AMSTERDAM — St. Mary’s Healthcare has added a new tool for treating chronic back pain, and the hope is that it will help patients who can’t gain relief through other means.
The spinal intracept is somewhere in the middle of the range of options, a minimally invasive procedure between physical therapy at the mild end and surgical removal of a disc or fusion of vertebrae among the strong end.
The problem is that not every patient will respond to physical therapy or surgery, said Dr. Joseph Popper, the orthopedic surgeon who performed the first spinal intracept at St. Mary’s on Aug. 3.
“This is a very defined subset of people,” he said, with a type of spinal degeneration called modic changes. For them, intracept offers a chance at pain reduction or elimination.
The procedure involves threading two slender needles through the skin into a channel in the bony protrusion of the affected vertebra.
The tips of the needles heat up for 15 minutes, creating two 6 mm scars on the nerve path where the pain is originating.
Scar tissue doesn’t conduct electricity, and nerve impulses are electricity. So if the procedure is successful, the nerve impulse can’t travel from the lower back to the brain, and the brain doesn’t realize there is pain from that spot.
Nerve impulses to and from other parts of the body continue normally along other pathways.
“About a third of people should get 100% relief from pain,” Popper said. “That tends to be the younger person, 30s to 40s, even 50s, that has a pretty normal looking spine but they have one bad disc.”
He continued: “10% see no benefit — it’s hard to know why. Obviously that wasn’t the pain generator.”
The rest, Popper said, will see partial relief, a 25% to 75% reduction in pain.
There’s a bit of a gray area on who falls into what category and why.
“Pain in general is very complex,” Popper said. “A host of psycho-social factors plays into it, and that doesn’t get examined. We can only go off the MRI and see who’s going to be a good candidate for this.”
Many Americans suffer lower back pain, but most will see relief within four weeks of onset, and don’t need treatment.
It’s the chronic sufferers — six months of pain or more — who need the most help, Popper said. Their ranks are estimated at 30 million.
Conservative treatment options such as over-the-counter painkillers, physical therapy, recommendation for weight loss, and core-strengthening exercises are the first choice, and work for a quarter to a third of patients.
For those still hurting, there are stronger options such as pain injections, epidurals or muscle relaxants.
Popper has begun using a procedure in which stem cells extracted from the patient’s bone marrow are injected back into the problem discs in the patient’s spine, but he doesn’t have a read on its effectiveness.
For the worst cases, surgery is an option.
“I do the full spectrum of spine surgery,” Popper said, “laminectomy, decompression, spinal fusion.”
Spinal fusion has mixed results with modic changes, in which the end plate of the vertebra starts to degrade and the adjoining disc starts leaking.
One particular receptor in the end plate, the basivertebral nerve, is the path of pain with this condition. So if it can be shut down with the intracept, the patient may notice pain reduction within a few weeks. And because it’s an unsheathed nerve, it won’t regenerate and start transmitting pain signals again.
Something else may start causing pain elsewhere in the back some day, but the successfully ablated basivertebral nerve is blocked for good.
This creates a potential secondary problem: Without pain as a warning signal, the patient might think it’s OK to resume the high-impact activities that may have caused the problem in the first place.
“Obviously, no one knows why there’s a nerve in there but presumably” there’s a reason, Popper said. “By taking it away, you’re losing some of that feedback.”
A 44-year-old man who had back pain for two years was Popper’s most recent intracept patient. It provided relief.
“That doesn’t let him go crazy and lift everything,” he said. “He’s very careful how he does things.”
There’s no certain trigger of low back pain, he said. Overexertion, traumatic impact or family history might all contribute, as might stress factors in one’s personal life. His patients run the gamut.
“I have had some that are powerlifters, I’ve had others that are physical laborers, warehouse workers, but there are a lot of people that just have sedentary jobs that have pain,” Popper said.