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So how does low back pain impact people’s lives? And it’s really diagnosis specific. And so earlier we talked about the four groups. So that’s the way we talk about impact on life and would it be mean to people both activity wise and financially. For your patient who comes in and it has an episode of low back pain that is muscular tenderness. In other words, low back pain, no leg pain usually self limited, they’re going to miss some days of work. A very rare patient will miss weeks of work that’ll have a small financial impact, but it can have a long-term financial impact if they have what I would call a twitchy back back that wants to go out. Sure you can become more active. You could wear the brace, ice, anti-inflammatory to cut those episodes down or make them go away sooner. But there may be some people who find that they just can’t do a particular job because of their back. And sometimes we counsel patients to look for a different less back intensive job. I mean, I may stand in the operating room for 10 or 12 hours picking in a tumor and not have any back pain, but when I go out with the shovel and the pick and I’m putting in the drip system to the mesquite trees, I may have back pain that bothers me for three or four days. So far it hasn’t bothered work, but other people may be bad enough that it does bother work so it can have an effect, but the vast majority of patients will get over it, move on in their lives and it’s okay. The same is true of the next subgroup, which is back pain with the acute leg pain. Ooh, gee. You get them over that and probably about 95% of those patients are going to do well. Long term, don’t need a whole lot of modifications. There really isn’t any really good data to suggest even that people need to have modifications. In other words, do you need a 25 pound lifting restriction when you go back and work at UPS or otherwise or something like that?
Usually the elderly group, the stenosis impacts their lives hugely. I had one lady who said that for two months prior to her surgery, her husband was carrying her around the house because she couldn’t get from room to room. She first went to a walker and then went to a cane and the last time I saw her she’d graduated away from the cane and was doing pretty well. Long Distance, she still had a cane, but both from an impact from the disease process and an impact you could make surgically just wow. I mean it’s just orders of magnitude in terms of of degradation or declining quality of life and then the ability to improve that for people. The nice thing would be is if we could do it for 100% of those people, and we can do it for 90-95% of those people and well sorted out cases, but some of those patients are your most rewarding when they’ve been operated on or when they’ve been injected that those patients come back to you and they say, you’ve given me my life back. So huge impact. Financially, stenosis tends to be a much longer process than the first two. And usually the decline has occurred over months and most often years. It’s not such an acute process. It’s chronic.
So that leaves us with the toughest nuts. And that is is that chronic low back pains, no leg pain, really pretty good looking studies. You can see everything from people who are functioning well, haven’t headed impact their lives terribly to people who are at home 24/7 don’t go out, don’t walk, don’t do anything. And that’s in spite of everything that modern medicine and medicine that isn’t organized medicine has to offer for those people. And it’s unfortunate, it’s a huge impact in their lives. They socially are not anywhere where they want to be with friends and family. They are monetarily, financially just not well off scraping together to get by, you know, living check to check, dollar to dollar. And it’s unfortunate. Probably one of the best things that we could do as a country. It would be to somehow say, okay, we need to come up with some sort of national program to rehabilitate those individuals and give them their lives back. Whether or not that’s ever going to happen. Tough to say. There are lots of priorities that we have.
So can’t get sick without having any impact from your insurance. And I know this very well because I’ve had a kidney stone did I know about that. So how will insurance impact your spine? Well, there may be limitations both in diagnosis and in treatment. Typically insurances fall into, we’ll say sort of three broad categories. One brand of insurance or type of insurance doesn’t really care what’s done. It’s just carte blanche to the practitioner, meaning what you and the practitioner come up with, that’s what’s going to be covered. There’s no intrusion. The second group is where there may be small intrusions and that is where you have to jump through certain hoops. An example of that would be that before you get to go on and have your MRI scan, you need to have any inflammatories, and unfortunately, sometimes it’s physical therapy, whether it’s really gonna help the particular issue or not. But most insurance plans are looking for something called evidence of a conservative treatment regimen and generally over at least a couple of weeks before he imaging in a similar vein that may also apply to surgery. In other words, gee, you can’t be just going to surgery because you haven’t been to the physical therapists, you haven’t had injections, you haven’t had this, you haven’t had the MRI or whatever, treatment-wise. Not so much the MRI, but MRI is necessary to go to surgery because you have to have your roadmap.
The problem with some of this is is that someone doing the deciding may not be well versed in this particular medical problem. They may be a lay person who’s occupied a desk at an insurance company and this is the sheet that tells them this is what everybody needs. Problem is with your healthcare that everybody fits in exactly the same slot. In other words, you and I look a lot different today and, gee, we may have totally different problems and presentations. I might come in and I might not be able to pull my foot up. I don’t want to go to physical therapy. I want to be in that operating room tomorrow. I don’t care about having steroids or shots. I want to just get out of there because I want my foot to work so that I can go hiking and not have any problems with that. The other side of the coin is is that sometimes people can go to surgery too soon. Certainly the rates of surgery in different countries is different and in the United States I want to be taken care of now. You may not want to be out six or eight weeks with a ruptured disc and see if it gets better. My, you know, my supervisor wants me back. I’ve got projects, I’ve got things to do. If I’m not at work, you know, that may have adverse financial effect on me. So we have to balance what’s the right thing from a medical standpoint, what’s the right thing from a financial standpoint.
Then of course we have people who come in who either may not be insured at all or maybe under insured. And one of the things that really isn’t talked about much even with the more recent advances in healthcare insurances is that there are patients who have insurances that won’t cover particular things or that their copays are really insufficient. There’s a lot of sort of national enquirer press paid to people who go to healthcare practitioners and maybe turned away without insurance. I think the reality of that is really that it is quite small. Here where I practice, we don’t turn people away because they don’t have insurance because, and we work with them in order to take care of them in spite of whatever it is. And also if their insurance, but it can be frustrating if their insurances will cover A but not B or their copay, you know, you need an MRI but your copays 500 and you’re making 10K a year, that’s a big chunk to have to pay. But we try to figure out ways that we can take care of people, but not have bad things happen to them financially.
Well, you’d think there ought to be organizations for low back pain, but I don’t know of any really that I can think of off the top of my head. And part of one of the problems is, is that it’s not a one disease. And you could argue that, for instance, diabetes is not one disease or Ms is not one disease, but it’s more of a one diagnosis with different presentations. Low back paint isn’t like that. People aren’t rallying in the streets in terms of, ooh, let’s get the local chapter of low back pain, 231 together and see what we can get accomplished. So there aren’t, unfortunately, and I might argue that it’s just the opposite. There are lots of websites that we’ll talk about it and lots of things that may not prove very helpful for patients, that those places instead have a rod and reel to wheel in a patient for a treatment or a surgery or something that may not be at all helpful for that particular patient.
Thank you for watching and listening to this discussion today of lower back pain and all its different facets. Of course it’s not totally complete, but hopefully it’s helped you and you’ve gotten something out of it and hopefully you’ve learned that it isn’t this great big mystery and it shouldn’t be intimidating. There are treatments and we do make people better and it doesn’t have to be something that you live with and debilitates you for the rest of your life. I’m Kurt Schroeder, practicing neurosurgeon in Tucson, Arizona, and thank you for listening and watching.
