With regard to pain, the spine can be thought of as two parts: the functional unit of the disk and the vertebra above and below, and the posterior unit, which includes the facet joint. As we age, disk degeneration accounts for most of the pain in patients over age 50. It is rare to have acute disk herniation in an older aged adult like that which we see in a younger person. Spinal stenosis becomes more common as we age, and degenerative spondylolisthesis (the “sliding” of one vertebra bone forward or backward with relation to the adjacent bone) becomes reason for these big fusion surgeries in older people.

Disk is made of fibrous tissue with very little blood supply. Smoking cuts off the blood supply off even further. Smoking is severely dangerous for the development and recurrence of back pain. If you or a loved one smokes and has back pain, talk to me about it because there are a lot of good, FDA approved therapies for quitting smoking that you may not be aware of. RP

If you put people over the age of 60 in an MRI scanner, whether they have back pain or not, the study is always going to show problems. But fortunately not all back issues that we pick up on MRI correlate with any symptoms.

Facet pain can radiate down the leg but almost always ends above the knee. Very rarely we see facet pain radiating all the way to the ankle. Reminder, even though facet pain can go down the leg, it doesn't have “nerve pain” qualities to it, and that is helpful in my diagnosing, particularly when someone has disk issues on their MRI which can confound the clinical picture.

Nerve root pain (caused by disk bulge) radiates in a “radicular” distribution. When it is combined with diminished reflexes, or motor or sensory loss, then you have RADICULOPATHY. This is the #1 most helped condition by EPIDURALS FOR PAIN MANAGEMENT.

Annular tear can cause back pain, aka “axial” back pain.

Most of the time, back pain is “multifactorial”. Meaning, it is sometimes a combination of disk, nerve root, facet joint, sacroiliac joint, ligament, muscle, and hip joint as the cause.

Spinal stenosis can be congenital or as the result of aging, whereby the facet joint, the ligamentum flavum, or anterior longitudinal ligament gets enlarged and causes spinal canal narrowing. Neurogenic claudication can happen due to spinal stenosis but can also happen at the same time as vascular claudication as well in people with edema and vascular disease.

Do you have to do three epidurals to be effective? No! That is a myth that has been around for many decades. Do as many epidurals as you NEED, and that may only be one or two. I think having sequential epidurals spread out by 3-6 weeks is most effective. Typically I won’t agree to more than three epidurals in a 6-12 month time period as we do not want to give steroid problems (which is a dose-dependent problem).

Is there a benefit to having epidurals done under xray (also known as fluoroscopy)? Studies show YES! More effective and safer than the “blind” technique.

Is there a proven benefit to epidurals for radicular pain (pain shooting from the back)? Studies show YES!

What about epidurals for low back pain ONLY (non-radiating)? Depends on the situation but often it is not effective.

MOST IMPORTANT THING TO REMEMBER: ALL forms of pain treatment work better when they are mixed with a multi-disciplinary approach!