Spinal Pain: Acute & Chronic Management

HEADACHE & PAIN DISORDERS Spinal Pain: Acute & Chronic Management

Navigating acute and chronic management of common spine-related disorders. By Ravneet (Sona) Bhullar, MD; Benjamin Portal, MD; James Lee, MD; and Charles Argoff, MD

are found on initial imaging, treatment of spinal pain is conservative, consisting of anti-inflammatories and analge- sia to make physical therapy and other conservative treatments more easily accomplished. This continues throughout the subacute period of 2 weeks to 3 months, after which time pain is considered chronic and interventional Spinal pain is common, with a prevalence in the US as treatments may be warranted. This review covers acute high as 70% to 80%, and lower back pain is the greatest and chronic treatment for some frequently experienced source of disability in the US. When no structural deficits causes of spinal pain. Case 1. Whiplash Type Neck Injury After a Motor Vehicle Crash

History and Clinical Presentation and felt her pain was more manageable for approximately Sandra is age 61 with a medical history of hypertension 1 week. She was able to return to work. After this time how- and hyperlipidemia, both under good control. Approximately ever, the pain and headaches that originate in her occipital 3 weeks ago she was involved in a motor vehicle crash in region and follow the distribution of the greater and lesser which her vehicle was struck from behind. Since this incident, occipital nerves returned. These headaches lasted throughout she had moderate-to-severe neck pain and headaches origi- the day and made it difficult for Sandra to perform her duties nating in the occipital region that radiate over the back of at work that involve sitting at a computer. She tried massage her head. She described the pain as a sharp and shooting. If therapy, heat, ice, stretches, and corticosteroids as well as she was driving and rotated her head to check her blind spot, topical local anesthetics but the relief was not significant or she was limited by pain and stiffness in her neck. The pain long lasting. did not radiate into her arms. She did not have any weakness in her arms or anywhere else. She had no other visual or Follow-Up Care hearing-related deficits. Over the counter analgesics including After 3 months had passed and Sandra’s pain was consid- acetaminophen and ibuprofen were not helping for her pain. ered chronic in nature, more interventional therapies were considered. Sandra had a diagnostic third occipital nerve Diagnostic Studies block and medial branch blocks with fluoroscopic guidance Plain films of the cervical spine should have been taken at the C2-C3 and C4-C5 levels on the right side. This inter- after the initial injury. In Sandra’s case there was no evidence vention relieved 80% of her usual pain for the duration of of any fracture or dislocation. She had no new neurologic local anesthetic effect, qualifying her for radiofrequency abla- deficit related to the injury, so further studies were not tion (RFA) at the same levels. Sandra’s response to RFA was ordered or obtained. excellent and she had more than a 60% reduction in overall pain. She also underwent formal physical therapy where sev- Initial Treatment eral modalities were used, including noninvasive ultrasound Sandra took oral corticosteroids (ie, methylprednisolone) for relief of myofascial pain.

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Key Points of Whiplash Type Injury tebral body fractures).1 Although additional imaging is not Diagnosis required for facet joint interventions, if there is concern about Sandra was diagnosed with whiplash-associated disorder any new neurologic deficit, more detailed imaging of the cervi- (WAD) and facet-mediated pain. cal spine may be warranted. Recovery from whiplash injury can vary. Some recover quickly, whereas others may experience Discussion ongoing pain and disability that leads to chronic pain.4 WAD is common, with 300 to 600 cases per 100,000 indi- For persistent occipital headaches with neck pain in the viduals in North America and Western Europe.1 Motor vehicle setting of WAD, diagnostic third occipital nerve blocks at accidents are the most common cause. In the case presented, the C2-C3 zygoapophyseal joint are indicated. Up to 60% of the inciting event helps explain the etiology of Sandra’s pain patients can obtain complete pain relief with diagnostic blocks presentation. WAD is characterized by sudden acceleration- with local anesthetic.2 Subsequently, radiofrequency ablation deceleration head movements with neck flexion and then (RFA) can be done for longer term relief lasting several months. extension resulting in injury.2 In WAD grades 1 through 3, if When choosing cervical facet joint blocks versus medial injury occurred within the last 2 weeks, a soft collar, rest, and branch blocks, there are a few points to consider. First, facet leave from work may not improve patient outcomes.1 In the joint intra-articular therapies can involve the placement of subacute period (2 weeks-3 months), a multimodal approach both local anesthetic and corticosteroid. This helps to theo- to treatment including supine relaxation training, counseling retically achieve a longer lasting analgesic response as both a to reduce anxiety, manual massage, mobilization of the cervical diagnostic and therapeutic intervention.5 In contrast, medial spine, and active exercises to reduce cervical lordosis can help branch blocks are usually only diagnostic and performed improve overall outcomes compared with passive treatment.3 with no more than 0.5 mL of local anesthetic only, targeting Oral corticosteroids such as methylprednisolone can be used, the medial branch of the dorsal ramus over the waist of the but the benefits of such medications is not entirely clear.3 articular pillars of the same numbered vertebra. Typically, if It is imperative to make sure there are no structural impair- the patient obtains more than 80% relief of their pain for the ments that might explain persistent pain (eg, tearing of the duration of local anesthetic effect, they may qualify for RFA or ligamentum flavum, anulus disruption, facet joint fractures, rhizotomy of the medial branches, which can provide more articular pillar fractures, endplate avulsion/fractures, or ver- than 50% pain reduction for several months.6

