Why Does My Back Hurt?
By Nathan S. Walters, M.D., Texas Institute for Surgery, North Dallas LIVING WELL Magazine
Up to an astonishing 90% of people will experience back pain at some time in their lives. According to the National Center for Health Statistics, over 14% of new visits to primary care physicians are for low back pain. As we age, we endure both macrotraumas, repetitive microtraumas and undergo changes in body habitus that alter and redistribute biomechanical forces unevenly on the spine. Much like your knee, the padding or cartilage (i.e., the disc) is mostly water-based and will progressively degenerate the longer we spend in gravity. This degeneration of the spine has characteristic anatomic, biomechanical, radiologic, and clinical findings and is called Degenerative Disc Disease. Factors such as weight, genetics, trauma, environment can contribute to an earlier presentation of this disease, affecting people of all ages, with radiologic evidence of disc disease increasing with age to nearly 100% by age 60.
Multiple pain syndromes can follow this degeneration. Weak discs can tear and cause back or neck pain. They can also bulge or protrude into the spinal canal and impinge on the nerves that are traveling through to control your arms and legs. Also, when bones don’t have as much padding (disc) as they would like, they form new bone, or “bone spurs”, which can obstruct the areas where the arm and leg nerves are traveling. This can cause arm/leg pain or numbness and tingling.
The patient’s history, as always, is extremely important in my effort to pin down the pain generator. Multiple key questions help me diagnose the source of pain. With pressures within the disc increasing significantly with forward flexion at the waist, patients will typically report exacerbation of pain with prolonged sitting, driving, rising from a seated position, first thing in the morning, bending over to pick something up, tie their shoes, doing dishes, bending over to shave, etc. However, the discs bear some amount of pressure in all positions, so there is some variability. Often there is a specific trauma: I’ve heard coughing, sneezing, vomiting, picking up a table, picking up something as light as a pen. However, just as often, there is no inciting event and patients will “wake up with it.” Relieving positions often include lying flat or on side with legs bent up, sort of in the fetal position. Staying active and moving around is often reported to ease discomfort. Often patients will point to the lumbar spine and report pain in a band-like pattern around the waist line and radiating into hips. Of course, if there is nerve root (sciatica) involvement, there can be a history of pain radiating into buttocks and down the leg.
MRI is currently the gold standard for detecting disc pathology. A magnetic field is used to obtain images with superb soft tissue detail and excellent resolution. This study can reveal disc dehydration, bulging, tears, bone spurs, and nerve impingement. The false-negative of MRI is extremely low; however, the false-positive can be significant (for example, there are millions of people with degeneration on MRI without pain).
What Can I Do?
Descriptions of treatment for low back pain date all the way back to Hippocrates (460-370 BCE), who described joint manipulation and use of traction and decompression. There is a range of treatment options that I routinely discuss with my patients, and my recommendations are tailored to their specific diagnosis. I address the benefits and data with respect to physical therapy, strength and conditioning, chiropractic manipulation, ART, Yoga, Pilates, etc. I then discuss the risks and benefits of all different medication classes, such as anti-inflammatories, muscle relaxants, neuropathic agents, and pain medication. Steroid, a powerful anti-inflammatory, is commonly injected directly at the pain source using x-ray guidance with quick and light sedation. And finally, surgical options are discussed. The majority of patients with back pain will succeed without surgery; however, many times this is the best option.
Remember, there are millions of people with degenerative disc disease that have NO PAIN. An accurate diagnosis is the crucial first step to restoring function and independence.
Nathan S. Walters, M.D., is double board certified in physical medicine & rehabilitation as well as pain management and is medical staff of Texas Institute for Surgery. To learn more about Dr. Walters, visit www.spinedallas.com or call 214-345-1476.