupture with or without an obvious

injury. As the disc comes out of place, it spills into the spinal canal and may press on the nerves

or even the spinal cord. This may result in pain, numbness and weakness at the source of the

problem and along the path the nerves take once they leave the spinal column. This is the reason

that back problems may also lead to pain and weakness of the arms or legs. (See figure 5).

Degenerative Disc DiseaseAs we age, the discs that separate our vertebrae tend to lose height and flexibility. The vertebrae

then begin to rub against each other resulting in extra bone formation by the vertebral bones.

The extra bone, known as bone spurs or osteophytes, can press on the nerve roots and cause

pain and inflammation.

Spinal Stenosis Stenosis is the term for narrowing or obstruction of the spinal

canal or foramina where the nerve roots exit. When the diameter

of the central canal is reduced to less than 10mm, it is considered

narrowed. Most commonly this results from bulging discs, extra

bone formation in the canal (osteophytes), enlargement of the

ligaments that support the spine, deposition of extra fat in the

epidural space and scar tissue from prior back surgeries. (See

figure 6). With less room to live, the nerves become irritated and

cause pain, numbness, tingling and weakness.

Facet ArthropathyArthropathy refers to deterioration and arthritis of the facet joints

of the spine (see figure 4). Arthritis occurs due to wear and tear,

disc problems and prior injuries. As the space between the

vertebrae decreases, the facet joints start to rub together and

enlarge. A nerve called the medial branch supplies each facet

joint. The medial branch nerve is a sensory nerve that produces

pain signals when the facet joint is diseased. Typically, this type of

pain remains confined to the back and gets worse with extension

and rotation.

Sacroiliac Dysfunction/SacroiliitisSacroiliac pain originates from either one or both of the sacroiliac

joints (see figure 4) due to abnormal movement of the joint

(dysfunction) and/or inflammation of the joint (sacroiliitis). The

inflammation in the joint can be a result of abnormal joint motion

or underlying conditions such as arthritis or injury. In both cases,

the joint pain can manifest as lower back pain, hip pain, buttock

pain and tenderness.

Figure 5

Side (lateral) view of the lumbar spine on MRI imaging. The vertebral bodies are separated by intervertebral discs. The spinal cord (light gray) is situated in the spinal canal and bathed in cerebrospinal fluid (white). The image demonstrates a herniated disc (circled) that spills into the spinal canal.

Side (lateral) view of the lumbar spine on MRI imaging demonstrating significant protrusion of the disc between the L4 and L5 vertebrae causing narrowing and almost complete obstruction of the spinal canal aka spinal canal stenosis

Now that you have a better understanding of the structure of your back and spine and the most common

abnormalities that can occur, the following chapters will help you understand how the physicians at

SpineCARE diagnose and treat back and spine pain, as well as work with you to prevent future injury and

pain.

Figure 6

LumbarStenosis

Severe DiscDegeneration

Disc Bulge

4 5

Abnormal Anatomy

Now that we have an idea of the normal anatomy of the back, we can touch on abnormalities that

can be the source of back pain. It is important to remember that these abnormalities can occur

at any level of the spine and cause symptoms anywhere from the neck downward.

Herniated DiscsThe fibrous tissue between the vertebrae can slip, bulge or rupture with or without an obvious

injury. As the disc comes out of place, it spills into the spinal canal and may press on the nerves

or even the spinal cord. This may result in pain, numbness and weakness at the source of the

problem and along the path the nerves take once they leave the spinal column. This is the reason

that back problems may also lead to pain and weakness of the arms or legs. (See figure 5).

Degenerative Disc DiseaseAs we age, the discs that separate our vertebrae tend to lose height and flexibility. The vertebrae

then begin to rub against each other resulting in extra bone formation by the vertebral bones.

The extra bone, known as bone spurs or osteophytes, can press on the nerve roots and cause

pain and inflammation.

Spinal Stenosis Stenosis is the term for narrowing or obstruction of the spinal

canal or foramina where the nerve roots exit. When the diameter

of the central canal is reduced to less than 10mm, it is considered

narrowed. Most commonly this results from bulging discs, extra

bone formation in the canal (osteophytes), enlargement of the

ligaments that support the spine, deposition of extra fat in the

epidural space and scar tissue from prior back surgeries. (See

figure 6). With less room to live, the nerves become irritated and

cause pain, numbness, tingling and weakness.

Facet ArthropathyArthropathy refers to deterioration and arthritis of the facet joints

of the spine (see figure 4). Arthritis occurs due to wear and tear,

disc problems and prior injuries. As the space between the

vertebrae decreases, the facet joints start to rub together and

enlarge. A nerve called the medial branch supplies each facet

joint. The medial branch nerve is a sensory nerve that produces

pain signals when the facet joint is diseased. Typically, this type of

pain remains confined to the back and gets worse with extension

and rotation.

Sacroiliac Dysfunction/SacroiliitisSacroiliac pain originates from either one or both of the sacroiliac

joints (see figure 4) due to abnormal movement of the joint

(dysfunction) and/or inflammation of the joint (sacroiliitis). The

inflammation in the joint can be a result of abnormal joint motion

or underlying conditions such as arthritis or injury. In both cases,

the joint pain can manifest as lower back pain, hip pain, buttock

pain and tenderness.

Figure 5

Side (lateral) view of the lumbar spine on MRI imaging. The vertebral bodies are separated by intervertebral discs. The spinal cord (light gray) is situated in the spinal canal and bathed in cerebrospinal fluid (white). The image demonstrates a herniated disc (circled) that spills into the spinal canal.

Side (lateral) view of the lumbar spine on MRI imaging demonstrating significant protrusion of the disc between the L4 and L5 vertebrae causing narrowing and almost complete obstruction of the spinal canal aka spinal canal stenosis

Now that you have a better understanding of the structure of your back and spine and the most common

abnormalities that can occur, the following chapters will help you understand how the physicians at

SpineCARE diagnose and treat back and spine pain, as well as work with you to prevent future injury and

pain.

Figure 6

LumbarStenosis

Severe DiscDegeneration

Disc Bulge

6 7

Before we can determine the best treatment option for your back or spine pain, we need

to identify the specific source. At SpineCARE, our back and spine specialists use the latest

imaging technology to pinpoint the source of your pain.

A variety of techniques are available to obtain the clearest image of your back and spine.

Your physician will select the imaging technique or combination of techniques based on your

specific medical history and symptoms.

Basic Spine X-raysYour physician will probably start with a series of basic spine X-rays. Images will be taken

of the front (anterior), back (posterior) and sides (lateral) of your back and spine. These

images can reveal abnormal curvature of the spine, degenerative disc disease or slippage,

or fractures. Your physician may order angled view X-rays (oblique) that are used to evaluate

the nerve root openings from your spine, another potential source of your pain. Finally, your

physician may order flexion and extension X-rays, which will be taken while you are bending

forward and backward to determine if you are experiencing any spinal instability.

Computed Tomography (CT)After evaluating your basic spine X-rays, your physician may order a CT scan series. CT

scans show much higher bone detail and better soft tissue detail. If your physician suspects

a narrowing within the spinal canal or around the nerve roots, he or she may request a CT

myelogram, a CT scan involving the injection of a contrast dye into your spinal fluid. Again,

your medical history and symptoms will help your physician determine the appropriateness

of a CT myelogram.

Chapter 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain

Magnetic Resonance Imaging (MRI)If you are experiencing numbness, tingling or weakness, or if your basic X-rays and CT scans don’t provide

enough visualization to determine a precise diagnosis, your physician may order a MRI. MRI scans show the

highest detail of soft tissue structures, including the spinal cord, nerve roots, discs, ligaments and muscles.

Contrast dye can be used with MRI to enhance images of conditions such as scar formation, infection or

cancer. Because MRI utilizes a strong magnetic field, it is not appropriate for patients with pacemakers/

defibrillators, spinal cord stimulators, insulin pumps and metallic objects in the body, such as ear implants,

aneurysm clips or small pieces of shrapnel.

Other Imaging TechniquesDepending on your medical history and presenting symptoms, your physician may order other imaging

tests. Bone scan imaging is a good screening methodology to help determine if there is any increased bony

activity due to inflammation, instability, infection, fracture or tumor. Electrodiagnostic (EMG) studies involve

electrical stimulation to test the function of the major nerves and muscles in the upper and lower extremities

to see if and how they are affected by a spinal disease or injury.

While all of these diagnostic imaging techniques can help your physician pinpoint the specific cause of your

back and spine pain, there is no perfect diagnostic study. That’s why your physician may order a combination

of studies to help him or her form a more complete and objective picture of your pain and determine the

most appropriate treatment plan to help you heal and enjoy life again as quickly as possible.

6 7

Before we can determine the best treatment option for your back or spine pain, we need

to identify the specific source. At SpineCARE, our back and spine specialists use the latest

imaging technology to pinpoint the source of your pain.

A variety of techniques are available to obtain the clearest image of your back and spine.

