Are X-Rays, MRIs, & CT Scans Helpful in Treating Back Pain?

August 5, 2013September 27, 2016 / Thomas Cohn, MD

One of the most common concerns of someone with low back pain is whether they need X-Rays or special scans such as a CT or MRI study. Usually, the answer is no. Most low back pain will resolve in weeks to a month or two with conservative care. For normal back conditions, imaging is not necessary to guide care and is needed only in a few circumstances. In this article, we will outline the three major imaging methods (X-Rays, MRIs, CTs) and discuss when each is recommended.

X-Rays

Plain X-rays of the lumbar spine can show all of the following:

Alignment and curvature
Disc space
Bones

X –rays are helpful when there is acute trauma to the spine and fractures are a concern. In children, where scoliosis is suspected, plain films of the spine are also helpful. In normal adults without the above 2 conditions, X-rays show very little information that is useful in managing low back pain. Chiropractic films of curvature do not contribute to management decisions in back pain, and just expose one to unnecessary radiation.

MRI Scans

MRI scans of the lumbar spine can give good detailed information with regards to the following:

Bones
Discs
Ligaments
Nerves
Other abnormalities in this region

In reality, MRI scans are best for determining surgical or advanced conservative pain intervention. If you have had a scan in the past, you probably wouldn’t need another one unless your physician suspects significant new changes such as cancer.

CT Scans

CT scans of the lumbar spine are very good at evaluating the bone structures, but are not as good when evaluating discs, muscles, and nerves. They are used in cases of trauma, since a scan can be done quickly, in minutes. CT scans are also used after surgery, or when the patient has implants that are not compatible with the magnets of an MRI scan. These scans are also done only when significant changes are suspected and a surgery type intervention is being considered.

Rarely is imaging absolutely necessary in the management of low back pain. Most low back pain heals rapidly with conservative treatment. If the low back pain is not improving, then one should find a Physical Medicine and Rehabilitation specialist.

Low Back Pain – A Common Problem, often Mistreated

July 31, 2013September 27, 2016 / Thomas Cohn, MD

Low back pain is a very common issue – 85% of the population will experience back pain at some point in their lives. However, back pain is often treated improperly and as a result, it has become a costly problem in American society. A lack of understanding of back pain, its causes, and usual treatment, leads to costly management.

Acute Low Back Pain

Acute low back pain is pain that has been present less than 3 months. Most back pain can be treated conservatively. Only rarely is back pain a serious medical emergency. There are many structures in the back that cause pain, including:

Vertebral discs
Bones
Joints
Nerves
Muscles

All of these can cause pain. Fortunately, most pain is caused by muscle strains and irritation of joints, discs or nerves. Initially all of these are treated the same, with ice and heat, minimal rest, stretching, and then muscle strengthening of the core.

Medications should be kept simple – use Tylenol or anti-inflammatories like naproxen to manage the pain. If pain is more severe, see a primary care physician for referral to a Physical therapist. Very short-term use of narcotic pain medicine is useful if other medications cannot be taken but these are not advised for more than several weeks.

If Back Pain Persists

If back pain persists for more than a month, despite basic management, you should seek out an expert in low back pain. The best medical doctors to evaluate and treat this type of pain are board certified physicians in Physical Medicine and Rehabilitation. These physicians are experts in the musculoskeletal and nervous system. They can guide a person through a detailed exam and diagnosis and more advanced treatments.

Surgery, MRIs, & CT Scans

Back pain is rarely a medical emergency. If a patient has had cancer and has new onset of back pain, aggressive evaluation is necessary to determine if cancer is affecting the region. Low back pain with loss of control of the bowels, or loss of muscle function in the legs is the other case when aggressive evaluation is necessary.

Back pain is usually relatively benign. Most pain will resolve within weeks with conservative treatment. Only in rare cases (such as cancer) should MRI or CT scans be obtained.

Surgery should only be considered if nerves are compromised, or bowel or bladder control is lost due to the spine being injured.

Facet Joint Pain of the Low Back – Symptoms and Treatment

July 22, 2013June 24, 2014 / Thomas Cohn, MD

Low back pain can have many causes. Structures in the lumbar region include:

Muscles
Bones
Joints
Discs
Nerves
Pelvic organs

Sensory feedback from these structures can be similar. As a result, determining the cause of low back pain often becomes more complex since multiple areas can produce sensory signals that are perceived the same way. Furthermore, there are often multiple structures contributing to the pain perceptions we have and it may be necessary to treat multiple pain generators to control symptoms.

The facet joints in the spine are small joints the size of our finger joints that articulate on both sides of the spine, posteriorly, between vertebral bodies at every level. They have significant mobility and carry the full body weight. Bending backwards closes the joint, while bending forward tends to open the joint. Since they have the same size and mobility as the finger joints, we can see the same wear and tear type changes in the hands, and assume fairly accurately that the same changes will be present in the low back facet joints.