Case 2: Low Back Pain After History of Lumbar Spine Surgery History and Clinical Presentation provocative exams. SIJ examination was performed with several Steven is age 60 with a history of L2-L5 decompression and maneuvers, including the flexion, abduction, and external rotation fusion surgery 4 years ago for spinal stenosis. His original pain (FABER) exam, Gaenslen test and compression test , which all related to neurogenic claudication was relieved by surgery and his were positive, reproducing Steven’s usual pain pattern. A straight postoperative course was uncomplicated. Steven returned, howev- leg raise test (for lumbar disc herniation) was negative bilaterally er, stating that he was experiencing bilateral (left>right) low back with no evidence of new weakness or sensory deficit. and buttock pain. The pain has been present for the last 4 months. His primary care provider recommended physical therapy and he Treatment completed a 6-week course while also using celecoxib and lido- Steven had already undergone a full course of physical therapy caine patches. Steven’s pain responded only minimally to these and was using nonsteroidal anti-inflammatory drugs (NSAIDs) medications and therapies. He reported no long-standing relief and topical patches for pain. His pain was chronic at this point and returned to the spine center for further evaluation and treat- and limited his physical and daily abilities. He was unable to per- ment. He had no new weakness, and the pain radiated into the form instrumental activities of daily living (IADLs), such as shop- posterior thigh but not further than the knee. The pain was wors- ping and meal preparation, house cleaning, and maintenance. ened by ambulation and going from a sitting to standing position. He had diagnostic and therapeutic intra-articular SIJ injections with fluoroscopic guidance. Placement of the needle within Diagnostic Studies each joint space and distention of the joint space with injec- Plain films of Steven’s lumbar spine were obtained to ensure tate resulted in Steven’s usual pain, further confirming involve- there was no instability or evidence of hardware compromise. ment of the SIJ. After the procedure, the pain was reduced by Alignment had been maintained and all hardware was intact more than 70% for 4 months. A repeat procedure provided without evidence of mobility on flexion and extension films. similar relief, and Steven continued physical therapy exercises Steven was examined and had facet joint and sacroiliac joint (SIJ) throughout this period.