Your physician will select the imaging technique or combination of techniques based on your

specific medical history and symptoms.

Basic Spine X-raysYour physician will probably start with a series of basic spine X-rays. Images will be taken

of the front (anterior), back (posterior) and sides (lateral) of your back and spine. These

images can reveal abnormal curvature of the spine, degenerative disc disease or slippage,

or fractures. Your physician may order angled view X-rays (oblique) that are used to evaluate

the nerve root openings from your spine, another potential source of your pain. Finally, your

physician may order flexion and extension X-rays, which will be taken while you are bending

forward and backward to determine if you are experiencing any spinal instability.

Computed Tomography (CT)After evaluating your basic spine X-rays, your physician may order a CT scan series. CT

scans show much higher bone detail and better soft tissue detail. If your physician suspects

a narrowing within the spinal canal or around the nerve roots, he or she may request a CT

myelogram, a CT scan involving the injection of a contrast dye into your spinal fluid. Again,

your medical history and symptoms will help your physician determine the appropriateness

of a CT myelogram.

Chapter 2: Diagnostic Imaging: Pinpointing the Source of Your Back Pain

Magnetic Resonance Imaging (MRI)If you are experiencing numbness, tingling or weakness, or if your basic X-rays and CT scans don’t provide

enough visualization to determine a precise diagnosis, your physician may order a MRI. MRI scans show the

highest detail of soft tissue structures, including the spinal cord, nerve roots, discs, ligaments and muscles.

Contrast dye can be used with MRI to enhance images of conditions such as scar formation, infection or

cancer. Because MRI utilizes a strong magnetic field, it is not appropriate for patients with pacemakers/

defibrillators, spinal cord stimulators, insulin pumps and metallic objects in the body, such as ear implants,

aneurysm clips or small pieces of shrapnel.

Other Imaging TechniquesDepending on your medical history and presenting symptoms, your physician may order other imaging

tests. Bone scan imaging is a good screening methodology to help determine if there is any increased bony

activity due to inflammation, instability, infection, fracture or tumor. Electrodiagnostic (EMG) studies involve

electrical stimulation to test the function of the major nerves and muscles in the upper and lower extremities

to see if and how they are affected by a spinal disease or injury.

While all of these diagnostic imaging techniques can help your physician pinpoint the specific cause of your

back and spine pain, there is no perfect diagnostic study. That’s why your physician may order a combination

of studies to help him or her form a more complete and objective picture of your pain and determine the

most appropriate treatment plan to help you heal and enjoy life again as quickly as possible.

8 9

Chapter 3: Conservative Therapies:

The Starting Point for Treating Your Pain

At SpineCARE, our passion is to put you, the patient, at the center of everything we do.

Our goal is to help you enjoy a life that is as pain free as possible by providing the most

appropriate, individualized treatment. Our back and spine specialists are experts in a variety

of treatment options, particularly conservative care. Conservative care encompasses

modalities such as physical therapy, pain management, chiropractic care and acupuncture.

Physical Therapy One of our licensed physical therapists will meet with you to perform an extensive evaluation

to help identify the cause of your symptoms before developing your individually tailored

treatment plan. The evaluation will include a review of your symptoms, health history,

posture, range of motion and spinal alignment. Physical therapy is designed to improve

your strength and flexibility with the goal of reducing your pain. Your treatment plan may

include a combination of approaches:

• Electrical muscle stimulation: Small adhesive electrodes are placed on your

skin in the area of pain. A small current is passed through the electrodes to

help relax tight muscles and decrease your pain. Many patients tell us that

this therapy feels like a great massage. This therapy can also be performed

at home or at work with a transcutaneous electrical nerve stimulation

(TENS) unit. Your physical therapist can provide information about TENS

and whether this is appropriate for you.

• Ice: Often, physical therapy uses the application of ice to the area of pain

to help decrease inflammation, pain and muscle spasms.

• Heat: Your physical therapist may determine that heat is an appropriate

treatment option, especially if improved circulation to the area of pain will

support the healing of aching muscles.

• Stretching exercises: Stretching is a basic component of physical therapy

because it improves flexibility and mobility as well as decreases muscle

tension and tightness. Your treatment plan may include targeted stretching

for areas such as the neck, mid-back, low back, hips and/or legs.

• Exercise program: Exercise also is a foundation of physical therapy and

that’s why your treatment plan will probably include an exercise program.

Your physical therapist will work with you to teach you the proper form

and technique for each exercise. The exercises will be specific for you

and your symptoms. The goal is to strengthen the area of concern – your

neck, mid-back or lower back. Over time these exercises promote long-

term stabilization and prevent future problems and/or injuries. By the time

you finish your treatment plan, you should feel confident, competent and

comfortable with performing these exercises at home or in the gym.

• Non-surgical decompression therapy: This therapy is used to gently pull

and move joints, taking pressure off certain regions in your spine. Often,

this therapy is prescribed for herniated/bulging discs where the pain level

shoots into either the arms or legs.

• Posture/body mechanics/ergonomics: The things you do every day, and

to which you generally don’t give a second thought, can be contributing

to the pain you are feeling. We call these activities of daily living and they

include things like sitting in a chair, the way you get in and out of your car,

the way you get in and out of bed and more. All of these routine activities

can affect the stability of your spine. Your physical therapy treatment plan

will help you identify these activities of daily living and will help empower

you to move the right way.

• Back braces: Your physician, chiropractor or physical therapist may

determine that a back brace is an appropriate component of your treatment

plan. Back braces help stabilize your spine and the muscles around it,

reducing the likelihood of injury, especially from repetitive motions. The

brace supports your spine and limits its motion, alleviating your pain level.

8 9

Chapter 3: Conservative Therapies:

The Starting Point for Treating Your Pain

At SpineCARE, our passion is to put you, the patient, at the center of everything we do.

Our goal is to help you enjoy a life that is as pain free as possible by providing the most

appropriate, individualized treatment. Our back and spine specialists are experts in a variety

of treatment options, particularly conservative care. Conservative care encompasses

modalities such as physical therapy, pain management, chiropractic care and acupuncture.

Physical Therapy One of our licensed physical therapists will meet with you to perform an extensive evaluation

to help identify the cause of your symptoms before developing your individually tailored

treatment plan. The evaluation will include a review of your symptoms, health history,

posture, range of motion and spinal alignment. Physical therapy is designed to improve

your strength and flexibility with the goal of reducing your pain. Your treatment plan may

include a combination of approaches:

• Electrical muscle stimulation: Small adhesive electrodes are placed on your

skin in the area of pain. A small current is passed through the electrodes to

help relax tight muscles and decrease your pain. Many patients tell us that

this therapy feels like a great massage. This therapy can also be performed

at home or at work with a transcutaneous electrical nerve stimulation

(TENS) unit. Your physical therapist can provide information about TENS

and whether this is appropriate for you.

• Ice: Often, physical therapy uses the application of ice to the area of pain

to help decrease inflammation, pain and muscle spasms.

• Heat: Your physical therapist may determine that heat is an appropriate

treatment option, especially if improved circulation to the area of pain will

support the healing of aching muscles.

• Stretching exercises: Stretching is a basic component of physical therapy

because it improves flexibility and mobility as well as decreases muscle

tension and tightness. Your treatment plan may include targeted stretching

for areas such as the neck, mid-back, low back, hips and/or legs.

• Exercise program: Exercise also is a foundation of physical therapy and

that’s why your treatment plan will probably include an exercise program.

Your physical therapist will work with you to teach you the proper form

and technique for each exercise. The exercises will be specific for you

and your symptoms. The goal is to strengthen the area of concern – your

neck, mid-back or lower back. Over time these exercises promote long-

term stabilization and prevent future problems and/or injuries. By the time

you finish your treatment plan, you should feel confident, competent and

comfortable with performing these exercises at home or in the gym.

• Non-surgical decompression therapy: This therapy is used to gently pull

and move joints, taking pressure off certain regions in your spine. Often,

this therapy is prescribed for herniated/bulging discs where the pain level

shoots into either the arms or legs.

• Posture/body mechanics/ergonomics: The things you do every day, and

to which you generally don’t give a second thought, can be contributing

to the pain you are feeling. We call these activities of daily living and they

include things like sitting in a chair, the way you get in and out of your car,

the way you get in and out of bed and more. All of these routine activities

can affect the stability of your spine. Your physical therapy treatment plan

will help you identify these activities of daily living and will help empower

you to move the right way.

• Back braces: Your physician, chiropractor or physical therapist may

determine that a back brace is an appropriate component of your treatment

plan. Back braces help stabilize your spine and the muscles around it,

reducing the likelihood of injury, especially from repetitive motions. The

brace supports your spine and limits its motion, alleviating your pain level.

