Non-operative Treatments


Medications play an efficient role in the treatment of back or neck pain. Your doctor may prescribe several medications to help reduce pain and associated symptoms that are caused by unhealthy spinal conditions or deformities.

When healthcare professionals prescribe a medication regimen, the precise needs of the patient including severity and period of pain and medical history of the individual are considered in the treatment of chronic low back pain. The main aim of prescribing medications is to reduce the pain and increase the comfort level of the patient and reduce the danger of misuse or abuse of the medications.

Pain Relief Medication

Mr Mistry may have prescribed you one or more of the following medications.Please read the patient information leaflet provided from the pharmacist for further information.

Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences them. These usually improve as your body adjusts to the new medicine, but speak with your GP or pharmacist if side-effects continue or become troublesome.

Always let your doctor know your medical history and what medications you are taking before being prescribed a new medication. Inform your doctor if you might be pregnant, or if you have any allergies to medication.

Paracetamol1g (2 tablets)Regularly every 4 hours, with a maximum of 8 tablets in 24hours. Breakfast, lunch, dinner, bedtime.

Codeine30mgup toevery 4 hours as required. Constipation is common.

Paracetamol plus Codeine (ParaCode, Panadeine, etc) Do not take at the same time as regular Paracetamol or Codeine.


May be used on an “as required” basis, or regularly for background pain relief. DiclofenacSR (Slow Release) 75mg every 12 hours, maximum twice per day Or Ibuprofen 400mg every 8 hours, maximum 3 times per day Take with food. They can irritate the stomach, so Mr Mistry may have also prescribed Omeprazole 40mg once per day to protect the stomach lining. Anti-inflammatories should be avoided if you have kidney disease; or ever had gastrointestinalbleeding or ulcers. They can worsen asthma in some people.

Tramado l50-100mg every 6 hours as required, up to four times daily Should be avoided if you have a seizure disorder. Caution if taking certain antidepressants. Common side effects include nausea, dizziness, drowsiness, constipation, or dry mouth.

Norflex 100mg twice daily as required to relieve muscle spasm. Should be avoided if you have glaucoma (high pressure in the eye); enlarged prostate, bladder obstruction, or intestinal obstruction. The most common side effect is a dry mouth. Tell your doctor if you notice a change in your vision, or difficulty passing urine while on this medication.

Gabapentin (Neurontin, Nupentin) Start at 300mg twice daily, with the first dose at bed time. Helps pain caused by irritated nerves. The most common side effects are sleepiness, dizziness, dry mouth, clumsiness or unsteadiness, and nausea.If after a week your pain relief has not improved, and you do not have significant side effects, visit your GP to discuss increasing your dose.

Amitriptyline 10mg or Nortriptyline 10mg at bed time

Helps the burning, shooting or stabbing pain caused by irritated nerves. These drugs work best if taken regularly and not so well on an ‘as required’ basis. This is because they gradually alter chemicalsin the spine and brain that are involved in registering pain messages. It can take 2 or more weeks to get the full benefit of the pain relief.

Dry mouth, constipation and sleepiness are common side effects. These usually reduce over the first few days of treatment. If sleepiness is problematic, reduce your dose to 5mg (half a tablet). You can then increase the dose back up to 10mg after a week if the sleepiness has improved.

If, after 3-4 weeks, you feel that your pain relief has not improved, and if you are not experiencing significant side effects due to this medication, you can increase the dose to 20mg at night for amitriptylline, or 25mg for nortriptylline.

Side-effects What can I do if I experience this?
Dry mouth Try chewing sugar-free gum or sweets. Saliva substitutes are available from the pharmacist.
Constipation Try to eat a well-balanced diet containing plenty offibre, and drink plenty of water. Try kiwifruit, pineapple, papaya, or “Kiwicrush” (in the frozen food section of the supermarket). Try fibre supplements such as “Benefiber” or “Metamucil”
Feeling of a fast or irregular heartbeat Speak with your GP
Feeling dizzy, faint or light-headed when getting up Getting up more slowly may help. If you begin to feel faint, sit down until the feeling passes
Feeling sleepy, blurred vision, Clumsy, unsteady If this happens, do not drive or use dangerous machines. Do not drink alcohol
Nausea Eat simple foods. Eat smaller meals but more often

Alcohol should be avoided with tramadol, amitriptyline, nortriptyline, norflex, codeine, and gabapentin. Use with caution with anti-inflammatories and paracetamol.

