The Use of Analgesia and Steroids in Cases of Back Pain
Back pain is notoriously difficult to diagnose exactly, and so is often referred to as nonspecific back pain, unless there are quite obvious findings such as a slipped disc, which can be viewed on a scan as at ‘Slipped Disk’, emedicinehealth or neurological symptoms as discussed by Spinasanta in 2001. Possible causes are listed in the NICE Guidelines ‘Low back pain, early management of persistent non-specific low back pain;.(Box 1)A major cause of work absences and disability, it is therefore often treated, in the first instance at least, by using both steroids and analgesia, the latter to control pain and the former to decrease any inflammation. Common treatments include such things as the application of heat, the use of acupuncture and massage as well as teaching on stress control.
In November 2007 Trang et al claimed that some 90% of patients with low back pain can return to work after a relatively short period with minimal medical and no surgical intervention. The researchers discuss the large number of diagnostic and supposedly therapeutic interventions, which may be of questionable value if the back problem is actually connected to such things as depression, lack of job satisfaction or a workers compensation case.
On the other hand Zloczover is quite specific in his article of 2010 ‘Epidural Steroid Injections and Low Back Pain’ and describes how, in cases of low back pain, this can be caused by pressure at the intervertebral foramen, where major nerves exit from the spinal column. Such pressure can also result in the leg pain known as sciatica, but epidural steroids have proved to be a very effective course of action. The injections are said to be most effective if given early on in a condition, and in some cases only one such injection is required. There are problems with such a course of action of course in that it requires expert medical care, often a series of injections are required, and of course such specialized treatment is expensive. The doctor does point out however, that when used alongside other treatments, such as the use of analgesics and physiotherapy, good results can be obtained and can mean that surgical intervention is not required. No statistical data is given in this report.
Steroids can be used to treat many different conditions. They are closely allied to the body’s own anti-inflammatory substances. Cortisone for instance is produced by the adrenal glands. Oestrogen and testosterone are also considered to be steroids and anti-inflammatory in their action as described by Duckles and Krause (2006).paragraph 4
When steroids are released into the body the liver is stimulated to provide carbohydrates as fuel for the muscles as when prednisone is converted to the active prednisolone as described by Tanner and Powell (1979) page 1110. There is also some rise in blood glucose levels and fatty acids are released into the blood stream. All this is part of the complex ‘fight or flight’reaction that is one way in which humanity protects itself.
The body’s inflammatory response to injury can itself cause problems as it can bring about swelling and resultant stiffnss and pressure and so doctors commonly prescribe steroids to moderate such inflammation.
When steroids are missused however these powerful agents can have devastating effects on the body according to Dane Fletcher in an article from January 2010. He describes results which might include liver tumours, mood swings, infertility and baldness. Also the normal secretions from the adrenal glands may have decreased. It is for these reasons that it is necessary that the amount of steroids used are carefully controlled by physicians, and patients are made aware of how important it is to take medication as prescribed and carry with them a steroid card which sets out dosages used. This is both so tha tthey have a written record of the amount to be taken , but so if they are treated by another physician for any reson he will be aware of the steroids taken and required. I t is equally important that dosages be tapered off slowly, thus allowing the body to take control of steroid levels for itself over an extended period.
Aspirin is one of several non-steroidal anti –inflammatory drugs ( NSAID) available and as such it is an anagesic that may be used in cases of back pain. Apirin works because it reduces the amount of cyclooxygenase. This then brings about a decrease in prostaglandin synthesis and so the nerves become less sensitive, therefore the amount of pain experienced is reduced. There are numerous other analgesics of varying efficacy and strength that could be used including opioids as decribed by Malanga (2009)
On occasions powerful opiods are the drugs of choice .Avitzur,however, in an article of May 2009 states ‘Be wary of narcotics to treat back pain.’.In a survey of those with low back pain she has discovered that more than half were prescribed opiates , although there is little research to back up such prescribing patterns. According to an editorial of February 2010 ( ChiroAccess) many practiitoners ignore guidleines on the subject.Those taking such powerful medications can suffer from a number of side effects such as vomiting, drowsiness, severe constipation and respiratory depression. This has has obvious implications for treatment choice. Those prescribing such medications need to be sure they are really necessary, as perhaps in the case of spinal cancer, or consider whether other remedies would suffice.