10 11

Chiropractic Care Chiropractic care is another conservative treatment approach. Based on the principle of spinal alignment,

chiropractic care can address a variety of issues, including neck pain, mid-back pain, low back pain,

sciatica, numbness and more. Your spine can become

misaligned from a variety of causes such as improper lifting,

a car accident, poor sleeping habits and repetitive motions.

Chiropractic care can realign areas in your spine that have

become restricted, restoring proper motion and relieving

pain, soreness, tension and inflammation. During your first

visit with your chiropractor, he or she will conduct a thorough

physical examination and evaluate your medical history,

current symptoms, posture, range of motion, condition of

your nerves radiating from your spine and alignment of your

spine. The examination will determine if chiropractic care is

appropriate for you. Spinal adjustment is the most important

component of chiropractic care. The adjustment involves

applying certain pressures and motions to your spine to help

loosen the joints, promote spinal alignment and restore proper

function to your nervous system. The number of visits with

your chiropractor depends on the extent of degeneration in

your spine and the severity of your pain. Your progress will be

evaluated throughout the duration of your chiropractic care.

AcupunctureAnother conservative treatment approach used by SpineCARE specialists is acupuncture. A form of

Chinese medicine, acupuncture is based on the principle of balancing energy in your body. This energy

is believed to follow certain pathways called meridians. Pain is believed to result when these pathways

are blocked or experience some type of interference. The goal of acupuncture is to remove these

blockages or interferences. A trained acupuncturist will stimulate various points on your body with small

needles to restore the balance and flow of energy. If the thought of needles makes you uncomfortable,

acupressure is an alternative. Acupressure involves the application of pressure, rather than needles, to

acupuncture points.

Chapter 4: Interventional Pain Procedures:

The Next Step in Treating Your Pain

Chronic pain from your back and spine can be especially challenging to treat. That’s why,

at SpineCARE, we offer a diverse array of procedures. Often, treatment plans include a

combination of approaches to achieve the best outcome for each and every patient. Our

goal is to help you achieve a decrease in your pain, enabling you to increase your ability to

function and enjoy a good quality of life.

We offer two types of interventions to address your pain – diagnostic and therapeutic.

Diagnostic interventions, also known as pain mapping, are designed to provide temporary

relief in order to establish the cause of the pain. Typically, a local anesthetic is injected

around a specific nerve or area. If you experience relief after the injection, then it is fair

to assume that the pain is originating from that nerve or region. Pain mapping is highly

effective in determining the exact origin of pain. Once our specialists have an accurate

diagnosis, an effective treatment plan can be tailored to your specific needs, giving you the

highest chance for successful pain relief. Therapeutic procedures are designed to treat the

pain condition after an accurate diagnosis has been determined.

Because our focus is on minimally invasive approaches, recovery times are generally quicker

and patients often experience pain relief sooner rather than later.

Diagnostic Procedures

• Medial branch blocks: The goal of this procedure is to anesthetize or numb the

small sensory nerves that carry pain signals from the irritated facet joints between

your spinal bones to the spinal cord and ultimately to the brain. Using X-rays to

ensure proper placement, a local anesthetic is injected directly onto the nerve. If

relief is provided, the physician has identified the correct area causing pain. Because

this is a diagnostic procedure, it is not designed to permanently eliminate the pain.

This procedure often serves as a precursor to a radiofrequency ablation, which is

designed to treat this pain in a more permanent fashion. This procedure is more fully

explained later in this chapter.

10 11

Chiropractic Care Chiropractic care is another conservative treatment approach. Based on the principle of spinal alignment,

chiropractic care can address a variety of issues, including neck pain, mid-back pain, low back pain,

sciatica, numbness and more. Your spine can become

misaligned from a variety of causes such as improper lifting,

a car accident, poor sleeping habits and repetitive motions.

Chiropractic care can realign areas in your spine that have

become restricted, restoring proper motion and relieving

pain, soreness, tension and inflammation. During your first

visit with your chiropractor, he or she will conduct a thorough

physical examination and evaluate your medical history,

current symptoms, posture, range of motion, condition of

your nerves radiating from your spine and alignment of your

spine. The examination will determine if chiropractic care is

appropriate for you. Spinal adjustment is the most important

component of chiropractic care. The adjustment involves

applying certain pressures and motions to your spine to help

loosen the joints, promote spinal alignment and restore proper

function to your nervous system. The number of visits with

your chiropractor depends on the extent of degeneration in

your spine and the severity of your pain. Your progress will be

evaluated throughout the duration of your chiropractic care.

AcupunctureAnother conservative treatment approach used by SpineCARE specialists is acupuncture. A form of

Chinese medicine, acupuncture is based on the principle of balancing energy in your body. This energy

is believed to follow certain pathways called meridians. Pain is believed to result when these pathways

are blocked or experience some type of interference. The goal of acupuncture is to remove these

blockages or interferences. A trained acupuncturist will stimulate various points on your body with small

needles to restore the balance and flow of energy. If the thought of needles makes you uncomfortable,

acupressure is an alternative. Acupressure involves the application of pressure, rather than needles, to

acupuncture points.

Chapter 4: Interventional Pain Procedures:

The Next Step in Treating Your Pain

Chronic pain from your back and spine can be especially challenging to treat. That’s why,

at SpineCARE, we offer a diverse array of procedures. Often, treatment plans include a

combination of approaches to achieve the best outcome for each and every patient. Our

goal is to help you achieve a decrease in your pain, enabling you to increase your ability to

function and enjoy a good quality of life.

We offer two types of interventions to address your pain – diagnostic and therapeutic.

Diagnostic interventions, also known as pain mapping, are designed to provide temporary

relief in order to establish the cause of the pain. Typically, a local anesthetic is injected

around a specific nerve or area. If you experience relief after the injection, then it is fair

to assume that the pain is originating from that nerve or region. Pain mapping is highly

effective in determining the exact origin of pain. Once our specialists have an accurate

diagnosis, an effective treatment plan can be tailored to your specific needs, giving you the

highest chance for successful pain relief. Therapeutic procedures are designed to treat the

pain condition after an accurate diagnosis has been determined.

Because our focus is on minimally invasive approaches, recovery times are generally quicker

and patients often experience pain relief sooner rather than later.

Diagnostic Procedures

• Medial branch blocks: The goal of this procedure is to anesthetize or numb the

small sensory nerves that carry pain signals from the irritated facet joints between

your spinal bones to the spinal cord and ultimately to the brain. Using X-rays to

ensure proper placement, a local anesthetic is injected directly onto the nerve. If

relief is provided, the physician has identified the correct area causing pain. Because

this is a diagnostic procedure, it is not designed to permanently eliminate the pain.

This procedure often serves as a precursor to a radiofrequency ablation, which is

designed to treat this pain in a more permanent fashion. This procedure is more fully

explained later in this chapter.

12 13

• Selective nerve root blocks: Nerves that supply our upper and lower extremities

originate from large spinal nerves that separate from the spinal cord at various levels.

Sometimes the nerve roots can become compressed or restricted from herniated or

bulging disks or from the bones in the spine. This is especially true in the presence

of degenerative disk disease. When this occurs the result is often pain in the neck

of lower back region that can radiate into the upper or lower extremities. Numbness

and tingling can also be present with the pain. The goal of a selective nerve root

block is to apply a targeted dose of local anesthetic to a suspected irritated nerve

with the help of X-ray guidance. Again, this type of injection is diagnostic and not

therapeutic. Usually, selective nerve root blocks are done in a series at multiple

levels to help determine which nerve or nerves are causing your pain. This series of

injections is sometimes referred to as pain mapping and can be useful prior to surgery

to verify exactly which levels need the operation. Sometimes the procedure becomes

therapeutic when a steroid medication is added to the numbing medication. The

steroid has an anti-inflammatory effect that can last from months to years. If a steroid

is added, it is known as a transforaminal epidural steroid injection.

• Discogram: Discography is performed on patients thought to be suffering from pain

arising from the discs between the bones in the spine. As we age, our spine is subject

to degeneration that can result in defects or tears in our discs making them more prone

to bulging. A discogram is an interactive diagnostic procedure in which the pressure

of the disc is increased, usually using a contrast material that is visible on X-ray and

CT scan imaging, to determine if the pain is coming from the disc being evaluated.

As the physician applies various pressures to the disc, it is important for the patient

to communicate if the pain is greater than that he or she normally experiences. A CT

scan may be performed immediately after a discogram to further evaluate the discs.

This is considered a diagnostic procedure and is typically performed prior to surgery

to help identify which discs to operate on.

Therapeutic Procedures

• Epidural steroid injections: This procedure involves placing a powerful anti-

inflammatory steroidal medication via injection into the area between the outermost

layer of the spinal cord and the inside bony surface of the spinal canal. The goal

of the procedure is to decrease irritation and inflammation that may contribute to

pain, especially if nerve compression or restriction is present. Sometimes these

injections are performed in a series of three over the course of several weeks to help

decrease chronic inflammation. Depending on your diagnosis, your physician may

choose to administer one of several types of epidural steroid injections – interlaminar,

transforaminal or caudal. Your physician will explain the specifics of the selected

injection to you prior to the procedure.

