Saturday, March 17, 2012

Oh, My Aching Back!

Growing up, I experienced my fair share of back problems. I suspect much of it had a genetic underpinning because my mother has her fair share as well.  Several years ago, I exacerbated my problems with some careless weight-lifting. I won't bore you with the technical details of my stupidity other than to say I ruptured a disk and endured pain that for the first time in my life gave me true empathy for the meaning of pain.

It was bad. If I tried to run, I would fall down due to weakness. The origin of the pain was at the L4-L5, or the fourth lumbar space, but I felt the referred pain predominantly in my hip. A MRI revealed that I had a ruptured disk impinging on my spinal column. (Disks are made of cartilage with a gel center, and sit between vertebral bodies as a form of cushion. As we age, our disks tend to get compressed and that is why most people shrink in height with aging.) I immediately consulted both orthopedic and neurosurgeons.

Due to my previous back pain experiences, my having trained as a surgeon including scrubbing in for back-surgeries, and my medical work in several back pain clinics, I was somewhat knowledgeable about the subject.  Nevertheless, my unbearable pain truly scared me and the prospect of surgery scared me more. As a surgery resident, I witnessed a routine back surgery go awry with the patient bleeding out in the recovery room.  I was in no rush for surgery, but I could also hardly bear the excruciating pain.

The neurosurgeon I consulted gave me what had become at that time widely rejected advice. He told me to get into bed and not move for 10 days. For older people, such immobility can increase the likelihood of a life-threatening blood clot. I was willing to take the risk to avoid surgery. He explained that ruptured disks tended to dry out relatively quickly and shrink. Furthermore, as they shrink they will move away from the spine and symptoms abate. If I continued to move freely, he said, I risked the disk material moving closer to the spine instead of wilting away.

I decided that I was willing to follow his plan to avoid surgery. I discovered a bed position that lessened the pain somewhat and otherwise did not leave my bed other than for toileting. (All I can say is thank G-d for my wife. She took incredible care of me.) The pain resolved and after ten days, I was mostly good to go.

However, during those ten days in bed , I tried to read everything I could about back-aches and back or spinal surgery. The internet was replete with information and I had plenty of time. I discovered that recent studies had shown that in most cases, at the two year mark, there was no difference between those who had undergone surgery and those who avoided it. In fact, many people with similar MRI findings were asymptomatic and most pain was due to muscle spasms that resolve over time.

There were, however, three major determinants for which these studies held no value.

Before I get to them, let me tell you what prompted this blog. There was a segment on this past Friday's Dr. Oz Show. Dr. Oz declared that 90% of back problems resolve on their own and therefore people should not undergo back surgery. He made it seem like his pronouncement was a big deal as he was ratting out his fellow surgeons.

I concur that most cases resolve on their own, but suspect, but don't know for sure, that more than 90% of back problems need no surgical intervention. It is reported that 9 out of 10 Americans have a back problem at some point in their lives and 5 out of 10 working people deal with a back problem during each year.

Dr. Oz made it seem as if most back surgeons, either orthopedic or neurosurgeons, routinely recommend back surgery. In fact, statistics show continuing declines in routine uncomplicated back surgeries.

(There have been some concerns raised  lately (see WSJ article from Feb. 2011 cited below) about increasing surgeries for older people related to spinal stenosis (narrowing of spinal canal). http://online.wsj.com/article/SB10001424052748704629004576136682824401852.html.)

Today, spinal surgery is considered the treatment of last resort for back problems. As I mentioned earlier, there are three exceptions.

The first is a rare, but serious condition called Cauda Equina Syndrome, related to complete blockage of the lower spinal canal. This condition is an indication for immediate surgery as it can result in permanent paralysis if not treated promptly.  It generally presents with increasing bilateral numbness of both legs. Again, it is rare and it is relatively easy to diagnose.

The second indication for back surgery is unrelenting, excruciating pain. Yes, the pain may very resolve over time, but in the interim you can't hear yourself think because the pain is so daunting. Phil Simms, the former NY Giants' quarterback and newscaster, suffered such back pain that he relented to having surgery, which he successfully underwent for a complete resolution of his problem.

The third indication is when the pain has become chronic. If you have had pain for a prolonged period of time and it either not getting better or is getting worse, surgery may be indicated.

However, as an aside, one thing is perfectly clear. Excessive weight puts excessive pressure on our skeletal frame including our back. People with unhealthy weight generally resolve many back problems with weight loss.

For some reason, Dr. Oz failed or chose not to mention this fact,even though the women he was speaking to seemed to be in this category. I'm not suggesting he should have embarrassed anyone. Nevertheless, it would have been proper for him to emphasize that unhealthy weight is a major cause of back problems and for that matter, many joint issues. More importantly, a healthy weight loss program helps resolve many of these musculoskeletal problems.

Perhaps there are still some unethical surgeons pushing unnecessary back surgery.  However, that is the exception to the rule. If you have back pain, and you can live with it, you should try to do so as long as possible because it will most likely resolve on its own. No need to run to a doctor for every back problem. This is not medical advice, just practical advice.

In the short term, I have found that the combination of a back-brace worn for NO MORE THAN 2 DAYS (after two days of wearing a back brace, back muscle begins to atrophy and will cause even bigger problems), with ibuprofen often allows an acute episode to resolve by letting the affected nerve inflammation decrease. As a preventive measure and to stop recurrence, strengthening your stomach core also works, as do certain back stretching exercises and yoga.

But know your body and if the pain gets worse or you develop numbness or tingling in one or both legs, take heed, and seek urgent medical attention.

As for me, after changing my lifestyle and losing some twenty plus pounds, I no longer suffer from back pain. Just one more benefit of healthy living. I highly recommend it.



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