Low Back Pain Poses a Difficult Clinical Problem
Maintaining Your Health
on Mackinac
By Yvan Silva, M.D.

Being that we are bipeds, being upright and facing gravity, we stress our musculoskeletal complexes of the vertebral column, predisposing ourselves to injury.

Chronic lower back pain ranks at the top of the misery index for most people who suffer with pain. In fact, 47,000 individuals responding to a survey ranked back pain as their most common physical complaint. After all, being that we are bipeds, being upright and facing gravity, we stress our musculoskeletal complexes of the vertebral column, predisposing ourselves to injury. Over time, normal wear and tear and improper and deteriorating body mechanics will cause damage to muscle, bone, and nerves, resulting in back pain.

Severe, recurrent, and incapacitating pain will, sooner or later, lead to questions regarding back surgery. In the past, very few patients had anything good to say about the results of their back surgery. But with recent technological advances in diagnosis and improved minimal approaches, results are encouraging and the statistics much improved. However, some old problems still remain. Back surgery can be suggested prematurely for some, but for others, if there is too much delay, the procedure might not successfully arrest ongoing deterioration in time.

Back pain can result from a minor tear or strain of the muscles and ligaments that support the back. Sometimes a specific incident, such as stooping to lift a heavy object or a specific bending or twisting motion, can initiate the agony. Emotional stress, excessive alcohol and drug use, and a sedentary lifestyle are known associated causative factors. Loss of tone of the musculature that supports the spine is an important factor. Most of the time, acute back pain will resolve by itself, but sometimes it will become protracted and lack of effective medical treatments lead patients to look beyond traditional medical help. Chiropractors and physical and massage therapists are able to do a good job in treating acute attacks. Costs are usually higher because of the duration of treatments these practitioners recommend. Many doctors candidly agree that they often order X-rays, CT (computed-tomography) scans, and MRI (magnetic-resonance imaging) tests to reassure patients that they’re trying to do something, even when these tests may be of little or questionable value in decision making for treatment. In acute back pain, the type of treatment chosen initially doesn’t seem to make a difference.

One study of 900 people with acute back pain, over a two-year period, reported that slightly more than half of them suffered a relapse, whether they initially saw a chiropractor or a medical doctor. A study reported in a national medical journal found that chiropractic care or physical therapy each resulted in costs roughly three times that of standard therapy, mainly because these treatments required more visits to the practitioner. Further, in the case of chiropractic care, higher costs also came from X-rays required to plan management. A survey conducted by the American Chiropractic Association found that 69 percent of its members routinely use X-rays before treating back pain; in contrast, only 20 percent of primary care doctors follow this practice. X-rays serve to rule out conditions such as tumors or fractures that might make chiropractic manipulation dangerous, but complications of spinal manipulations are rare.

The most common causes of chronic back pain are arthritis of the spinal joints and spinal stenosis from bony overgrowths that narrow the spinal cord or the apertures through which the nerves exit; or ruptured, bulging, or herniated disks, where one or more of these cushioning pads between the vertebrae protrude beyond the vertebrae and impinge on the nerves, leading to damage and muscle weakness.

Most back problems respond to non-surgical treatments. These may include limitation of activity, pain medication, heat and cold treatments, gentle massage, physical therapy, and chiropractic treatments. An individually designed exercise program is the best method to regain stability of the vertebral column. This can result in strengthening the para-spinal musculature to provide strong support for the vertebral spine. A well designed, back strengthening program may spare some people from having to undergo surgery.

Sixty patients, who were advised surgery for a protruding disk or spinal stenosis, were studied in a 10-week program; 16 months later, 35 of the 46 patients who completed the program were getting along without the surgery. There are several reasons to try the non-surgical approaches first. While back surgery relieves chronic pain in 85 to 90 percent of appropriately diagnosed patients, the benefit may not be lasting. In one four-year study of 126 patients with painful disk herniation, those who waited were suffering no more pain than those who had surgery. This occurred because pain recurred after the operation in some, and in others the pain eased in time without surgery. The overall long term experience after surgery for spinal stenosis is less well known at this time. All this information goes to show that there is no easy solution for individuals with chronic back pain, and that decisions should be tailored to the individual, depending on the symptom complex with appropriate studies that serve to identify the precise location and severity of the problem.

Surgery is usually recommended on precise findings on imaging studies correlated to the physical condition of the patient. For a protruding disk, the predominant problem is sciatica – pain, usually with numbness and tingling, radiating from the lower back through the buttock down the back of the thigh to the knee.

With spinal stenosis, key symptoms are back and thigh pain and weakness, usually in both legs, that gets worse on walking, especially downhill. A laminectomy involves removal of a small portion of the lamina, the bone covering the back of the spinal column, to remove pressure on the nerve and allow access to the damaged disk, which is removed in a procedure termed diskectomy. Spinal fusion is used to permanently connect two or more vertebrae to stabilize them, relieve deformity, and treat pain. With the introduction of your own bone (taken from your pelvis) or from a bone bank, or using wires, metallic cages, or plates, fusion is accomplished.

Qualified orthopedic surgeons and neurosurgeons trained in the principles used in these procedures perform back surgery. These procedures have come a long way in the past few years. Surgical techniques are improving rapidly. Less invasive back surgery techniques are becoming more common and results are improving considerably. Disk surgery usually entails a one-day stay in the hospital, with four to six weeks of recovery, and risks are common to major procedures, including the consequences of general anesthesia. Surgery for spinal stenosis generally requires a longer hospital stay, longer recovery, and greater risks; in general, patients requiring this are older and may have multiple health risks.

Here are some guidelines: For an acute attack, your best bet is rest and non-prescription pain medication, depending, of course, on the severity of the pain. It is best to lie on a flat, firm surface and not use a pillow if possible. Early on, ice packs are indicated. Later, applications of moist heat will help. As soon as possible, start on gentle active and passive exercises. It may take one to four weeks for return to normalcy. See your physician to get a good idea of the extent of the problem and for a referral if needed. You are free to seek hand-on manipulative treatmentsbut your insurance policy may not cover costs. For chronic pain, it’s better to start a serious program of strengthening and stretching exercisees, including manual treatments, prior to seeking a surgical solution. When you do, you will require appropriate imaging studies, and if you have clear evidence of one of the two major conditions for which surgery is indicated, when possible, a second opinion will be valuable. It’s important to remember that while surgical results can be excellent, the benefits may not last a lifetime.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.