Symptoms of Facet Joint Pain

The symptoms related to facet joint pain are similar to pain from other joints:

Stiffness after sitting or lying in one position
Pain often with extension of the spine backwards

Pain from facets is often just along the spine and does not radiate significantly into the legs. Often, the lumbar muscles are very tight, trying to prevent excessive spine movement. Severely degenerated facets have significant bony overgrowth, and then can narrow the exit of spinal nerves and cause radiating pain into the leg.

The diagnosis of facet pain is made by:

Patient history
Physical exam
Radiologic imaging
Nerve blocks to the joints

The typical history of facet joint problems is pain along the spine without significant radiation. X-rays and CT scans often show facet problems in detail, but pain can be present even with normal radiologic studies. Diagnostic medial branch blocks are the most reliable tool to establish the etiology of pain from facet joints, and two nerves provide the sensory feedback from each joint.

Treatment

Treatment of facet joint pain must be multifaceted to be successful. Basic level management includes stretching and core strengthening of the lumbar region, with using good body mechanics. Nonsteroidal anti-inflammatory drugs like naproxen and aspirin often are very helpful. More advanced physical therapy including a TENs unit for electrical stimulation and traction of spine is sometimes helpful in addition to the above. For persistent symptoms, facet joint steroid injections and medial branch blocks with radiofrequency denervation of the joint can be extremely beneficial.

Top 4 Causes of Back Pain

July 10, 2013October 30, 2015 / Thomas Cohn, MD

The human spine consists of roughly 30 bones, known as vertebrae that are stacked on top of each other. In between each of these vertebrae are discs – bits of cartilage that prevent the bones from rubbing against one another. When something disrupts the organization of the spine, it often results in back pain.

Many people suffer from back pain, but it’s often difficult to pinpoint what exactly is causing the pain. Here are four of the most common causes of back pain:

Injuries to the muscles, and ligaments. This can include injuries from sports, car accidents, or simple slip and fall accidents. Jarring your back in an unnatural way can result in move the vertebrae or discs out of their place, resulting in chronic back pain.
Herniated Disc. This is also known as a slipped disc. It happens when a spinal disc expands and presses against the nerves in the spinal column.
Degenerative Changes. Over time all areas of the body gradually break down. The spine is no exception. As a person ages their bones generally weaken, and the spinal discs can weaken or shrink (causing vertebrae to rub against each other).
Pinched Nerve. When discs bulge or shift, they can press against or pinch nerves, resulting in sometimes extreme pain.

You don’t have to live out your life just dealing with back pain. There are numerous treatment options available that can help you get back on the road to a pain free life.

Do Opioids Reduce Inflammation in Chronic Pain Patients?

July 3, 2013September 27, 2016 / Thomas Cohn, MD

A recent preliminary study found that inflammation in patients with chronic pain is persistent despite long-term opioid treatment.

The study was carried out by Forest Tennant, MD, director of the Veract Intractable Pain Clinic in West Covina. Dr. Tennant examined 40 patients from July 2012-October 2012. All of these patients had been receiving heavy doses of opioids to treat their chronic pain for the past 10 years.

While many patients reported improved levels of depression and function, 20% of those surveyed still had high levels of inflammation markers. Further, a number of patients had abnormally high hormone levels.

Dr. Cohn Comments

Opioids are used to treat all types of pain, but they do not treat inflammation. If a chronic condition causes pain, such as osteoarthritis, treating this with opioids will not change the inflammation that is occurring. The pain may be better with the opioids, but the disease is not being modified and one should expect to see inflammatory markers.

Chronic pain is defined as pain lasting longer than 3-6 months. Pain can be caused by any number of factors, and is a response to ongoing stimulation of pain receptors in the body. It is not very surprising that if we monitor blood borne markers, we can find elevations in those that are indicators of inflammation.

Osteoarthritis is a chronic degenerative joint disease. If it is painful, there is likely active destruction of tissue, and the joint may be warm and swollen. Osteoarthritis of the knees is very common, and we all know many older adults who complain of painful, swollen knees. Furthermore, the most common treatments are nonsteroidal anti-inflammatory drugs, like Motrin and Aleve.

Low back pain has many causes, such as:

Inflammation of nerves causing radiculopathy
Degeneration of the facet joints

First line treatments are meant to reduce inflammation. This is done sometimes by oral steroids, or long-acting steroid epidural injections. Steroids treat inflammation directly, and finding inflammatory markers when someone has low back pain is not surprising.

If a person has chronic pain, a good pain physician will recognize the causes of the condition. Treating the cause of pain with interventions that modify the disease is the best strategy. Treat the disease, and the disease markers will improve. Opioids are often a Band-Aid – they help in the short term but fail to address the underlying condition.

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