• Radiofrequency ablation: Usually performed after successful medial branch blocks,

radiofrequency energy is used to render the medial branch nerves in the neck or back

non-functional. These nerves carry pain signals to the brain from inflamed or arthritic

joints in the neck or back. Using X-ray guidance, small specialized insulated needles

are placed in appropriate locations along your spine. A small, radiofrequency ablation

probe is placed through the needle. The probes are attached to a small generator

capable of producing thermal energy that makes the nerves non-functional. The

procedure takes up to two minutes per nerve, but often several nerves can be ablated

at the same time. This procedure usually provides relief for six months to two years.

• Non-invasive pain procedure (NIPP): SpineCARE is proud to offer our patients

the NIPP. This exciting new technology involves temporarily placing a peripheral

neurostimulator unit on the skin to help decrease pain. The procedure has minimal to

no side effects because it requires no medications or anesthesia. The neurostimulator

is attached just under your ear with some adhesives and dressings. Three small wires

are attached to nerve endings in your outer ear. You will wear the device for three to

four days and then remove it at home. While wearing the device you may notice a

gentle intermittent stimulation of your ear. This is generally very mild and does not

interfere with sleep. The sensation helps stimulate certain portions of your central

nervous system that results in improved blood flow, decreased inflammation and

decreased pain. Many patients feel significant relief after just one placement. The

procedure takes 10 to 15 minutes to perform. For more information and to see patient

testimonials, visit www.fixpain.com.

12 13

• Selective nerve root blocks: Nerves that supply our upper and lower extremities

originate from large spinal nerves that separate from the spinal cord at various levels.

Sometimes the nerve roots can become compressed or restricted from herniated or

bulging disks or from the bones in the spine. This is especially true in the presence

of degenerative disk disease. When this occurs the result is often pain in the neck

of lower back region that can radiate into the upper or lower extremities. Numbness

and tingling can also be present with the pain. The goal of a selective nerve root

block is to apply a targeted dose of local anesthetic to a suspected irritated nerve

with the help of X-ray guidance. Again, this type of injection is diagnostic and not

therapeutic. Usually, selective nerve root blocks are done in a series at multiple

levels to help determine which nerve or nerves are causing your pain. This series of

injections is sometimes referred to as pain mapping and can be useful prior to surgery

to verify exactly which levels need the operation. Sometimes the procedure becomes

therapeutic when a steroid medication is added to the numbing medication. The

steroid has an anti-inflammatory effect that can last from months to years. If a steroid

is added, it is known as a transforaminal epidural steroid injection.

• Discogram: Discography is performed on patients thought to be suffering from pain

arising from the discs between the bones in the spine. As we age, our spine is subject

to degeneration that can result in defects or tears in our discs making them more prone

to bulging. A discogram is an interactive diagnostic procedure in which the pressure

of the disc is increased, usually using a contrast material that is visible on X-ray and

CT scan imaging, to determine if the pain is coming from the disc being evaluated.

As the physician applies various pressures to the disc, it is important for the patient

to communicate if the pain is greater than that he or she normally experiences. A CT

scan may be performed immediately after a discogram to further evaluate the discs.

This is considered a diagnostic procedure and is typically performed prior to surgery

to help identify which discs to operate on.

Therapeutic Procedures

• Epidural steroid injections: This procedure involves placing a powerful anti-

inflammatory steroidal medication via injection into the area between the outermost

layer of the spinal cord and the inside bony surface of the spinal canal. The goal

of the procedure is to decrease irritation and inflammation that may contribute to

pain, especially if nerve compression or restriction is present. Sometimes these

injections are performed in a series of three over the course of several weeks to help

decrease chronic inflammation. Depending on your diagnosis, your physician may

choose to administer one of several types of epidural steroid injections – interlaminar,

transforaminal or caudal. Your physician will explain the specifics of the selected

injection to you prior to the procedure.

• Radiofrequency ablation: Usually performed after successful medial branch blocks,

radiofrequency energy is used to render the medial branch nerves in the neck or back

non-functional. These nerves carry pain signals to the brain from inflamed or arthritic

joints in the neck or back. Using X-ray guidance, small specialized insulated needles

are placed in appropriate locations along your spine. A small, radiofrequency ablation

probe is placed through the needle. The probes are attached to a small generator

capable of producing thermal energy that makes the nerves non-functional. The

procedure takes up to two minutes per nerve, but often several nerves can be ablated

at the same time. This procedure usually provides relief for six months to two years.

• Non-invasive pain procedure (NIPP): SpineCARE is proud to offer our patients

the NIPP. This exciting new technology involves temporarily placing a peripheral

neurostimulator unit on the skin to help decrease pain. The procedure has minimal to

no side effects because it requires no medications or anesthesia. The neurostimulator

is attached just under your ear with some adhesives and dressings. Three small wires

are attached to nerve endings in your outer ear. You will wear the device for three to

four days and then remove it at home. While wearing the device you may notice a

gentle intermittent stimulation of your ear. This is generally very mild and does not

interfere with sleep. The sensation helps stimulate certain portions of your central

nervous system that results in improved blood flow, decreased inflammation and

decreased pain. Many patients feel significant relief after just one placement. The

procedure takes 10 to 15 minutes to perform. For more information and to see patient

testimonials, visit www.fixpain.com.

14 15

• Spinal cord stimulation: If you have experienced persistent pain even after undergoing

multiple therapeutic measures, you may be a candidate for spinal cord stimulation.

This therapy is used for very specific indications and is preceded by an outpatient

trial to see if it can relieve your pain. Performed using a minimal amount of sedation

and X-rays for placement, small needles are used to place little wires into the epidural

space in close proximity to the spinal cord. The wires are attached to an external

battery source (programmer) that will create a variety of stimulation programs to cover

and alleviate your pain. As the programmer is turned on, your pain will be replaced

by a mild pleasant sensation, known as paresthesia. The concept is that if the nerves

that cause your pain are stimulated to cause paresthesia, they are no longer able to

carry pain signals to your brain. The trial phase will usually last from three to seven

days. A SpineCARE team member will closely monitor your condition to ensure that

you are getting adequate pain relief. If the trial proves successful, you will undergo an

outpatient surgery to have the wires permanently implanted under the skin along with

a programmer, usually in the abdominal or buttocks region.

• Vertebroplasty/Kyphoplasty: Aging increases the chances for spinal fractures. Recent

trauma, a history of spinal fractures and osteoporosis are risk factors. Kyphoplasty,

a minimally invasive technique, involves injection of bone cement into the spinal

fractures using small instruments. Sometimes an inflatable balloon is used to make a

small space for the cement. The cement stabilizes the vertebrae, often resulting in a

dramatic reduction in pain immediately following the procedure. Patients usually go

home the same day or the day after the procedure. The procedure is performed most

often under local anesthesia and intravenous sedation.

Although this is not a complete list of the interventions we provide at SpineCARE, these

are the most common procedures we perform. Your physician will help you determine

which intervention is appropriate for your specific situation.

Chapter 5: Surgical Options and Lifestyle Changes

The thought of any kind of surgery can be scary.

Spine surgery can be especially intimidating. Once

you make the decision to have surgery, there are

several steps you can take to give yourself the

best possible chance for success. This chapter is

designed to provide you with information that will

help you make an informed decision about whether

to have surgery and to maximize the likelihood that

surgery will help you.

A wide variety of conditions can affect the spine,

but spine surgeons tend to think about these

problems in terms of whether they cause pressure

on the spinal cord or nerves, whether they cause

instability or deformity (curvature), or whether they

cause arthritic back pain. In reality, you may have a

condition that causes symptoms from a combination

of two or even all three problems. For your surgery

to be successful, it must address all the conditions

contributing to your symptoms.

The most common reason to have spine surgery is to relieve pressure on the nerves, either

in the spinal canal or as they exit the spine. This is known as stenosis, or narrowing of

the spinal canal or the foramen, the hole where the nerve exits the canal. When only one

nerve is involved we may refer to it as a radiculopathy, also known as a “pinched nerve”

or “sciatica.” Stenosis has many causes including a herniated disc, a bone spur, overgrown

ligaments and curvature or instability in the spinal column. Symptoms of stenosis can be

anything from a tired, weak feeling in the legs when walking, to severe pain down one or

both legs during activity or even at rest. Some patients get actual weakness or numbness

that corresponds to a single nerve. In severe stenosis, you might even have difficulty with

bowel or bladder function.

14 15

• Spinal cord stimulation: If you have experienced persistent pain even after undergoing

multiple therapeutic measures, you may be a candidate for spinal cord stimulation.

