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The secret of healing your spine

The secret of healing your spine

Lower back pain is one of the leading reasons for issuing sick leave, second only to colds. More than 85% of the population faces these pains. The most common cause is a sprain or muscle spasm, usually caused by the wrong way of lifting weights, incorrect posture or hypothermia. Less common causes are degenerative-dystrophic diseases of the spine (those same herniated discs, spinal canal stenosis, spondylolisthesis, osteoarthritis, osteoporosis, etc.).

The primary task of any doctor to whom you turn with such complaints is pain relief. And this task is not at all simple, as it seems, and with these pathologies it often has an interdisciplinary approach, because in most cases, in addition to pain relief, you require both increased physical activity and “moderate” use of medications, and a competent doctor will also try to adjust your lifestyle. In this essay, I will try to introduce you to the various methods and ways of relieving your condition that modern medical science currently offers.

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Let’s understand the terms. We will make a reservation that we will not analyze the simplest anatomical concepts, such as the vertebra, the cervical spine or the pelvic bones. But let me dwell on the intervertebral disc in more detail: it is believed that it consists of a gel-like core and a connective tissue shell (coarse protein fibers tightly envelop the jelly-like core). A characteristic feature of the disk is the lack of blood supply; it receives nutrition by “seeping” substances through the shell. It is clear that this is not the best way to deliver the substances necessary for vital activity, and that is why already in 15-20 years we sometimes see "old" disks (in medicine this is called degenerative-dystrophic altered disks). Now add here an almost constant (vertical) 

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load and you will get protrusions of the gel-like core through the shell and ruptures of this shell. So, the protrusion of the core through the still “unbroken” shell is called a disk protrusion, but if the shell ruptured and the core gel began to "leak out" - you will get a herniated disk. A more serious condition occurs when a piece breaks off from the jelly-like nucleus and, in fact, becomes a foreign body in the spinal canal called a sequester (most doctors, finding a similar picture, say about 100% indications for surgical treatment).

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Another fairly frequent indication for surgery is spinal canal stenosis – this is a condition in which, under certain conditions, there is a “muff-like” compression of the spinal cord. Imagine that one of the vertebrae has shifted posteriorly or anteriorly (a not very rare condition called vertebral prosthesis), thereby reducing the space in which the spinal cord is located (it has “squeezed”). This is not the only cause of stenosis, but the essence of all of them is about the same: lack of space for the normal functioning of the nervous system.

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It seems that the most frequently encountered terms have been sorted out. Although let me mention one more term, you have all heard it – this is osteochondrosis of the spine. Here's what kind of confusion came out: in our post-Soviet understanding, this is a group of diseases (or not exactly diseases, but conditions, or something) of the spine; in short, these are all the numerous problems that we are now trying to figure out: hernias, prosthetics, stenoses, and inflammation of the joints of the vertebrae (they are also called facet joints), and... in general, everything that can happen to the spine if it is used the way we use it. In the English-language literature, osteochondrosis of the spine is called only a few diseases where there is really a lesion of cartilage and bone (osteochondrosis: other-Greek. στέον — bone + χόνδρος — cartilage + Lat.- ōsisµ): the most striking example is the Schmorl hernia, which was not considered as pathology in the Soviet medical school.

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By the way, many “healers” use this confusion, promising to cure osteochondrosis – and, indeed, they improve the condition of both cartilage and bones in various ways. And they even publish books, claiming that only their method treats the cause of osteochondrosis, and all the others are engaged in nonsense, restoring the conductivity of the spinal cord and relieving pain.

By the way, about the types of lower back pain:

Acute pain is actually a sequence of several “short-term” pains. In foreign literature, it is also called “self-restraint pain” (pain attacks occur to force you to stop active activity, which can lead to more dangerous damage to the nervous tissue). Interestingly, a prolonged period of acute pain is likely to lead to the development of chronic pain. Only recently, scientists have found out why this happens: in short, as a result of intense pain, neurons in the spinal cord that transmit information about this "unbearable" pain die. At the same time, new neurons are formed that “remember” this pain, but transmit it somewhat differently. This process is called neuroplasticity in the English literature, and it indicates the ability of the nervous system not only to learn "useful" information, but also to “form” chronic pain.

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Chronic pain. Given the previously mentioned neuroplasticity, it becomes clear that this pain is not a symptom of a pathological process, it is in itself a separate disease. It can persist for many years and even decades.

