Which Spine Intervention
Is Best For Me?
There are many factors to take in account when determining this and there is no one treatment that is best for everyone. Here we will discuss the advantages and disadvantages of different spine interventions.
In order to answer this question, one has to have an in-depth assessment. In addition to an assessment, most often some freezing injections are needed to determine the source (or sources) of the pain. Often patients have a combination of different pain generators and will benefit from treatment of multiple areas or require more than one type of treatment.
Before doing any spine intervention, it is important to identify lifestyle factors that contribute to chronic back pain such as obesity, depression, anxiety, poor diet, smoking, sedentary lifestyle, poor posture and core muscle weakness. Even you undergo spine inventions, addressing these factors will result in the most improvement in your pain and function, along with the numerous other health benefits.
When selecting the best spine intervention for your condition, several factors need to be taken into account such as the suspected source of the pain (disc vs facet vs SI joints etc), the number of joints or discs involved, and your age and health status. Cost is also a consideration as not all procedures are covered by Alberta Health Care (i.e. PRP).
Facet Pain(Spine Arthritis)
Sacroiliac Joint Complex Pain(SI Joints)
This type of pain is more common as you get older but can be the source of pain even in younger adults. The main interventions to consider for facet and/or SI joint pain are injections and radiofrequency (RF) ablation.
Facet and/or SI joints can be injected with cortisone or PRP using ultrasound or fluoroscopy (x-ray guidance). RF ablation involves cauterizing the small nerves that carry the pain signals from the joints.
The advantages of facet and/or SI joint cortisone injections are quick onset of pain relief (usually within 1-2 days), and low cost (we charge $20 to use cortisone from our office supply and no cost if you bring it from your pharmacy). Duration of pain relief can vary from a few weeks to up to 6 months. A typical duration would be 3 months, although with repeat injections the duration usually becomes less. The disadvantages are the side effects from cortisone which include bone density loss, adrenal gland suppression and hastening of the progression of arthritis. If you are diabetic, cortisone shots will also raise your blood sugar for a few days. These side effects are dose dependant with minimal side effects with a few injections and more significant side effects with repeat injections over extended periods of time. Most physicians do not recommend spine cortisone injections more than 3-4 times a year.
PRP injections of the facet and/or SI joints have emerged as a treatment within the past 10 years. Overall, PRP injection of the facet and/or SI joints have been less studied than some other procedures, but evidence is accumulating and promising. When the procedure is effective, it is really the ideal treatment in our opinion due to it’s good safety profile and long-lasting benefit..
Spine PRP is not effective in everyone (although none of the procedures are always effective). We find that around 20 % of our patient do not achieve significant pain reduction. We also find that patients with health issues such as obesity, smoking, and diabetes are less likely to achieve good results. Patients often have an increase in their back pain and stiffness for up to 3-4 weeks following the procedure. Best results are noticed 2-3 months after injections. We feel the main downsides to PRP are the lack of large randomized controlled trials and cost. PRP is not covered by Alberta Heath Care. Please refer to our page on PRP for pricing.
Radiofrequency (RF) ablation is an option for you if you have had facet and/or SI joint nerve blocks (medial/lateral branch blocks) and most of your back pain goes away for a few hours after the injection when the freezing is working. With RF ablation, a special needle is placed over the nerve - the tip of the needle is heated to 80o C for 90 seconds to ablate or “burn” the nerve. By disrupting the pain signal to the joint, you will not feel as much pain from it.. The nerves do grow back, but it usually takes about a year, at which time the procedure can be repeated. It is vitally important to use the time of less pain following RF ablation to get yourself and your spine in better shape and address the lifestyle factors mentioned above.
The advantages of RF ablation are long duration of pain relief (average about one year), absence of the side effects of cortisone, and it is completely covered by Alberta Health Care. Serious adverse effects are extremely rare with RF ablation.
