Lower & Upper Back Pain Management Our Philosophy Pain is a complex problem that requires treatment and management by a pain medicine specialist. Millions of people suffer from headaches and nerve pain at great personal cost. If you find that you cannot safely control your pain with over-the-counter medications, or have failed to find relief from other treatments or practitioners, you should consider consulting with our pain management physicians. For most patients, interventional pain management procedures can treat or reduce pain, allowing the patients to regain function, and thereby improving their quality of life. Lower Back Pain Resources LUMBAR SPINE OVERVIEW LUMBAR SPINE ANATOMY CAUSE OF LOW BACK PAIN LUMBAR MEDIAL BRANCH BLOCK FOR DIAGNOSIS OF FACET JOINT PAIN Low back pain is a very common health problem worldwide and a major cause of disability – affecting performance at work and general well-being. Low back pain can be acute, sub-acute, or chronic. Though several risk factors have been identified (including occupational posture, depressive moods, obesity, body height and age), the causes of the onset of low back pain remain obscure and diagnosis difficult to make. Back pain is not a disease but a constellation of symptoms. Low back pain affects people of all ages, from children to the elderly, and is a very frequent reason for medical consultations. The lifetime prevalence of low back pain is estimated at 60% to 70% in industrialized countries, with a one-year prevalence of 15% to 45%. Prevalence increases and peaks between the ages of 35 and 55. As the world population ages, low back pain increases due to the deterioration of the intervertebral discs and the development of arthritic degeneration. Low back pain is the leading cause of disability and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments. Several studies have been performed in Europe to evaluate the social and economic impact of low back pain. In the United Kingdom, low back pain was identified as the most common cause of disability in young adults, with more than 100 million workdays lost per year. In the United States, an estimated 149 million workdays are lost every year because of low back pain, with total costs estimated to be US$ 100 to 200 billion a year (of which two-thirds is due to lost wages and lower productivity). Pain from the lumbar spine can present in several ways. Pain can radiate to the buttocks or legs. To a lesser degree, pain can also be referred to the upper back, buttock, or posterior thighs. It is important to evaluate patients with spinal origin pain for cord impingement (myelopathy), radiculopathy, and dangerous underlying causes such as cancer, fractures, and osteomyelitis. As such, identifying the underlying pain generator and accompanying symptoms is essential in creating a differential diagnosis for low back pain. VIEW IMAGE Non-Radiating Low Back Pain To determine treatment options for low back pain that does not radiate, the first step is to come to a differential diagnosis. When it comes to chronic low back pain, or pain that lasts more than 6 months, the most common diagnoses are facet joint mediated pain or pain stemming from the intervertebral discs. DEGENERATIVE DISORDERS OF THE LUMBAR SPINE LUMBAR FACET MEDIATED PAIN RADIOFREQUENCY ABLATION DEGENERATIVE DISC DISEASE & DISCOGENIC PAIN INTERVENTIONAL PAIN MANAGEMENT OPTIONS FOR DDD SPONDYLOLISTHESIS SPONDYLOLISTHESIS TREATMENT OPTIONS VERTEBRAL COMPRESSION FRACTURES VERTEBRAL AUGMENTATION-KYPHOPLASTY AND VERTEBROPLASTY MINIMALLY INVASIVE LUMBAR DECOMPRESSION Degenerative disorders of the spine typically develop over time from over-use, abnormal wear and tear, repeated heavy lifting, or continued bad positioning. Such abnormal wear and tear over time may cause micro-traumas that can weaken soft tissues of the low back. Traumas such as falls, or acceleration deceleration movements such as whiplash are sudden in onset and may present immediately or days to weeks later. Other findings include: • Spondylosis is a generalized term to refer to injury to the posterior elements (the joints, spinous process, or ligaments. Lumbar facet osteoarthritis is a common degenerative disorder which would fall into this category. • Discogenic Pain is pain stemming from the intervertebral discs. This pain typically does not radiate and has correlating imaging on the MRI which shows damage to the discs. • Osteophytes are bony overgrowths. An osteophyte may irritate or impinge a spinal nerve causing inflammation and pain. Ostephytes that do not contact neural tissue may be asymptomatic as well. • Radiculitis is pain described as electric or shooting pain in the distribution of a nerve. Disc herniation and osteophyte formation are common causes of radiculitis. VIEW IMAGE Lower Back Pain Radiating To The Legs Evaluation of