This is lumbar stenosis. Lumbar stenosis is the principal cause of people who will have long-term back pain with pain that goes down one or both legs. And sometimes people will say, well why doesn’t it go down both when it’s tight on both sides and it’s probably a function of that just might be just a little bit more open on one side. But lumbar stenosis is not a glorious disease. When you go to bowling or you sit around and you’re having a good beer with your buds, it’s just not cool to say I have lumbar stenosis. But it’s okay to say, you know, I just had my knee scoped, or hey, take a look at this. This is my new total hip. Lumbar stenosis is this sort of vague thing and stenosis was coined in the 1950s by of all things a Dutch spine surgeon and he chose that term and it stuck. In medicine, when we’re talking about a stenosis, we’re talking about a narrowing and generally a narrowing through which something flows. And the reason that Verbiest chose that term was that spinal fluid in his mind was flowing through spinal fluids around the nerves and the spinal column. And so he chose that term and it stuck, but it’s not the best. It’s a narrowing and the bone grows and the ligament that’s on the inside of the bone, so it’s like having, a pair of shoes that, gee, you know, I wear size nines, it’s like me buying a size eight. And then on top of it, putting on my thickest, wool boot socks. My feet don’t like that. And your nerves won’t like it when the bone gets thick and the ligaments around them get thick on the inside too.
Generally people start having the symptoms that, gee, I’m having troubles getting through Costco. I can’t get through the grocery store without a grocery cart. I’m cutting up the vegetables and I got to sit down in the kitchen because it starts in the back and goes to the leg or legs. The thing that always has to be looked at is that this can be mimicked by two things. One is arterial disease and so smokers, diabetics, people with high blood lipids in a recent study can have arterial disease rather than actually spinal disease as a cause. So that needs to be looked at ultimately, if you’re thinking about it. And sometimes patients with orthopedic problems, it can be confusing with hip, things that might go to the groin particularly, or things that are in the knee and this is where a good doc can help sort that out for you and especially a spine surgeon who’s going to be cognizant not only of the spinal potential causes for your symptoms, but also for the other ones that lie outside the spine.
So spinal stenosis and its treatment. The first treatment is simply anti-inflammatories and a fair number of people will actually get better with anti-inflammatories. Again, it’s Ibuprofen, two or three, maybe three or four times a day. Again, remembering if you have kidney disease or you’re over 70, probably better talk with your doc before you’re going to go on that much. Two Aleves, two naproxen sodiums twice a day, maybe one twice a day. Again, since it’s an anti-inflammatory it has effects on kidney and liver. I want to make sure that if you’re certainly have any medical things going on, you want to be talking with your doctor, your primary care. Generally a trial of a couple, three weeks to a couple, three months. I like to tell my patients that I don’t want them to be on the medicines chronically. Certainly if someone is on those medicines chronically, they need to have their kidney and liver tests done so that those are evaluated on an ongoing basis so that things aren’t creeping up. The biggest risk was so called nonsteroidals, which is what these drugs are non-steroidal anti-inflammatory drugs. N-S-A-I-D-S. Is what we call them. NSAIDs. That is that they can result in things that happened to kidneys happen to liver, but the biggest risk group, again, the elderly, and as I recently found out, some researchers think the elderly is 60 plus. That’s important to me because I just turned 60.
But if the anti-inflammatories fail, then the next step is the diagnostic tests and that generally in a patient who’s a nonsmoker, non-diabetic without hyperlipidemia is going to be an MRI of the lumbar spine. If you have any of those vascular risk factors, then it’s reasonable also to get what are called noninvasive arterial studies. That’s generally where you get on a treadmill and your blood pressure in your legs is compared to the blood pressure in your arms. Although there are some variations on a theme where ultrasound looks at the arteries as well and sees if they’re open and with exercise and without exercise. And that helps sort things out. Well, so now we have a diagnosis of Lumbar stenosis and it’s causing the back pain that goes down the leg or legs. What are we going to do in terms of treatment? Number one is is potentially the lumbar epidural steroids, and again, these are injections of the steroid into the spine. Something either like prednisone or a variation on a theme of that. It’s a steroid, it’s at ground zero there so it gets the highest quantity there. It’s almost counterintuitive to think that somehow adding something extra is going to make it so that things have more room, but what it’s doing is by being an anti-inflammatory, it’s getting rid of the redness, the swelling, and buying time and probably best guess, 30% of patients, maybe 40% of patients, some people say it’s as low as 10 some people say it’s as high as 60 you can find many articles will have improvement. Have an injection, wait and see if you’re all better, don’t need another injection. You have an injection. Gee, doc, I think I’m 50% better. Might be worth a second injection. Is 50% good enough? Might be for some, Gee, I have an injection. Didn’t make me any better. Probably not worthwhile to do another one. Although one can make a case for certain individualized patients that it might be better to go ahead and give them a second or third, particularly if they’re not a surgical candidate for a variety of reasons.
Physical therapy for Lumbar stenosis. It’s interesting, it was within the last six months a year, marvelous paper in Spine, which is a journal that crosses all sorts of different specialties, chiropractic, physical therapy, neurosurgery, orthopedics, physical medicine. The title of the article was to sort of distill it, physical therapy improves walking distances 100%. And when you read this study, it was more interesting because the patients started with a distance of about 100 to 200 feet that they could walk. And if they went to vigorous physical therapy over three to five weeks, they might now be able to get up to from 100 to 200 to 200 to 400. but in our culture, and especially here living in Tucson, Arizona, the difference between walking 100 feet and 400 feet isn’t so much. So even though physical therapy may double the distance, you can walk, you’re still left sort of not doing very well. Physical therapy may help some patients. The problem is is that in big studies, you may have a small number of patients, 5% who do spectacularly with the physical therapy and are virtually cured, but they don’t stand out in the statistical analysis because the sampling is so high. It’s like saying, well, if we didn’t do physical therapy, 200 out of 1000 patients got better. And if we did do physical therapy, 205 patients, well those are is out of a thousand statistically those are even odds of the same thing. It didn’t stand out. So it doesn’t show up as being significant, in other words, making a difference. But for those five patients, maybe big deal. So physical therapy, not so good perhaps, but especially for a patient who has a lot of medical problems and remembering that lumbar stenosis, as we talked about earlier in this is a disease, mostly people in their fifties sixties seventies eighties nineties they may have a lot of things going on medically, and certainly physical therapy has very low risk associated with it the majority of the time.
Probably the definitive treatment for Lumbar stenosis is going to be surgical, and the tried and true treatment has been what’s called decompressive laminectomy. This involves taking this circle of the spine with the Vertebra nerves running through here, drilling away the back part and doing it either one or multiple levels, depending upon what the imaging shows. In some cases, this may be a simple one hour, two hour outpatient surgery and some situations that may require admission. It may be multiple levels because some patients will have stenosis at four or five levels. Some patients will only have it at one. Some patients may have a slip of malalignment that then requires the instrumentation in the fusion, and so there’s a big broad spectrum surgically.
There were some other intervention surgically that have been tried and are currently, let’s say being thought about. And one of those is to take those patients and sort of prop them forward so that they have more room. Originally the surgery was described being done under local. The vast majority of practitioners who do it actually do it under general and these are called inner spinus spacers and they have a variety of sort of unusual names. The good news is is that some patients are made better by it. The most recent data has suggested though that finally requiring definitive operation occurs and maybe as high as 20 or 30% of the patients and the data isn’t really very solid because it’s just not there yet. And these things haven’t been around for 20 or 30 years and it takes a long time sometimes in medicine for the thing to get sorted out as to what’s the best treatment. And then there are a variety of other treatments, but most of those fall into the realm of less than 1% in terms of ever being used by practitioners. The good news about decompressive laminectomy is, is that probably if you look at the patients who undergo decompressive laminectomy at the end of a year, 95% of those patients will tell you that it was worthwhile and they probably have the surgery again. If you wait 10 years, that falls off to about 85% and so there’s about a 1% per year plus or minus attrition rate of people out of the original hundred percent who say that they wouldn’t have it again. One of the big myths is is that one spine surgery sort of predisposes you to this awesome cascade of more and more and more, and that particularly in the lumbar spine isn’t necessarily true for the pathologies, for the things that we’ve talked about today. And so that should not be a fear. It’s something to think about that you might have to have a second surgery, but generally the odds should fall in the 5 to 7 to 10% range depending upon whose paper you read of having a second surgery, if you have a first surgery for any of the things that we’ve talked about today.