This therapy is used for very specific indications and is preceded by an outpatient

trial to see if it can relieve your pain. Performed using a minimal amount of sedation

and X-rays for placement, small needles are used to place little wires into the epidural

space in close proximity to the spinal cord. The wires are attached to an external

battery source (programmer) that will create a variety of stimulation programs to cover

and alleviate your pain. As the programmer is turned on, your pain will be replaced

by a mild pleasant sensation, known as paresthesia. The concept is that if the nerves

that cause your pain are stimulated to cause paresthesia, they are no longer able to

carry pain signals to your brain. The trial phase will usually last from three to seven

days. A SpineCARE team member will closely monitor your condition to ensure that

you are getting adequate pain relief. If the trial proves successful, you will undergo an

outpatient surgery to have the wires permanently implanted under the skin along with

a programmer, usually in the abdominal or buttocks region.

• Vertebroplasty/Kyphoplasty: Aging increases the chances for spinal fractures. Recent

trauma, a history of spinal fractures and osteoporosis are risk factors. Kyphoplasty,

a minimally invasive technique, involves injection of bone cement into the spinal

fractures using small instruments. Sometimes an inflatable balloon is used to make a

small space for the cement. The cement stabilizes the vertebrae, often resulting in a

dramatic reduction in pain immediately following the procedure. Patients usually go

home the same day or the day after the procedure. The procedure is performed most

often under local anesthesia and intravenous sedation.

Although this is not a complete list of the interventions we provide at SpineCARE, these

are the most common procedures we perform. Your physician will help you determine

which intervention is appropriate for your specific situation.

Chapter 5: Surgical Options and Lifestyle Changes

The thought of any kind of surgery can be scary.

Spine surgery can be especially intimidating. Once

you make the decision to have surgery, there are

several steps you can take to give yourself the

best possible chance for success. This chapter is

designed to provide you with information that will

help you make an informed decision about whether

to have surgery and to maximize the likelihood that

surgery will help you.

A wide variety of conditions can affect the spine,

but spine surgeons tend to think about these

problems in terms of whether they cause pressure

on the spinal cord or nerves, whether they cause

instability or deformity (curvature), or whether they

cause arthritic back pain. In reality, you may have a

condition that causes symptoms from a combination

of two or even all three problems. For your surgery

to be successful, it must address all the conditions

contributing to your symptoms.

The most common reason to have spine surgery is to relieve pressure on the nerves, either

in the spinal canal or as they exit the spine. This is known as stenosis, or narrowing of

the spinal canal or the foramen, the hole where the nerve exits the canal. When only one

nerve is involved we may refer to it as a radiculopathy, also known as a “pinched nerve”

or “sciatica.” Stenosis has many causes including a herniated disc, a bone spur, overgrown

ligaments and curvature or instability in the spinal column. Symptoms of stenosis can be

anything from a tired, weak feeling in the legs when walking, to severe pain down one or

both legs during activity or even at rest. Some patients get actual weakness or numbness

that corresponds to a single nerve. In severe stenosis, you might even have difficulty with

bowel or bladder function.

16 17

Options for Spine Surgery

Surgery for stenosis involves removing all of the tissue that is pressing on the nerve or

nerves. This procedure is known as a decompression. If you do not have any significant

back pain and if you do not have any deformity or instability, a decompression, especially

through a minimally invasive approach, has an excellent chance of curing your symptoms.

The procedure involves making a 1-inch or smaller incision on your back and inserting a

tube through which the spine can be accessed and visualized using either a microscope

or a camera. A high-speed tool and small, bone-trimming instruments are used to remove

just enough bone and ligament to free up the sack containing the nerves (dura) as well as

the nerves as they exit. This approach allows safe visualization of the problem area without

removing or damaging the muscles and other stabilizing structures of the spine.

Some patients have a deformity rather than or in addition to stenosis. The most common

deformity is a spondylolisthesis. This condition is commonly referred to as a “slipped

disc” or “slipped vertebra,” and is caused by instability in the spine either by lax ligaments,

overgrown joints or stress fractures that allow one vertebra to slide forward on the vertebra

above or below it through the disc.

The other type of deformity is a scoliosis, or curvature of the spine, which can be an

abnormality that occurs during growth of the spine or as a result of degeneration of the

spine as an adult. These conditions can cause back pain and can result in stenosis, with

the type of symptoms described above. Sometimes there is no back pain, only symptoms

in the arms or legs. However, if a deformity is present, it has to be addressed during

surgery; otherwise, there is a risk of the deformity getting worse after surgery and the

symptoms returning.

The goal of surgery for a deformity is to realign the spine to normal followed by a fusion of

the spine. There are many ways to perform a spine fusion, but most involve using titanium

rods and screws to hold the vertebrae together and a plastic or bony cage to hold the disc

space open. Bone graft either from the patient or from a donor is then placed across the

disc space and/or along the back side of the spine to cause two or more vertebrae to grow

into one. Stem cells, either from the patient or from a donor (and occasionally genetically

engineered medications), usually are added to the bone graft to increase the likelihood of

the fusion’s success. While a fusion increases the complexity and possible complications

of a surgery, modern technology allows it to be done with less invasive methods that result

in less muscle damage, faster recovery times, and possibly better long-term outcomes

than traditional fusions.

Finally, there are patients that have significant back pain without evidence of stenosis

or deformity. These patients are usually suffering from degenerative disc disease and/

or facet arthritis. They may have some leg pain, but it typically does not extend below

the knee and there is no weakness or numbness. Their imaging studies do not show any

nerve compression or problems with stability or alignment. This is the most difficult group

of patients to help with surgery. A fusion is the most common procedure offered, but the

long-term success rate of a fusion in the absence of a deformity or stenosis is only 50%.

Artificial disc replacement is approved for this condition, but at this point most insurers

consider it experimental and will not approve it. If you have back pain from this condition,

you should consider surgery only as a last resort, and only if you have one or two levels

involved.

Preparing for Surgery – Ensuring a Successful Outcome

Once you reach the point where you have decided to go forward with surgery, you should

do everything in your power to ensure a successful outcome. There are several things you

can do to prepare yourself both mentally and physically for the procedure.

Ideally, these steps should begin well before your surgery is even scheduled, and believe

it or not, the two greatest factors that can influence whether your surgery will go well are

directly within your control: smoking and weight.

Smoking• We have known for decades that long-term smoking has a negative effect on health.

It causes and is associated with cancer, lung disease, heart disease, stroke, and

vascular disease resulting in amputation and kidney failure. These problems tend to

become worse in the elderly population, so younger active people who smoke don’t

consider themselves at risk for smoking-related problems. Smoking does, however,

16 17

Options for Spine Surgery

Surgery for stenosis involves removing all of the tissue that is pressing on the nerve or

nerves. This procedure is known as a decompression. If you do not have any significant

back pain and if you do not have any deformity or instability, a decompression, especially

through a minimally invasive approach, has an excellent chance of curing your symptoms.

The procedure involves making a 1-inch or smaller incision on your back and inserting a

tube through which the spine can be accessed and visualized using either a microscope

or a camera. A high-speed tool and small, bone-trimming instruments are used to remove

just enough bone and ligament to free up the sack containing the nerves (dura) as well as

the nerves as they exit. This approach allows safe visualization of the problem area without

removing or damaging the muscles and other stabilizing structures of the spine.

Some patients have a deformity rather than or in addition to stenosis. The most common

deformity is a spondylolisthesis. This condition is commonly referred to as a “slipped

disc” or “slipped vertebra,” and is caused by instability in the spine either by lax ligaments,

overgrown joints or stress fractures that allow one vertebra to slide forward on the vertebra

above or below it through the disc.

The other type of deformity is a scoliosis, or curvature of the spine, which can be an

abnormality that occurs during growth of the spine or as a result of degeneration of the

spine as an adult. These conditions can cause back pain and can result in stenosis, with

the type of symptoms described above. Sometimes there is no back pain, only symptoms

in the arms or legs. However, if a deformity is present, it has to be addressed during

surgery; otherwise, there is a risk of the deformity getting worse after surgery and the

symptoms returning.

The goal of surgery for a deformity is to realign the spine to normal followed by a fusion of

the spine. There are many ways to perform a spine fusion, but most involve using titanium

rods and screws to hold the vertebrae together and a plastic or bony cage to hold the disc

space open. Bone graft either from the patient or from a donor is then placed across the

disc space and/or along the back side of the spine to cause two or more vertebrae to grow

into one. Stem cells, either from the patient or from a donor (and occasionally genetically

engineered medications), usually are added to the bone graft to increase the likelihood of

the fusion’s success. While a fusion increases the complexity and possible complications

of a surgery, modern technology allows it to be done with less invasive methods that result

in less muscle damage, faster recovery times, and possibly better long-term outcomes

than traditional fusions.

Finally, there are patients that have significant back pain without evidence of stenosis

or deformity. These patients are usually suffering from degenerative disc disease and/

or facet arthritis. They may have some leg pain, but it typically does not extend below

the knee and there is no weakness or numbness. Their imaging studies do not show any

nerve compression or problems with stability or alignment. This is the most difficult group

of patients to help with surgery. A fusion is the most common procedure offered, but the

long-term success rate of a fusion in the absence of a deformity or stenosis is only 50%.

