By Dr. Ronald S. Dubin
Guest Columnist

Today we will be discussing one of the most common complaints of pain in the human body —low back pain. Soft tissue injury like sprains (ligaments) and strains (muscles) are, by far, the most common injury that produces low back pain. Treatment for these maladies are simple, initial rest, ice (first 48 – 72hours) then warm packs, exercising, cessation of smoking, anti-inflammatory medications and no narcotics (unless absolutely necessary and then for just a day or two). The other group we will discuss is when there is external pressure on a nerve root from scar tissues, herniated disc, bone spur (osteophyte) and other conditions. 

Lets say you go to your doctor and he orders an MRI with the findings of a herniated disc abutting against the nerve. And then he says that you need an operation and sends you to an orthopedic or neurosurgeon to have this surgery. What then? What’s the next question you should be asking yourself at this time? Is the pinched nerve actually causing the back pain or is the pain coming from another source and the pinched nerve is an incidental and insignificant problem. It is extremely important to know where the pain is coming from because doing spine surgery for the wrong diagnosis usually results in a poor outcome.  

There are no magical or universal methods of back pain treatment. Go see 10 doctors for LBP, and you’ll get at least 15 diagnoses of the cause of the pain and maybe 30 ways of treating it. Many doctors approach problems differently. Go to a Chiropractor, and he will tell you your spine is not in alignment and he will pop your back. Go to a physiatrist and he will order physical therapy. A Family doctor or internist will probably order you medications. A surgeon? He will naturally include surgical options. So then, how does a patient without much medical knowledge decide what’s best for them? Advice from a friend? Advertisement? Meetings? Referral from your doctor? 

I have always practiced that the simplest things in medicine are the best treatment options — initially. I almost always recommend conservative treatment (non-surgical) first. This would include PT or a trial of steroid medication. Try a back brace or whirlpools, hot tubs, ice baths (ouch) or spinal manipulation. Anti-inflammatory medications should also be used.  If these modalities don’t work, you lose nothing for the most part. It’s not only the safest means of treatment for low back pain, but it also allows your own body to try to heal you. After all, the best healer in the world are the powers above and your own biological frame. 

And speaking about your biology as a healer, no matter what treatment you ultimately will undergo, even surgery, your body will need to complete the healing process. So let the natural wonders of the human body take its course. Sometimes all your body needs is a little push and encouragement from your physical therapist or Chiropractor.

So now it’s now six months after your original non-surgical treatment and the pain is still there. You can’t sleep at night, every time you move it strikes pain. Something further has to be done. It might be time for a trip to your spine surgeon. So who do you go to now? I would always recommend getting a referral from your family doctor who hopefully knows the best experts in your area. Be sure to ask him who he would send his family to. If he is not sure of this, ask another professional the same question. 

A lot of people want to go to the Mayo Clinic because they have a good reputation. But wait, if you want the Mayo, always remember to be referred to a particular doctor there, not just the clinic. The bricks that built the “Mayo Clinic” building do not treat you. A doctor does. Always try to get the name of a good specialist and make sure you’re referred to that person at the Mayo. Remember, even the Mayo has some bad doctors and you probably would want to stay away from them. 

Choosing the right surgeon to operate on your back is vitally important. Some suggestions to think about? Neurosurgeon or orthopedic surgeon? University setting, outpatient surgery vs. inpatient? Local doctor with a good reputation or a distant medical center with all the headaches involved in long distant travels. A prolific surgeon who brags they have performed hundreds of these operations you need or a more measured surgeon who more carefully screens their potential patients. I would choose the latter physician for many reasons based upon the indications they use for their surgery. A surgeon who operates on just about every patient that they see might be a good surgeon but not everyone needs the operation he frequently performs. Their indications for surgery casts a wide net with undoubtedly many poor results.

Let’s move on to what I believe is of underestimated importance in the spine business. The “cause and effect” of what’s causing your back pain. We will use you as the patient with a herniated disc pushing against a nerve in your back. You go see the doctor your primary provider referred you to. You walk in with the MRI in hand and he reviews the scan and report that shows you have a herniated disc. He then advises that you need to have surgery. WAIT, how do you know this is a cause and effect problem? He tells you that he has performed hundreds of these operations and they all got better. “Huh,” you shrug as you begin to have some doubt in your mind. No doctor needs to brag about their accomplishments to their patients. 

“Doctor, how about doing a physical examination on me?” He politely says OK and does a precursory exam and you notice that you have no weakness, numbness or tingling in your legs. After all, these are what pinched nerves do to your legs. You tell the doctor that you are the patient and that you want everything lined up for this pending operation to be successful. You remind him of all the previous people you knew who had back surgery, many had chronic pain afterwards and that their operation was unsuccessful. You demand more testing. You demand to have a 3D CT scan of your lumbar spine. You remembered from your past readings that this 3D rendering can display in great detail the bony structures of your spine and you want to be sure this is all taken into consideration. 

He tells you that his hospital does not have this test available. Disappointed, you tell him that you want, instead, a complete nerve study on your back to make sure that the herniated disc in your back aligns with the level of the disc associated with your history and physical exam as well as the side it’s on. A right sided herniated disc for your left sided symptoms, for example, will not help you. Now you got him shaking. He hesitates because he knows how important this study is to determine the success of disc surgery but that very few people ever get this test preoperatively. He trembles at the thought of the nerve test telling you and him that it might be normal and that he just recommended an unnecessary and probably unsuccessful operation to you. But you demand this test because you know this is the best test to confirm your MRI test. What might he do at this point? Probably send you home and tell you that he can’t be of help because you ask too many good questions. 

Nearly everyone who gets a spine operation will have an MRI performed preoperatively. Some patients cannot have this (metal in the eye, aneurysmal brain clip, pacemaker, defibrillator, pregnancy, and some other contraindications.) Let’s say you have a large herniated disc which touches a nerve root in your back. The MRI is clearly abnormal. But is it really? Do all herniated discs in the back cause pain? If you have answered yes, better read on. Very few people in the world have normal MRI scans after 45 years old. 

Bulging discs, herniated discs, degenerative disc disease, degenerative arthritis, and other maladies frequently show up on MRI scans in older people. And in most cases these people have no pain. So, then you ask, how do I determine if my herniated disc is really causing the pain I am experiencing and what my doctor wants to operate on? Remember, in medicine, we do not operate on MRI scans, we operate on people. If a patient has an abnormal MRI, it is up to the doctor to be nearly 100% sure that the disc is really the problem. If the disc is really causing the pain, then there has to be other ways of determining this cause and effect. The best way is to perform a nerve test from an objective neurologist who can confirm this. Most spine surgeons do not order this nerve test in the face of an abnormal MRI scan. 

This is where the educated patient can make a difference. If you are having back and leg pain due to a pinched nerve, you must have a nerve test preoperatively. No exceptions! The cause (nerve root impingement) must be responsible for the effect (leg pain) or the operation will likely fail. A very thorough physical examination is also needed to assess any reflex changes or sensory and motor functional loss. Sometimes a CT Myelogram is performed or a 3D CT scan. But in all instances, all these tests must point to that particular pathology as causing the pain for the operation to work. We could go on forever discussing confirming tests associated with spine surgery for other pathologies. The point here is that spinal surgery is not perfect. A certain percentage of people will not do well post operatively. According to the American Society of Anesthesiologists it is estimated that 20 to 40% of back surgeries fail.  Under these circumstances, it is imperative to get the best diagnostic tests possible and they should all be consistent with the proposed surgery.