Lower Back Pain – Main Line Spine

There is no single magic treatment that works for all forms of chronic low back pain. The first key in successfully treating it is to determine the source and cause. Then with a diagnosis, your medical professional can evaluate appropriate alternatives to relieve the symptoms.

Until about 20 years ago, the medical community believed there were only three primary sources for low back pain. Today, doctors recognize a fourth source of low back pain that involves damaged vertebral endplates.

We’ll bring you up to speed on what you should know about this pain source and a treatment option to consider if you are suffering from it.

What are three of the sources of low back pain?

For years, medical specialists believed the sources of low back pain were rooted in three spine structural components:

The zygapophyseal joints. These both allow and limit rotation and bending movements in the spine. Degenerative changes in the facet joints can lead to low back pain.
The sacroiliac joints. These joints link the hip and the lower spine. Low back pain can result from joint damage or injury.
The intervertebral discs. These provide cushioning and flexibility for the spinal column during everyday activities. Disc degeneration can pinch spinal nerves, leading to low back pain that may radiate into the legs.

There are many different conditions across these three sources that can cause problems for patients. The complexity of diagnosing them usually requires an in-depth examination by a medical professional.

What is a fourth source of low back pain?

The more recenlty discovered fourth source of low back pain can arise from a damaged vertebral endplate.

What are vertebral endplates?

The spine has a series of stacked small bones called vertebrae that form the spinal canal. Between adjacent vertebrae are intervertebral discs that provide cushioning and flexibility.

At the top and bottom of each vertebra are vertebral endplates. These endplates serve as the interface between each vertebra and the adjacent disc. (In the image below, the vertebral endplates are illustratated by the lighter yellow rings).

What is vertebrogenic pain?

As intervertebral discs deteriorate with wear and tear with age, stress occurs on the vertebral endplates. With this stress, the endplates may become damaged.

Damaged vertebral endplates can become inflamed, leading to vertebrogenic pain. The basivertebral nerve (BSN) transmits pain signals to the brain from the endplates.

What are the symptoms of a damaged vertebral endplate?

The symptoms of a damaged vertebral endplate are similar to that of a damaged intervertebral disc.

In both cases, patients describe:

The source of the pain is in the middle of the low back.
Pain that worsens with physical activity, prolonged sitting, bending, and lifting.

This similarity presents a challenge when identifying the difference between the two. A damaged vertebral endplate requires distinctly different treatments than a damaged intervertebral disc.

How do doctors determine if a patient has vertebrogenic pain?

To confirm that a patient has vertebrogenic pain, doctors use an MRI to look for specific changes that occur with endplate inflammation. These are called Modic changes.

They look for two of the three types of bone marrow changes: type 1, inflammation and edema, and type 2, fatty infiltration, which each indicate vertebrogenic pain.

Modic Changes Illustrated by Type — **Illustrations of Healthy Endplate Alongside Those With Modic changes:** Healthy endplate, Type 1, Type 2, and Type 3 changes.

What indicates if someone might be a good candidate for the Intracept Procedure to relieve vertebrogenic lower back pain?

A patient may be a good candidate for the Intracept Procedure if:

They have had chronic back pain for at least 6 months; and
They have failed to respond to conservative care for a period of at least 6 months; and
An MRI has shown that they have Type 1 or Type 2 Modic changes in at least one vertebrae from L3 to S1.

The Intracept Procedure

The Intracept Procedure is a minimally-invasive outpatient procedure for patients with vertebrogenic pain. The procedure targets the basivertebral nerve to relieve this chronic pain. It may be considered after other conservative options fail to relieve pain.

A doctor uses fluoroscopic guidance to target a radiofrequency probe. The probe heats the basivertebral nerve, stopping it from sending pain signals to the brain.
The Intracept procedure typically lasts an hour and takes place in an outpatient surgery center using local anesthetic and light sedation.
The Intracept back procedure is minimally invasive and preserves the overall structure of the spine.
The Intracept procedure recovery time, when most patients feel pain relief, is within two weeks after the procedure.

basivertibral-nerve — Vertebrogenic pain is a distinct type of chronic low back pain caused by damage to vertebral endplates, the interface between the disc and the vertebral body. The basivertebral nerve (BSN) transmits pain signals to the brain from the endplates.

What’s the Intracept Procedure success rate? A recent study on Intracept showed function and pain relief improvements that lasted more than five years¹.

Wrapping it up, there are two key takeways if you have lower back pain:

Vertebral endplate damage should always be considered as a possible alternate pain source in addition to spinal disc degeneration.
For appropriate patients with vertebrogenic low back pain, the Intracept Procedure can be an effective option.