Do not double doses of medication, even if you missed the previous dose.

Opioid pain medications:

Because of possible toxicity to the body, physical dependence, and the loss of efficacy due to developmental tolerance and psychological dependence or addiction, opioid medical care or narcotic administration is widely rejected in the treatment of chronic back pain.

Opioids are typically prescribed for patients with chronic nonmalignant pain, including low back pain that experience high levels of comfort while not developing toxicity to the body or having any indication of psychological dependence or addiction. Opioid therapy should be considered as the last treatment option in cases of unrelieved pain despite alternative medications (such as use of non-opioid drugs). Patients should be informed regarding the side effects of opioids and suggested to follow-up with their doctor regularly. Monthly appointments should be scheduled to assess the dose of the drug until the patient experiences partial or complete relief of pain.

Corticosteroids: Corticosteroids are used to reduce swelling caused due to inflammation. When used to control pain, corticosteroids can be prescribed in the form of pills or injections.

Muscle relaxers: Muscle relaxers are drugs that are commonly used to treat acute muscle problems. Sometimes, they can help treat painful muscle spasms. These medications help in reducing muscle tone and tension in skeletal muscles. Some muscle relaxers have direct effect on the skeletal muscle fibers, while others work at the level of the spinal cord.

Nutrition and Your Spine

Nutrients are the chemical components present in food which provide energy for carrying normal physiological functions and also aid in metabolic processes of the body.

Nutrition refers to the entire cycle of chemical changes occurring within the body depending on what we eat or don’t eat. Nutrition determines the strength of the teeth, bones, and the connective tissues. A healthy diet during childhood paves the way for a healthy adulthood. A well balanced diet is essential for the repair and maintenance of bones, cartilage, ligament, tendons, and muscles. Vitamin B, C, D, K, and minerals such as calcium, magnesium, copper, zinc, boron and manganese are essential for healthy bones and connective tissues.

Nutrition plays a vital role in maintaining a healthy spine. Good nutrition helps in managing pain and disability in the patient suffering from different types of spinal disorders. Damage to the spine can occur due to daily wear and tear or due to injuries from work, sports or accidents. Poor nutrition and inadequate hydration can increase the incidence of such injuries.

A major part of the connective tissue involved in joining and holding the joints together is made up of protein and water. Degenerative disc diseases (DJD) can damage the connective tissues as well.

Adequate dietary protein, along with vitamins A, B6, C, E and minerals such as zinc and copper are essential for maintaining strong and healthy connective tissue.

Minerals such as calcium, phosphorus, magnesium, and boron are essential for healthy bones. Healthy nutrition is required for repair and maintenance of bones. Lack of nutrition can lead to bone disease such as osteoporosis.

Calcium helps in improving bone density. Other factors such as vitamin D, collagen, magnesium, and L-lysine are also essential for maintaining healthy bones. Calcium metabolism can be hampered due to various conditions, some of which include:

  • Chronic mental or emotional stress causes inflammation of the digestive tract
  • Inadequate acidity of the digestive tract hampers calcium absorption
  • Deficiency of certain nutrients such as vitamin D and L-lysine
  • Excessive urinary excretion of calcium due to intake of caffeine-containing drinks such as coffee and colas

Inflammation results in the loss of the normal cellular framework that keeps bone and connective tissues together. The inflammatory conditions such as osteoarthritis can damage the joints. Inflammation also results in pain which arises due to some chemical changes in the surrounding tissues.

Abdominal obesity can induce strain on the muscles and ligaments supporting the spine causing back pain.