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Key Points of Low Back Pain After Lumbar Spine TABLE. SACROILIAC JOINT AND LUMBAR Surgery SPINE EXAMINATION MANEUVERS Diagnosis Flexion, abduction, and external rotation (FABER) test Steven was diagnosed with SIJ dysfunction bilaterally. 1. 2. Gaenslen maneuver Discussion 3. Compression test SIJ dysfunction can be the primary cause of low back pain in 4. Distraction test 15% to 40% of cases.7 The SIJ is a synovial joint that is stabilized Sacral thrust test by the sacrotuberous, sacroiliac, and sacrospinous ligaments. 5. The SIJ is supported by the gluteus medius, maximus, erector 6. Thigh thrust test spinae, latissimus dorsi, biceps femoris, iliacus, psoas, piriformis, 7. Fortin test oblique and transverse abdominus muscles, and the thora- NB: although 1 maneuver for SIJ dysfunction raises suspicion codorsal fascia.7 Innervation is from the L2-S1 ventral rami, for SIJ pathology, positive results on 3 or more maneuvers are lumbosacral plexus, superior gluteal nerve and L4-S4 dorsal needed to conclude the SIJ is a pain generator. rami.7 Because of the complex innervation and anatomy of this joint, there are multiple potential pain sources. Several provoc- tion targeting the branches of the dorsal rami of L4-S4 for ative maneuvers are used to help determine if SIJ dysfunction pain from the posterior joint and ligaments.7 In some cases, is the pain generator. In general, at least 3 provocative tests joint fusion can be offered. (Table) are used to optimize sensitivity and specificity of the In individuals who have had previous lumbar spine sur- musculoskeletal exam to make the diagnosis and help increase gery, SIJ dysfunction can be a source of pain caused by the likelihood of a positive response to injection therapy.8,9 several factors, including increased mechanical load, iliac Imaging is not needed or helpful in diagnosing SIJ dys- crest bone grafting, or misdiagnosis of SIJ syndrome.10 As function.7 If it is suspected, an intra-articular joint injection with those who have not had previous lumbar spine surgery, should provide at least 50% to 75% pain relief for positive treatment is often more conservative initially. NSAIDS, anti- diagnosis.7 If longer-term relief is desired, other treatments depressants, SIJ belts, and physical therapy are some of the are available, including radiofrequency denervation or abla- less invasive therapies to consider prior to injections.10

Case 3: Lumbar Radiculitis (continues on next page)

History and Clinical Presentation Maggie is age 39 with an unremarkable medical history. She has 2 young children, and approximately 6 weeks ago, bent at the waist to pick up her 30-lb toddler when she noticed a sudden “popping” sensation in her low back. She also noted sharp, stab- bing pain in her low back on right side that radiated like an elec- tric shock into the leg to the great right toe. Maggie was evaluat- ed by her primary care provider and had a positive supine straight leg raise test. Maggie was referred to physical therapy but was unable to perform any of the exercises because of extreme pain. She had been using cyclobenzaprine, ibuprofen alternating with acetaminophen, ice, and an occasional hydrocodone at night.

Diagnostic Studies Maggie had an MRI of her lumbar spine 1 week before presenting to the spine clinic that revealed a posterolateral/ Figure. MRI of the lumbar spine shows right-sided L4-L5 paracentral right-sided L4-L5 disc herniation impinging on the disc herniation impinging upon the right L5 nerve root. right L5 nerve root (Figure). Reproduced with permission from GSCC English Wikipedia. pain 10% to 15% over the last week. Maggie now seeks alter- Treatment native therapies and is advised to wait until at least 8 weeks On learning Maggie’s MRI findings, her primary care pro- after the inciting event to determine if more invasive thera- vider prescribed oral methylprednisolone, which reduced the pies may be warranted.

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Case 3: Lumbar Radiculitis (continued from previous page) Follow-Up Care usual pain for more than 4 weeks enabling her to participate Maggie did not have improvement over the 8 weeks and in physical therapy. She was considerably more functional was offered an epidural steroid injection that was performed because of the injection and did not require additional injec- with a transforaminal approach targeting the right L5 nerve tions. She did, however, continue with her physical therapy root. She subsequently had almost complete relief of her exercises indefinitely.