Reference

Fischgrund J. Ryne A. Macadaeg K. et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized, double-blind sham-controlled multi-center study. Eur Spine J. 2020 Aug;29(8):1925-1934. doi: 10.1007/s00586-020-06448-x [PubMed]

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When you are in pain – particularly if it’s low back pain – your initial reaction may be to stop all activity and rest. In fact, however, the opposite is often true.

Let’s stop for a moment and not get ahead of ourselves. If you have back problems, you should first see a medical professional for diagnosis and guidance before following any treatment protocols. But after you do, your doctor will often recommend that you work to move and stay active, despite the pain.

a woman participates in gentle exercise with others — A woman participates with others in gentle exercise to increase flexibility and strength and improve cardiovascular fitness

Lower Back Pain Is Often Persistent

When you have an acute musculoskeletal injury, it’s important to get pain, swelling, and inflammation under control as soon as possible. One recommended treatment approach to do so is RICE:

Rest
Ice
Compression
Elevation

However, this kind of “take it easy” approach is normally only recommended for a period of 48 to 72 hours. If your pain persists after that, you should be seeing a doctor to find out why.

Low back pain is often chronic. However, it can come and go on an ongoing basis at different levels of severity. ICE, heat and taking over-the-counter anti-inflammatories may help – but you need to do more to help yourself for the long term. You need to move.

Mechanical Pain

80% of all back problems are mechanical in nature. This means that these problems will respond best if you keep moving – even if your pain is persistent.

Your spine is made up of a series of joints. Mechanical pain occurs when anything happens that restricts the movement of one or more of those joints. This is why back pain is also accompanied by stiffness. A bulging disk, ligament issue, or forms of arthritis can create obstructions within the structure of your spine.

If you move the right way as your medical professional has recommended to you, you can release those obstructions. And as they are released, stiffness is reduced, and you usually will experience less pain.

Sitting Too Long and the Pain-Spasm-Pain Cycle

Most of us know that sitting too long can be bad for our health. However, it also can be a cause of back pain. When you sit too long, your joints aren’t being used. The area of your low back is a nerve-dense location, and with the immobility of sitting too much, it can start what’s known as the pain-spasm-pain cycle – where a skeletal muscle spasm causes pain in your spine.

The pain-spasm-pain cycle can first be triggered from an underlying condition such as a herniated disc, arthritic joint or bulging disc. When that happens, usually without warning, one of these conditions suddenly triggers a muscle spasm in your spine.

In turn, the triggered muscle spasm causes ischemia, which is a lack of blood flow in and around the muscle. The ischemia then causes pain. The muscle sees that pain as a threat to the spine – and reacts in an effort to protect it with another new spasm.

As a result, you can get locked into a never-ending back pain-spasm-pain cycle.

The good news is that your medical professional can help you break this cycle with therapies that will release and reset the affected muscle.

Diagram illustration of how a trigger can start an ongoing pain-spasm-pain cycle — A muscle spasm triggered by an underlying back condition can start a never-ending pain-spasm-pain cycle.

Get Moving!

One of the most important things that people with low back pain can do is to stay as physically active as possible in daily life and exercise regularly. Not moving enough can weaken your core muscles, make the pain worse over the long term, and lead to other health problems. It’s a fact that regular physical exercise has been shown to reduce pain – but do it after reviewing your plans with your doctor.

If you have low back pain, it’s a good idea to go about your daily life as normally as possible, and not to let the pain limit your activities too much. Don’t isolate yourself but get out and do the things you enjoy. This will make it easier for you to cope with your back pain.

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The causes and symptoms of spine issues, including neck pain and lower back pain, are extremely diverse and complex. Accordingly, there are many non-invasive treatment options that your doctor will initially consider to help you address your issues.

However, if your neck or lower back pain is chronic and persists, there is a minimally invasive option, called radiofrequency ablation, that you may want to discuss with your doctor. This procedure is also known as a radiofrequency neurotomy as well as a rhizotomy.

In this nonsurgical procedure, radiofrequency waves are used to generate heat to target specific nerves. It temporarily turns off the ability of those nerves to send pain signals. For some patients, radiofrequency ablation may reduce or eliminate pain for months at a time.

Targeting Facet Joints and Sacroiliac Joints

Radiofrequency ablation is typically used to target pain from the facet joints, which can contribute to chronic pain in the neck or lower back, and the sacroiliac joints, which can contribute to chronic low back pain.

