Ask the Expert: Dr. Vladimir Kramskiy, Pain Medicine Specialist, Answers Your Questions About Managing Chronic Back Pain
Q1. Are there things we can do to minimize chronic back pain other than strengthening the core?
In addition to “core strengthening,” I typically recommend the following exercise programs for patients with acute and chronic low back pain. Always consult with your physician before starting an exercise regimen.
- McKenzie method – includes flexion/extension stretches where patients perform exercises using repeated movements or sustained postures.
- Alexander technique - individualized, hands-on instruction focused on improving balance, posture, and coordination, as well as recognition of harmful habits in order to avoid painful movements.
- Mind-body exercises (e.g., yoga and pilates) - helps to improve strength, flexibility, and balance as well as body positioning and mental focus.
- Tai chi – Chinese martial art that involves slow movements, breathing exercises, and meditation. Further studies are needed to determine its long-term efficacy for low back pain.
- Aquatic therapy - offers aerobic activity in addition to core strengthening that may be particularly helpful for chronic low back pain.
Q2. Have you ever treated pudendal nerve entrapment/neuralgia successfully? If so, how?
Pudendal neuralgia is a challenging condition to treat due to difficulty in making the initial diagnosis. Treatments include behavioral modification and physical therapy coupled with medical management utilizing anti-epileptic and anti-depressant agents. Pudendal nerve injections with CT guidance can aid in making the diagnosis and offer therapeutic relief. I have used spinal cord stimulation with some success for a number of patients with refractory pain, or pain that’s resistant to treatment. If the patient doesn’t respond to those treatments, other options include a procedure using heat generated by radio waves to temporarily interfere with their ability to transmit pain signals, and surgical decompression. Consult with a physician for the best course of treatment.
Q3. What are some ways to control pain from facet arthropathy?
Treatment of facet-mediated low back pain ideally involves a multimodal approach comprised of conservative therapy, medical management and procedural interventions. Consult with a physician for the best course of treatment.
- Conservative therapy – can include tailored exercise programs (e.g., core strengthening, yoga, pilates and aquatic therapy), manipulations and acupuncture.
- Medical management – nonsteroidal anti-inflammatory drugs and acetaminophen are considered first-line agents. Adjuvant drugs, such as antidepressants and muscle relaxants, can be added to the regimen as well.
- Procedural interventions – steroid injections and blocking medial branch nerves can help confirm the diagnosis and provide short term relief. Medial branch nerves are very small nerve branches that carry the pain message from the facet joints and the muscles around the joints. If the nerves are blocked or numbed, they will not be able to transfer the pain sensation from the joints to the brain. Long-term pain relief can be achieved with a procedure using heat generated by radio waves to temporarily interfere with their ability to transmit pain signals.
Q4. I heard that people with slipped discs shouldn’t get too many cortisone shots for their pain. What are the side effects of the cortisone shots?
Complications from epidural steroid injections fall into two categories:
- Extremely rare but serious, adverse events can occur but vary by the level of injection. The majority can be avoided with stringent antiseptic technique, expert and proper needle placement and appropriate use of fluoroscopy (i.e. x-ray) with contrast.
- Transient and infrequent post-injection reactions may include non-positional headache, mood changes, nausea, increased blood pressure, increased serum glucose (particularly in patients with diabetes), sleep disturbances, and facial flushing. These are due to systemic absorption of the steroid component.
I typically do not recommend more than three epidural steroid injections per year due to potential for steroid-related bone loss that can lead to an increased risk of osteoporosis. Talk to your physician about the best course of treatment.
Q5. How can low back pain from spondylolisthesis be treated?
I offer patients a conservative treatment course consisting of activity modification, pharmacological interventions, and physical therapy (with short-term use of a lumbar orthotic device). Anti-inflammatory medications in combination with acetaminophen are first-line agents. Patients with clinical evidence of concurrent leg pain may benefit from an epidural steroid injection. I refer patients that do not improve after 4-5 months to a spine surgeon for a consultation. Talk with your physician about treatment.
Dr. Vladimir Kramskiy is a pain medicine specialist and neurologist at Hospital for Special Surgery. He uses a comprehensive approach to treat acute and chronic spine and musculoskeletal pain, neuropathic pain, headaches and complex regional pain syndromes.