So let’s look at alternative therapies too. And this can be problematic because we don’t have good data about it, but ever since Nixon came back from China acupuncture has been of interest in the United States and is actively practiced. And I say it with a smile and the reason is is that, in terms of my travels and Washington Hospital Center, actually did acupuncture with anesthesiologists and so sort of like Harry Potter, I think I’ve seen the dark arts a little bit. And I can laugh about that. I don’t consider it a dark art, but I do think that we don’t always understand what acupuncture is all about. What we do know is, is that a certain number of patients will be made better. That number isn’t really very high for chronic low back pain. It may be higher for acute low back pain. The place where we get into trouble is, is that is randomization of the patients to the two groups. There have been very, very few studies that have been done where patients in one group get what is called dry needling. In other words, acupuncture defines where the needle’s ought to go and says, according to Chinese principles, this is where you put the needles for this particular thing. So having a true placebo, you’ve got to be needling patients, putting those needles in and putting them into other places so that it’s not in the accepted places. And then comparing those two groups. That research, first of all, it’s tough to do, cause not a lot of people want to sign up for getting potentially needles in places that they aren’t supposed to help them. And then also there hasn’t been a whole lot of enthusiasm for doing that. So we know that some people may get better with acupuncture, but we don’t know how many of them or who is the best patient for that.
It probably isn’t going to be sorted out. It takes modern organized medicine a long time to sort a lot of these things out, and I’ll quote an example. It was thought for a long time and promoted that we should be taking vitamin C for colds. And it took long, long time. Finally, a number of studies, one of which was fascinating, which was came out of New Mexico and it was done on one of the Pueblos where the school children, half were given vitamin C and half were not given vitamin C. It was a very controlled environment and the followup was very close and nobody was really lost, no one moved away and went somewhere else. And what was interesting and came out of that and was the start of the decline of vitamin C is a cold preventative was actually the children who had the vitamin C actually ended up with more colds, although not more on a statistical basis than the kids who were getting a placebo. So that’s the kind of study that’s really needed to look at a lot of these things in the interventions. There’s naturopathic medicine, massage, certainly hypnotherapy, biofeedback. The problem is is that again, it affects us and may help a small number of patients, but trying to define who those are, we don’t have the tools yet, and we’re always looking for that. For instance, just in the last several years, we always thought DNA spread this spread things to people and information. We found out that Mitochondria, which are things inside the cells, which are the powerhouses of cell, well, they have their own DNA. Their own DNA well it came from one of their parents, ooh, maybe that’s the reason some people have this inheritance pattern of particular disease processes and it’s opened up a whole new field of research and smarts and intelligence about disease. So in medicine, hopefully we’ll continue to do research, continue to do population studies, we’ll continue to find out who does best with what kind of intervention for what kind of disease process.
So let’s talk a little bit about risk factors for back pain. And some that are maybe self evident and some that aren’t. First of all is age. And the four types of back pain that we’ve talked about today, generally we can divide them up. Acute low back pain where your back goes out, that can start really at any age. Although certainly you’re going to see that acute muscular tendinous stuff that’s going to occur, 30s, 40s, or 50s, 60s. Is just start slowing down and 70s and 80s a lot less so. For back pain and the ruptured disc, I’ve always been fond of saying that when you’re young and in your 20s that material which is called the annulus, which is a ligament that holds in the disc rupture or holds in the disc material itself that is really in good shape and like a bicycle that ages and the tire ages and the tube ages, so does that annulus and you then again start having a higher risk, 30s, 40s, 50s. Although occasionally you’ll see ruptured discs in teenagers and we now know that ruptured as teenagers behave just like they do in adults. But then as we start slowing down and the disc dries out more than also much less risk of it than herniating seventies eighties nineties although any spine surgeon can tell you that they’ve had patients in probably all those age groups, maybe not in the 90s who’s had a true, bonafide ruptured disc. Chronic low back pain. You can see it from adolescence. You can see it in 20 year olds, 30 year olds, every decade that you’ve ever seen, and there really is no specific age that defines it. Lumbar stenosis, fourth group by and large, major category, people with back pain that goes to the legs associated with walking and standing. That’s almost always 50s and up.
So, what’s the data on obesity? Because we always hear, well, if you’ll just lose some weight, your back pain will be so much better. The answer to that is fairly nebulous and that is, is that probably patients who are morbidly obese, if they do lose some weight, will do better. And there are certain pathologic processes where people have the slips and their spines that if they lose weight that they will do better because they’ll have less sort of traction to make the slip go. But it’s not a one to one correlation and that again is one of the major problems that it’s not just who here take these pills for two weeks and your urinary tract infection will be gone. Obesity is a predisposing factor, but it’s interestingly enough, not necessarily as strong as what your average citizen would like to believe and just losing weight may not make you back pain all that much better. Which again makes it frustrating because if we are overweight we should be losing some weight and doing better for other reasons too. Not just simply for the back pain. Patients who have obesity and are obese who come to surgery have certain risk factors and interestingly enough, most of those risk factors are not the outcomes of the surgeries. The outcomes of the surgeries generally, and you can always find a paper here or there that might say otherwise, but the vast majority of the papers are saying that your weight doesn’t matter in terms of your outcome for any of these things that get operated on. But you risk factors for developing a blood clot in the legs and pneumonia, a urinary tract infection might be higher and certainly if you’re morbidly obese, then airways and pneumonias and things, really those things come to the fore. Those things are really important. It doesn’t mean you can’t have a good outcome from surgery, but you’re at a higher risk of developing a complication because of your weight. And same thing is true for instance, if you’re diabetic, you have a higher risk. So we can try to mitigate those risks, waiting for people to lose weight. We can get their sugars under better control in case you’re diabetic, and that’s the way we look at it in medicine, we tried to lessen the risk.
So in terms of occupation, are we at more risk or less risk in terms of what we do. And I love spine because every month we learn something new about either occupation or a particular treatment that sort of, it’s like doing a jigsaw puzzle and seeing a few more pieces go in but still not getting the whole. And probably the easiest way of putting it is is that couch potatoes and marathon runners don’t do well with their backs for all of these things. Those people who are in the middle who exercise maybe three, maybe four days a week, sweat inducing, maybe not even sweat inducing. Maybe all they have to do is go do walking. That those are the patients who do the best and can then cut their risk of back pain or if they do have back pain, maybe actually help improve it. Something where the patient can be a participant in getting him or herself even better. But it would be really, really nice if again, in each individual patient we could know just what was the silver bullet in that particular patient for the back pain. And so we try all these different things to try to get them better.
So let’s talk about smoking and all the different types of back pain. Well, we all know that smoking’s bad anyway. If somebody here thinks that smoking is good, they’re wrong. Good studies show that smokers have increased risk of low back pain and the interventions that we take to get back pain better are lessened in smokers. For instance, let’s just look at a very, very dramatic example. Let’s say that you have a malalignment. A slip. The vertebra’s aren’t aligned and oh my gosh, they’re squeezing the nerves and you’ve got back pain and leg pain with it and you get operated on. You need to have the bone taken away so you have room and it needs to be made solid. So you get screws and rods that hold it until the bony fusion can get solid. Well, if you have it done and you are not a smoker and you’re 50 years old, you have about a 96 to 98% odds that your fusion’s going to get solid, which is what you want. But if you are a smoker, then you have only 60% odds of getting a solid fusion. So marvelous data, clear data, not where you have to manipulate the statistics and have some mathematician crunch numbers for hours. But here it is in black and white. If you get a fusion, please don’t be smoking. Don’t cheat, don’t smoke after you’ve quit. You know you want that to get solid. And we do know that smokers have higher risk of low back pain. What we don’t know, nobody’s done this study yet and that is okay. We’ll take 200,000 smokers, we’ll make them quit and see if their back pain gets better. We don’t know the answer to that yet. All’s we know is the incidence of back pain, how often people have back pain to what degree, higher in smokers and nonsmokers that are equally matched.