Usually anti-inflammatory drugs are given in combination – steroids plus analgesics, and perhap also physical therapy in the form of heat and exercises such as Souchard’s global postural re-education, as described by Laino ( 2005) in which a series of precise movements are used in order to realign the spinal column joints and at the same time restore strength to and stretch the muscles.It must be remembered that relief of pain is not in itself a cure , but until the injury is cured and while inflammation persists then analgesics and all the rest will help.
In some cases of low back pain there are obvious causes and it is in these patients that usually longer term treatment is required, on occasions requiring surgical treatment. Much pain is caused by the inflammation that follows injury, so it follows that any possible medical intervention should begin early before the inflammation has got to too great a degree. If steroids are used as an anti-inflammatory measure then great care must be taken by staff to ensure that patients fully understand the importance of taking the medication exactly as prescribed, including the important tailing off period, even if their symptoms have subsided. It may be that personal and social factors need to be addressed if the person is not to develop long term problems involving much time off work, they may for instance dislike their work or have mental health problems such as depression which require attending to. Such things as knowing the correct way to lift for example may be important or perhaps how to warm up before exercise. It is therefore important tha tall health service personel see person is seen as a whole , including knowledge about his work or exercise habits, rather as just another bad back.
References
Avitzer,O., May 2009, Be wary of narcotics to treat back pain, Consumer Reports, Health Org, available from http://www.consumerreports.org/health/prescription-drugs/be-wary-of-narcotics-to-treat-back-pain/overview/be-wary-of-narcotics-to-treat-back-pain.htm accessed 8th February 2010)
Duckles,S. and Krause,D. Cerebrovascular Effects of Oestrogen: Multiplicity of Action, Clinical and Experimental Pharmacology and Physiology, Volume 34, issue 8,pages 801-808, available from http://www3.interscience.wiley.com/journal/117964496/abstract?CRETRY=1&SRETRY=0 accessed 3rd Matrch 2010
Fletcher,D.,2010, An In-depth Look At The Usage And Misuse Of Anabolic Steroids, EZine Seeker.com, available from http://health.ezineseeker.com/an-in-depth-look-at-the-usage-and-misuse-of-anabolic-steroids-144e0cadc4.html, accessed 8th February 2010
Laino,C., Innovative physical therapy relieves back pain, WebMed 14th April 2005, available from http://www.webmd.com/back-pain/news/20050414/innovative-physical-therapy-relieves-back-pain accessed 3rd March 2010
Low back pain, early management of persistent non-specific low back pain; Nice Guidelines, May 2009m available from http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf accessed 3rd March 2010
Malanga,G., Medications to optimize outcome in low back pain, Spine Universe, available from http://www.spineuniverse.com/conditions/back-pain/low-back-pain/medications-optimize-outcome-low-back-pain accessed 3rd March 2010
Many physicians ignore low back pain guidelines, ChiroAccess, Editorial 10th February 2010, available from http://www.chiroaccess.com/Articles/Medical-Physicians-Ignore-Low-Back-Pain-Guidelines.aspx?id=0000130 accessed 3rd February 2010
Slipped Disc, emedicinehealth, available from http://www.emedicinehealth.com/slipped_disk/article_em.htm accessed 3rd march 2010
Spinasanta,S. Neurology Basics: Neurological Examinations, available from http://www.spineuniverse.com/exams-tests/neurology-basics-neurological-exams accessed 3rd March 2010
Tanner,A. and Powell,L. Corticosteroids in liver disease: possible mechanisms of action, pharmacology and rational use, available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1412835/pdf/gut00457-0089.pdf accessed 3rd March 2010)
Trang,H.,Nguyen,T. and Randolph,D. November 2007,
Nonspecific low back pain and return to work, American Family Physician, 76:1497–1502, 1504., available from http://www.aafp.org/afp/2007/1115/p1497.html , accessed 8th February 2010
Zloczover,G., Epidural Steroid Injections and Low Back Pain, Spine Universe, available from http://www.spineuniverse.com/treatments/pain-management/epidural-steroid-injections-low-back-pain accessed 8th February 2010