Features November 2007 Issue

Breakthroughs in Back Therapy

When conventional methods fail, a range of newer options may offer relief from the misery of back pain. But do they deliver?

If you’ve ever endured a backache, you’re not alone. Back pain plagues eight out of 10 Americans at some point in their lives.

In older adults, back pain typically stems from one or more of four sources: wear and tear of spinal joints due to arthritis; degenerated or herniated disk; fractured vertebrae due to osteoporosis; or soft tissue problems involving ligaments, tendons, or the muscles that support, operate, and stabilize the spine.

Back Therapy

Marty Bee Illustration

Still the standard procedure, microdiscectomy involves removal of part of a herniated disk to relieve pressure on an adjacent spinal nerve.

Conservative treatment involves medications, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, or celebrex; physical therapy; and exercise. Some patients try chiropractic manipulation, acupuncture, and massage therapy. Other means of physical support such as bracing, orthotics, and canes may also ease pain. But medications can have side effects, and many treatments offer only temporary relief. Surgery, often a last resort, can be risky.

"Current treatment is certainly imperfect," says Daniel Mazanec, M.D., associate director of the Cleveland Clinic Center for Spine Health and head of the Section of Spine Medicine. "We’re continually looking for ways to improve treatment outcomes, avoid side effects, and maintain function."

Ongoing research has led to several innovative treatments. Some are on the horizon, while others—available now—bring hope of relief.

Repairing disks

Disks are the cushioning pads between the vertebrae in your spinal column. When a disk herniates, part of its nucleus pushes through the outer edges of the disk and puts pressure on nerves, causing the pain of sciatica.

Standard treatment for a herniated disk is minimally invasive discectomy, or micro-discectomy. A portion of the disk is removed, the disk is decompressed, and pressure on the nerve is eliminated. The procedure involves an incision of less than a centimeter, minimal tissue damage, and a hospital stay of often just one day.

The newest techniques use specialized instruments. In percutaneous discectomy, a tiny puncture is made and disk material is removed through a needle, creating a space for the disk to return to its normal shape. Another device, called the ArthroCare Spine Wand, involves the delivery of an electrical charge that vaporizes and extracts tissue.

Are the newer techniques an improvement over micro-discectomy, considered the gold standard? "These options need further study," says Dr. Mazanec. "In comparing them to micro-discectomy, we need to ask, are they better in terms of relieving pain? Are these procedures less expensive? Is recovery time less?"


Zapping pain

The neurostimulator, an implantable device similar to a heart pacemaker, was introduced more than 20 years ago, but in recent years it has become increasingly smaller and longer lasting. Now the size of a pocket watch, it can operate for nine years with a battery recharge once every four to six weeks.

Electrodes are implanted in specific areas of the spinal column. The electrodes are connected to a battery pack that delivers a mild electrical charge, which overrides painful impulses coming from the nerves, dulling or eliminating the pain.

"Neurostimulator technology has greatly improved," says Dr. Mazanec. "But the treatment is usually reserved for someone with severe, incapacitating pain despite having had one or more surgeries."

Another back-pain weapon, only recently introduced, is peripheral nerve field stimulation (PNFS), in which electrical leads are placed just under the skin at the source of pain and the area is stimulated by an electrical feed from an implanted power pack.

"PNFS attempts to extend spinal-cord stimulation to peripheral nerves," says Dr. Mazanec. "Unfortunately, it’s unproven and virtually unstudied. At best, it can be considered an investigational adaptation of spinal-cord stimulation not yet supported by evidence of effectiveness."

Fusing vertebrae

Disks tend to shrink with age as the water content in the cells diminishes. With less cushioning, the vertebrae can press against each other, irritating a nerve.

Spinal fusion, the welding of two or more vertebrae with bone grafts or metal rods, eliminates motion between the vertebrae, a benefit if motion is causing pain. But spinal fusion also eliminates spinal flexibility. Another downside is the stress placed on the vertebrae above and below the fused area.

A newer technique, approved for spinal fusion three years ago, uses bendable materials consisting of plastic tubing that surrounds a cord and spacers to provide stability while preserving movement.

"Fusion surgery to treat degenerative disk disease is controversial," says Dr. Mazanec. "The biggest issue before undertaking the surgery is certainty that a degenerative disk is causing the pain. The second issue is the risk of adjacent segment disease, or degenerative changes in the vertebrae above and below the fused vertebrae.

"Bendable hardware is designed to avoid the late complications of adjacent segment disease," he adds. "But it’s not yet known whether these motion-preservation devices will result in better long-term results."


On the horizon

An infrared belt, called the Lumbar Wrap, uses low-level infrared energy to improve blood circulation and promote healing. The belt can be worn while sleeping or while engaged in daily activities. "The downside to traditional thermal therapy is that the benefits are short-lived. What’s new about this device is that it is wearable and portable," says Dr. Mazanec. "But we don’t know yet if it will be a significant advantage until we see research evidence."

One novel therapy for degenerative disks promises to treat the cause, not just the symptoms, of back pain. It uses the patient’s own bone-marrow stem cells to regenerate damaged disks. The extracted cells are mixed with a gel that resembles human collagen and then implanted during minimally invasive surgery. Researchers hope that the stem cells will produce new disk tissue. "The approach is promising," says Dr. Mazanec. "But restoring the disk alone may address just one part of a complex problem if a patient has spinal joint problems, for example, as well as disk problems."


Conservative measures first

If you have severe pain and haven’t responded to conservative measures or surgery, you may want to consider a newer technique—which may be unproven and costly. First make sure you’ve exhausted all conservative measures.

"The majority of people with back pain improve without surgery," says Dr. Mazanec. "Exercise, physical therapy, and appropriate medication in a combined treatment approach can be very effective."