Back disorders (e.g. chronic neck pain, chronic low back pain, sciatica, etc) are the leading cause of a reduced quality of life in New Zealand. It is estimated that about 10% of New Zealanders have chronic back pain. Fortunately chronic back pain is rarely sinister in nature and there is no association between the severity of the pain and "damage" to the spine. Most people living with back conditions don't seek medical input. However some may see their GP or allied health providers. A minority may be referred to various specialties including Musculoskeletal Medicine, Orthopaedics, Rheumatology, Occupational Medicine, and Pain Medicine. Research on diagnostic techniques over the past 20-30 years has meant that the source of the pain can often be diagnosed (or at least a probability for a pain source can be given) but unfortunately for most people there is no proven medical "cure" that the diagnosis leads to. However often there are things that can make life more manageable. It is usually something that is "managed" like diabetes, rather than something that is "cured" like a skin infection. In some rarer cases the problem isn't the back itself but rather a problem with the way that the nervous and immune systems function.

Sciatica is a term that generally refers to nerve pain in your leg caused by a problem in your lower back. The medical term for sciatica is ‘radicular leg pain’ because of the way the pain radiates from your back and hip into your legs through the spine. Sciatica pain is usually felt within a 2cm wide line that runs down the back of your leg. Different areas of the leg are affected depending on which spinal nerve is irritated. The most common pattern is pain down your buttocks and the back of your leg, and down to your foot. The pain in your leg is normally worse than the pain in your back. There may be no back pain at all. In the acute stage scans are not normally required for diagnosis. This is because most people will get better on their own, and so the scan does not change the treatment and is therefore not needed. In the uncommon situation where a scan is needed, the best scan is an MRI scan. There are a variety of treatments to consider for sciatica including using time as a treatment, pain killers, gentle stretches and exercise, heat and cold, activity modification, epidural steroid injections, and surgery. At this clinic we can offer epidural steroid injections if required. Around 70% of patients achieve relief with around 50% relief at the two month mark. The best method for injection is done under x-ray (fluoroscopy) guidance which we do at SRG radiology.

Osteoarthritis occurs when there is a breakdown of the cartilage, leaving less protection for the bones. It is very common and usually affects people as they get older. You can get it at any age and are more likely to if you have previously injured a joint, or are overweight. The symptoms can be very mild with just occasional pain with activity. Worsening symptoms include pain with activity and stiffness with rest. Joints can become swollen and restricted in movement. Joints can change shape as the bone changes in response to loss of protection. You otherwise feel well. The diagnosis is made on the basis of the history, examination findings and sometimes x-rays. The severity of joint damage seen on x-ray does not always correlate with the degree of pain you experience. Treatment includes exercise, weight reduction if needed, pain relief and sometimes surgery. For most but not all types of osteoarthritis injections are not suitable. For more information see www.arthritis.org.nz

Tendons are the structures that connect muscle to bone to allow movement. Tendinopathy is a tendon disorder where there is a problem with the structure of the tendon leading to a reduction in its ability to take on load. This can occur from a sudden injury, repetitive stress, or be due to the ageing process. It can lead to pain and difficulty in using that part of the body. Some common forms of tendinopathy are gluteal tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy (also called tennis elbow), patellar tendinopathy (also called jumpers knee). The older term for tendinopathy was tendinitis.

Most headaches are not due to significant underlying problems but you may be referred if your GP is worried about the nature of your headaches or you are having difficulty controlling them with standard treatment. Migraine headaches are repeated or recurrent headaches, often accompanied by other symptoms. They can be triggered by certain factors/events/foods. In some people, a visual disturbance called an aura may happen before the headache starts. Nausea, vomiting, profound fatigue, light sensitivity, and sound sensitivity may be additional symptoms that can occur during the headache. For more information about migraines and headache visit www.migraine.co.nz Cervicogenic headaches are headaches that are referred to the head from the upper cervical spine (upper neck). This can be due to an injury to the neck such as whiplash, repetitive injury, or through the ageing process. The symptoms can be similar to migraine. It can be difficult to diagnose without specialised diagnostic techniques. Treatment options for cervicogenic headache are watchful waiting, manual therapy, exercises, stretching, and specialised interventional techniques.

