Back Pain

Back Pain and Surgery – The Double-Edged Blade of Surgery

One of the most common complaints by patients is back pain.  At some point, almost everyone will experience some form of back pain that prevents them from doing the things they enjoy.  With the billions of dollars that are spent each year, it is important to understand that what was once thought as best for treating back pain may not, in fact, be the best option:  surgery.  That’s the big, scary word that gets thrown around a lot these days.  To some of us, it rings terrifying images from those horror stories we have all heard.  Yet for others, it is the first thing that comes to mind when this kind of pain arises, especially considering all the times we are inundated with news about a professional athlete going under the knife to fix an injury.  We see it so much in our daily news, it almost appears as if surgery is the best and only option for your ailments.  What is usually missing from these stories is information about all the complications that can arise, all the weeks of intense physical rehabilitation, the laboring recovery and, just as important, all the times surgery fails.  The truth of the matter is we now know that too much surgery has been done in the past for the treatment of back pain.

What is back pain?
Back pain can typically be divided into two categories:  acute and chronic.  The types of therapies available for each will vary, as will the length of recovery time.  Most back pain results from injury or trauma to the back.  One of the most common forms of injuries we see is from repetitive stress, which is something that occurs from years of abuse by way of poor posture, poor sleeping habits, poor physical conditioning, smoking, obesity, and many other various causes.  We so often hear about that friend who “threw out his back” while tying his shoe lace.  What is often forgotten about this picture is that the shoe lace was not the cause of the back pain; it is often the “straw that broke the camel’s back.”  Through years of repetitive trauma mentioned above, your back is harmed by micro-trauma, causing small tears in the tissues of your back.  Over time, those tissues begin to scar, which is part of your body’s healing process.  Scar tissue is neither as strong nor flexible as normal tissue.  As this scar tissue builds up from continued micro-trauma, the back slowly weakens, which can lead to more serious injury.  In addition to that, as we age, our strength and flexibility decreases.  The intervertebral discs (the cushions between our vertebrae) begin to lose fluid and become less flexible, which decreases their ability to cushion our spine.

Other causes of back pain can result from degenerative arthritis, infection, tumors and other serious conditions.  Some of the conditions that will require help from a specialist include:

Bulging disc, which is not to be confused with herniated or ruptured discs (both of which can present very similarly, but are more serious types of disc injuries).  The joints of your back need the proper biomechanics to maintain the health of these discs.  Did you know that they play a role on how tall you are?  Did you ever notice that when you enter your car for the first time in the morning that you have to adjust your rearview mirror?  What about at the end of the day?  That is because your discs expand slightly while you rest at night, and they get a little thinner through daily stresses. To picture this, think of your intervertebral discs as water balloons that are wedged between two hard surfaces.  When the balloon is put under too much pressure, it starts to flatten and bulge, just as your intervertebral disc does.  These bulges can then put pressure around the surrounding tissues, particularly the spinal cord and nerve roots.  This can cause one of the most common symptoms:  back pain.  If even more pressure is put on the discs, they can become further injured, resulting in a herniation or even a rupture of the disc, causing the inner substances of the disc leaks out, which further irritates the tissues.

Sciatica is a term describing pain that travels down the back of leg below the knee, and sometimes into the foot.  The sciatic nerve is actually a large bundle of nerves that exits the lower part of the spine and travels through the buttocks and down the back of thighs.  Impingement of this nerve bundle can be caused by a disc injury, degenerative arthritis, muscle spasm, or by a more serious condition such as a tumor.

Cauda Equina Syndrome occurs when a disc injury or bony protrusion is severe enough to place direct pressure on the lower part of the spinal cord.  This condition is much more serious, as it can lead to permanent neurological deficit if not treated.

Spinal Degeneration occurs when arthritis sets in and decay of the spine narrows the spinal canal or spinal foramina; patients often complain of stiffness of the back, particularly in the morning.  The spinal discs also become dehydrated and shrink in size.  Smoking reduces the blood flow to these areas, thus increasing the rate of degeneration.  So if you smoke, it is recommended that you quit.

