People tend to view pain management as a last-resort option after surgery. This is a mistake, especially when it concerns back pain. 

We tell the primary care physicians and specialists we work with that we’d really like them to refer patients to us as soon as they say the words “back pain” because in many cases, surgery can be delayed for years or avoided altogether.

Types of back problems

There are three types of common back pain that we see: spinal stenosis, disc herniation, and spondylolisthesis.

Spinal stenosis is the narrowing of the spinal canal, which puts pressure on the spinal cord and causes pain. It can be caused by a variety of factors, including age, arthritis, and trauma. Spinal stenosis is often degenerative.

Disc herniation is a problem with the rubbery disc between vertebrae. Think of a jelly donut – normally, you can’t see the jelly inside but if you squeeze it, the jelly starts to seep out at the edge. That’s kind of what happens with a disc herniation – the rubbery disc starts to seep out between the bones.

Spondylolisthesis means that a vertebra has slipped out of place. Some people experience no pain from this condition but in others, the pain is severe. 

Three questions

All three of these conditions can be treated with surgery but in many cases, surgery is not always the best option. A physician has usually explained one of those diagnoses before a client comes to see me so for pain management, the terminology is less complicated. I want to know first “does it hurt more when you’re sitting or when you’re walking?”

Spinal stenosis hurts more when you’re walking while disc herniation hurts more when you’re sitting. Spondylolisthesis may not hurt at all or it may hurt under either or both conditions. 

The second question I ask is “do you have back and leg pain or back pain alone?” Back pain alone is a mechanical problem that surgery is unlikely to help. Pain in the back and legs together is usually caused by one of these three main conditions and could be treated with surgery if other options don’t work.

And the third question is “do you have weakness in your leg?” That doesn’t just mean getting tired or achy when you walk. If you are physically unable to lift one of your legs, you need to consult a surgeon – pain management isn’t going to fix it.

Treatment options

Of course, for most people, a surgical consult doesn’t mean they have to have surgery. It just means that a surgeon assesses the situation and offers an opinion on whether surgery is a good option. About 50% of the patients we see have already had surgery and either they are still in pain or the pain has started back some years after surgery.

That number is better than it used to be; a few years back, 70% of our patients had already tried surgery and were in our office because they were still in pain. We – and other pain specialists nationwide – have been working hard to let doctors know that pain management works best as an alternative to back surgery, not as a last resort when surgery has failed.

So what do we do? It depends on the client and it depends on the problem. Physical therapy, injections, medication, and braces are the typical treatments but everything is individualized to the client because no two cases are exactly alike.

We don’t completely oppose the use of narcotics, but we rarely prescribe them. Aside from being addictive, narcotics can hinder therapy. They often serve as an unnecessary band-aid, masking the true source of pain and making patients less inclined to work at other more effective therapies for lasting pain relief. 

There are some cases that require surgery, but far fewer than many people realize. Too many patients come to us after having multiple surgeries, when a simple combination of physical therapy, steroid injections, and a wellness regimen would have brought relief. 

We can usually tell within 3 months whether surgery is necessary. If you’re contemplating surgery as an option, we urge you to schedule a consultation first to see if an integrative pain treatment program can work for you. 

Benjamin Seeman, DO is the head physician at Integrative Pain Specialists. Board-certified through the American Board of Physical Medicine & Rehabilitation with a fellowship in pain management, Benjamin specializes in osteopathic techniques and integrative therapies for managing pain. He has been voted Richmond Magazine’s Top Doc since 2012.

Find out more about Dr. Ben’s approach to pain management or schedule an appointment at