a patient experiencing pain radiating to the legs starts with a thorough patient history, physical exam, and review of pertinent imaging studies such as X-rays or MRI’s. If it is deemed that the pain is spinal in origin, the two common causes are Herniated Discs in the Lumbar Spine & Lumbar Spinal Stenosis. HERNIATED DISCS IN THE LUMBAR SPINE LUMBAR SPINAL STENOSIS MINIMALLY INVASIVE LUMBAR DECOMPRESSION VERTIFLEX THE INTRACEPT PROCEDURE FAILED BACK SURGERY SYNDROME As previously mentioned, the disc forms part of the anterior border of the epidural space, along with the vertebral bodies. Then there is damage to the outer layer (annular fibrosis) of the disc, the integrity of the disc can be lost. This can lead to bulging of a disc, which is analogous to a bulge on a car tire. A disc bulge occurs secondary to a weakening of the annulus, and the pressure from the inner contents pushing outward. While a bulge often does not cause symptoms itself, if it is significant enough or near a nerve root, it may cause radicular pain. This is a less often cause of a sciatica type pain. If the tough, outer annulus fibrosis ruptures, the nucleus pulposus can exit through the defect and enter the epidural space, this is known as a disc herniation. Disc herniations can range in their symptomatology. Disc herniations can occur acutely with trauma or an inciting event, or may be a gradual progression, starting with an annular tear, to a bulge, to a herniation. Symptoms can range from asymptomatic, to causing pain in the low back, or radiating pain if a nerve is impinged. VIEW IMAGE Sciatica is a symptom meaning pain felt in one or both legs.Sciatica pain can be severe and debilitating. A first line of treatment is over-the-counter and non-interventional low back treatments. While pain can be severe, the natural course for disc herniation is for the bulge or herniation to be resorbed – or pull back into a more normal position between the upper and lower vertebral bodies. Usually, pain improves over weeks to months. Alternatively, pain may persist. Our body’s natural response to injury is to attempt to heal or correct the problem is inflammation. We see this in our body all the time, from a sprained ankle or knee, or a simple cut in our skin. Inflammation is our body’s natural system to heal itself. Inflammation is a process by which our body sends cells and nutrients to an area or to fend off any foreign substances. A herniated nucleus pulposus in the epidural space is recognized as a foreign material in that space and the inflammatory response is our attempt to remove this material. Our spinal cord ends at approximately the L1-2 and below that region the spinal canal is filled with cerebrospinal fluid and contains the spinal nerve roots. This allows for slightly more give than in the cervical spine When a lumbar disc bulges or herniates, nerve roots may become irritated and possibly impinge on nerve roots and cause radiating (travels) pain in specific areas of the legs based on what nerve was irritated. Severe spinal cord impingement can cause symptoms throughout the body and legs and may be a surgical emergency. Signs and symptoms of cord impingement range from being asymptomatic to loss of bowel or bladder function and paralysis. Figure 3. Evidenced based dermatome map of Lee et al. This is in contrast to the popularly used Keegan et al. where dermatomes were parallel in nature. Blank regions indicate areas of major variability and overlap. The S3,4, and S5 supply the perineum but were not shown for clarity. VIEW IMAGE When Pain Does Not Improve Treatments Initial conservative efforts include over-the-counter medications such as anti-inflammatories and Tylenol. Physical therapy, chiropractic manipulations, and home exercises are common conservative care modalities that be utilized to assist in improvement. It is important to understand that it is not uncommon for a disc to naturally resorb – pull back into normal position within the upper and lower vertebral bodies. Pain and related symptoms may diminish. Often in the management of disc herniations it is a pain physician’s role to assist in the healing process, in essence ‘buying time’ to allow one to heal on their own. However, sometimes the pain does not resolve with treatment, and becomes persistent, or may worsen. Epidural Injection An epidural injection is a common treatment to relieve pain associated with a nerve impingement. The goal of the epidural is to relieve the pain that radiates into the legs, and also hopefully the back pain. An epidural injection is performed using fluoroscopic guidance — a fluoroscopy unit is similar to real-time x-ray. Using fluoroscopy, a very small needle is guided as close to the disc herniation as possible. The needle enters the epidural space and a very small amount of saline and steroid is