Lower Back Pain

with Steven Donatello, M.D., Pain Management Specialist with Columbia St. Mary’s

Last Updated: Sept. 1, 2003

Back pain affects about 80% of people in the U.S. at some time in their lives. Usually, the problem resolves itself with time and rest, often accompanied by over-the-counter pain medications. Physicians often prescribe anti-inflammatories, physical therapy or suggest lifestyle modifications to help speed recovery.

For some patients, this conservative treatment is not enough. “Any time pain is severe or goes on for more than four weeks, a patient should see a physician for an appropriate diagnosis,” said Dr. Steven Donatello, a pain management specialist with Columbia St. Mary’s.

Steven Donatello, M.D., Pain Management Specialist with Columbia St. Mary’s "Any time pain is severe or goes on for more than four weeks, a patient should see a physician for an appropriate diagnosis." Steven Donatello, M.D., pain management specialist with Columbia St. Mary's."

Pain management specialists
Dr. Donatello’s specialty, pain management, is an area of medicine that incorporates neurology, physiatrics (the curing of disease through natural methods), anesthesiology, surgery and other medical disciplines.

Pain management physicians use a comprehensive approach to pain, including such things as behavioral modification and biofeedback, physical therapy and rehabilitation services to try and regain functional status. Columbia St. Mary’s also offers exercise programs to help patients maintain back function.

“It is important for a patient to find a doctor who can use many different methods of treatment, not just invasive procedures or surgeries. And patients should be educated so they can act as their own advocates. To do that, they need to know what’s out there," the doctor said.

What doctors can do
For patients with severe back pain, the first goal of a physician is to make the patient comfortable, then to diagnose the problem. “A good patient history and physical exam is imperative so that we are certain we are treating the condition that is causing the pain,” Dr. Donatello said.

Sometimes an X-ray is used, but there are also more specific tests. These include discography, in which a dye is injected into a suspected herniated (“slipped”) disk and a scan taken of the results. If the disk is leaking dye, it may need repair.

Another test involves anesthetizing the nerves near a suspected spinal problem. If the patient feels better afterwards, it indicates that that particular area of the spine is the source of the problem. In these, as in nearly every case, treatment options become clearer once the problem areas are pinpointed.

Treatments vary depending on the cause of the problem.

Cortisone injections
For lumbar, or lower back pain, treatment is most often cortisone injections into the spine. Cortisone, an anti-inflammatory, reduces nerve irritation and the symptoms of numbness, tingling and weakness. “Often the shots take care of all of the symptoms. A patient can safely have up to three in one specific area in the spine within a one year period,” Dr. Donatello said.

One of the benefits of localized injections is that patients get significant results without being exposed to the risks of oral cortisone drugs. “Up to eighty percent of patients who haven’t gotten better on their own improve following a cortisone injection. Disk irritation may get better permanently, while symptoms of stenosis may improve for nine months to two years,” Dr. Donatello said.

Nucleoplasty
For herniated disks that do not improve with cortisone injections, or which need more aggressive care, there is a minimally invasive disk surgery called nucleoplasty. Nucleoplasty involves going to the inside of the disk with a special probe that vaporizes part of the disk. When the disk becomes smaller, there is room for the bulge to be pulled back into place.

“The benefit of nucleoplasty is it is minimally invasive. A patient can be back to work within three days so long as their job is not physical. In addition, it has over an eighty percent success rate. Unfortunately only a small percentage of patients are good candidates for the procedure,” Dr. Donatello said, and added that proper diagnosis is the key to the procedure’s success.

Facet joint procedures
Facet joint procedures are often used on older patients who have developed arthritis in the facet joints (slip joints) of the spine. This condition causes back pain and pain down the front of the thighs that usually stops at the knees.

The first step is to determine the source of the problem. This is done by injecting cortisone into the tiny joints in the back or next to the nerve going to that joint. If the injection gives good temporary pain relief and the patient feels more comfortable, a back specialist will follow with a radio frequency probe that destroys the specific nerve transmitting the pain. The patient still has arthritis in that area but the body no longer senses it.

“We do this because arthritis of the spine cannot be cured, so we treat the symptom. The rest of the spine and the limbs themselves will still have normal feeling,” Dr. Donatello explained.

Success stories
In his practice as a pain management specialist, Dr. Donatello sees patients of all ages. These include the very young who cannot do athletics and after treatment are able to work out at their gym or do recreational hiking.

He also sees elderly patients. “Sometimes the elderly can’t do even normal activities like cooking. We know they are feeling better because they start bringing in cakes or cookies, when before treatment they couldn’t even wash the dishes,” Dr. Donatello said.

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