The complicated issue involving low back pain is determining the exact source of pain.  Pain may arise from one or a combination of many structures involving the low back.  There are various muscles, five vertebras, five discs, ten lumbar facet joints, two sacroiliac joints, 12 spinal nerves, and various ligaments that can all cause pain.  This does not include referred pain from the hips or from other non-musculoskeletal systems.  There can also be biopsychosocial contributing factors — strenuous work, workers’ compensation, job dissatisfaction, anxiety, depression and smoking. 

It is a misconception that an MRI can pinpoint an exact source of pain.  An MRI is an anatomical study, not a pain study.  It needs to be clinically interpreted.  There are incidental findings that show up on MRIs, such as bulging discs and arthritis that might have no relevance to the patient’s pain.  Studies have shown that people WITHOUT low back pain can have similar findings.  That is why there is an old medical saying that says, “Treat the patient, not the image.”

In regard to treatment, the five most common options are observation, medications, manual treatment such as physical therapy, spinal injections (if indicated), and surgery (if indicated).  Most patients opt for conservative treatment initially.  No matter the cause, this usually entails taking medications and starting a physical therapy program.  The aim of medications is two-fold, to provide pain relief, and in some cases, to reduce any potential inflammation that can be contributing to the cause of the pain.  Unless there is a medical contraindication, prescription medications like a Medrol dosepak, Naproxen, Mobic, Diclofenac, or over-the-counter medications like Ibuprofen or Aleve can help reduce inflammation.  Extra Strength Tylenol (1000 mg every eight hours) can also be used to help with pain, even though it does not reduce inflammation.  Cyclobenzaprine (5 – 10 mg at bedtime), a muscle relaxant, can help with sleep if the pain keeps one up at night.  There are other medications that can be prescribed if the pain is still uncontrolled.  Physical therapy can also be used to help alleviate pain via modalities, stretches and exercises, and to optimize your muscle health.

If a patient does not improve with medications and physical therapy, a spinal injection can be considered if there is a structure identified as the potential cause of the persistent pain.  Spinal injections are unlike office injections involving the shoulder and the knee.  They usually cannot be performed same day because they require specialized equipment (a special type of x-ray machine called a fluoroscope) as well as prior insurance approval.  Furthermore, the decision to proceed with an injection needs to be correlated with the history, physical exam, as well as any imaging studies that may be ordered.  There is no “one injection solves all” procedure that can be performed for low back pain.  There are different types of injections (i.e. epidural steroid injections, facet joint injections, sacroiliac joint injections) that are specific for the potential source of pain.   An epidural steroid injection is not going to help with pain if it is stemming from the joints of the spine.  Similarly, a facet joint injection is not going to help if a herniated disc is causing the pain.