A question and a challenge that comes up for anyone who treats spine for long enough is, “How do you treat chronic lower back pain?” Chronic is defined as pain that lasts, in the lower back, that lasts for longer than three months. Here what I’m talking about is chronic lower back pain in the sense of somebody that has been through multiple different treatments – seen a lot of different doctors. Anyone who treats spine long enough will have at least one story, but probably several, of patients who come in with a stack of files about yea big, multiple MRIs. They feel like they’ve been everywhere and done everything and they still don’t have an answer.
And the first thing that one has to do when they’re treating someone in this situation is to back up and recognize, first of all, that chronic lower back pain in and of itself is not really a diagnosis, right? Chronic lower back pain describes a set of symptoms that have lasted for a certain amount of duration.
So, the first thing that we need to find out is, “Do we know what it is exactly that we’re treating? Do we know what’s causing the chronic lower back pain?” We can figure out in more than 80, 85-90% of the time what causes chronic lower back pain – discogenic pain, facet joint pain, sacroiliac joint pain, spondylolisthesis. We know what tends to cause most cases of chronic lower back pain. So, the first thing to do is to step back and see whether or not an evidence-based algorithm has been applied in which a diagnosis has been established.
And so you back up and you go through things and you just march down a very evidence-based path. And you see if you can find the diagnosis. And usually you can, because usually a diagnosis is obtainable. And if that diagnosis is obtained, or if someone comes in and they have a diagnosis but they haven’t been successful with treatment, then the next step is, “Well, we’re usually successful in treating chronic lower back pain, so what got missed here? Was an evidence-based paradigm followed?” If it wasn’t on either of those questions, then you know your answer of what to do. You follow an evidence-based path to seeing whether or not you can get to the bottom of where the chronic lower back pain is coming from so you can address it and successfully treat it.
With that said, there are certainly times – I must emphasize rare times, but it does happen – when you march down an evidence-based path of diagnosing and you still don’t have a diagnosis. Or sometimes you march down an evidence-based path, of diaganosing and you have a treatment, and you have a diagnosis, but when you go through an evidence-based paradigm of treating, you get to the end of that rope and you say, “You know what? These things usually work, but here we are and the pain is still there. And we haven’t had an evidence-based allopathic answer to the problem that the person is facing.”
When that’s the case, it’s important at that point to really make sure that you’re addressing the symptoms, even when you don’t have an answer necessarily of what’s causing it, or you don’t have a treatment answer that’s really going to fix the problem. What you want to make sure, first and foremost, is that you enable the patient so that they can control the pain and the pain isn’t controlling them. And you do that through a variety of means.
The first is, I think, it’s very important to emphasize the role of exercise and movement. Anyone who has pain, if they sit still for long enough, if they start to close in on themselves and not move, that’s a bad cycle to start. And the less we move, the more muscles tighten up, the more that we feel that pain. So, we want to make sure that movement is part of a treatment paradigm where we get the person moving.
And then we talk about oral medications, adjunctive treatments, acupuncture, sometimes relaxation training can be helpful, and even cognitive behavioral to think about how we orient to the pain so that, again, with the ultimate goal here of making sure that the patient is empowered to be in control of the pain and not the other way around.