Back pain is a very common problem and it is even more common for people with scoliosis. Some people with scoliosis don’t have pain or it is not a major issue. However, for others, pain can be very severe and affect every part of their lives.
Causes of pain
There are many reasons why a person’s scoliosis causes them pain. The curve of the spine can irritate, squash, or stretch the nerves. It can also put a strain on joints, which become worn or inflamed. Joints are the places in the body where two bones meet. Scoliosis can also affect posture, which can lead to the muscles becoming tight or tired, causing pain.
Much of the pain of adult onset (de novo) scoliosis is caused by the discs becoming worn. Discs are part of the spine. They sit between the vertebrae (small bones that make up the spine) and act as a kind of cushion, stopping the vertebrae from rubbing against one another. They also work like shock absorbers for the spine.
The worn discs themselves can cause pain. Worn discs can also put strain on the facet joints (small joints between each of the vertebrae in your spine) causing pain. Muscles can be put under strain if posture becomes unbalanced, which can be painful. It is not only adults who develop scoliosis later in life that have these problems. Adults who had scoliosis as children or teenagers may also have pain caused by worn discs, especially if their scoliosis was never treated.
A lot of work has been done to understand the science of what causes pain. However, no one can ever truly know what another person is feeling. That means it can be very difficult for someone with pain to explain their suffering to family, friends, and doctors and can make people feel lonely and misunderstood.
It is not uncommon for people to say things like “the doctor didn’t believe me” or “the doctor thinks the pain is all inside my head” or even for a doctor to say “I believe you have pain”. None of this is helpful. What we experience does not depend on whether or not someone else believes us. Pain is what we feel not what causes it.
What we feel is not just what happens to our bodies. It is also how well our nervous system can block pain signals from reaching our brain. Our genes, environment, medication, and even our beliefs all affect how well our nerves work to reduce pain signals. This makes it very hard to say for certain what is causing our pain. All we can do is describe it to others as best we can.
The doctor or pain specialist may ask you a lot of questions to try to find out more about the pain you are feeling. The answers you give will help them to work out the best treatment.
Depending on the type of pain, there are treatments called complementary therapies that might help.
These include things like hydrotherapy and massage and are usually done alongside medical treatments.
Exercise that strengthens the core muscles (the back and stomach muscles) such as yoga, Pilates, and swimming can also help with back pain.
If over-the-counter paracetamol and ibuprofen don’t work, the next step is to visit your doctor. The doctor will usually prescribe pain medication or refer you to a pain clinic. Your doctor could also arrange you for to see a counsellor.
Counselling can help when the causes of pain are long term, and when medical treatments do not work well. A type of counselling called cognitive behavioural therapy (CBT) can be used to help patients manage pain. CBT is where a counsellor will talk to a patient about how they manage their pain. It can help a patient to overcome beliefs or behaviour that could be doing more damage or making the pain worse. The counsellor can also help the patient to develop techniques that can help them to deal with pain. Although CBT will not change the amount of pain the patient feels, it can help them to find ways to cope.
If the GP is not able to help then she or he may refer patients to a pain clinic. Pain clinics have teams of staff who specialise in different areas. This is because spine problems are complicated so the knowledge of a wide range of people is needed. There are a range of medical treatments for pain including:
Spinal injections are when steroids are injected into the nerves and joints to help ease pain. Injections do not have any proven long-term effect but can be useful for acute pain or as part of a formal pain management programme. Injections do seem to be helpful for some patients. However, for people with long term conditions such as scoliosis the effect of injections always wears off. Also if a patient keeps having injections they often seem to have less effect over time. It is unusual for things to go wrong, but nerve damage from injections is possible. Therefore, injections are used sparingly. They are often useful in the short to medium term but often not in the long term.
There is a special kind of injection treatment, when needles with wires inside are used to heat up the tiny nerves to the facet joints. This is called radiofrequency denervation. It can last much longer than ordinary injections, sometimes for several years. However, it usually lasts for about 6 to 9 months. It can be difficult to use on a curved spine. Therefore, it is a treatment that may only be useful for a small group of patients.
Spinal cord stimulation
There is another treatment that is now being used for some people with pain from damaged spinal nerves. It is called spinal cord stimulation. This is where electrical wires are placed along the back of the spinal cord. The wires are attached to a small stimulator box that can be buried under the skin and controlled with a hand held remote control.
There are any different types of medication that can help to relieve pain. These include opioids (morphine, oxycodone, codeine, fentanyl patches, buprenorphine patches), non-steroidal anti- inflammatories (ibuprofen, naproxen, diclofenac, celecoxib, etc), nerve pain agents gabapentin and pregabalin) and hybrid medications such as tramadol and tapentadol.
Tricyclic antidepressants such as amitriptyline can also be used as pain relief because they have a direct effect on pain as well as affecting mood. Diazepam is sometimes used alongside other medications for very bad pain. However, it can be very addictive so would not be prescribed in most pain clinics.
Even with such a wide range of pain medication, it is not easy to control chronic pain. Chronic pain behaves very differently to acute pain because it alters our nervous systems. The changes to our nervous systems means that the pain will not easily be switched off by pain killers alone. Also the body gets used to painkillers so they work less well over time. Sometimes this can also cause the patient to feel unwell if they stop taking the drug. This is known as withdrawal and can last from a few days to a few weeks.
Sometimes people can become addicted. Also, opioids can make it hard to think straight and often cause very bad constipation. Because of all these issues, pain clinics will only give low doses of opioid medication. They keep a check on how well they work. If there are side-effects or they are not helpful they will be stopped.
Some patients are given non-steroidal anti- inflammatories. There are concerns over the effect they have on the stomach and bowel and on circulation, so doses are kept low. Even paracetamol must be used with caution and no more than six tablets should be taken a day, wherever possible
Prognosis (the outcome)
Unfortunately, treatment will not entirely get rid of pain for many people. However, by working as a team with trained staff, patients can be given the means to help manage their pain so it puts less of a limit on their daily lives.