Your spine ages with time, just as your hair gets gray and your skin wrinkles. An impressive study followed the spine MRIs of 2,000 patients of different ages having no back pain. Changes showed disc degeneration, disc protrusion, and/or disc bulge began as early as 20 years old, worsened steadily over the years, reaching 90% by their 80’s but still no complaints of back pain in the vast majority. My own spine MRI at 45 looked like a bull mastiff had been chewing it for hours. The chiropractor who ordered it reassured me it was nothing serious, just a pulled muscle. Do my prescribed stretches and my back pain would go away (it did).
Orthopedic surgeons use these Xray and MRI changes to start “the back pain patient” on the assembly line that all too often leads to one or more utterly useless back surgeries. (Many patients have several surgeries.)
Does an MRI of the spine followed by a surgical procedure ever help dramatically? Yes, of course. If the MRI locates a spinal tumor, a totally herniated disc with nerve compression, bleeding within the spine. These are less than 5% of cases.
If you, after several months of back pain, the new mattress does not work and you’re tired of popping Advil, still have pain, then it’s time for a doctor visit. Your primary care doctor does not seem worried because there’s no evidence of nerve damage (weakness of one leg). Although you don’t tell your primary, you’ve been seeing a recommended chiropractor who interestingly does not take x-rays or order an MRI. His treatments are somewhat helpful but temporary.
This is it. You’re not worse, but not better either. You wait four months for one of the mega-orthopedic centers to allow you to enter. The Physician’s Assistant takes your history, examines you, orders an MRI and has you schedule a return visit in a couple of weeks.
This time the orthopedist is present, a worried look on his face. He points out several areas of structural damage. If you were reading what I’ve been writing carefully, most ‘structural damage’ is normal age-related changes and don’t need fixing.
“We’ll try to avoid surgery with physical therapy and steroid injections.”
The “avoid surgery” part is something termed the nocebo effect, from the Latin, “I shall harm.” He says “We’ll try to avoid surgery” conveys to you that eventually you will need surgery. He will try to save you from having surgery. But don’t get your hopes up.
He knows that physical therapy will give you 6 weeks of relief (if that) and you’ll be back again.
He’ll also suggest steroid injection, often painful and often useless. At best, you’ll get a few weeks of relief. And yes, some patients do feel worse.
Ultimately, you’re back, hat in hand, all set for spine surgery.
To be fair, back surgery works best depending on the location of the pain. Sciatica, in which the pain is coursing down one leg, usually caused by a disc compressing a nerve, generally responds best. Most other surgical results can be pretty dismal. Very large worldwide studies show persistent pain in about 40% of patients and a complication rate of 36%.
Other studies show recurrence pain in 60% of patients and with numbers like these, health insurances are less quick to approve back surgeries, one of the main reasons you might have seen a rise in your premiums recently.
A fairly new and expensive procedure has been the spinal cord stimulator in which electrodes are implanted into your spinal cord to deliver electrical current and allegedly reduce pain. The stimulator is fraught with issues (infection, device failure, and a recent study showed that ‘sham’ stimulation work just as well).
Orthopedic surgeons and pain management physicians are extremely resistant to mind-body therapies. Once, when I was invited to give a lecture on Mind-Body Medicine to the Pain Management Group over at Rush, there were some pleasant nurses who attended but no physicians. Not one. “Really,” a nurse said, “Those guys are only interested in expensive procedures. Not your stuff.”
I suggested the nurses read the Bible of mind-body medicine for back pain, “Healing Back Pain: The Mind-Body Connection” by John Sarno, M.D.
And keep in mind the great quote of Upton Sinclair, “It is difficult to get a man to understand something when his salary depends on his not understanding.”
Be well,
David Edelberg, MD