Jason Yong, MD, MBA
We advise patients to seek treatment whenever the pain is limiting their functional status, in that they can't walk, or they can't sit or stand for a prolonged period of time. We also advise patients to seek medical attention if their pain is greater than 6 out of 10, because if that's the case, then we as physicians can prescribe medication or physical therapy appropriately.
Not all lower back pain requires medical treatment. We can get by with conservative therapy on a lot of low back pain. Low back pain is one of those things that is very vague but tends to get better on its own. So the natural history of most low back pain is that it gets better on its own. And it's just temporizing them, getting patients healthy through that period of pain so that the body can cure itself.
Before consulting a physician, low back pain can be managed by the patients themselves. If a patient has low back pain and it's acute, meaning less than three weeks, then they can get by with Motrin, physical therapy exercises, with core strengthening. Or they can just do lift restrictions and watch what they do.
The general gateway of health is the primary care physician, so we generally advise patients to seek help with their primary care physician before seeking help from any specialists. From the primary care physician, they can refer them to the comprehensive spine center like we have at Brigham and Women's Hospital. And from there, they can be triaged to the appropriate modality.
Medication can give long-term relief. And I would say injections typically give short relief. But the idea of doing the injection is to provide the patient with a short-term relief so that they can get through the physical therapy exercises that are required to help them get better. So if a patient is limited by their functional status, they're not going to be able to push themselves and do the appropriate therapies that they need. In that case, we would do the injection, get them comfortable for a few months, and get them through physical therapy.
So the patients that are surgical candidates would be screened in our Comprehensive Spine Center and referred to the surgeons if it's indicated. And the indications for spine surgery would be if it's intractable 10 out of 10 pain that cannot be controlled with medication or injections, or if there is frank weakness or any kind of structural instability.
At Brigham and Women's Hospital, we're able to offer patients the whole spectrum of pain modalities. These modalities include intrathecal pumps, where we put a hockey-puck-sized device in their abdomen and infuse medication into their spinal fluid.
We can get by with a tiny amount of medication through the intrathecal pump when you compare that to oral regimens. And so the total opioid dose can be a lot lower when we do these implantable devices.
And also, it's targeted specifically to the area they having pain. So if they're having low back pain, we'd put the catheter so that it exits right at the low back. And we're able to get control of their pain right at the area.
Another interesting modality that we have at Brigham and Women's Hospital are spinal cord simulators and peripheral nerve simulators.
A spinal cord stimulator is an electrode that sits in the epidural space right behind the spinal cord. The idea of that is if we're able to generate impulses through those electrodes, we're able to confuse some of the nerves and decrease the amount of pain patients feel. The analogy would be a white noise maker. So when I turn on a white noise maker for my kids going to sleep at night, they don't hear all the ambient noise around the house, outside on the street, honking cars. But then when you turn it off, you're like, oh, all of a sudden I start to hear all that.
It's similar to the spinal cord stimulator. We turn the spinal cord stimulator on and patients feel a little bit of a paresthesia, which is a vibration sense that they would feel in the area of their pain. The vibration they feel replaces the pain signals that they would normally feel, so patients have a decreased sensation of pain even though the pain itself is still there.
The future of low back pain will be continued collaboration with multi-disciplinary support, so physical therapy, psychology, pain management, and spine surgery. We're able to offer patients spinal cord stimulators that have extremely high frequency, where we haven't had that option before. The high frequency nerve stimulators, spinal cord stimulators, are able to treat low back pain and leg pain, whereas before with the traditional spinal cord stimulator, we've only been able to really target leg pain. But now that we're able to target low back pain and leg pain, patients that have had spine surgery already and are not surgical candidates for further surgery can come to us and trial some of these implantable devices to see if they're able to get relief.
Because pain is such a complex and dynamic problem, we need everyone's expertise and thought into each patient. And that's the benefit of coming to a comprehensive pain management center, such as Brigham and Women's Hospital.
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