Subluxation
Looking at the anatomy of the spine and intervertebral discs, you will see that discs cannot “slip,” as the saying goes.  The intervertebral discs are securely connected to the vertebrae surrounding them, and thus do not translate in relative motion to the spine.  When people describe that feeling of a “slipped disc,” it is often more accurate to describe it as a slipped vertebrae, otherwise known as a subluxation.  Subluxated vertebrae can become fixated and cause irritation to the surrounding nerves, often presenting as back pain.

How is back pain diagnosed?
It is important to remember that there can be many causes of back pain, and that back pain itself is not a diagnosis.  In order to properly treat back pain, you need a proper diagnosis; and the earlier it is found the better your prognosis will be.  To get the proper diagnosis, a thorough examination is required.  As a patient, you can recognize what a thorough exam is because your appointment will probably be more than 2 minutes long.  If all your doctor did was ask you a couple of questions, it probably was not sufficient.  If they just lay you on the table and start treating, or hand you a prescription for medication without even touching you, it would be in your best interest to seek a second opinion.  A thorough examination should include:

• A detailed health history – This includes questions about your current complaint AND your past problems. You can help by clearly answering the questions asked.
• A visual inspection – Visually looking at your posture and area of complaint.
• Palpation – This means to physically touch and feel at the areas of complaint and other associated areas.
• Instrumentation – There are many tools your doctor can use to measure their findings. These tools provide more accurate and objective findings. Would you be okay with relying on your carpenter’s ability to estimate the measurements of the cabinets he’s building? Or would you be more comfortable with him using a ruler?
• Range of motion – This is to physically measure your ability to move your back in all directions.
• Orthopedic tests – There is a wide range of specialized tests that can be done to help confirm the cause of your back pain. These often include testing your ability to perform specialized tasks or maneuvers.
• Muscle testing – This is used to check your strength.
• Neurological testing – This includes motor and sensory testing to make sure your nerves are working correctly. Your reflexes are one of the most common ways to test this.
• Special tests – these could include things like X-rays, an MRI, CT scan, EMG, etc. These types of tests should be performed when they are medically necessary, which is determined by your doctor.

Know what is causing your back pain
Keep in mind the danger of self-diagnosing your problem.  As with most ailments, back pain can be caused by very serious conditions.  Only your doctor should diagnose the cause.  Many people self-diagnose their ailments and prescribe themselves over-the-counter medication, often failing to mention to their doctor they are taking them.  Remember that all medications, prescription and over-the-counter, can have serious side effects.  On top of that, they can have very serious adverse reactions to other medications, or are even unsafe to take in certain situations, such as pregnancy.  If you choose to use medications of any type, be sure to keep your doctor informed about it.

Treatment Options
In a recent survey conducted by Consumer Reports, subscribers were asked which type of care they were highly satisfied with to treat their back pain.  The results were as follows:

59% – Chiropractor
55% – Physical Therapy
53% – Acupuncture
44% – Physician, specialist
34% – Physician, primary-care doctor

This report is a survey, and not a scientific study comparing the effectiveness of each treatment.  This does not mean that there is not useful information here.  One of the most important things we can gather from this is that as consumers, we do not tend to continue using something that does not work.  The results of this survey are compelling in that they indicate more people are satisfied using hands-on treatments such as Chiropractic, massage, physical therapy, and acupuncture than the traditional western medicine approach.  This is consistent with the findings of Hertzman-Miller from 2002, which found that Chiropractic patients were more satisfied with their care than medical patients.

The good news is that most low back pain can be treated properly without surgery.  With that being said, let us look at some treatments available for back pain:

Surgery
As mentioned previously, surgery for back pain has often been an over-used treatment option.  The majority of low back pain can be treated effectively without the use of surgery.  As most professionals agree, surgery can be effective to treat back pain, but should be the absolute last resort.  If the cause is serious enough or if conservative care is not helping, only then should surgery be seriously considered.  Surgery is a life-altering procedure and, once done, your spine will never be normal again.  There is also no guarantee that a successful surgery will relieve your pain.

