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5/30/17: The right treatment for back pain

It’s difficult to forget a first bout of back pain. Should you move, despite the pain, or bring regular activities to a halt? After that first bout with back pain, many worry there will be more episodes in the future. The concern is real: after a first episode of back pain, there is a 50 percent recurrence rate within a year.

Henry Nields, MD | Healthworks, Winter 2017Henry Nields, MD, beat those odds, but he was understandably alarmed when he experienced intense back pain — again — last spring. As chief medical examiner for the Commonwealth of Massachusetts, Dr. Nields is on his feet, often bending over an autopsy table, for hours at a time. “Seven years ago,

I developed back spasms that were so bad I couldn’t stand up,” recalls the Lincoln resident, who went to Emerson for a diagnosis and treatment.

An MRI revealed a protruding disc in his lumbar spine. “It was touching the nerve,” he says. “I was given medication and prescribed a course of physical therapy at Emerson. Those exercises were a huge help, so I continued doing them. I got back in the swing of things in a few months.”

With that first episode behind him, Dr. Nields proceeded to run the state’s 24/7 pathology service. During a typical day, it’s not unusual for him to perform a six-hour autopsy, which requires lifting and leaning, and to sit at a microscope to review slides.

In May 2016, his back pain returned. “This time it was different,” he says. “It was sciatica in my left leg, and at times I couldn’t sit.” He made an appointment with chief of physical medicine and rehabilitation for the Emerson Spine Program, Arthur Lee, DO. An MRI showed that the same disc had ruptured: a piece of it had broken off.

It is not always serious, Dr. Lee notes. “There is a chance the body will absorb the disc fragment. But if the patient experiences weakness, we become concerned and consider surgery. Dr. Nields’ case wasn’t clear-cut; that’s why we work closely with Dr. Whitmore. We always have a back-up plan for our patients.” Robert Whitmore, MD, a Lahey neurosurgeon specializing in spine surgery who is affiliated with Emerson Hospital, often sees patients who have been evaluated by Dr. Lee or James Spinelli, DO, an interventional physiatrist.

Dr. Nields was immediately started on prednisone, a steroid medication that treats inflammation, and he experienced some relief. “I was impressed with Dr. Lee,” he says. “But I was thinking I wanted this fixed quickly, so I was inclined to have surgery.”

This scenario is familiar to Dr. Whitmore. “Conservative treatment, such as a therapeutic pain [cortisone] injection and physical therapy, can take time to work,” he says. “Some people feel like they can’t wait.”

In assessing patients for surgery, Dr. Whitmore weighs several factors. “How long has someone had symptoms and how severe are they? Has the patient tried conservative treatment already? Based on the imaging, do I expect the patient’s problem to resolve over time, which is often the case? If there is a sudden onset of weakness or bowel/bladder symptoms, and symptoms are rapidly progressing, we perform surgery. This signals a severe amount of compression on the nerves. Left untreated, it could result in permanent neurologic deficits.”

After treatment, keeping back pain at bay

Dr. Whitmore evaluated Dr. Nields and reviewed his MRI. “I understood that he had an episode a few years earlier, and he wanted to avoid more of the same,” he says. “However, I suggested that he have a cortisone injection and physical therapy.”

Dr. Nields returned to see Dr. Lee. “I had the injection and felt relief within a day,” he says. Dr. Lee referred him to Emerson’s Center for Rehabilitative and Sports Therapies, where he was seen by Joseph Marcotte, PT, DPT, a physical therapist.

“We trust the rehab staff,” says Dr. Lee. “They review the patient’s imaging studies and perform their own independent evaluation. They do a great job.” Dr. Nields responded well to the exercise regimen that Mr. Marcotte designed for him and has continued doing them.

He has made other adjustments aimed at keeping back pain at bay. “I’d been standing on a concrete floor during autopsies, but now I have a pad under my feet, and I often wear a back support. I pay more attention when I’m lifting something. I use my legs and go slowly.”

He knows he received the right treatment for that second episode of back pain. “My back pain could return, but I’m optimistic,” Dr. Nields says. “I feel good, and I know where to go if my back pain returns.”

Treatment for back pain, from exercise to surgery

The right treatment begins with a careful evaluation by one of the physicians at the Emerson Spine Program. They provide the full range of treatments, including:

  • Medication can be effective at lessening inflammation.
  • Image-guided therapeutic pain injections — also known as cortisone injections — potentially provide months of relief.
  • Physical therapy, either at Emerson’s Center for Rehabilitative and Sports Therapies (in Concord or Westford) or another location, can address pain and, over time, build strength and flexibility in the spine.
  • Complex and minimally invasive surgery is performed using a state-of-the-art intraoperative microscope and neuro-monitoring.
  • Integrative therapies, such as yoga, that encourage stretching can be effective at relieving pain and maintaining long-term spine health.