So let’s talk about things that in medicine we’d say, ooh, you don’t want to miss this as a diagnosis. Or in lay terms we’d say other things that can cause back pain that you best be at your doctor for. So those fall into a number of categories. But let’s first of all talk about kidney stones. Kidney stones typically cause one-sided back pain. It’s excruciating and as one of my surgical technicians described it, it felt like something the size of a sun made out of glass shards going through a soda straw. And it is the worst pain of your life for the most part. And it’s the the acute onset in someone who’s otherwise healthy and doesn’t really have much of a history for having had an event such as shoveling the snow or moving the rocks or whatever, the twisting and turning. And that pain is so bad that you almost aren’t gonna miss it. You’re going to end up in an ER. There’s sometimes people will pass a stone real quickly and it’ll transiently go away. But if you have suspected, especially it’s more of a flank pain, it may start up under your rib cage and go down on one side and may even feel like it’s going down into the pelvis as the stone progresses or may not progress. But usually if it’s such terrible pain, you’re going to end up in an emergency room.
Also something that shouldn’t be missed, and this is in people, if you’ve had your carotid arteries operated on, you’ve had your heart bypass, Ooh, you’ve had vessel bypasses in your legs. In other words, you have what we call arterial disease, arterial insufficiency. And this comes in patients who high blood pressure, high lipids, and diabetics, and smokers. And if you have the sudden onset of terrible back pain, you need to be seen in an emergency room. And the reason is there’s something called a dissecting abdominal aortic aneurysm. It’s where the pipe, the aorta, which carries the blood from your heart down to your legs and it’s a big pipe, gets sort of rusted, rotted, not so good. And what the body lays down around it isn’t anywhere near as good as the original muscular wall. And it starts getting big. And then what happens is the blood flow creates a false lumen through it. And that’s called the dissection. It’s a funny medical term, but that dissection can oftentimes be very painful and people will sometimes ignore it. But for the most part is going to present, and this isn’t my field, but for the most part, it’s going to present in patients who already have known vascular disease and things aren’t coming just out of the sky and totally unbeknownst. So if you’ve had those other conditions and you have this terrible pain that starts in your back, ooh that’s a visit to the ER too, to make sure that you don’t have an abdominal aortic aneurysm that’s getting bigger.
Probably the third big Kahuna has to do with cancer. We touched on this earlier elsewhere in this discussion and that is is that if you have a known cancer, it might be breast, might be lung, gastrointestinal, but start to have back pain. And the classic history is the back pain is slowly worse every night a little bit worse. Every day a little bit worse than the day before, over three weeks, four weeks. It’s time for a study because especially if it’s new onset back pain and you’ve never had back pain before, it could be a metastasis or spread of the tumor spread of the cancer to the spine and that’s what’s causing that particular back pain. People will often ask or or will say and well, gee, it’s been 20 years since my breast cancer. One of the things that we often, I think many medical practitioners will say, once you’ve had breast cancer, you have to be alert the rest of your life. And it’s an unfortunate thing because it can hang over like a sword of Damocles sort of something over your head all the time. But I think it’s just smart to heed warnings. Think about things. Doesn’t mean you have to lie awake nights, but at the same time, if you’re presenting with back pain that just slowly is worse every night and every day need to think then, especially axial rate up and down, not much in the way of leg pain, then you need to be thinking, especially with the primary tumor somewhere else that’s been taken out or just treated with radiation or chemo. Ooh, tumor might be somewhere else, might have metastasized.
There are good orthopedic spine surgeons and there are good neurosurgical spine surgeons. There are bad orthopedic spine surgeons and bad neurosurgical spine surgeons. Most of the things that deal with neurologic deficits or someone has weakness, the orthopedic spine surgeons don’t want to deal with. So the evolution was is that with the original instrumentation stuff, screws and rods and scoliosis, it was originally done by orthopedists and neurosurgeons were like, well, we clip aneurysms in the head and you know, well in spine and we take care of nerf things, but if it’s the bone stuff, the orthopedists do it well. As you can imagine, people don’t go well. I think we’ll do less things in the future. They think, well, we’ll do more things in the future. And so the orthopedic spine people started fellowships and so then they did more and more and more and so now the one place where what we will do that they won’t, they will, orthopedic spine surgeons will not do things that are inside the spinal cord or things, for the most part that are in the dura. The dura is the spinal fluid package that’s around the spinal cord and then lower down the nerves that are the continuation of the spinal cord, like my hand ends and the fingers go. That happens right about T12 lumbar 1. And so you would, I don’t know any orthopedic surgeons that will muck about much inside the Dura, for instance, like an intradural tumor or a spinal cord tumor that’s in there, but a ruptured cervical disc. Sure. Or a lumbar stenosis. Sure. Somebody has got to slip. That’s their bread and butter because they originally started out as instrumentation surgeons. Neurosurgeons were slow, but now you can’t finish neurosurgery residency, but you know how to put in screws and rods. Most neurosurgeons, although even now, some of our surgeons are doing deformity, which is scoliosis surgery, whereas that was the, almost the pure province of the orthopedists.
So let’s talk a minute about your visit with your doctor or even your spine specialist. There’s really, I mean if the simple main rules apply here, you want to be able to give a good history. So you may want to just write a few things down. Most docs don’t want to look at a whole, literally a verbatim list of every day of your life cause that that can be a long thing and you’ll notice that oftentimes the doctor will take that out of your hand immediately and start scanning it. But you should definitely bring a list of your surgeries, your medical problems, and your medicines. Now from the spine practitioner, definitely what we want to know is have you had this problem before? Who have you seen before? What’s been done before? Have you had any surgery before? You might want to bring the op notes or the histories and physicals to those surgeries in particular because that way we have a really good idea about what went on. The other thing is if you’ve had any spine surgery or spine problems, get those images on CD and bring them in. A good idea before you present to the doc’s office is to have looked at the images yourself. It often is not very hard to open those images at home and make sure that CD isn’t blank or that it’s scrambled and won’t open. Usually they autoload and autorun. So beyond that, the usual things apply, but if you come prepared like that, most docs will accept you with open arms.
For testing, it would be nice if we had biological markers that we could draw bloods on and say, ooh gee, this makes your diagnosis. And there are a few. Those are not so common rheumatologic, in other words, arthritic kinds and subgroups, that would be sort of too complex to talk about today because it’s a very small but important part of back issues. But the long and short of it is is that we don’t order a spine practitioner much in the way of blood work unless we’re suspecting infection. But we do order a lot of testing, that’s imaging wise. And one of the imaging tests is called MRI. MRI is a huge electromagnet that excites water molecules that then give off that energy. It’s magnetic energy, it’s picked up by detectors and a 3D image of that is then reconstructed, so things that don’t have water in them don’t show up very well on MRI, but since the human body is a large proportion made of water, then, gee, it shows up really pretty well. This is why it’s so marvelous. It shows soft tissues really well. For years, we were stuck with something called CT computerized tomography. And by the way, MRI is magnetic resonance imaging. And just as an aside, it was originally called nuclear magnetic residence. And MR and the first studies that I saw were in MR images and they haven’t changed in terms of what’s done. It’s just that when patients are nuclear, they thought, oh my gosh, I’m going to glow in the dark after this study, which isn’t true at all. It had to do with the nucleus of the water molecules.
