Kraus Back and Neck Institute in Houston, TX

Relief from Lower Back and Neck Pain

surgery optionsavoid surgery
      At the Kraus Back and Neck Institute (KBNI), we specialize
                 in non-surgical as well as surgical treatments
                                of Back and Neck  Pain
     Conservative to Surgical Options: MINIMALLY INVASIVE SPINE SUGERY 
 "Applying Science to the Art of Medicine"                                                  
                 Dr. Kraus is available for Neurosurgery consultation (surgical and non-surgical) in Houston.
                      Offices:  1) West Houston Medical Center
                                    2) Memorial Hermann Memorial City Hospital
                                    3) Katy
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      To arrange  an appointment, call 281-870-9292,  visit
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              For national and international patients, we can help with  travel arrangements
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                                            Dr. Kraus is honored to be listed in
                                            "Best Doctors in America" (2001-2008) and
                                             "Top Doctors of Houston, Texas" (2007, 2008, 2009)     

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Low Back Pain, can be very debilitating.  The effects of Low Back Pain in the USA are staggering!!

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Invasive Management of Low Back Pain


William O. Witt, M.D.

Professor, Anesthesiology and Neurosurgery

Chairman Emeritus, Department of Anesthesiology

Director, Pain Management Center

University of Kentucky

Lexington, KY



In discussing invasive management, it is imperative to remember that invasive management is only one modality involved in the treatment of pain.  Similarly, it is important to remember that nociception is only one component involved in the total experience of pain.  Nociception, pain, suffering, pain behavior, pain impairment, and disability must all be identified and treated.  Accordingly, treatment should also include a multi-disciplinary approach involving physical, medical, behavioral, and perhaps surgical interventions as well as invasive pain management.  Finally, it is important to remember that conservative treatment for low back pain is generally very effective, and the vast majority of patients improve on their own within four weeks of the onset of pain.  Having laid this background, it is appropriate then to discuss invasive modalities. 


Invasive modalities fall into three broad groups, those that produce partial resolution of the problem, those that are involved with neuromodulation of the problem, and neurodestructive techniques.  Partial resolution is perhaps best demonstrated by epidural steroid injection.  This may be accompanied by epidural lysis of adhesions, and may involve different routes of administration into the epidural space, including single nerve root injection.  A new technique of laser annuloplasty has recently been described as well. 


Neuromodulation involves the use of nerve blocks, intrathecal infusion, spinal cord stimulation, and peripheral nerve stimulation.  Intrathecal infusion and spinal cord stimulation are discussed in another lecture, and peripheral nerve stimulation is beyond the scope of this presentation.  Nerve blocks are known to have effects at multiple levels.  Clearly they produce direct afferent nerve blockade as well as efferent blockade.  They also exert an influence indirectly by interfering with “wind-up” of wide-dynamic-range neurons in the dorsal horn.  They also produce decreased receptor sensitivity and buffer hydrogen ions.  There is also a component of dilution of inflammatory mediators, which explains the observation that even physiologic saline can produce pain relief when injected into inflamed tissue.


Neuroablation has a limited but important role in the peripheral nervous system.  In addition, neuroablation may be utilized in the autonomic nervous system, the spinal cord, and the brain.  The latter two are beyond the scope of this lecture.  Historically, destruction of the Gasserian ganglion in 1891 was the first application of neuroablation, and remains one of the great success stories in modern pain medicine.  Prior to any neurolytic technique it is wise to inject local anesthetic first.  Whereas this will not necessarily predict the effect of neurolysis, it may well predict the extent of the neurolysis.  In performing neurolytic lesions in the peripheral nervous system it is critical to avoid techniques that produce destruction of the nerve sheath, unless dealing with a terminal disease states that is expected to be terminal within a few months.  The importance of this cannot be overstated in that the axon will always regenerate, and if the nerve sheath is destroyed, neuromas will form and result in pain that is often worse than the original pain being treated.  It is also more refractory to subsequent treatment.  Both radiofrequency heat lesioning as well as cryotherapy achieve this objective. The temperature for radiofrequency lesioning should not exceed 80° Celsius if deafferentation pain is to be avoided.  Radiofrequency destruction of a portion of the dorsal root ganglia is useful in the treatment of neuralgias in selected conditions.  The use in tic douloureux has already been described and is extraordinarily effective.  It may have an application in any radicular pain syndrome. 


One of the more common and well-accepted applications of radiofrequency lesioning is treatment of “facet syndrome”.  This was first described in 1933 and accounts for 80% of “sciatica”.  In dealing with patients afflicted by this syndrome, it is important to recognize that radiographic imaging is not useful and that the diagnosis is made by clinical examination.  This clinical examination includes aggravation with extension, rotation, and side-bending and a typical sclerotomal pattern of radiation.  Prior to radiofrequency lesioning, local anesthetic should be administered in the form of medial branch blocks, and this should produce a dramatic reduction of pain with active range of motion.  It is critical to restrict the amount of volume of local anesthetic used for these blocks to no more than 1 milliliter in the lumbar spine and no more than ˝ milliliter in the cervical spine, if reasonable specificity is to be obtained.  The success of medial branch lesioning is critically dependent upon precise needle placement.  It is also important to remember that each zygapophyseal joint has multiple sources on innervation, and that accordingly, pain relief can be expected only with multiple sites of lesioning.  Medial branch lesioning also plays a role in the management of thoracic degenerative joint disease, although this is much less common.


Published results of successful treatment of chronic pain with radiofrequency medial branch lesioning range from 30% to more than 90%.  This extreme variability is probably accounted for by variability of patient selection and of technique. 


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