Neuropathic pain is usually described by patients as burning, “goosebumps”, tingling and lumbago. Often this type of pain is not relieved by traditional analgesics (diclofenac, etc.). Pain relief in this case is achieved by drugs that were not intended as painkillers when they were created.

Nociceptive pain is usually described by patients as acute, aching or throbbing pains, pain in the “bones” of the legs. Nociceptive pain is usually relieved by nonsteroidal anti-inflammatory drugs (NSAIDs).

So far, everything is simple, but the question arises: how to remove this pain? It’s more complicated here. Let’s start with what is closer to us, with drug therapy:

Antidepressants. Why our “post-Soviet” patients are so afraid of them is completely unclear. There is a large amount of evidence that tricyclic antidepressants are effective for the treatment of various pain conditions, such as migraines and neuropathic pain. After all, any pain (and even more so if it lasts for several days) is depression, and starting to treat it together with antidepressants, you will get rid of it faster. Isn't that what you want from your doctor?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the “gold standard” for the treatment of degenerative diseases of the spine. I think everyone knows one of the oldest representatives of this group – diclofenac. These drugs perfectly relieve inflammation, and with it pain, do not change the cognitive functions of the patient (it is possible to drive vehicles), do not depress breathing, do not cause nausea. However, the use of NSAIDs is associated with significant side effects, especially with prolonged use. I think that many have heard of “diclofenac” stomach ulcers.

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Epidural injections of steroids. The traditional injection technique involves the use of an X-ray machine to place the needle exactly at the place of compression of the nerve roots before they exit the spinal canal. Steroid injections in the lumbar region are especially useful for relieving pain that radiates from the lower back to the leg. This pain can be caused by a herniated disc or spinal canal stenosis, which causes nerve irritation, inflammation and pain.

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Blockage of the facet joints involves the introduction of steroid drugs into the affected joints of the vertebrae to reduce inflammation and pain. Injections into these small joints (or blocking the nerves that “feed” the joints) can often be very useful for pain relief. Unfortunately, little attention is paid to this problem, although inflammation of the "facets" is a very common phenomenon in the lumbar spine, and if you and your doctor cannot relieve pain for a long time, it is probably because you did not pay attention to this problem.

Blockage of trigger points of muscle blocks. When acute pain occurs (for example, when the root is squeezed), the body “tries” to reduce it by reducing the tension of the root: for this, the muscles on the side of the pain are strained (contracted) and pull the vertebrae behind them. This process (muscle tension) leads to a spasm, which itself causes pain. This newly arisen pain causes an even greater spasm, which causes new pain, and in response, the muscles spasm even more… This is how a vicious circle is formed. That is why weak muscle relaxants (for example, midocalm) are always used in drug therapy. But more effective are injections into the muscles, which can help break the vicious circle.

Nerve or root blockade (peripheral or paravertebral blockade) can help with acute (unbearable) pain, it contributes to the desensitization of sensory pathways. At the same time, local anesthetics, steroids and opioids are more often used. Steroids help reduce inflammation of the nerves and joints.

Electro-thermal disc destruction is a minimally invasive manipulation used to reduce lower back pain. With this method of treatment, a hollow needle is inserted into the affected disk under the control of an X-ray machine (the accuracy of the installation of this needle is very important here: it is in the place of the "fallen out" part of the disk), an electrode is passed through the needle, which is heated to a certain temperature. The purpose of the procedure is to destroy small nerve fibers that have invaded the degenerate disk, in addition, the temperature slightly melts the “wall” of the disk at the site of the breakthrough, which in turn causes the regeneration process, and new protein fibers strengthen the disk wall.

This method of treatment is not as common as, for example, the following. This is due to low efficiency: thus, only in 18% of cases, patients note a long-term regression of the pain syndrome.

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Radiofrequency nucleoplasty of intervertebral discs is similar to the previous technique. Here, in the same way, the needle is inserted into the disk. Only instead of a heating wire, a special radio frequency sensor is passed through the needle. It generates a special plasma field of sufficient energy to “vaporize” part of the core. As a result, 10-20% of the core “disappears”, which reduces the pressure inside the disk and after a while the “bulging part” settles inside.