A good circulatory system is essential for the repair of surgical incisions, injured bone, or connective tissue such as cartilage and ligaments. The blood vessels carry all the nutrients to the bone and connective tissues. A diet rich in fat and low in protein and fiber can constrict blood vessels reducing blood flow to the injured areas needing repair. Herbs, fruits, and vegetables are rich in anti-inflammatory and antioxidant components like flavonoids which can strengthen the healing process.

Various nutritional supplements are also available which may be recommended based on the specific musculoskeletal condition of the patient. Along with good nutrition, regular exercise is also important for a healthy spine.

Sacroiliac Joint Injections

Sacroiliac joints (SI joint) are joints in the lower back region, located where the sacrum and ilium bones conjoin. Despite of the fact that these joints are small and have limited motion, they have an important role of connecting your spine to the pelvic bone and thus the lower part of your body. They perform important functions by absorbing the injurious shock forces of the upper portion of the body. Any inflammation or irritation in SI joints may cause pain in the lower back, abdomen, groin, buttocks or legs.

Sacroiliac joint injections can be used both for diagnostic as well as therapeutic purposes. As a diagnostic tool, it helps your doctor locate the origin of pain. To diagnose SI joint pain, an anesthetic injection is given to the joint under X-ray guidance. An acute relief in low back pain following the injection indicates an abnormality in SI joint. For therapeutic uses, SI joint injections will contain a steroid medication along with an anesthetic agent in order to provide relief from pain for a longer duration. When steroid medication is injected into the painful & inflamed joint, the inflammation reduces and thus relieves the pain.

You will have an intravenous catheter placed in your arm before the procedure begins. The catheter is to provide medications if necessary during the procedure. You will be lying on your stomach and the area where the needle is to be inserted near the SI joint is numbed with a local anesthetic injection. Then your doctor will advance the needle under the fluoroscopic guidance. Once the needle is in the right position the medication is injected.

Complications are very rare, but do occur sometimes. Possible complications after SI joint injections include allergic reaction, infection, and increased pain.

Facet Injection

The facet joints are the tiny joints situated at the upper and lower part of each vertebra connecting one vertebra to the other. Each of the vertebrae has four facet joints which include a pair that connect to the vertebra above (superior facets) and another pair that connects to the vertebra below (inferior facets). They guide motion and also provide stability. Pain may arise in these joints as a result of an injury to the back, spinal arthritis, or because of increased stress on the backbone. A minimally invasive treatment called facet injection offers symptomatic relief of the back pain caused by inflammation of the facet joints but is not a permanent solution for the condition.

The facet injection procedure may be performed primarily as a diagnostic test to check whether the pain is actually originating from the facet joints. Secondly, it is used to treat inflammation caused by several spine conditions. A facet injection contains a long-acting corticosteroid and an anesthetic agent which is given either directly into the painful facet joint capsule or into the tissues near the joint capsule. The objective of the treatment is to suppress the pain so that normal activities can be resumed and patients can perform physical therapy exercises.

Facet injection is indicated in conditions where all other conservative treatment modalities such anti-inflammatory medications, rest, back braces and physical therapy have become unsuccessful. Facet injection may reduce inflammation in the facet joints caused by conditions such as spinal stenosis, spondylolysis, sciatica, herniated disc, and arthritis. This treatment is not appropriate for patients with an infection, bleeding disorder or during pregnancy. Patients on aspirin or blood thinners will be advised to stop taking them several days prior to the procedure.

Facet injection is performed as an outpatient procedure where you can return home on the same day but make sure you have someone along to drive you home. Usually the procedure lasts for around 15-30 minutes followed by a short recovery period.

You will be lying face down on a table and be conscious throughout the procedure. Sedatives may be given to make you comfortable and a local anesthetic is administered to numb the area of injection. Then, your doctor will insert a hollow needle through the skin and muscles into the sensory nerves situated at the facet joints under the guidance of a fluoroscope. Once the position of the needle is confirmed, the medication is injected into your facet joint capsule following which the needle is withdrawn.