CT or computerized tomography is x-rays that are sort of rotated about the body and then collimators or sensors pick that up and it’s actually relies on the transmission to the x-rays and their absorption just like an x-ray does. And the computing gives you, in some cases a 3D but really a plain or a two dimensional slice through. CT is marvelous for bone, just like x-ray is good for bone. And computer algorithms, computer crunching numbers was good for looking at soft tissue but not anywhere nearly as good as MRI. Sometimes we’ll still do CT to see what the bony anatomy looks like, maybe for fractures or otherwise or we may want to look at a dye study where you actually get an injection in the back, which is usually an iodinated compound. The myelograms of today are water soluble and are not nearly the horrendous experiences of the oil soluble dyes of 20-30 years ago. And then we’ll do CT pictures after that’s called a myelographic CT. And in my own practice, probably 200 MRIs for every myelographic CT that I order. And the myelographic CTs are usually things where I have a particular problem or interest that I need help sort it out with a specialized imaging.
One thing that doesn’t have to do with imaging because those are structural studies, how things are put together. So MRI and CT are both structural studies. You may want a functional study and it’s called EMG/NCV and we have lots and lots of initials in medicine. But EMG is electro electric, myo, muscle, gram, study. NCV as nerve conduction studies, nerve conduction velocity. So we can look at nerves and we can tell how well they’re functioning was certain limits. The tests have their limits, but you stimulate, one thing you can do is you can see, gee, how fast the nerve travels. In other words, this is like going out with a radar gun on I-10 and see, gee, some of the nerves are traveling at 70 meters per second. Some are traveling at 50 meters per second. Some are traveling at 30 meters per second. And so it’s a function of telling you how fast that nerve is conducting. That’s one part of it and that’s a gross oversimplification but is still useful for patients to understand. The second part is the needle exam where needles are actually put into muscles. We know that just like highways that end in streets that end in particular places that the nerves and in particular places. Gee, that C6 nerve root that comes out of our neck is going to come down and is going to go to a muscle called the pronator which twists our hand in. I’m not a tennis player, but twist your arm in at the end of that. Maybe in golf someone pronates, I don’t know. But if you put a needle in that muscle and ooh, you see particular changes called fibs or positive waves and it’s not important what they’re called, but you see those changes that can tell you that that nerve root is irritated. And if you see one nerve root irritated, that may tell you one diagnosis. If you see lots of nerve roots that light up, it may tell you a different diagnosis and then used in conjunction with the nerve, conductions can tell you whether this is really peripheral neuropathy or whether this is a pinched nerve or whether this patient avulsed some of their nerves and their fall off of the truck. And so it was really helpful too, and it’s a functional study as opposed to a structural study.
So now that you’ve gone to see your doctor, you’re probably asking yourself, well, how’s he going to sort this all out? How are we going to get to the bottom of things? How are we going to really get a diagnosis? And there’s probably a good place to say that sometimes we don’t always have exactly the diagnosis. Sometimes people do have pain and we don’t come to it numerical diagnosis as it were, and that can be frustrating. But the patient shouldn’t necessarily always come to the diagnosis. The doctor is going to often come to the diagnosis and how’s he going to do that? Number one is the history is hugely important. Second part is being a good examiner. The things that we do, people come in and always wonder about my reflex hammers. Am I going to get a stick that somewhere? And the reality is is I’m very interested in their reflexes. I’m very interested in their strength and very interested in their sensation and I’m very interested in their backs. I think stepping up on a, maybe not a soapbox, but something like that, that there was a interesting article that looked at people who went to practitioners for their backs and only 45% of the time did somebody put their hands actually physically on the back. And there are things to be gained there feeling muscle spasms, feeling if people can actually reverse their curvature when they lean over, march in place does do things relax, seeing where it really hurts. Sometimes patients will be very far off. They’ll say, oh, well I know this. It hurts it L1-2, and it really doesn’t, it’s not really L1-2 at all. It’s it’s either way above that are way below. So history physical, that’s going to get you about 90% of your diagnoses. The last 10% you’re going to get probably 6% of those, the MRI’s going to help you with the next 2% the EMG is going to help you with in the last 2% maybe that’s why we lose our hair. Maybe that’s way we scratch our heads, but we may never have exactly a diagnosis. It may be worthwhile to have a second look months later, maybe worthwhile to have someone else take a look. Clearly, experience and facility, ability examination really helps to get to the right diagnosis straightaway.
So let’s talk about a little bit about the past, a little bit about the future of low back pain. And is there something right now that’s marvelous on the horizon that’s going to make everybody’s low back pain better? If there is, I’d certainly like to see it because right now there is a lot of research going on. There’s a lot of interest in terms of the neat things that we have in terms of screws and rods and X staples and things like that that we can put into spines. But remembering the nodal back pain is surgical. So ultimately there probably two avenues that are going to be of interest. The first avenue is imaging and identifying pain generators. A pain generator is the thing that’s causing the pain. And when someone has a rupture disc our MRI shows, ooh, that’s the pain generator. When someone has that pain that goes down the leg with walking, that’s the Lumbar stenosis. CT or MR show us that. Ooh gee, that patient had pain lying at night in bed. The EMG shows us that it’s their peripheral neuropathy from their diabetes. So those are that we can identify those pain generators in gross waves, but we’ll get better and better. We’ll have more and more things that can identify things that are in soft tissues and think back 15 years people were very interested in something called thermography, which was to take photos as it were or images on a screen and see what the various temperatures were in various portions of the body and try to then postulate if those areas were sick. And those images, of course were very gross because you were looking at surface temperatures and to some degree temperatures that were further in, but you really weren’t getting to the heart of that. But think if you can use the same MRI technology that we now exploit water molecules, but somehow we can figure out places that hurt or maybe we can do an MRI and we can give somebody something in their veins that goes to only places where inflammation has taken place and we can identify those. So we might be able to identify places that we have our low back pain from the arthritis that’s in the actual joints of the low back. I mean, you see that it’s on the left at L3-4 but it’s not on the left at L4-5. So imaging and identification of the pain generators is one avenue.
Are we going to be able to come up with things that we can then implant? And the corollary of that is, in other words, like for instance, new spines, Well, new spines would be really technically difficult right now, but we may come up with things so that we can grow new things in people just as they’re sitting there. In other words, there’s a recent material, and I won’t use the trade name, it’s injected in knees and with the idea of providing some lubrication to knees. Well this is really crude. This is like, you know, the first sundials and thinking that we’re going to get to, you know, atomic watches soon. But having said that, if we can come up with things that we can then grow from stem cells or from even people’s own regular cells to extract the DNA. Ooh, Gee, you’ve got this mucked up L3-4 and we’re going to give you a new L3-4. But what we’re gonna do is we’re going to inject it and then it’s going to grow there. It’s going to take the place of the bad one. That’s, you know, a long ways away. But that’s ultimately what it is. But that dovetails then with something else. And that is, is that when we start investigating, why do we age? Why can’t we make an exact copy of a skin cell that was there yesterday and we make a new one today? Why is it different? Why does our skin get different as we age? Why do our spines get different as we age? Why do they do these things? Why don’t they just stay static? Why don’t we replace, you know, just like we can’t a carburetor and a 57 Chevy, with that one goes bad and rots, we put in a new carburetor. So that’s another avenue.
One thing we haven’t talked about so far and that is narcotics. And everybody who you talked to is going to have a different opinion about this. So there’s a disclaimer. This is one man’s opinion sitting in front of a camera talking about narcotics and back pain. There was an enthusiasm probably in the last 10 to 15 years for the use of narcotics in chronic low back pain. But let’s rewind it a little bit. Let’s start with acute low back pain. Yes. If the back pain is excruciating and you’re sitting there at your doc’s and you’ve had three days of it or four days of it or two weeks and it’s just excruciating, acute narcotics are very reasonable treatment in order to make life more tolerable. Just like if you’d had a broken arm, you don’t want to hurt. So for that acute low back pain without leg pain, acute low back pain with leg pain, narcotics are reasonable treatment. For chronic low back pain, the pendulum has really swung five years ago, seven years ago, 10 years ago, people were given narcotics. And it seems to take more and more to get less and less. In other words, it’s like having a key that fits one log, and that’s the way it is with narcotics today. And then tomorrow we need two keys because now we have two locks, and the next day we need four keys because now we have four locks that we have to do. And so this is the tolerance of narcotics. Not many medicines in our armamentarium are like this, but seemingly and sort of on a very simplistic basis as our body sees more narcotics, it makes more receptors, that needs more narcotics. And so that’s this ever increasing spiral.