injected into the space. Because the needle is precisely placed within the irritated area, only a small amount of medication is needed. Steroid is the strongest anti-inflammatory medication and our hopes is that this medication would facilitate improvement. The amount of pain and symptom relief a patient experiences depends on the susceptibility of the underlying pathology to the effects of the injected medications. Many patients experience pain relief from minutes to days after a procedure, however there are times the response does not reach clinical effect. DRG-S for Low Back Pain and Leg Pain Effective treatment for chronic low back pain (LBP) is considered the ‘holy grail’ of neuromodulation. Spinal Cord Stimulation (SCS) was introduced in 1967 to treat chronic pain. Over the years it has shown mixed results for LBP, with limited improvements in pain and function, and loss of efficacy over time. Dorsal root ganglion stimulation (DRG-S) was developed as a treatment for nerve-related pain syndromes and has proven to be superior to SCS for complex regional pain syndrome (CRPS), which typically affects the hands or feet. As utilization of DRG-S increased, so did our understanding of its underlying mechanisms of action. One such mechanism of action is a result of the stimulator device sending inhibitory signals into the spinal cord. Based on this principle, the team at the Spine & Pain Institute of NY pioneered the treatment of low back pain with DRG-S at the T12 spinal level1. Their publication on a case series of patients using DRG-S at the T12 level for intractable low back pain was better than previous studies with other forms of neurostimulation for low back pain. The study included patients who had failed extensive treatments and included several patients who had multiple spinal surgeries. They reported not only excellent pain relief, but also great improvements in physical function and psychological testing that were not previously seen with neuromodulation therapy. The results of the study are shown on the right, here, and below. In our clinical experience, these results are readily reproducible and have been maintained over time. After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2. VIEW PAPER After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2. To better understand this complex subject, which for many may be challenging to fully grasp, the major points have been illustrated in this animated graphic. Since that time, the team has expanded the use of DRG-S by placing additional leads at S1 along with T12 as an off-label treatment for low back and associated leg pain. Our results continue be superior to our doctor’s experiences with other forms of neurostimulation for similar pain conditions. Our doctors have collectively published over 20 articles in peer reviewed medical journals on DRG-S and are considered thought leaders and pioneers of DRG-S therapy. While results from our practice with DRG-S are quite impressive and have been published and shared with the medical community, the team also recorded patient testimonials to further illustrate the great improvements seen with this therapy. The testimonials can be accessed on our Youtube page. DRG-S LOW BACK PAIN OUTCOMES DRG-S COMPARED TO SCS FOR LBP Multiple studies have published positive results using DRG-S therapy for low back pain. For instance, DRG-S was utilized at the L2 level to treat discogenic low back pain following failed back surgery. The graphic below shows the changes in patient reported survey scores used to measure treatment response before and after DRG-S therapy in each study. Collectively, improvements with DRG-S therapy in VAS (visual analog scale) which measures pain severity, ODI (Oswestry disability index) and SF-36 Physical which measure physical function, EQ-5 which measures quality of life, and SF-36 Mental which measures psychological improvements were consistent with or superior to prior spinal cord stimulation studies. If you are interested in learning more about DRG stimulation for low back pain and leg pain, or have failed other forms of neuromodulation, please feel free to reach out to our physicians at the Spine and Pain Institute of NY to learn more. 1. Chapman KB, Groenen PS, Patel K V., Vissers KC, van Helmond N. T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series. Neuromodulation Technol Neural Interface. 