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smoking, and relief of stress, decreasing the axial load and avoiding twisting and turning. This should be augmented by long-term low impact motion exercises. The most important decision in treatment is deciding the cause. The course of action for one malady of the back will exacerbate another. The anatomical basis of the pain, as well as the chemical nature of the pain, must be addressed.
VERTEBRAL PLASTY
Symptomatic, angulated or compressing bone fractures are treated with bracing or fusion. If the fracture is due to osteoporotic bone collapse and less than seven months old then the patient may be a candidate for outpatient percutaneous vertebralplasty. This involves injecting acrylic cement into a space created in the vertebral body by a balloon, this may instantly reduce pain and may add height to the collapsed bone. The patient can go home in very short time.
OTHER TREATMENTS
Metastatic tumors of the bone, if they are not compressing the neural elements are treated first with radiation possibly combined with bracing. If this modality fails and the patients are candidates, surgery may be considered. Bone edema from degenerative disk disease usually responds to removal of the offending chemical irritating herniated disk. Of course, if surgery and bracing has been utilized, physical therapy must be started and continued. Without physical therapy, the brace supported back will lose muscle mass and therefore muscle stability, becoming more prone to injury.
MUSCLE TREATMENT
Muscles themselves are often the source of back and even radicular pain. Unused muscle shrink or atrophy, become tired toward the end of the day, hurt with normal use and cannot support the spine leading to further degeneration of the disk and facet. Initial and long term mandatory treatment consist of low impact, continuous motion exercises. Spine stabilizing exercises are started after two weeks. These are done on a daily basis to help rid the body of this very common aliment. The use of non-sedating muscle relaxants continuously for two weeks, but no longer, will help with the spasms. Longer use makes the muscles dependant and weak leading to further loss of tone and pain. Anti-inflammatory medication may help with pain and muscle irritation. Along with exercise and medication, muscle spasms respond to ice early on in the first two weeks and later to warm moist heat for 30 minutes at a time, 4-5 times per day. The use of heat for greater periods of time can promote muscle tissue swelling and of course worsen the problem. Manipulation, massage, ultrasound and muscle stimulation therapy help the spasms associated with muscle disease.
FACET (JOINT) TREATMENT
Facet disease, sometimes called lumbar osteoarthritis, can be helped with facet blocks and if appropriate facet rhizotomies. In addition, in order to rid the joint of the chemical irritation, an anti-inflammatory is used. The person then exercises in water at 95 degrees F to relieve the gravitational stress on the joint and to rebuild the muscles to support the spine, taking further pressure off of the facets. The warm water tends to increase blood flow improving outcome; cold water tends to aggravate chronic back spasms. After improvement with aquatic exercises, long term, low (Continued on page 18)
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