There are many types of nerve compression syndromes that can cause chronic pain. Some patients may respond to an injection of steroid or dextrose around the compressed nerve and/or the injection of a large amount of fluid to "stretch out" the space around the nerve called hydrodissection. The most common form of nerve compression is Carpal Tunnel Syndrome. This is caused when the median nerve in the wrist is compressed causing tingling, numbness and pain in your hand, and especially night pain. Another common syndrome is meralgia paraesthetica which is when a nerve to the outer thigh is compressed in the groin.

Management of musculoskeletal pain problems may require reassurance, time, manual therapy, medication, injections, referral to allied health professionals including physiotherapists, osteopaths, chiropractors, psychologists, psychiatrists, occupational therapists and physicians, ACC programmes etc.

Any joint in the limbs may be a source of pain, and an intra-articular injection may be a treatment option. Often these can be done as an office procedure using landmark or ultrasound guidance, but certain cases may require x-ray guidance.

Spinal facet, sacroiliac joint, and coccyx injections can be done for some kinds of low back and buttock pain. These injections are typically done precisely under x-ray (fluoroscopy) guidance.

Patients with sciatica (leg pain) after a prolapsed disc with abutment or compression of a nerve root may get significant relief from a steroid injection into the site of the problem. These injections are given under ultrasound or x-ray guidance to improve safety. It is usually only done after the patient has had an MRI to confirm the diagnosis and level of the problem.

A variety of substances are injected around certain nerves in order to improve pain coming from irritation of the target nerve or to aid in the diagnosis of certain chronic pain problems. The following nerve injections are available diagnostic cervical and lumbar medial branch blocks for the diagnosis of chronic pain in those regions (under fluoroscopy) injections under the flexor retinaculum at the wrist for carpal tunnel syndrome injections around the suprascapular nerve for varieties of shoulder and periscapular pain ilio-inguinal, ilio-hypogastric, and genitofemoral nerve blocks intercostal nerve blocks lateral femoral cutaneous nerve blocks

Platelet rich plasma (PRP) treatment involves taking your blood, concentrating the platelets using a centrifuge, and then re-injecting the concentrated platelets from the blood into areas of chronic pain using ultrasound guidance. Platelets contain growth and healing factors and are an important part of the healing process. The most evidence is for mild to moderate knee osteoarthritis however it is not completely proven. There is mixed evidence for osteoarthritis in other areas and for tendinopathies. Due to the mixed evidence it is not covered by the major health insurance providers such as ACC and Southern Cross. An assessment is required before this can be offered.

Prolotherapy is an injection technique where an irritant solution (usually dextrose i.e. a type of sugar) is injected to the area of pain or tissue weakness under landmark or ultrasound guidance. The goal is the stimulation of beneficial inflammation to promote the production of new connective tissue. It is an option for some forms of joint instability, ligament pain, and some other settings. The evidence for prolotherapy is mixed. Prolotherapy is not funded by ACC and generally not funded by other insurance companies.

Injections for tendon problems are only generally offered when there is significant inflammation such as in de Quervain's tenosynovitis. For most other tendon problems the best treatments are time and a good tendon loading programme. Injections may otherwise be offered in cases of very severe pain and the options include corticosteroid, dextrose prolotherapy, platelet rich plasma, and autologous blood.

Radiofrequency neurotomy can be done for some people with neck or low back pain that is proven to come from the facet joints. This involves heating the nerve supply to the affected joints to block the pain signals. The nerves eventually grow back (the duration varies depending on the joint) and the procedure can be repeated if needed. Facet joint pain must first be proven and this is not a straightforward process. One must first have injections of local anaesthetic to test if the pain goes away, called diagnostic injections. These injections must be done to the nerve supply of the joint or joints. It also needs to be done on two separate occasions to prove that its definitely coming from there. This process is funded by most private insurers. It is also sometimes funded by ACC if there is definite proof of injury with no other non-injury cause such as significant osteoarthritis. The most common injury scenario is chronic neck pain following a significant whiplash event. It is not done for the thoracic spine.