Spinal pump. A little history: patient-controlled analgesia is widely used in surgery in many modern clinics and is more often used to treat postoperative pain. In fact, it is a pump that controls the usual intravenous system that you see all the time in hospital wards (well, or in movies, if you are a healthy lucky person). It is programmed to “pump” the correct dose (it is noticeably less than in the manufactured ampoules) of painkillers into the bloodstream. The patient gets control over the pain with the help of a push-button mechanism. Thus, the doses when using this pump are smaller, but can be used more often. This allows the patient to independently control the pain, prevent drowsiness and weakness caused by drugs, allows the patient to move faster. This type of anesthesia is also called “sequential”. It has been proven that the use of such devices reduces the total amount of medication needed to control pain.

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And our “spinal pump” is one of the varieties of such a pump and introduces drugs directly into the fluid surrounding the spinal cord. As you understand, medications taken orally, intramuscularly or intravenously are “dispersed” throughout the body, and the spinal pump "delivers" analgesic medicine exactly where it is needed. Currently, this procedure is considered the next stage of analgesia if standard conservative methods of treatment have proved ineffective or have led to side effects.

The pump is implanted under the skin of the patient’s abdomen, the catheter is installed at the level of the spine where the pain “comes from”. Medications are “pumped” directly into the cerebrospinal fluid. This significantly reduces the amount of the drug and provides better pain relief with fewer side effects. If necessary, the pump is replenished every 1-3 months (a needle is inserted through the skin into the membrane on the pump surface). Since the system is “hidden” under the skin, the risk of infection is minimized, and the patient can be fully active and lead a normal life. And although the process of installing a spinal pump is a small operation, this type of treatment is considered conservative.

Spinal stimulator.

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The stimulator is similar to a spinal pump: it is also implanted under the skin, but instead of a medicinal substance, electrical signals are used to relieve pain. Electrical signals are transmitted through the tip of a catheter installed near the “suffering” segment of the spinal cord. The basis of the stimulator’s action is the theory that a special electric current changes the conductivity of pain impulses along the nerve endings, so it is possible to repeatedly increase pain sensations and significantly reduce them. In modern devices, it is already possible for the patient to control pain by changing the characteristics of the current (strength, voltage, amplitude, etc.) by pressing on the skin at the top of the implanted generator disk.

And finally, surgical anesthesia is used when all other methods did not give the proper result. You can talk about surgical methods for hours: about historically significant methods, and about the latest ones that are just being developed. In order not to take up your time, I just want to remind you once again that the operation is also analgesia and... nothing more. That is, after the operation, it is very wrong to expect a complete healing of your spine, to say the least. Consider the operation as a preparation for the next type of treatment:

Physical therapy is the most important of the treatment methods, it is aimed at restoring the mechanics of the body (posture), giving strength and flexibility to the muscles with the help of exercises. In addition, physical therapy is the prevention of injuries (remember that the lower back often hurts due to sprains and torn ligaments). We will not take away the bread from the doctors of physical therapy, the Internet has already done this for us for a long time, but still I always recommend my patients to work out under the supervision of a specialist for at least the first month. Physical therapy is almost always supplemented with physical therapy (electrical stimulation, exposure to heat and cold, hydrotherapy, ultrasound and massage).

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There is an interesting concept in the English-language literature as “PAIN MANAGEMENT”, which is used for the “treatment” of many types of diseases, including chronic pain, migraines, spinal cord injuries, movement disorders. This is something like learning relaxation and changing the patient’s behavior. Pain management allows to control physiological reactions, such as muscle tension, body temperature, heart rate, brain wave activity, etc. This therapy program requires "intensive" patient participation, and a competent instructor will help you learn how to manage these functions. Unfortunately, pain management does not work for all patients. During the training process, electrical sensors are attached to the patient, connected to control and diagnostic equipment that serves to monitor the operation of the patient's organs. At this time, the doctor teaches the patient mental and physical exercises, visualization and deep breathing, so that he can, in fact, by the effort of thought, relieve spasms of the back muscles.

So, what I tried to tell you: any treatment that the doctor prescribes to you will be directed only to one thing-anesthesia (remember about neuroplasticity). For example, in the textbooks of the Sackler School of Medicine (Tel Aviv University Medical School) - all these measures are called “prevention”, and not treatment at all. And again, I repeat: any treatment (even if not mentioned by us) is temporary anesthesia, that is, anesthesia for continuing the main treatment-physical therapy.

Vladimir Vladimirovich Balkovoy 

Spine neurosurgeon