Medicine
Most back pain can be resolved within 3 months, with a great number of cases being traced back to a biomechanical cause.  However, recovery can be complicated if your body is not allowed to heal as it should.  Pain and anti-inflammatory medication, including spinal injections, can help with back pain, but it is well known that this type of care is more of a bandage on the problem than a solution.  Numbing the pain does very little to address the cause of the problem, and many times can make it worse.  Pain is an important part of the healing process, as it is a warning sign to alert you that an injury is present.  Though medication might make you feel better, it prevents this vital warning process.  Thus you may play that extra round of golf causing more injury because this warning system has been shut off by the medication.  There are also concerns of drug addiction and serious side effects of prescription and over-the-counter drug use.

Bed Rest
Though it has been known for years, recent studies have confirmed that bed rest is not the best option for treating back pain.  In may be necessary in severe cases, but it is generally recommended that you resume activities as soon as you are able.  There are severe complications that can arise from long-term bed rest and it can make back pain worse.  The idea is not to go play a game of full contact football, but instead to be up and moving doing the activities you normally do.

Physical Therapy
Strengthening exercises can be very effective in reducing the recovery time of back pain.  Physical therapists are highly trained in working with back pain.  The use of routine stretching and strengthening exercise not only can help recovery, but can prevent the recurrence of back pain.  Some physical therapists may also perform general manual manipulation.

Graston Therapy
As mention previously, many causes of chronic back pain may result in significant scar tissue.  This can often cause further pain and muscle spasm to these already injured areas.  One method used to treat soft tissue scars is Graston Therapy.  Through the use of specialized stainless steel tools, the grainy scars are broken down, thus mobilizing these tissues.  The premise of this procedure is to re-injure the scar tissue in a controlled environment.  Patients are prescribed specific exercises that must be done in order for those tissues to heal correctly.  Cases can be treated with as few as 6 visits before seeing significant progress.  Graston Therapy has been successful in treating post-surgical scar development, plantar fasciitis, carpal tunnel syndrome, and various other chronic conditions.  Although this procedure currently does not have many peer-reviewed studies published about its effects on relieving back pain, many practitioners are reporting substantial success with Graston Therapy.  Since it may be considered experimental, many insurance coverage plans do not cover this therapy, so patients may need to seek care out of their network.  Practitioners using this method are required to have additional training for this therapy.   To find a certified practitioner near you, visit Graston’s website.

Chiropractic Care
Recent studies have indicated that Chiropractic adjustments are very beneficial with back pain, and are one of the most cost effective forms of care, especially compared to spinal surgery.  Chiropractic adjustments work in restoring alignment and function of the spine.  There are varying methods to provide the adjustment, which should be tailored toward the severity of your back pain and your personal profile.  One method that is often used is Activator Methods.  Doctors must receive additional training to become certified practitioners of Activator Methods.  This method utilizes an instrument that delivers a gentle high-speed adjustment while the patient is kept in a neutral position.  See the Activator website for a doctor that is certified in your area.

Other Alternative Therapies
There are other types of conservative care including acupuncture, biofeedback, naturopathy and massage that can help back pain.  Often times, doctors will recommend these types of care in adjunct to the care they prescribe.

Let’s Prevent Back Pain
Regardless of which type of care you choose, the most effective treatment for back pain is prevention.  If you have already suffered from back pain, this does not mean it is too late.  Preventing future occurrences may still be possible.  This type of care requires your active participation through modification of lifestyle, ranging from diet, ergonomics and posture, strengthening exercises, stretching exercises, stress management, and maintaining alignment.

Eating a healthy diet is absolutely essential.  Being overweight puts excessive stress on the joints of the spine.  Your body also needs the proper nutrients to keep you healthy, including the proper amounts of calcium and vitamin D to maintain bone strength.  The best sources of your nutrients come from fresh fruits and vegetables, particularly the green leafy vegetables and colorful fruits (strawberries, tomatoes…).

Keeping active and fit through regular core strengthening exercises and stretches can decrease your chances of a back injury.  Other exercises such as yoga or pilates are wonderful for this too, since they promote both strength and flexibility.

