Surgery is not the only option for people with chronic neck or back pain. Raj Rao, MD, a neck and back surgery specialist, says most patients can gain relief through education, medical treatment and therapy. Dr. Rao, Medical College of Wisconsin Associate Professor of Orthopaedic Surgery and Director of Spine Surgery, practices at the Froedtert & The Medical College of Wisconsin Orthopaedic Surgery Clinic.
Q. What causes neck pain?
The most common cause of pain between shoulder blades or in the back of the neck is muscular pain. In most cases, that’s because of faulty posture, poor ergonomics at work or fatigue of the muscles from repetitive activities using improper body mechanics. The muscles in the back of the neck get fatigued and the neck begins to hurt.
Sometimes patients who are presumed to have muscular neck pain will have underlying degenerative or “wear and tear” changes in the discs or the facet joints of the neck. These changes can refer pain to the muscles in the back of the neck and give you the same type of neck pain.
Sometimes you have a herniated disc that pushes out on the spinal cord or the nerves in the neck – if you have this pressure, you can have neck pain and sometimes pain going down the arm in a nerve pattern. Occasionally there are patients with tumors or infections in the bones of the neck, which can also give you neck pain. And of course we must not forget the patient with neck pain who might have a fracture from a car accident or trauma.
Q. What are the most common causes of back pain?
With back pain, the causes are similar. They could be muscular pain aggravated by underlying degenerative changes in the disc or facet joints in the low back. Pain can be generated from a herniated disc that is pushing on the nerves in the low back, causing both low back pain as well as nerve root irritation. Or severe chronic arthritis in the low back causes a condition called spinal stenosis, which can produce both back pain as well as pain going down the legs.
In addition, you can have developmental conditions from childhood that seem to occasionally flare up in people after they have reached adulthood.
Q. When should you seek medical attention for back pain?
I don’t think anyone should feel that it’s unusual or uncommon to have back pain occasionally and for short periods of time, particularly as we get older. Often, it’s just because of poor posture, lack of stretching, poor ergonomics or muscle strains. It’s when these symptoms persist for a long period of time that we should get them checked out by our primary care physician.
Q. What are the treatment options?
In most cases, when the pain is short-term and mild, leaving it alone is not a bad option. If the pain is at a level beyond which it can be left alone, then over-the-counter anti-inflammatory agents containing ibuprofen are good measures. Whichever pill we take, we have to be cautious – particularly if we are using it repeatedly and on a daily basis – because any pill, even over-the-counter pills, can cause side effects.
It’s not a bad idea to try some over-the-counter liniments. I would recommend that they not be rubbed in, but instead be lightly applied to the area that’s hurting. Local application of ice or heat is a good option. The first few days after the pain begins, ice probably works better than heat, but if the pain has been persistent a little longer, heat may work better than ice. Sometimes sitting in a hot tub or a hot shower makes the neck or the back pain feel better. You can sometimes also get a soft brace – women can get an old-fashioned girdle and wrap it around their low back and some physicians may use a soft neck collar for a short period of time.
If none of these measures are working, your primary care physician most likely will set you up with a program of physical therapy. The physical therapists in our rehabilitation center are specially trained in the management of neck and low back pain. They treat the patient primarily with education, instructing the patient on how their neck works, how their low back works, and how they can protect their neck and their low back to avoid recurrent pain. The therapists also treat the patient with modalities such as ultrasound, heat and electrical stimulation. Once the acute pain has settled down, they can also treat the patient with some muscle-strengthening exercises that will in many cases reduce the long-term incidence of pain. Particularly for patients who have disc herniations in the neck with both neck and arm pain, I believe a short period of cervical traction is useful.
If the patient has pain in spite of all these measures, then the next step, especially if they have nerve pain going down into the arm or the leg, is consideration of injections around the nerves of the spine. These injections, known as epidural steroid injections, can help patients who have severe pain caused by displacement of the spinal nerve. The injection helps by treating the inflammation around the nerve root at the spine. Once the inflammation goes down, the pain seems to settle down in many patients.
If none of these measures help out, I typically reassess the patient. Some of these patients, particularly if they have significant nerve pain going down into the arm or the leg, may be a candidate for surgery on their neck or their low back for their herniated disc or for the arthritis that’s pinching the nerves in these regions.
Q. You specialize in neck surgery. What are the patient’s options here?
The options can get quite complex depending on the exact situation involved. When we do an operation for a herniated disc in the neck, there are typically two options. They depend on the type of disc and the type of symptoms the patient is having. One option is to go in the back of the neck and take away a little bone and soft tissue to relieve the pressure on the nerve and try to take out a small fragment of disc. The second option is to go in the front of the neck and take out the disc that’s putting pressure on the nerve, put a little plug of bone into that disc space and do what we call a fusion of the cervical vertebrae. Many patients do better with removal of the disc from the front because we don’t have to cut through the thick muscles in the back of the neck.
Modern techniques for these operations involve the use of microscopes and smaller incisions. This has reduced the number of complications and helps patients go home earlier and begin their rehabilitation much faster than they used to 30 years ago.
Q. Are surgery outcomes better today in terms of functionality?
That’s a difficult question to answer because it also depends on what society is expecting and willing to put up with. To the farmer of 50 years ago, even if he had pain, there was no option – he would go back to work tilling the fields. But to the computer technician of today or the person who has a desk job, they may find it difficult to go back to work if they have persistent pain. To some extent it depends on patient expectations and pain levels.
Whether outcomes are better today than they were 30 or 40 years ago is a very good question. There is not that much data on whether neck surgery outcomes are better. Regarding low back surgery, there was one paper that showed outcomes aren’t that much different today compared to 20 years ago. Outcomes are about the same, in spite of the fact that technology has improved dramatically.
Q. Out of a hundred patients, how many eventually go to surgery of some kind?
For every hundred patients who have neck pain or who have nerve pain going down into the arm from a herniated disc in the neck, I would say that less than five eventually need surgery. A large portion of the rest will get better within six weeks with appropriate treatment. Many will have some degree of symptoms with which they feel they can live.
Q. What can a person do to prevent back and neck pain?
I think the most important thing is to keep our weight under control. The less we weigh, the less load there is on the discs of the low back and the less likely we are to have long-term problems. In addition to that, I think we should maintain a healthy, active lifestyle, because the discs do need activity to maintain their nutrition and the bones need activity to maintain their strength and prevent osteoporosis. We should avoid smoking. We should consider a regular stretching program, such as yoga or tai chi, to keep our joints flexible. We should also maintain proper body mechanics and ergonomic activity whether we are at work or at home.