Facet injections are considered as the most appropriate nonsurgical means of treatment with minimal risks. The possible risks and complications associated with needle insertion may include bleeding, infection, allergic reaction or rarely damage to the nerves. Some of the adverse effects of the corticosteroid medication include weight gain, water retention, flushing and mood swings which usually resolve in 3 days.

Transforaminal or Epidural Spinal Injections

Transforaminal and Epidural spinal injectionsare a non-surgical treatment option utilized for relieving back pain. Spine degenerative conditions such as herniated disc, spinal stenosis and many others may induce back pain due to the compression of the associated spinal nerves. This pain or numbness may extend to the other parts of the body such as hips, buttocks, and legs. Doctors start with non-surgical methods to treat back pain and spinal injection is one of these preferences. In cases where the patient finds no relief from non-surgical methods then finally surgery is recommended.

Spinal injections contain a strong anti-inflammatory agent called corticosteroid (also known as cortisone) and a local anesthetic. The local anaesthetic agent usually works immediately and lasts for between 6 to 24 hours. It’s main purpose is to confirm the site of the pathology to your doctors. The corticosteroid can take between a few days to a few weeks before becoming effective, and it works by dampening the inflammation associated with the pathology in your spine.

Transforaminal injections are administered around the spinal nerves, just as they are exiting from the main spinal canal, through gaps in the vertebral bones called foramina.

Epidural injections are administered into the epidural space of the spine. The epidural space is the space between the outermost covering of the spinal cord (dura mater) and the wall of the spinal canal. It is approximately 5mm wide and is filled with spinal nerve roots, fat and small blood vessels.


Spinal injection may be employed both for diagnostic and therapeutic reasons, including:

Medications to determine the specific nerve root involved in the spinal problem (diagnostic purpose)

Medication for inducing short or long-term relief from pain and inflammation (therapeutic purpose)

It is to be noted that spinal injection is not a curative intervention rather it’s a treatment tool to reduce the discomfort of the patient so that rehabilitation programs such as physical therapy may be well executed.


Pain management in different conditions such as spinal stenosis, disc herniation and arthritis can be achieved through spinal injections

Usually spinal injection is done on an outpatient basis. The procedure involves the following steps:

Patient is taken to the pre op area where trained nursing staff makes prepares the patient for the procedure by taking vitals and reviewing medications. Blood sugar and coagulation status may also be checked if needed.

Patient is taken to the procedure room and will lie face down on a table.

The injection site is then cleansed and injection of a local numbing agent is given in the area so that you don’t feel pain during the procedure.

A thin hollow needle is then inserted into the appropriate part of your spine, guided by fluoroscopic X-ray to place the needle in the correct position. This system gives real time X-ray images of the position of the needle in the spine on a monitor for the doctor to view.

A contrast material is then injected through the properly placed hollow needle to confirm that the drug flows to the affected nerve when injected.

When the doctor is satisfied with the position of the needle, the anesthetic drug and corticosteroid are injected through the same needle inserted in the spine.

Finally, the needle is removed and the injection site is covered with a dry, sterile bandage.

Patients may feel some pressure during the injection but mostly the procedure is painless. The procedure takes about 15-30 minutes to complete. After injection, the patient should not drive or go back to work and should rest and avoid any vigorous activities for 24 hours. Your surgeon may give specific post-care instructions. Please follow the instructions to recover faster.

Recovery time

Patients may feel numbness in the arms or legs just after procedure along with other side effects related to the anesthetic component that usually settles down within 1-8 hours. Patients may continue to feel some back pain, as epidural spinal injections takes about 24-72 hours before showing its pain-relieving action. In some cases, if the desired effect is not obtained then reinjection may be recommended.

Risks and complications

With any procedure some risks factors will always be there. Likewise, epidural spinal injections have complications such as bleeding or infection at the injection site, pain during or after injection, post-injection headache, nerve injury, bladder dysfunction, fluid retention, respiratory arrest, epidural hematoma, and spinal cord infarction. Discuss with your doctor if you have any concerns prior to the procedure.