Maintaining Your Health on Mackinac
Many Factors Can Result in Chronic Lower Back Pain
By Yvan Silva, M.D.

Chronic lower back pain ranks at the top of the complaint index for most people who suffer with pain. In fact, 47,000 individuals, responding to a health-oriented survey on pain, ranked back pain as their most common physical complaint. After all, being that we are bipeds facing gravity, we regularly employ the musculoskeletal complexes of the vertebral column. This area, which is used during most physical activities, endures repeated stress, predisposing the back to injury. Over time, normal wear and tear and improper and deteriorating body mechanics will cause damage to muscle, bone, and nerves, and this can result in chronic 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 surgical techniques, results are encouraging and the statistics much improved. However, some old problems still remain. Back surgery can be advised by surgeons prematurely for some patients, but for others, when surgery is indeed indicated, if there is too much delay, the procedure might not successfully arrest ongoing deterioration in time.

Back pain can occur acutely from what might seem a trivial incident, when a minor tear or strain of the muscles and ligaments that support the back occurs. 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 usage, and a sedentary lifestyle are well 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 utilize. Many doctors candidly agree that they often order X-rays, CT (computedtomography) 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 just over half of them suffered a relapse, regardless of 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, higher costs also came from X-rays required to plan management. A survey conducted by the American Chiropractic Association found that 69% of its members routinely use plain X-rays before treating back pain; in contrast, only 20% of primary care doctors follow this practice. Xrays serve to rule out conditions such as tumors or fractures that might make chiropractic manipulation dangerous, but complications of spinal manipulations are rare. An acute attack of low back pain does not necessarily presage a chronic condition. Active, young people frequently recover in a couple of weeks, and the condition resolves.

The most common causes of chronic back pain are arthritis of the spinal joints and spinal stenosis from bony overgrowths that impinge upon and cause compression of the spinal cord. They can also affect the apertures through which the nerves exit, causing what is commonly called "pinched nerves." Also ruptured, bulging, or herniated disks, when one or more of the cushioning pads between the vertebrae protrude beyond the vertebrae and impinge on the nerves, will lead to nerve damage and muscle weakness.

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

Sixty patients, who were advised surgery for a protruding disk or spinal stenosis, were studied when enrolled in a 10-week back-strengthening exercise 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% 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 that 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 longterm experience after surgery for spinal stenosis is less known at this time, but it is known to provide effective relief of pain, and patients are able to return to full activity. 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 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 and 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 or other devices, back fusion can be accomplished.

Qualified orthopedic surgeons and neurosurgeons trained in the principles used in these procedures to 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, 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 with gentle active and passive exercises. It may take one to four weeks to return to normalcy.

See your physician to get an evaluation of the extent of the problem, and for a referral if needed. You should feel free to seek hands-on manipulative treatments. Your insurance policy may not cover costs.

For chronic pain, it is better to start a serious program of strengthening and stretching exercise, including manual treatments prior to seeking a surgical solution. When you do, you will require appropriate radiographic 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 is 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.