Artificial disc replacement is approved for this condition, but at this point most insurers

consider it experimental and will not approve it. If you have back pain from this condition,

you should consider surgery only as a last resort, and only if you have one or two levels

involved.

Preparing for Surgery – Ensuring a Successful Outcome

Once you reach the point where you have decided to go forward with surgery, you should

do everything in your power to ensure a successful outcome. There are several things you

can do to prepare yourself both mentally and physically for the procedure.

Ideally, these steps should begin well before your surgery is even scheduled, and believe

it or not, the two greatest factors that can influence whether your surgery will go well are

directly within your control: smoking and weight.

Smoking• We have known for decades that long-term smoking has a negative effect on health.

It causes and is associated with cancer, lung disease, heart disease, stroke, and

vascular disease resulting in amputation and kidney failure. These problems tend to

become worse in the elderly population, so younger active people who smoke don’t

consider themselves at risk for smoking-related problems. Smoking does, however,

have a more immediate impact on people with spine problems. Aside from the toxins

in the smoke, nicotine itself causes blood vessels to constrict, limiting their ability to

deliver vital oxygen and nutrients to the tissues of the body. This lack of blood flow

results in more rapid deterioration of the discs and joints and irritated nerves that tend

to remain irritated.

• Aside from potentially making symptoms related to your spine condition worse,

smoking can adversely affect your surgery as well as your recovery. Changes in the

lungs make it harder for the anesthesiologist to keep you breathing. Lack of blood

flow to the surgical site can increase risk of infection or delay healing. If the nerves

have active inflammation, the inflammation may persist even though the pressure

on them has been removed. Smoking prevents the nerves from getting the oxygen,

nutrients, and repair cells they need to help them heal. If your surgery requires a

fusion, being a smoker drops the rate of fusion from greater than 90% to 75% or

less, because new bone requires an excellent blood supply to form. It also increases

the chance of getting a blot clot in your leg or pelvis. So quitting smoking, though

extremely difficult, can pay huge dividends in terms of a successful surgical outcome.

You should try to quit at least six weeks prior to surgery and remain smoke free for

six months or more afterward. Talk to your surgeon or primary care provider about

effective methods to help with quitting.

Body Weight • The other risk factor that you can modify to increase your success rate is body weight.

Carrying extra pounds affects the health of your spine in several ways. It’s a simple

matter of physics: The more weight your spine has to support, the more wear and tear

on the discs and joints, and so the faster they will break down. Since being overweight

often is associated with lack of exercise, there also may be lack of flexibility, poor

muscle tone, and lack of stamina, all of which can increase the chance of an injury.

There is a subgroup of overweight patients who have a condition called metabolic

syndrome. These patients have excess weight carried mostly around the midsection,

are typically not physically active, and begin to develop hormonal imbalances such

as insulin resistance and increased cortisol levels. These imbalances are associated

with increased production of chemicals by the body that cause inflammation and can

damage tissues, including the nerves, discs and joints in the spine. Many of these

patients also are malnourished despite being overweight.

• A quick test for obesity is the Body Mass Index or BMI. There are several online calculators you can

use to calculate your BMI by inputting your height and weight.

• If your BMI is greater than 30 but less than 39 you are said to be in the obese range. When compared

to non-obese patients, obese patients have statistically increased risk of poor outcomes from

surgical treatment of spine disorders. For those patients with BMI greater than 40, those risks

are even higher. In addition to ultimately having a less successful outcome from surgery, obesity

increases the chance that you will have a complication from the surgery itself. Excess weight around

the midsection means a further distance from the skin to the area where the surgeon will be working,

meaning longer time to access the area, longer working distance, and often the need for a larger

incision to take care of the problem. In addition, the hormonal imbalances mentioned above can

result in problems with the immune system, so the risk of infection or delayed wound healing is

higher in this group of patients than in those of normal weight.

• Significant weight loss may take months or even a year for success. While this may seem like too

long to wait for your surgery, if you have a BMI of 39 or greater you should strongly consider waiting

until you have lost the weight. Of course, if your condition requires urgent or immediate intervention

this may not be possible, so this is something you should discuss in detail with your surgeon.

Other chronic medical conditions also need to be well managed to minimize your risk from surgery

and maximize your chance for a successful outcome. If you have diabetes, having your blood

sugars under control is extremely important to ensure proper wound healing and reduce the chance

of infection. If you have any heart, lung, kidney, or blood pressure issues, make sure they are

addressed and stable prior to having spine surgery or any elective procedure. Major depression, if

present, should be treated as well. Your surgeon will rely on your primary care provider and perhaps

select medical specialists to ensure your overall medical condition is compatible with the planned

surgery.

Stress and Anxiety• The biggest mental factors to overcome as you prepare for surgery are stress and anxiety. The main

potential sources of stress related to a spine condition and its ultimate surgical treatment are home/

family, work and finances. Obviously there is much overlap and interrelating of these sources, and

the chronic pain itself can be an added stressor. Finally, the fear of the unknown is a huge source

of anxiety, and being comfortable with your surgeon and knowing what questions to ask regarding

your specific condition and the procedure you are having will help alleviate much of that fear.

• A stable home environment with strong family support is ideal for a person dealing with a painful

spinal condition and an upcoming spine surgery. You will need help around the house with chores,

18 19

have a more immediate impact on people with spine problems. Aside from the toxins

in the smoke, nicotine itself causes blood vessels to constrict, limiting their ability to

deliver vital oxygen and nutrients to the tissues of the body. This lack of blood flow

results in more rapid deterioration of the discs and joints and irritated nerves that tend

to remain irritated.

• Aside from potentially making symptoms related to your spine condition worse,

smoking can adversely affect your surgery as well as your recovery. Changes in the

lungs make it harder for the anesthesiologist to keep you breathing. Lack of blood

flow to the surgical site can increase risk of infection or delay healing. If the nerves

have active inflammation, the inflammation may persist even though the pressure

on them has been removed. Smoking prevents the nerves from getting the oxygen,

nutrients, and repair cells they need to help them heal. If your surgery requires a

fusion, being a smoker drops the rate of fusion from greater than 90% to 75% or

less, because new bone requires an excellent blood supply to form. It also increases

the chance of getting a blot clot in your leg or pelvis. So quitting smoking, though

extremely difficult, can pay huge dividends in terms of a successful surgical outcome.

You should try to quit at least six weeks prior to surgery and remain smoke free for

six months or more afterward. Talk to your surgeon or primary care provider about

effective methods to help with quitting.

Body Weight • The other risk factor that you can modify to increase your success rate is body weight.

Carrying extra pounds affects the health of your spine in several ways. It’s a simple

matter of physics: The more weight your spine has to support, the more wear and tear

on the discs and joints, and so the faster they will break down. Since being overweight

often is associated with lack of exercise, there also may be lack of flexibility, poor

muscle tone, and lack of stamina, all of which can increase the chance of an injury.

There is a subgroup of overweight patients who have a condition called metabolic

syndrome. These patients have excess weight carried mostly around the midsection,

are typically not physically active, and begin to develop hormonal imbalances such

as insulin resistance and increased cortisol levels. These imbalances are associated

with increased production of chemicals by the body that cause inflammation and can

damage tissues, including the nerves, discs and joints in the spine. Many of these

patients also are malnourished despite being overweight.

• A quick test for obesity is the Body Mass Index or BMI. There are several online calculators you can

use to calculate your BMI by inputting your height and weight.

• If your BMI is greater than 30 but less than 39 you are said to be in the obese range. When compared

to non-obese patients, obese patients have statistically increased risk of poor outcomes from

surgical treatment of spine disorders. For those patients with BMI greater than 40, those risks

are even higher. In addition to ultimately having a less successful outcome from surgery, obesity

increases the chance that you will have a complication from the surgery itself. Excess weight around

the midsection means a further distance from the skin to the area where the surgeon will be working,

meaning longer time to access the area, longer working distance, and often the need for a larger

incision to take care of the problem. In addition, the hormonal imbalances mentioned above can

result in problems with the immune system, so the risk of infection or delayed wound healing is

higher in this group of patients than in those of normal weight.

• Significant weight loss may take months or even a year for success. While this may seem like too

long to wait for your surgery, if you have a BMI of 39 or greater you should strongly consider waiting

until you have lost the weight. Of course, if your condition requires urgent or immediate intervention

this may not be possible, so this is something you should discuss in detail with your surgeon.

Other chronic medical conditions also need to be well managed to minimize your risk from surgery

and maximize your chance for a successful outcome. If you have diabetes, having your blood

sugars under control is extremely important to ensure proper wound healing and reduce the chance

of infection. If you have any heart, lung, kidney, or blood pressure issues, make sure they are

addressed and stable prior to having spine surgery or any elective procedure. Major depression, if

present, should be treated as well. Your surgeon will rely on your primary care provider and perhaps

select medical specialists to ensure your overall medical condition is compatible with the planned

surgery.