1. Rodriquez A, Barr K, Burns S. Whiplash: pathophysiology, diagnosis, treatment and prognosis. Muscle Nerve. Key Points of Lumbar Radiculitis 2004;29(6):768-781. 2. Al-Khazali HM, Ashina H, Iljazi A et al. Neck pain and headache after whiplash injury: a systemic review and meta- Diagnosis analysis. Pain. 2020;161:880-888. Maggie was diagnosed with acute lumbar radiculopathy. 3. Peterson G, Nilsson D, Trygg, Peolsson A. Neck-specific exercise improves impaired interactions between ventral neck muscles in chronic whiplash: A randomized controlled ultrasound study. Sci Rep. 2018;8(1):1-11. 4. Ritchie C, Sterling M. Recovery pathways and prognosis after whiplash injury. J Ortho Sports Phys Ther. 2016;46(10):851-861. Discussion 5. Manchikanti L, Singh V, Falco FJE, Cash K et al. Cervical medial branch blocks for chronic cervical facet joint pain a randomized, double-blinded, controlled trial with one year follow up. Spine. 2008;33(17):1813-1820. With an acute lumbar radiculopathy, treatment is more 6. Burnham T, Conger A, Salazar F, et al. The effectiveness of cervical medial branch branch radiofrequency ablation for chronic facet conservative for the first 6 weeks. Most people will improve joint syndrome in patients selected by a practical medial branch block paradigm. Pain Medicine. 2020;21(10):2071-2076. 7. Nejati P, Safarcherati A, Karimi F. Effectiveness of exercise therapy and manipulation on sacroiliac joint dysfunction: a randomized during this time independent of treatment because disc controlled trial. Pain Physician. 2019;22(1):53-61. herniations often regress over time.11 The severe pain expe- 8. Ou-Yang DC, York PJ, Kleck CJ, Patel VV. Diagnosis and management of sacroiliac joint dysfunction. J Bone Joint Surg Am. 2017;16(5):336-342. rienced can be caused by inflammation of the nerve root 9. Telli H, Telli S, Topal M. The validity and reliability of provocation tests in the diagnosis of sacroiliac joint dysfunction. Pain and possible irritation of the dorsal root ganglion, leading Physician. 2018;21(4):E367-E376. 12 10. Yoshihara H. Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. Eur Spine J. 2012;21(9):1788-1796. to pain in a dermatomal pattern. During this period, oral 11. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc corticosteroids can be prescribed, and have been shown herniation with radiculopathy. Spine J. 2014;14(1):180-191. 12. Patel E, Perloff MD. Radicular pain syndromes: cervical, lumbar, and spinal stenosis. Semin Neurol. 2018;38(6):634-639. to improve functional status significantly but often do not 13. Goldberg G, Fitch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized relieve pain sufficiently.13 clinical trial. JAMA. 2015;313(19):1915-1923. 14. Kennedy DJ, Plastaras C, Casey E, et al. Comparative effectiveness of lumbar transforaminal epidural steroid injections with Once pain is subacute and even chronic in nature, particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospec- injection therapies may be considered. The most com- tive, randomized, double blind trial. Pain Med. 2014;15(4):548-555. 15. Rabin A, Gerszten PC, Karausky P, Bunker CH, Potter DM, Welch WC. The sensitivity of the seated straight-leg raise test mon injections performed are epidural steroid injections, compared with the supine straight-leg raise test in patients presenting with magnetic-resonance imaging evidence of either with particulate or nonparticulate corticosteroids lumbar nerve root compression. Arch Phys Med Rehabil. 2007;88:840-843. and local anesthetic. Both particulate (eg, triamcinolone, methylprednisolone) and nonparticulate (eg, dexametha- Ravneet (Sona) Bhullar MD, FASA sone) corticosteroids can help alleviate radiculitis. There Associate Professor of Anesthesiology may, however, be longer-lasting relief with the use of par- Director of the Division of Chronic Pain Management ticulate steroids.14 There are certain safety considerations Associate Program Director Chronic Pain Fellowship with particulate corticosteroids. For example, inadvertent Department of Anesthesiology, Albany Medical Center intra-arterial injection of particulate steroid can result Albany, NY in an embolic effect that may cause neurologic deficits, 14 Benjamin Portal, MD including paralysis. With regards to interlaminar versus Fellow, Chronic Pain Fellowship transforaminal approaches for the injection, it is generally Department of Anesthesiology, Albany Medical Center recommended that a transforaminal epidural steroid injec- Albany, NY tion can provide short-term (2-4 weeks) pain relief in some patients with a lumbar disc herniation and radiculopathy.11 James Lee, MD In general, there is insufficient evidence to support either Resident Physician 11 Department of Anesthesiology, Albany Medical Center injection approach over another. Albany, NY Summary Charles E. Argoff, MD Spinal pain often resolves within 2 to 12 weeks of the incit- Professor of Neurology, Albany Medical College ing event. When spinal pain is not resolved with conservative Director Comprehensive Pain Program therapy during the subacute period, however, more invasive Albany Medical Center interventions can be considered. Injection of anesthesia with Albany, NY steroids often provides enough pain relief for individuals to Disclosures better participate in physical therapy. When this is not the RB, BP, JL and CEA report no disclosures case, more aggressive interventions can be considered. n

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