Ouch — Pain in the Back

Pain in the backBy most accounts, low back pain is the leading cause of lost work time in the US, and perhaps in much of the developed world. In the early days of the Industrial Revolution, at least one physician associated the malady with the “back-breaking” work of railroad construction, and described the condition as “Railway Spine.”

Although back pain is somewhat better understood these days, it is still the most common complaint heard in a doctor’s office. Most of these complaints are attributable to degenerative arthritis of the spine, which all adults have as a natural part of the aging process. The word arthritis actually means inflammation in the joints, and the spine is one long series of joints.

Virtually everyone will experience back pain at some point in life. In addition to occasional excruciating back pain, symptoms can include numbness and weakness in one or both legs, difficulty walking, bowel and bladder problems as well as sexual dysfunction.

Fortunately, most people will only have a few minor episodes, which will respond to home remedies such as rest and over-the-counter medications. Others, however, may require additional measures, including altering work habits or replacing an old mattress with a new, more supportive one. Still others who experience ongoing chronic back pain will get partial relief from more advanced treatments and go on to live relatively normal lives.

Those with the most severe cases may continue to find themselves in declining health and be referred by their general practitioners to see a neurosurgeon. These specialists are trained to operate on the brain and spine. Some orthopedic surgeons also perform spine surgery—a procedure which should always be a last resort.

Traditional therapies include medication, physical therapy, chiropractics, pain management and sometimes surgery. Non-traditional treatments include acupuncture and acupressure. Unfortunately, no treatment is completely effective in every case.

Use of non-traditional potions and herbs not regulated by the FDA should be approached with caution. Most are ineffective, while others, if used improperly, can cause liver damage and other problems.

Often, there is a psychosocial component to back pain. Life stressors or depression, for example, may require specific therapies. When the stress or depression is addressed, the pain may vanish.

Those on a quest to ease chronic back pain should beware. While many therapies are touted, success rates are disappointingly low. This can be as frustrating for care providers as it is for patients. A person who has exhausted most available remedies and seeks the advice of a physician can expect a somewhat regimented approach. The primary care physician may prescribe a slightly stronger pain medication or simple exercise regimen. This is an appropriate stall tactic, as back pain often resolves on its own or with simple intervention.

If symptoms persist despite initial treatments, a primary care physician may then refer the patient to a physical therapist. A trial of physical therapy frequently involves moist heating pads, massage and range-of-motion exercises applied during a series of several visits per week. Strength training or more rigorous therapies are reserved for periods when pain is absent or minimal. Frequently, an MRI scan is obtained to better assess the exact nature of any degenerative changes in the spine. In the case of low back pain, the MRI will show the lower part of the spine, called the lumbar spine. Aside from excluding the rare, more serious diagnosis, this contributes little to the initial management of low back pain. Most of the time, an MRI only shows the degenerative changes in the spine that all adults have. Most of us are not aware that we have these age-related changes in our spines because we are not having severe enough symptoms to warrant an MRI scan.

When physical therapy is no longer effective,

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the next step may be a referral to a pain management specialist, who usually has expertise in anesthesia or physical medicine. This person may invoke a number of treatments from careful administration of potent narcotics to injections of anesthetics and steroids directly into the lumbar spine.

All too often in this country, the next step is referral to a spinal surgeon (neurosurgeon or specially-trained orthopedic surgeon). In many instances, spine surgery is relatively effective. However in others, there is little
or no improvement or the relief is temporary and symptoms return in a few years. Though most operations are completed successfully and many patients recover without a hitch, never lose sight of the fact that such back operations are considered major surgery and therefore involve risk.

For those who suffer pain in their cervical spine (neck), the story is nearly the same. However, degenerative arthritis in the neck can cause symptoms in the arms as well. Cervical spine disease is fraught with an additional concern in that the spinal cord itself can be involved. Pressure on the spinal cord causes a greater array of symptoms, some of which may not recover even if the pressure is relieved surgically. This lowers the threshold for surgical treatment in the case of cervical spine disease, but does not change the scrutiny with which the decision to have surgery should be made.

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by E. Thomas Chappell, MD

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