The argument for chronic use of narcotics is function. Ooh, this guy is on a 50 gallon drum of morphine every day, but he’s still functioning. He’s going to work. He interacts well with his family. He’s sleeping nights. That might be an instance where chronic narcotic use may be reasonable for either particularly chronic low back pain that doesn’t have any leg pain associated with it, which means that probably the studies look pretty normal. The problem has been twofold. Number one is, is that the patients who have been started on the chronic narcotics and are taking more and more don’t function any better. In other words, if you ask many of them, what are you doing now? Well, I’m staying at home and I’m watching TV all day. Why do you watch TV all day? Because they don’t feel good enough to do anything else. So now what you’ve done is you’ve had a patient who isn’t doing very well to begin with. You’ve given them a second problem and you haven’t made their original one any better, but now they’re hooked on the narcotics.
So what’s the second problem with narcotics? Well, I believe, at least at the time of this filming, the last year we have data is from 2012. And in 2012 there were roughly in round numbers, just about 30,000 overdoses on prescription strength, prescription narcotics, no prescription strength, but first prescription narcotics. So the great American narcotic experiment with pain contracts and things. Has it been the great success that people originally thought it was. Pendulum swinging back the other way. So might there be a patient who it’s reasonable to have on chronic narcotics? You have that patient who has osteoporosis and gee isn’t doing so well as a little bit of settling. It’s really not really treatable any other way. They might need one Vicodin three times a day in order to get by. They’re 85 years old. There’s no surgery to do. That might be a reasonable patient. It’s like a lot of things in medicine, finding the right patient and matching to the right treatment and not adding to the problem.
Well, the back pain that’s important to separate out is as we talked earlier, what’s acute and what’s chronic? With acute back pain. Generally the patient will present with having had an incident or maybe no incident, maybe they just got out of bed, maybe they live in Boston and they were shoveling snow and the back went out. But it’s the acute onset of terrible back pain or even maybe mild back pain, but it doesn’t radiate. It doesn’t go anywhere. It doesn’t go down the leg and it stays pretty much localized to the lumbar spine, which is basically right at belt level or maybe a little bit above and a little bit below. Generally there’s not much with it. You can see a big, big spectrum. Everything from, Gee, you know, this is a minor nuisance and who maybe I’d better take a little bit of an anti-inflammatory for a day or two. Two, I can’t even get out of bed and I can’t function and this is bringing tears to my eyes. And so the vast majority of these though can be easily treated and people can treat them at home without even having to see a doctor.
Chronic back pain is back pain that persists and lasts longer than really six weeks. And chronic back pain comes in a lot of different flavors as well, it can have a variety of different causes, it may not have anything to do with the muscles, ligaments and tendons like acute back pain does, or it may have the cute muscle tenderness and spasm that’s been going on and acute back pain that’s becoming chronic and it just hanging around and has been very difficult to treat or maybe hasn’t been treated. But a lot of the patients who have the chronic low back pain it may come from muscles, ligaments and tendons. It may come from bony arthritis. It may come from the fact that there’s malalignment. Not so much scoliosis. A lot of people believe scoliosis in the lay public, but not so much unless it’s really rather severe scoliosis. It may come from a malalignment where the vertebrae are actually sliding forward one on another or it may come from infectious processes or it may come from unfortunately, processes that are neoplastic. Neoplastic is medically used for tumor tumor causing back pain is very rare, but in patients who’ve had a previous known cancer, perhaps lung cancer or uterine cancer or thyroid cancer, that then those patients may then, if they have back pain, that’s a red flag as it were. It’s a signal that says, Gee, this needs to be investigated.
So then we look at patients who have acute back pain, who also have leg pain. And most often this’ll be in a demographic that’s older than teens starting in the 20s more people in their forties and 50s fair number in their sixties interestingly enough, not so much in their seventies, eighties, and nineties. And the important part of this is that it’s the leg pain signals that something’s going on in the back that’s pinching one of the nerves and is causing the leg pain. Commonly, this is called sciatica and Sciatica, sort of a poor term as it were because it just means leg pain and it doesn’t really tell you anything much about the diagnosis for the most part. But if somebody is having pain that radiates down to their front or their thigh back of their calf, then you start thinking of things that are pinching on nerve roots. The most common cause of that in an acute setting is actually a ruptured disc. Americans have been taught that ruptured discs account for everything. Perhaps even the satellites fallen out of the sky or the stock market going down. But the reality is, is that disc ruptures are in and of by themselves things that can cause no problems can cause big time problems, can cause a lot of leg pain and may cause some back pain as well. So the long and short of it is, is that again, we’re thinking of things that cause the leg pain. Other things can be cysts. They can be bone that’s overgrown, where the bone has gotten too tight and is squeezing things.
If you’ve been listening along, you know that there’s one category that we haven’t been talking about yet. And that is chronic back pain with leg pain. And that typically instead of being just in one leg, is usually in both, although not always, most often that’s a function of bony overgrowth and that’s called stenosis. And the demographic for that is people who were sometimes in their forties but most often you’ll see it in late fifties, sixties, seventies, eighties and you’ll actually see it in 90s. And what happens is, is the bone just gets thick and the center of the bone and the vertebrates, which is where the nerves run and higher up the spinal cord, that that just gets tight. People start having a very stereotyped presentation. And that is, Ooh, Gee, my back starts hurting when I’m walking or standing. And if I’m going through Walmart or Costco that I have to use a grocery cart. Or, Gee, I need to park really close to the front of the store because when I’m trying to get into the front of the store, I got to have the shortest distance possible. Or, Gee, I’m standing in the checkout line and you know what? My legs are starting to hurt. My back is starting to hurt and I got to find a place to sit down now. Not everybody actually hurts with spinal stenosis and I’ve seen a number of patients and it’s been described where patients actually will have troubles, but it’s not that it’s painful, it’s that their legs get woody. They sometimes feel like their legs are numb, the legs won’t want to do what they want them to, and those symptoms will start in the back and extend down the legs. Although some patients will tell you, it seems like it starts in the legs and actually goes up into the back. There was a recent article published a couple of years ago. We used to think that stenosis in particular didn’t cause nighttime pain, but if I remember right off the top of my head, about 56% of patients in that study that they looked at who had stenosis also had trouble sleeping at night because they had leg pain. And so that tells you that sometimes we can learn something over time and looking backward at patients and be a little smarter about symptoms. So those are the four major groups, and there are four major presentations.
Back pain can be a real tough nut to crack, not only from the person who’s at home, but also from the treating medical practitioner. And the bottom line is, is that back pain doesn’t have to be this confusing array of symptoms and presentations and diagnoses. There’s logic to it, but it requires a little bit of time and a little bit of seeing lots of patients, for instance, when you’re a medical practitioner and you can’t be just a lumper, you have to learn to be a splitter, you have to learn to take a good history. The history with back pain is hugely important. A lot of people will believe that, oh gee, it must be the studies, the MRIs and the CTs. Well, those things are really your confirmatory tests to what your clinical impression is. I will freely admit there’s sometimes when I see patients that, gee, you know, I’m not really sure what the right cause here is and I’ll look to the studies, but the majority of the time you should have a pretty good idea about what’s going on from your clinical history and your exam in terms of what the causes are and then that determines what the treatment is. Unfortunately back pain has become this sort of huge, almost wastebasket or huge net in the ocean that catches lots of different disease processes and different diagnoses. And that’s what makes it both so confusing. But also so vexing because it’s hard I think a lot of times for the patients to really sort out and even from what they’re told by their medical practitioners, what really is the diagnosis here? Why do I hurt? And in many cases we can tell them why, but in some cases we can’t really tell them it’s exactly one thing. We can say, well here are the things we know it isn’t. And you’ve got a pretty clean look and study. So it must be in the muscles, ligaments and tendons. And that’s not always a very satisfying answer for patients because that’s more vague than what they would like.