What are facet joints? They are small stabilizing joints that are located in pairs between and above each adjacent vertebra at every level of your spine – except at the uppermost two levels. They are weight bearing structures and are subject to mechanical stress.

Facet joints enable you to bend and twist. However, they have a rich nerve supply – called medial branches – that allows them to perceive pain when they are injured. Those pain signals are carried by these nerves to your spine and brain.

And what about sacroiliac joints? These joints sit between the sacrum and the iliac bones of the lower back, in the lowest part of the spine where the spine meets the pelvis. Like facet joints, they are weight bearing structures and are subject to mechanical stress. We each have two sacroiliac joints – one on either side of the sacrum.

Sacroiliac joints move very little compared to other joints of the spine. They also have a rich nerve supply – called sacral lateral branches and lumbosacral plexus – that allows them to perceive pain when they are injured.

The goal of a radiofrequency ablation is to interrupt the pain signals from the nerves in these joint areas before they reach the brain.

Illustration of active nerve cells — An illustration of active nerve cells.

Testing Prior to the Procedure

In order to determine if you are a good candidate for a radiofrequency ablation, your doctor will first perform a test. This test uses a diagnostic nerve block to determine if the nerves that would be targeted by the ablation procedure are the same nerves that are responsible for your pain.

Depending on the outcome of this test, your doctor will either schedule a radiofrequency ablation procedure for you – or determine that a different procedure will be more appropriate to help your specific symptoms.

How the Radiofrequency Ablation Procedure Is Done

Radiofrequency ablation is a minimally invasive procedure that is done in an outpatient surgery center, so you’ll go home the same day.

During the procedure, you will lie on your stomach, or for some neck procedures, on your side. An intravenous (IV) line will be placed in your arm or hand to deliver medication that will keep you comfortable during the procedure.

Your doctor will numb a small area of skin around your spine with an anesthetic before inserting the radiofrequency needles. The doctor will then use a special X-ray machine (fluoroscope) to help guide a the needle alongside the targeted nerves.

To confirm proper position, a small amount of electrical current is then used to test nerve targeting. Once proper position is confirmed, the radiofrequency ablation is performed.

The length of the procedure depends on the treatment site and number of treatments performed, but frequently lasts less than an hour. From arrival to departure at the surgery center, the entire experience normally lasts between 3 and 4 hours.

It can take three or more weeks for the full effects of radiofrequency ablation to be felt. Although results vary from patient to patient, the effectiveness of radiofrequency ablation may last from six months to a year or even longer.

Sometimes, nerves do grow back. In such cases, the radiofrequency ablation may be repeated.

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Musculoskeletal pain is a broad term. It refers to any pain affecting the bones, muscles, tendons, ligaments and nerves. It can come on suddenly with severe symptoms, be acute or chronic, and be either localized to one area of your body or widespread.

The most common type of musculoskeletal pain is lower back pain. According to the National Institute of Health, about 80 percent of adults experience low back pain at some point in their lifetimes.

A man with lower back pain clutches his right back with his hand.

Lower back pain is the most common cause of job-related disability and a leading contributor to missed workdays. In a major survey, more than a quarter of adults reported experiencing low back pain during the past three months.

The good news is that if you are suffering with lower back pain, there are a wide range of options to treat it that don’t require major orthopedic surgery. Identifying appropriate treatment options however starts with identifying the underying causes.

What causes lower back pain?

Your lower back is subject to a lot of mechanical stress and strain. This happens because the weight in your upper body is supported by your spine.

The spine is made up of more than 30 small bones called vertebrae stacked on top of one another. A spongy piece of cartilage, called a disc, sits between each vertebra. It acts as a shock absorber, preventing the bony vertebrae from grinding against one another as the body moves.

The vast majority of lower back pain is mechanical in nature. As we age, the discs in our spine can gradually wear away and shrink, a condition known as degenerative disc disease or spondylosis. The National Institute of Health outlines some of the examples of mechanical causes of low back pain to include:

Sprains and strains account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
Degenerative disc disease is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
Radiculopathy is a condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on this nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
Sciatica is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain, but numbness and muscle weakness in the leg because of interrupted nerve signaling. This condition may also be caused by a tumor or cyst that presses on the sciatic nerve or its roots.
Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column.
A traumatic injury, such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted to the spinal cord. When spinal nerves become compressed and irritated, back pain and sciatica may result.
Spinal stenosis is a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.

With these and so many other potential causes and types of lower back pain, it’s best not to assume your pain is simply overuse or old age. Like most conditions, the earlier the problem is identified, the more treatment options are available. It naturally follows that early diagnosis also supports a higher probability of success with treatment.

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