Back pain and sciatica

Back pain is one of the commonest causes of disability and needing to take time off work and not being able to enjoy quality of life and engage with daily activities.

Pain could arise from various structures in the back including muscles, joints, nerves, and discs between the vertebrae or mix of these together secondary to inevitable wear and tear process that we all experience to varying degrees throughout our life.

Luckily most back pain problems are self-limiting and usually respond well to rest, physiotherapy rehabilitation program and simple pain killers.

Sometimes the problem is too severe to cope with no indication for surgical intervention, and this is when our role as pain physicians come to assess the patient and decide the probable source of pain and plan injections accordingly. Dr Alkholany’s approach is to fit those injections in a wider picture that minds the 3-dimensional nature of long-standing pain; biomedical, social, and psychological with adoption of a parallel rehabilitative program to achieve excellent results for his patients.

We offer our patients wide range of evidence-based interventions to help with their on-going back pain:

• Facet joints are small joints between the vertebrae along the spine, they are susceptible to wear and tear especially with bad habits and weak back muscles and are common source of low back and neck pain. In lower back that could translate into back pain and refereed leg pain. In the neck that could translate into neck pain and headache and sometimes referred pain down the arms. Those joints are supplied by small nerves called medial branches. Numbing those nerves on diagnostic basis with local anaesthetic under x ray guidance as day case procedure helps to prove or disprove the contribution of those joints to back or neck pain and if that proves successful by giving patients good quality pain relief for short period of time then we offer them ablation of those nerves via the use of radiofrequency waves through needles placed where those nerves run to give them longer term pain relief and using the benefit of this pain relief to reduce need for medications and engage in a rehabilitation program.

• Sacroiliac joints are the large joints at the bottom of the back between tail bone and hip bone. They bear the weight of the body and are very susceptible to wear and tear hence constitute another common source for low back pain. We offer our patients direct injection in the joint as day case procedure guided by X ray using local anaesthetic and steroids. We also offer an alternative by numbing the nerves that supply the sacroiliac joints and if that proves successful by giving patients good quality pain relief even for short period of time then we can do ablation for those nerves using radiofrequency waves applied through needles placed where those nerves run to give our patients longer term pain relief allowing them excellent window to engage with rehabilitation and physiotherapy.

• Not uncommonly, our patients present with nerve pain travelling down their legs commonly known as Sciatica which is not very accurate term but commonly in use or their upper limbs, and the reason could be irritation of a nerve root by a prolapsed disc. In this situation having a surgical opinion is very important to exclude any imminent need for surgery and usually the outcome is conservative management and trial of nerve root injection with local Anaesthetic and steroids to reduce inflammation around nerve root and ease the pain which could save the patient an un-necessary surgery yet communication with spine surgeons is very important to exclude the need for surgery first place. We offer this injection to our patients as day case guided by X ray. Pulsed radiofrequency could also be applied here to modulate how those nerve roots work to give our patients longer term pain relief.

• Sometimes pain around gluteal region travelling down the leg could be related to specific conditions that could easily be overlooked unless suspected such as pyriformis syndrome or Cluneal nerve entrapment. Pyriformis muscle is a small muscle sheet in the gluteal region that runs on top of sciatic nerve and if it’s tight and spastic, it could irritate the sciatic nerve and give picture typical of sciatic when the problem is in the muscle. We offer simple injection for this muscle guided by ultrasound as day case procedure which along with stretching exercises helps to improve symptoms. Cluneal nerves are another group of nerves that run along the hip bone lateral to the spine. They could get entrapped in a muscle tunnel and give symptoms very similar to sciatica, gluteal pain, and hip pain. Diagnosis needs high index of suspicion and treatment is very simple by doing injection, diagnostic and therapeutic at the same time using local anaesthetic and steroids to open-up this muscle tunnel and relieve the pain. Pulsed radiofrequency could also be used to modulate the way those nerves work and give longer term pain relief to our patients.

• Sometimes the wear and tear changes are too advanced, this is when multidisciplinary discussion takes place with our spine surgery colleagues to decide best course of action and whether there is indication for / patient is fit for surgery or our way forward is optimising medical treatment and developing coping and acceptance to this pain and making sure that physical activity and independence are maintained to an acceptable level.

• On other occasions the main driving cause behind disability secondary to back pain is not the magnitude of wear and tear but rather psychologic distress such as previous psychologic trauma and/or social stressors and this is when a holistic approach via the help of pain psychology and physiotherapy is needed to address any abnormal thinking or behaviour that could have developed around this pain and to support our patients with self-management and regaining confidence in engaging with physical activity and enjoying quality of life.