I think we’re finding in our talk here today, it’s hard to compartmentalize it. And so what let’s do is let’s talk about the various four compartments that we’ve defined and we’ll talk about each individual one and we’ll talk about what’s causing the pain. what a rational approach to it is, and then further on in our discussions we’ll talk about when surgical intervention is potentially a thing to do? Also such things as injections and also such things as physical therapy and chiropractic. So let’s first start with just talking about acute back pain and this is, Gee, I’ve been out in the yard and I’ve got the ax and I’m putting in the sprinkler system and oh my gosh, I straight up and the world is coming to an end because it feels like every muscle in my back is spasming. This is not a function of the discs. This is not a function of the bony overgrowth. This is not a function of the arthritis. This is a function of the muscles reaching a point that they’ve been exercised, they’ve been utilized and they’ve been gotten into either a position that they don’t like or a position that’s unfamiliar to them and they’ve gone into spasm. And it’s pain then it spasm, which triggers more pain, which triggers more spasm. And it’s sort of like looking at a swirling amount of water. Things are just going downhill rapidly, but the treatment is fairly rational. The problem is, is that your average person really lets it go a long time. And will say, oh, it’s just going to get better. But there’s a triad of early intervention, which not only can abort the episode, but can take the peak off, make it shorter, which is exactly what you want to do. And it’s called brace, ice, anti-inflammatory. So let’s talk about that treatment of acute muscular tenderness, low back pain. And it goes without saying that we’ve talked in that it is muscles, ligaments, and tendons, not the other structures, the discs, the bones that we need to be worried about.
So those things, the treatment with brace, ice, anti-inflammatory. You can make a trip down to your local drug store. And what you want is a brace that at least stretches from your ribs down to your hips. Weightlifting belts, too short. So you want something that’s probably about this big, and if you’re six foot four, you’re going to want it bigger than that. Having three stays in it, not a bad idea because what you’re doing is you’re splinting the muscles so that they don’t have to spasm. Even if you’re on vacation or at the beach or hiking in the mountains and the back pain starts, hit the drug store, get a brace. That’s number one step. Number two is icing it. And we find amongst patients that some patients love ice, some patients hate ice. We live here, and I’m talking from Tucson, Arizona, which you may see in some of the background. But the bottom line here is people don’t come to Arizona for the ice. They come for the warmth. So some people will be more responsive to heating pads, but generally ice is better. Think about it, that you’re in the shopping mall and someone’s going to pierce your ears. They don’t put heat packs on your ears. They put ice on your ears. It takes away pain, takes away spasm and easy way of doing that is a simple over the counter kind of thing, you can get some Ziploc storage bags, double bag, about a quarter of an inch of dawn dishwashing detergent. You can make your own ice bags that now you can keep 10 or 12 of them in the freezer and alternate them inside your brace for getting things better.
The third intervention is anti-inflammatories. The American public hasn’t been taught well about any inflammatories although it’s certainly getting smarter about it and there’s more information now than there ever was, which is good. What we’re specifically talking about is drugs that aren’t Tylenol and drugs, which generally are either aspirin or other, so called nonsteroidals. There’s are things like Naproxen, which is in naprosyn or things like Piroxicam which is in Feldene. That’s a prescription drug. Sulindac which is in Clinoril. Some are available over the counter and so it’s easy enough to go down and get some Ibuprofen or Aleve. Ibuprofen, new printed Advil are the trade names you can use generally in the order of 400 milligrams, which is two the pills three or four times a day. You have to use it three or four times a day because the half life, a little variable on patients, but some it may be as short as six hours to summit baby as long as eight. Naproxen on the other hand, which is Aleve and is sold under a variety of other different trade names in Costco and Walgreens. But that is twice a day dosing of two the pills. Now there are certainly, you don’t want to rush out and do that if you’re a patient who has kidney failure and maybe if you’re over 65 you may want to cut it down to just one. Or if you have other health factors, and certainly talking with your doctor isn’t a bad idea. But brace, ice, anti-inflammatory for acute muscular tendinous, low back pain, that’s a smart move.
Let’s talk about treating acute back pain where the pain radiates down the leg. And just to refresh, that’s most likely on the basis of a ruptured disc. It may be on the basis of a cyst, which has been eyeing. It may be on the basis that the bone was tight, just like a tight pair of shoes that you are and you walked five miles in and started to hurt so that it may be from stenosis. But generally the first line of treatment for that is going to be an anti-inflammatory. Brace won’t help you much with this. The packs probably won’t help you much. And the reason is initially it’s mostly the back pain, but generally the back pain then starts giving way to the leg pain. And so anti-inflammatories are going to be a reasonable start. And again, we talked about this under acute back pain that didn’t radiate down the leg, but Ibuprofen in the form of new print and Advil, two pills, three pills, three times a day, maybe four times a day if things are bad and Aleve is two pills twice a day, which is Naproxen sodium. And again, remembering that what you want to do is if you have any major health issues, getting into your seventies, any kidney issues, you’re going to definitely want to modify that. Talk with your doc before you’re going to start that.
If the back pain and the pain down the leg doesn’t get better, that’s called a visit to the doctor. And the reason is is that a nerve is being pinched and you need to be at the doc because now this is a situation in which you need a diagnostic study. The major diagnostic study, here’s we talk in this day and age, is an MRI of the lumbar spine, which is done without contrast, it’s a big huge electromagnet that excites water molecules and then the water molecules give off the energy. And so that energy then is read by things that say, ooh, where those water molecules are. And so it gives you much the same as light gives you a photograph, it gives you a picture. And we can slice people almost any way we want. And so MRI is a huge advance over CT, which was x-rays done in a similar, although non-excitatory manner. So ruptured discs, synovial cysts, maybe stenosis and there are a whole host of other things. But if you’re having pain down the leg and it’s acute and it’s getting worse and you’re not happy and anti-inflammatories aren’t making you better, it’s a trip to the doc. Now, once you see the doctor and you may or may not get an imaging study, some doctors will go ahead and start you on a steroid burst and there are many different steroids and steroid burst sometimes come in packs. We take five pills the first day, three pills the second day, two pills, the third, et Cetera, and then there are other ones where you may be on a steroid burst where you’re on the same dose three times a day, four times a day for a week. Generally that’s a first line treatment for excruciating back and leg pain. Then if the patient isn’t better than it may be time for the MRI. Then after that depends on what the pathology is. So let’s finish up on the potential treatments of acute low back pain. We’ve talked about brace, ice, anti-inflammatory and that’s really the treatment. The vast, vast majority of acute muscular tenderness, low back pain is going to get better that way. If it doesn’t get better, then the next step may be physical therapy. It may be Chiropractic, or it may be even a stiffer brace, or ultimately maybe injections. Surgery for acute muscular tenis, low back pain really doesn’t have any place in terms of management. There’s nothing surgical to do. You’re only going to make a patient worse with that, and not any better.