2020;23(2):203-212. doi:10.1111/ner.13047 2. Chapman KB, Groenen PS, Vissers KC, van Helmond N, Stanton‐Hicks MD. The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment. Neuromodulation Technol Neural Interface. Published online April 23, 2020:ner.13150. doi:10.1111/ner.13150 VIEW ON YOUTUBE LEARN MORE ABOUT SPINAL CORD STIMULATION (SCS) Splanchnic and Celiac Plexus Blockade The celiac plexus is a web of nerve fibers that lies in the abdomen near the aorta. It is a relay station for the nerves that innervate the abdominal contents from the lower esophagus to part of the colon. The nerves are responsible for sending messages back and forth and innervate the intestines and are responsible for pain transmission. The nerves that innervate the abdomen come from the spinal cord and meet in several places to form their diffuse connections, and lie in a web like structure called a plexus. The celiac plexus block is a procedure in which a long-acting local anesthetic is placed at the celiac plexus to block the transmission of pain from the abdomen. The celiac plexus block procedure is most frequently used in patients when other pain medications or other less invasive therapies are not effective. This type of pain may be caused by irritation, compression, or entrapment of the nerve bundles because of tumor invasion, fibrosis, or chronic inflammation resulting from chronic pancreatitis or Crohn’s disease, among others. Pain attributed to the pancreas is a common indication for a celiac plexus blockade. The splanchnic nerves are the nerve fibers that connect the spinal cord to the celiac plexus. These nerves can also be blocked using a local anesthetic. The splanchnic nerves lie close to the side of the spine. These are groups of individual nerves, not a diffuse plexus. Thus, is possible to lesion (therapeutically burn) the splanchnic nerves with energy generated using radiofrequency. A celiac plexus block procedure involves the use of fluoroscopic x-ray imaging (real time x-ray) for precise needle placement and injection of a long-acting analgesic block to manage pain. Celiac plexus blocks typically provide temporary relief with less risk. Longer pain relief can be obtained with a neurolytic agent. Another option for abdominal pain control is spinal cord stimulation. This involves using electrical stimulation to modulate the transmission of nerve signals to and from the abdomen. EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES TYPES OF PAIN Let's live pain free. Is Pain Management Right for You? Depending on many factors, such as the type of pain and your general health, there are numerous options for treating your pain. Some patients are surprised to learn that a treatment that previously failed to provide relief may be effective when combined with a multi-treatment approach. Our specialists treat complex pain issues. There are many different physical and neurological disorders that contribute to pain, and we treat all types of pain including: LEARN MORE ABOUT PAIN MANAGEMENT Practice Policies We are pleased you chose The Spine and Pain Institute of New York for the diagnosis, treatment and management of your pain. To acquaint you with our office policies, we provide the following information. PRIOR TO PROCEDURE FORMS *If your insurance requires a referral for a visit to a specialist, you must obtain this referral from your Primary Care Physician prior to your visit. INITIAL CONSULTATIONS Please bring the following relevant information to your consultation. Photo ID Insurance Information Referral* Diagnostic Studies & Reports (MRI/X-Rays) List of Medications INSURANCE & BILLING We accept most insurance programs and their subsidiaries. If we do not participate in your insurance plan, please contact Billing to find out if other arrangements are possible. Text us via Klara using the messaging option to the bottom right of this page! Just detail your concern or question, and a member of the team will reply via return text message or phone call. Insurance co-payments are due at the time of arrival. We accept cash, checks and credit cards. APPOINTMENTS If you are a new patient, please arrive 15 minutes prior to your appointment to allow time to register. If you are running late or need to reschedule, please contact us as soon as possible to make us aware. Unfortunately, if you are more than 30 minutes late for your appointment time, we will have to reschedule. PROCEDURES If you are scheduled for a procedure or plan on having one in the future, please read the attached important instructions to follow prior to a procedure.You will be called prior to your procedure and notified about the following information as well. MEDICATIONS & REFILL REQUESTS Please discuss your medication needs, including refill requests, with your provider at the time of your appointment. Medications should be taken only as prescribed. Please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave the office. AFTER HOURS EMERGENCIES Our regular phone lines are transferred to an answering service after normal business hours. Please proceed to the nearest emergency room for after-hours emergencies. MANHATTAN 860 Fifth Ave New York, NY 10065 212.724.7246 NEW JERSEY 1 Bay Ave. 2nd Fl. 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