Stress and Anxiety• The biggest mental factors to overcome as you prepare for surgery are stress and anxiety. The main

potential sources of stress related to a spine condition and its ultimate surgical treatment are home/

family, work and finances. Obviously there is much overlap and interrelating of these sources, and

the chronic pain itself can be an added stressor. Finally, the fear of the unknown is a huge source

of anxiety, and being comfortable with your surgeon and knowing what questions to ask regarding

your specific condition and the procedure you are having will help alleviate much of that fear.

• A stable home environment with strong family support is ideal for a person dealing with a painful

spinal condition and an upcoming spine surgery. You will need help around the house with chores,

18 19

errands, and more, even after a minimally invasive procedure. You will need to take at least a week

and maybe more off from work, depending on your type of job and the procedure you are having.

Timing the surgery to coincide with loved ones’ availability to help out and making sure the surgery

will not interfere with completion of any critical tasks at work will give you quite a bit more peace of

mind and allow you to focus all your attention on getting better. If there is no one at home to help

out, discuss this fact with your surgeon so arrangements can be made for home health or even

inpatient rehab after surgery, depending on the procedure type.

Choosing Your Surgeon

• Assuming you are in the best possible physical health and have a supportive home life and stable

job situation, you should be primed for success. The last thing to do to minimize your stress level

and get ready for surgery is to make sure you are comfortable with your surgeon and completely

understand your condition and the proposed procedure. You should familiarize yourself with your

surgeon’s level of training and competence, and you should have your spine condition and the

surgery explained to you in terms you can understand, preferably with the aid of models and

illustrations. You also should expect a discussion of the most likely complications, as well as less

likely but severe complications that can occur with the surgery. Finally, you should expect to have

all your questions answered to your satisfaction.

• There is great variability in the training of spine surgeons in our country. At a minimum, your spine

surgeon should be board certified in either neurosurgery or orthopaedic surgery. This means he or

she successfully completed an accredited residency program; that is, several years of formal training

after graduation from medical school at a facility that meets the requirements of the Accreditation

Council for Graduate Medical Education. He or she then demonstrated the competency and

proficiency needed to meet the standards of either the American Board of Neurological Surgery

or the American Board of Orthopaedic Surgery. During his or her residency he or she would have

received training in spine care as part of a broader training in disorders of the brain and nervous

system in the case of a neurosurgeon or the musculoskeletal system in the case of an orthopaedic

surgeon. In our opinion, the surgeon should also have completed a fellowship in spine surgery; that

is, one or more years of training following residency focusing solely on diagnosis and management

of, and surgery for disorders of the spine. This extra focused training in spine care is critical given

the complexity of the disorders and the rapid advances in diagnosis and treatment options.

Understanding Your Surgical Plan• Once you have satisfied yourself with your surgeon’s qualifications, you should make sure you understand

the nature of your condition and how the proposed surgery will address it. Some of the questions you

should ask are listed here, but you should make your own list and bring it to your doctor’s visit. Do not

rely on your memory, as you are likely to forget much of what you want to ask. Also take notes during

your visit with your physician. Studies show patients remember less than half of what their surgeon tells

them during the pre-operative counseling session.

Some questions you should ask:

• Is there any deformity or instability present?

• If so, what type of fusion will be done?

• Where and how large will the incisions be?

• How long will I be in the hospital?

• How long will I be confined to home?

• How long will I be off work?

• Will I have to wear a brace after surgery, and if so for how long?

• If having a fusion, will an external bone stimulator be prescribed?

• When will physical therapy begin?

• When will I be able to resume light physical activity?

• When will I be able to resume full activity?

• When will I be able to resume sexual relations?

Spine surgery can be a life-altering endeavor, hopefully for the better. By taking an active role in your spine

care and by being your own best health advocate, you can put yourself in position to have the best possible

outcome. Choosing the right surgeon, educating yourself on your unique condition and its best treatment,

and maximizing your physical condition prior to surgery increase your chances for success, as does ensuring

you have strong social supports you can lean on around the time of surgery and during your recovery. If it all

still seems too daunting, have an honest discussion of your fears with your surgeon. He or she can put you

in touch with a counselor or even a patient who has already been through the process.

20 21

errands, and more, even after a minimally invasive procedure. You will need to take at least a week

and maybe more off from work, depending on your type of job and the procedure you are having.

Timing the surgery to coincide with loved ones’ availability to help out and making sure the surgery

will not interfere with completion of any critical tasks at work will give you quite a bit more peace of

mind and allow you to focus all your attention on getting better. If there is no one at home to help

out, discuss this fact with your surgeon so arrangements can be made for home health or even

inpatient rehab after surgery, depending on the procedure type.

Choosing Your Surgeon

• Assuming you are in the best possible physical health and have a supportive home life and stable

job situation, you should be primed for success. The last thing to do to minimize your stress level

and get ready for surgery is to make sure you are comfortable with your surgeon and completely

understand your condition and the proposed procedure. You should familiarize yourself with your

surgeon’s level of training and competence, and you should have your spine condition and the

surgery explained to you in terms you can understand, preferably with the aid of models and

illustrations. You also should expect a discussion of the most likely complications, as well as less

likely but severe complications that can occur with the surgery. Finally, you should expect to have

all your questions answered to your satisfaction.

• There is great variability in the training of spine surgeons in our country. At a minimum, your spine

surgeon should be board certified in either neurosurgery or orthopaedic surgery. This means he or

she successfully completed an accredited residency program; that is, several years of formal training

after graduation from medical school at a facility that meets the requirements of the Accreditation

Council for Graduate Medical Education. He or she then demonstrated the competency and

proficiency needed to meet the standards of either the American Board of Neurological Surgery

or the American Board of Orthopaedic Surgery. During his or her residency he or she would have

received training in spine care as part of a broader training in disorders of the brain and nervous

system in the case of a neurosurgeon or the musculoskeletal system in the case of an orthopaedic

surgeon. In our opinion, the surgeon should also have completed a fellowship in spine surgery; that

is, one or more years of training following residency focusing solely on diagnosis and management

of, and surgery for disorders of the spine. This extra focused training in spine care is critical given

the complexity of the disorders and the rapid advances in diagnosis and treatment options.

Understanding Your Surgical Plan• Once you have satisfied yourself with your surgeon’s qualifications, you should make sure you understand

the nature of your condition and how the proposed surgery will address it. Some of the questions you

should ask are listed here, but you should make your own list and bring it to your doctor’s visit. Do not

rely on your memory, as you are likely to forget much of what you want to ask. Also take notes during

your visit with your physician. Studies show patients remember less than half of what their surgeon tells

them during the pre-operative counseling session.

Some questions you should ask:

• Is there any deformity or instability present?

• If so, what type of fusion will be done?

• Where and how large will the incisions be?

• How long will I be in the hospital?

• How long will I be confined to home?

• How long will I be off work?

• Will I have to wear a brace after surgery, and if so for how long?

• If having a fusion, will an external bone stimulator be prescribed?

• When will physical therapy begin?

• When will I be able to resume light physical activity?

• When will I be able to resume full activity?

• When will I be able to resume sexual relations?

Spine surgery can be a life-altering endeavor, hopefully for the better. By taking an active role in your spine

care and by being your own best health advocate, you can put yourself in position to have the best possible

outcome. Choosing the right surgeon, educating yourself on your unique condition and its best treatment,

and maximizing your physical condition prior to surgery increase your chances for success, as does ensuring

you have strong social supports you can lean on around the time of surgery and during your recovery. If it all

still seems too daunting, have an honest discussion of your fears with your surgeon. He or she can put you

in touch with a counselor or even a patient who has already been through the process.

20 21

Chapter 6:

Understanding and Managing Your Medications

Pain relieving medications, both over-the-counter

(acetaminophen and ibuprofen) and prescription, play an

important role in the treatment of neck and lower back pain.

They can be helpful in the treatment of acute and chronic

pain. Medications not only provide pain relief, they also

treat the underlying cause of pain and improve function.

Lower back pain is a common presenting complaint to

primary care physicians. The good news is that the majority

of lower back pain will not require long-term medication

management.

The main classes of medications commonly prescribed by SpineCARE physicians include

NSAIDs (Non-steroidal anti-inflammatory drugs), muscle relaxants, neuropathic medications and

narcotic medications (opioid therapy). The medications prescribed to you will be based on your

symptoms, diagnosis and treatment plan. Medications can be used alone or in conjunction with

interventional procedures and physical therapy. It is important to follow your medication regimen

and communicate any changes in your health or concerns to your prescribing physician.

NSAIDS (Non-steroidal Anti-Inflammatory Drugs)

Physicians commonly prescribe NSAIDs for cervical, thoracic and lumbar back pain. NSAIDs

are used to block inflammatory factors that produce pain. NSAIDs also block enzymes that are

important for the maintenance and protection of your stomach lining thereby increasing your risk

for gastrointestinal problems. Some NSAIDs are considered selective enzyme blockers that do

not affect the stomach but the majority of NSAIDs on the market are not selective.