So let’s recap about back pain, which is acute, sudden onset with leg pain, which most likely is, I’ve said signals that one of the nerves is being pushed on. And again, the starting point is with an anti-inflammatory and anti-inflammatories in the form of Naproxen sodium or Ibuprofen are appropriate. The brace doesn’t help much. Some people will believe that the next step is seeing a physician and that it may be involved physical therapy, but for really acute leg pain, that’s usually not going to help much. There may be a steroid burst, which is a three, five, seven, nine day intense regimen of either a slightly declining number of pills or a consistent number of pills and the steroids you may have heard of such things as hydrocortisone, which isn’t used very often or prednisone, which is used more often, and many neurosurgeons such as myself, use dexamethasone. Then if the patient’s still isn’t doing better, the imaging studies become important because you want to see what the real pathology is.
Many patients at that point we’ll opt if they don’t have any neurologic deficits, which are weakness and numbness, then to go for what are called epidural steroid injections. Sometimes these things are called epidurals. Sometimes they’re called transforaminal injections. The needle trajectory in the spine is not so important as it is that the deposition that now you’re getting steroids right where the problem is and that’s why you don’t put the cart before the horse. You get the imaging study first and with the imaging study it tells you, ooh, that problem is it lumbar three dash lumbar four. And we talk about places in the lumbar spine with generally two numbers so that we can stay oriented. It’s like coordinates on a map so it gets us to the right place and that way the steroid can be delivered by a physician in the form of an injection right to the right place so that it could have the highest concentration there. With that injection, there are systemic effects. For instance, your whole body does see the steroid, just like as if you took it as a pill, but the ground zero as it were, sort of like with a bomb is where the most of it is going to be and do its job and so you can get a higher concentration. That’s why it’s advantageous.
So steroid injections, then if the patient still is not bitter, that patient may ultimately come to surgery. If it’s simply a ruptured disc, it may be an outpatient surgery that takes an hour, hour and a half to do where you take those pieces of disc out away from a nerve root. And think of it as like having a rock in your shoe. You want to get the rock out, but you don’t want to destroy the shoe and you don’t want to destroy the foot. The analogy here being that the foot is the nerve and the shoe is the bone integrity of the spine and modern techniques of operating have really made this marvelous procedure done with microscopes, sometimes done with endoscopes and there’s no real advantage of one over another. The incisions for the small microdiscectomy are hardly bigger than the ones with the scopes. Some people are not as fast though with the scopes and like those so called mini open procedures and they’re many, many practitioners who do small approaches are many approaches for this as an a simple outpatient procedure. In fact, it’s almost not so much done as an inpatient procedure as it was 20 years ago.
The other thing is is that with patients who do have other pathologies, it may require more extensive surgeries. For instance, if you have a big cyst that comes off a joint, it can look just like you have a ruptured disc from the standpoint of symptoms and signs, symptoms being what hurt, how you tell the doc it hurts and signs being things that are on exam and only with the imaging do you see that it’s a big cyst and that may require a more extensive surgery even including excision of the cyst and maybe stabilization of the joint there, which might be even including an instrumented fusion. But not all cysts required instrumented fusion. And then after that we’re talking about a lot of things that are less common, although sometimes you’ll see a patient who has what’s called stenosis where the bone has grown, made things tight, the patient’s been doing really well and starts to have a lot more leg pain. There isn’t a ruptured disc. There isn’t a cyst, but things are real tight. And it depends on how many levels of stenosis you have as to whether a surgery for that it’s going to last an hour or it’s going to last three hours, and so that becomes then more complex and very much more individualized to the patient.
So now we’re talking about another category of low back pain, and that’s chronic low back pain and chronic low back pain without radiation down the leg is, I think, probably not fair to say it’s still a medical mystery, but I think it’s fair to say that medicine doesn’t do very well with it. If you just have low back pain day in, day out, it doesn’t go down your legs, isn’t made worse with walking, isn’t made worse with standing. You’ve treated it with any inflammatories, which are things such as new printer, Advil, two pills, three maybe four times a day or Aleve, one or two pills twice a day. And you’ve done that for several weeks in the back pain’s just hanging on. And now we’ve gotten to not just six weeks, but we’ve gotten to eight weeks, we’ve gotten to 12 weeks. This often is a tough nut to crack and the imaging becomes hugely important. It’s difficult to probably list every known possible thing that you could see on the imaging. But the most common thing that you will see on the imaging is that the imaging is normal.
If the imaging is normal, some patients may respond to injections. Some patients may respond to bracing. Some patients may respond to physical therapy. Some patients may respond to Chiropractic, some patients may respond to nerve stimulation. Some patients may respond to tens units. Notice that I’ve used the same language for all of those. And the reason is is that some patients is this small amount of patients who respond to each one of those, but we don’t really have anything that tells us what will predict the response of each individual patient to each of those individual scenarios. And so it can be tough and it can be enormously frustrating for the patients because here they go from one thing to the next, looking for the holy grail to make their back pain better when indeed medicine may only be able to take a chunk out of it with one thing or another, and not actually as people would want curate. So it can be enormously tough.
One thing that I haven’t mentioned is that a minority of patients will find help in places such as in they’re characterized as back stores, places where there may be changes in ergonomics. For instance, seats, chairs. Personally, I tried one of the no bad chairs with my knees down. That did terrible things for my 60 year old knees and I’m not sure it made my back feel all that much better. But there are a lot of things that people can do that are relatively simple that may make a change in their back pain, but it’s hard to predict which one is going to be made better, for instance, by losing weight, which one’s going to be made better by going to the mattress store, which one’s going to be made better by going and getting inserts in their shoes. That one’s an interesting one because there was a recent military study that looked at back pain and shoe inserts and the bottom line was is that there was absolutely no difference whether they got shoe inserts or not, whether that can be generalized to the regular population. Hard to say, but also, English from that claimed their shoes, made people’s back pain better, and a nice English study that looked at that and people actually abandoned wearing the shoes for the most part because they weren’t happy with the improved lack of, I should say, the lack of improvement in their back pain.
We look for all these different things to try to make chronic back pain better. There are some certain instances in which surgery can help people with chronic back pain. The first instance is when people have true instability in the spine. Instability is a fancy medical term and even defined by the experts can be very tough to pin down exactly. It’s almost like the Supreme Court justices. I know it when I see it, but stability refers to the fact that the vertebra is which sit one on top of another may slip forward generally. Slipping backward is usually not such a big deal, but if it slips forward and it moves a lot, sometimes you can help back pain by taking away that slip in the sense of making it solid. That’s a fusion and in this day and age that usually is accompanied by screws and rods or another mechanism of holding the bones until the fusion can get solid. The other thing that sometimes with chronic low back pain that you can help or things that maybe grow in the bone, and these are more esoteric and probably not appropriate for this audience, but the imaging defines that and if you operate on those. And the whole spectrum can be everything from simple kinds of surgeries to very complex kinds of surgeries for things that grow in the bone.
In a patient with a normal study, surgery has really no place. Normal pictures don’t get operated on. Very important principle. Sometimes patients in their frustration will want to have something done, just do something, but it’s about the same as saying, well, you know, I couldn’t get this watch to run, so I’m going to go out in the garage and I’m going to get my hammer and chisel and we’ll see if doesn’t help. It doesn’t make much sense. The right surgery for the right problem, results in good outcomes. The wrong surgery for a particular problem when it’s wrong, very, very unlikely to help people.
Chronic low back pain is also often addressed with physical therapy and chiropractic. The problem is is we don’t really have good data about either one. And just recently I was fascinated to read an article in spine that talked about people with chronic low back pain that it occurred at work and whether or not physical therapy that was specifically designed to sort of look at their work and then tailor the physical therapy appropriate to their improvement, showed absolutely no difference over generic physical therapy in terms of improvement. So it can be tough. And that brings us back again to where I started that some people will get some better by some of our interventions.
Back pain is really present in almost every gender, every occupation, and every age group to varying degrees. At any one time, 40 million Americans are seeing their doctors with complaints of back pain. And so thinking that somehow back pain is special to one particular group or another, just as a jive, people are visiting their doctors, talking about back pain, and it comes in many different types and sizes.
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