The medial/lateral branch nerves that are ablated with RF ablation do control some smaller spine muscles (multifidi muscles), but the loss of these muscles does not cause any significant loss of spine movement or strength . However some health experts do feel that the weakening of these spine stabilizer muscles could cause some increased slippage of one vertebrae on another, and thus more wear and tear on the discs and joints in the spine. We are unaware of any evidence to suggest this, but long term studies are lacking and it is a legitimate concern. We feel that it’s more of a concern in younger patients and when a larger number of joints that are treated. In such cases, PRP may be a better option.
Discogenic Pain
Disc pain is one of the most challenging sources of back pain to treat. Effective, safe and proven treatment options are limited. Disc pain can occur at any age, but is more common in younger patients (20-50 years old). Acute disc pain episodes usually decrease with time, but often recur and eventually becomes chronic, lasting for many years, even decades.
The fundamental treatment for disc pain has and continues to be supporting the spine by minimizing unnecessary spine loads (i.e. weight reduction, proper posture/biomechanics) and protecting and stabilizing the spine (i.e.strengthening core muscles). This should be part of the treatment plan of any patient with disc pain. The guidance of a physiotherapist or other trainer with experience with disc pain is important and will help you avoid injury.
Surgery is rarely advised for discogenic low back pain, particularly in younger patients. Surgery is more of an indication for disc bulging (herniations) that impinge a nerve in the spine and cause pain that is predominately in one or both legs.
Some of the interventions that are done for disc pain are epidural injections. Please refer to our page on epidurals for more information about epidural injection procedures and potential risks.
Cortisone or PRP can be injected into either the disc or the epidural space to treat disc pain. Cortisone injections into the disc has little evidence to support it’s use. Epidural injections with cortisone to treat disc pain are somewhat controversial due to lack of effectiveness in many studies. There are also concerns about the long term side effects of repeated injections with cortisone. Patients who respond best to epidural cortisone injections are typically those that have back and leg pain. If an epidural injection results in significant pain relief lasting at least a few months, it may be a very reasonable treatment to improve function and facilitate an opportunity to start a back exercise program.
PRP disc and epidurals injections for disc pain have only early evidence and would be considered by most spine physicians to be experimental. PRP injections have an excellent safety record in other parts of the body. The studies that have been done on PRP disc and epidural injections suggest that PRP injections are reasonably safe and effective. PRP disc injections carry a greater risk of infection compared to PRP epidurals, are more invasive and expensive. For that reason, we generally recommend PRP epidural injections be tried before PRP disc injections.
1. The highest quality PRP epidural study that we are aware of is a randomized controlled double blinded trial comparing PRP and cortisone epidurals for chronic low back pain. One month after the injection the cortisone group had slightly better pain reductions, but beyond that the effects of cortisone quickly faded and the PRP group had significantly better pain reductions at 3 and 6 months after the injection. They also measured ‘Health Quality of Life” and the PRP group showed better scores in all 5 of the categories and in 4 of the 5 categories the scores were dramatically better in the PRP group. But the largest benefits of PRP over cortisone may be the absence of the long-term side effects of cortisone and improved long term health of the spine.
This study measured the outcome with just one injection - it is our experience that PRP is more effective when 2 sets of injections are performed around 3 months apart. We anticipate even better and longer lasting outcomes with the 2 injection protocol. If you experience good results with the initial 2 PRP injections, repeat injections can be done as needed, be it every 6, 12 or 18+ months.
1. A Randomized Double-Blind Controlled Pilot Study Comparing Leucocyte-Rich Platelet-Rich Plasma and Corticosteroid in Caudal Epidural Injection for Complex Chronic Degenerative Spinal Pain Ricardo Ruiz-Lopez, MD, FIPP*; Yu-Chuan Tsai , MD, FIPP†,‡ *Clinica Vertebra, Barcelona Spine and Pain Surgery Center, Unit of MISS, Barcelona, Spain; †Department of Anesthesiology and Center of Pain Management, E-Da Cancer Hospital, Kaohsiung