Your teeth require proper maintenance and routine check-ups with your dentist to keep healthy.  Your spine is no different, and should not be ignored if you wish to keep it healthy.  Keeping your spine aligned with routine check-ups can help keep it healthy and moving well.  The frequency of your check-ups should be discussed with your Chiropractor.

Thousands of work-related injuries are caused by ignoring the principles of ergonomics and posture, along with the exposure to heavy lifting, repetitive stress, vibration, and long hours.  Many successful companies these days have begun applying ergonomic awareness programs in the workplace.  These programs promote the reduction of risks to injury at the workplace AND at home by maintaining health, use of ergonomic equipment, education, and exercise.  Many of these companies are now starting to hire outside agencies to help with these programs.  These agencies provide doctors and specialists who educate their employees during monthly safety meetings about precautions they can take to prevent injuries.  The obvious cost benefit can be very significant for the employer.  Discover Chiropractic has been very active in providing these programs to the community, which provides the Mankato area businesses/organizations cost-effective alternatives to outside agencies.

If surgery is recommended
If your doctor recommends surgery, the most important thing to do is to get a second opinion.  If this means you have to travel some distance to see another specialist, it would be in your best interest to do so.  Do not be afraid to seek more opinions.  The decision to have surgery is life-altering, so make sure you are well informed.

Do not be afraid to ask the hard questions.  Find out how many of the specific types of surgery proposed your surgeon has performed.  Ask to speak with someone the surgeon has performed a similar surgery on.  There might be a lot of people who have gone through the same thing, and they are often very willing to discuss it.  Speaking to the therapists that you will be working with for recovery can give you insight on what to expect.  You might find that with the more research you do, you may get a better picture of your surgeon’s reputation.   Though it might be important to like your doctor as a person, finding one with surgical expertise should be your focus.

Also be ready for the help of others.  The process of surgery cannot be done alone, and neither can the recovery.  Simple tasks that you take for granted (as bathing, cleaning, cooking, walking…) are going to be much more difficult.  Having a good support system around you is absolutely essential.

You may also want to consider alternative care for post-surgical recovery.  There are various types of care that are helpful in pain management and the healing process.  Many post-surgical patients seek these alternative methods in addition to traditional physical therapy and pain medications.  Chiropractic care is very safe and effective in post-surgical care, not only with pain relief and the healing process, but also with prevention of further deterioration.

As important as anything else: If your doctor does NOT recommend surgery, consider seeking other types of care.  The “wait until it’s bad enough for surgery” approach often includes weeks, months, or years of unnecessary suffering.  Most patients in this situation are in severe enough pain that they are willing to do almost anything.  You do not need to wait until it is this severe.  Just remember that there are options available.  Many people who suffer from back pain have found great relief through Chiropractic care.  It is amazing to see the number of people who were able to avoid surgery under the care of their Chiropractor.

DID YOU KNOW?

• See your doctor if your symptoms include radiating pain down the leg, numbness, weakness, difficulty with bowel or bladder control, or any unexplained weight loss.
• Smoking can have devastating effects by decreasing needed blood flow to injured areas.
• If your pain persists for more than a couple of days, it is time to see your doctor.
• Medication may help your pain, but this is more of a bandage over the problem.
• The types of treatment and length of time to treat back pain can vary.
• Surgery should be the last resort.
• Get a second opinion.  If never hurts to get a second opinion, especially when any type of surgery is being recommended.
• A successful surgery may not alleviate your symptoms.
• The best treatment for back pain is PREVENTION.  Do not wait until the problem becomes severe.
• Your Chiropractor can provide very effective methods to treat back pain, and is significantly less costly than other types of care.

Sources:

Haas et al (2005), Journal of Manipulative and Physiological Therapeutics

Hoving et al (2002), Annals of Internal Medicine

“Low Back Pain Fact Sheet,” NINDS.  Publication date July 2003.

NIH Publication No. 03-5161

Nyiendo et al (2000), Journal of Manipulative and Physiological Therapeutics