List of Commonly Prescribed NSAIDs

Celecoxib (Celebrex)

Diclofenac (Voltaren)

Etodolac (Lodine)

Ibuprofen (Advil)

Indomethacin (Indocin)

Ketorolac (Toradol)

Meloxicam (Mobic)

Nabumetone (Relafen)

Naproxen (Naprosyn)

Oxaprozin (Daypro)

Potential side effects of NSAID use include gastrointestinal problems, renal damage and cardiovascular

complications. Your physician will discuss each medication that is prescribed, possible side effects and

ways to monitor your health after you begin taking the medications.

Muscle Relaxants

Muscle relaxants are commonly prescribed for neck and lower back pain. They are particularly useful where

muscle spasms contribute to pain. Muscle relaxants can vary in the way that they work.

Diazepam (Valium)

Baclofen (Lioresal)

Tizanidine (Zanaflex)

Cyclobenzaprine (Flexeril)

Carisoprodol (Soma)

Methocarbamol (Robaxin)

Common side effects from these medications can vary and include dizziness, somnolence, confusion and

dry mouth. Psychological side effects include anxiety, irritability, euphoria, depression and paranoia. Your

physician will discuss each medication that is prescribed, possible side effects and ways to monitor your

health after you begin taking the medications.

Neuropathic Medications

Neuropathic medications are commonly prescribed when the pain is a result of nerve irritation and/or

injury. These conditions may include, but are not limited to, cervical and lumbar nerve roots, long-term pain

related to an outbreak of shingles or irritation of nerve tissue resulting in a burning pain sensation. These

medications are also commonly referred to as “membrane stabilizer” medications.

22 23

Chapter 6:

Understanding and Managing Your Medications

Pain relieving medications, both over-the-counter

(acetaminophen and ibuprofen) and prescription, play an

important role in the treatment of neck and lower back pain.

They can be helpful in the treatment of acute and chronic

pain. Medications not only provide pain relief, they also

treat the underlying cause of pain and improve function.

Lower back pain is a common presenting complaint to

primary care physicians. The good news is that the majority

of lower back pain will not require long-term medication

management.

The main classes of medications commonly prescribed by SpineCARE physicians include

NSAIDs (Non-steroidal anti-inflammatory drugs), muscle relaxants, neuropathic medications and

narcotic medications (opioid therapy). The medications prescribed to you will be based on your

symptoms, diagnosis and treatment plan. Medications can be used alone or in conjunction with

interventional procedures and physical therapy. It is important to follow your medication regimen

and communicate any changes in your health or concerns to your prescribing physician.

NSAIDS (Non-steroidal Anti-Inflammatory Drugs)

Physicians commonly prescribe NSAIDs for cervical, thoracic and lumbar back pain. NSAIDs

are used to block inflammatory factors that produce pain. NSAIDs also block enzymes that are

important for the maintenance and protection of your stomach lining thereby increasing your risk

for gastrointestinal problems. Some NSAIDs are considered selective enzyme blockers that do

not affect the stomach but the majority of NSAIDs on the market are not selective.

List of Commonly Prescribed NSAIDs

Celecoxib (Celebrex)

Diclofenac (Voltaren)

Etodolac (Lodine)

Ibuprofen (Advil)

Indomethacin (Indocin)

Ketorolac (Toradol)

Meloxicam (Mobic)

Nabumetone (Relafen)

Naproxen (Naprosyn)

Oxaprozin (Daypro)

Potential side effects of NSAID use include gastrointestinal problems, renal damage and cardiovascular

complications. Your physician will discuss each medication that is prescribed, possible side effects and

ways to monitor your health after you begin taking the medications.

Muscle Relaxants

Muscle relaxants are commonly prescribed for neck and lower back pain. They are particularly useful where

muscle spasms contribute to pain. Muscle relaxants can vary in the way that they work.

Diazepam (Valium)

Baclofen (Lioresal)

Tizanidine (Zanaflex)

Cyclobenzaprine (Flexeril)

Carisoprodol (Soma)

Methocarbamol (Robaxin)

Common side effects from these medications can vary and include dizziness, somnolence, confusion and

dry mouth. Psychological side effects include anxiety, irritability, euphoria, depression and paranoia. Your

physician will discuss each medication that is prescribed, possible side effects and ways to monitor your

health after you begin taking the medications.

Neuropathic Medications

Neuropathic medications are commonly prescribed when the pain is a result of nerve irritation and/or

injury. These conditions may include, but are not limited to, cervical and lumbar nerve roots, long-term pain

related to an outbreak of shingles or irritation of nerve tissue resulting in a burning pain sensation. These

medications are also commonly referred to as “membrane stabilizer” medications.

22 23

Common side effects include dizziness, sleepiness, stomach upset, dry mouth, constipation, swelling

and fatigue. Your physician will discuss each medication that is prescribed, possible side effects and

ways to monitor your health after you begin taking the medications.

List of Commonly Prescribed Neuropathic Medications

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Amitriptyline (Elavil)

Nortriptyline (Pamelor)

Opioid Medications

Opioid medications can be useful in the treatment of neck and lower back pain. A short-term course

of opioid medications can be appropriate to relieve pain and restore function when your physician

determines that all treatment options you have tried have failed. The use of these narcotic medications

needs to be done with precautions because the most serious risks associated with their use are addiction

and misuse. Your physician may ask you to sign a “Pain Contract” which will outline your responsibilities

as the patient and the physician’s responsibilities while opioids are being prescribed during the treatment

period. Many physicians are now employing the use of periodic urine toxicology screening to monitor

compliance and drug efficacy. Common side effects associated with opioid medications include

dizziness, stomach upset, nausea, constipation, itching, depression, urinary retention and sleepiness.

Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor

your health after you begin taking the medications.

List of Commonly Prescribed Opioid Medications

Short Acting:

Hydrocodone/Acetaminophen* (Vicodin, Lortab, Norco)

Acetaminophen*/Codeine

Oxycodone/Acetaminophen* (Percocet)

Morphine Sulfate

Hydromorphone (Dilaudid)

Long Acting:

Morphine Sulfate (Ms Contin, Avinza)

Fentanyl Patch (Duragesic)

Buprenorphine (Butrans Patch)

Oxycodone (Oxycontin)

Dilaudid (Exalgo)

Oxymorphone (Opana ER)

Medications are an important component of your treatment plan for neck, back and spine pain. Your physician

will prescribe the most appropriate medications based on your current diagnosis and health status. The

medications are designed to treat your pain, restore function and help your return to normal activities of

daily living. It is important that you clearly understand the purpose of each medication prescribed for you

and how to take each medication properly. Please don’t hesitate to ask you physician questions about your

medications.

24 25

Common side effects include dizziness, sleepiness, stomach upset, dry mouth, constipation, swelling

and fatigue. Your physician will discuss each medication that is prescribed, possible side effects and

ways to monitor your health after you begin taking the medications.

List of Commonly Prescribed Neuropathic Medications

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Amitriptyline (Elavil)

Nortriptyline (Pamelor)

Opioid Medications

Opioid medications can be useful in the treatment of neck and lower back pain. A short-term course

of opioid medications can be appropriate to relieve pain and restore function when your physician

determines that all treatment options you have tried have failed. The use of these narcotic medications

needs to be done with precautions because the most serious risks associated with their use are addiction

and misuse. Your physician may ask you to sign a “Pain Contract” which will outline your responsibilities

as the patient and the physician’s responsibilities while opioids are being prescribed during the treatment

period. Many physicians are now employing the use of periodic urine toxicology screening to monitor

compliance and drug efficacy. Common side effects associated with opioid medications include

dizziness, stomach upset, nausea, constipation, itching, depression, urinary retention and sleepiness.

Your physician will discuss each medication that is prescribed, possible side effects and ways to monitor

your health after you begin taking the medications.

List of Commonly Prescribed Opioid Medications

Short Acting:

Hydrocodone/Acetaminophen* (Vicodin, Lortab, Norco)

Acetaminophen*/Codeine

Oxycodone/Acetaminophen* (Percocet)

Morphine Sulfate

Hydromorphone (Dilaudid)

Long Acting:

Morphine Sulfate (Ms Contin, Avinza)

Fentanyl Patch (Duragesic)

Buprenorphine (Butrans Patch)

Oxycodone (Oxycontin)

Dilaudid (Exalgo)

Oxymorphone (Opana ER)

Medications are an important component of your treatment plan for neck, back and spine pain. Your physician

will prescribe the most appropriate medications based on your current diagnosis and health status. The

medications are designed to treat your pain, restore function and help your return to normal activities of

daily living. It is important that you clearly understand the purpose of each medication prescribed for you

and how to take each medication properly. Please don’t hesitate to ask you physician questions about your

medications.

24 25