How do you diagnose a disc herniation?

This seems to be a popular question so, here we go.

Disc herniations are easy to find. 30 minutes in the old MRI machine and wham, there they are (or aren’t if you don’t have any). Case closed, right? Wrong!

Many disc herniations that show up on MRI are not causing any problems. They are innocent. I know what you’re thinking. My disc is torn or ruptured or slipped or something terrible like that and you are saying that is OK??!!

Actually, sort of. Studies have shown that if you go out to your local mall and grab the first 100 people you see that don’t have back pain and never have and take them to get an MRI…………..about 30 of them will have disc herniations.

But, you say, it must be about to snap!! Like a tinder box about to go up in flames!! Not really. Disc herniations are one of those things that don’t matter…unless of course they do.

Figuring out whether they do or not is what you need a doctor and a good old physical examination for. I guess you can’t outsource the docs yet.

My back hurts. What kind of treatment should I get?

It is hard to be a patient with back pain. Everywhere is conflicting advice. Surely, though, your healthcare team will give you up-to-date and unbiased advice, right?

In short, not a chance! Most (MD’s, DC’s, LMP’s, PT’s, DO’s, ABC’s, etc) are going to tell you either: a) you’ll be fine, just wait b) you need whatever it is that I do. If their treatment fails, you may get one referral to someone else that they like (personally). Otherwise, the pain is in your head…or there is nothing more to do…or just keep getting my treatment…or….

Since nobody is going to give you a straight answer, here is my guide on how to use the different providers:

Family Practitioner (MD or DO): They are going to be fairly good at ruling out a nasty cause of your pain, particularly cancer and infection. If you have an exotic arthritis, they will probably figure it out with time.

Massage Therapist (LMP): Massage is a great adjunct to other treatment, but not enough usually on it’s own. Combine with Physical therapy and/or chiropractic.

Chiropractor (DC): I wish I could say, go find a chiropractor and he will help you with what he can and manage the referrals for the other care that you need (massage, physical therapy, surgical consults, etc.). Many do this, but not most.

Chiropractic adjustments are very efficient and effective treatments for a majority of back and neck complaints. Combined with physical therapy exercises it is even better in most cases. Generally, the chiropractor should be able to guide you through the exercises that you need, which should not be too many – if so, you may need a physical therapist.

Unfortunately, many chiropractors treat everyone the same and just crack your back without good diagnosis or making sure you get the other treatment you need. Finding a good chiropractor can be difficult, but it is worth it.

Physical Therapist: For most back pain, physical therapy exercises are effective and often necessary. PT’s tend to give to many useless exercises along with the useful ones. Often a chiropractor can give you the exercises that you need more efficiently, but if it is more complicated, or your chiropractor can’t handle it, you will need a PT. You can’t throw a dart at the phone book here either and have a reasonable chance, but good PT’s are out there.

Surgeons (MD, DO): You probably should not have back surgery. Just having a herniated disk does not mean you need back surgery. However, if you do, go to a neurosurgeon that does mostly spine surgeries. You will have the best luck here.

What about cortisone injections and prolotherapy and those fancy traction machines with an “86% success rate” and…and how much treatment do I need? Next time.

Warning: This is a (very) general guide on who does what well. It is to help you find someone to treat you, not so you can diagnose yourself and ignore medical advice given to you. If you are unsure of your current treatment or diagnosis, etc, get a second opinion from a live person in the flesh, not a blog!

When should I see a doctor for low back pain?

When back pain strikes, I know your first response: It will go away. Actually, at first this is a good reaction. However, if these symptoms mean you NEED to be checked out:

1. New pain that lasts longer than 2 weeks.
2. Pain that does not improve with rest.
3. Weakness in your leg (i.e. dragging your toes on one foot, etc).
4. Fever.
5. Numbness in the areas that would touch a saddle if riding a horse, or difficulty going to the bathroom (whether unusually difficult, or coming without your intention).

So, if you have any of the above you MUST go and be checked out at least. However, what if your back pain comes and goes?

If you have 3 or more episodes of the same pain that last longer than 1-2 days, you should be treated.

Now, of course, you are wondering: who should I see? what kind of treatment do I need? how much treatment do I need? We’ll get to some of these questions in the next day or so.

The Back Pain Vaccine

Last time we talked about endurance exercise being important for back health. Today I’ll show you an exercise.

This exercise is called the Bird-dog, because………………it makes you look like a bird-dog. (Google that if you don’t know what that is ). This is one of the best exercises for those multifidus muscles that we showed last time.

The elements of endurance and coordination are both present in this exercise. She is making one mistake and should move her “down knee” forward until it is straight up and down. Also make sure that your pelvis is level with the floor.

You want to hold this position for 10 seconds per side. Work up to doing this 10 times per day, for a total of 100 seconds per side – easy! If you do this less than three days per week you are probably wasting your time. 3-5 days is great. More than 5 days won’t add much.

How easy, or hard this exercise is will tell you something about the shape of your back muscles. If you are bouncing, jerking and generally having a hard time holding this position, good news! You have room for improvement. : p

When this gets too easy, don’t add ankle weights or have your little brother sit on your leg. Instead, lift the arm opposite your “up leg”. So lift your right leg and left arm, for example. Still hold for 10 seconds and 10 sets per side.

This is the first step to health and happiness…or, at least, less back pain!

Back Pain Myths: Strong Back Muscles

On a daily basis, I see patients who suffer more than they should because of some common back pain myths. Today’s myth: Strong back muscles will protect your spine.

Wrong!

Your body has two types of muscle (really more than this, but the others are in your internal organs), movers and stabilizers. Movers are big muscles that move your body parts, hence the name. Stabilizers are muscles that hold your parts in place and prevent you from being damaged while the movers are moving you.

Your multifidus muscle, pictured below, is an example of a stabilizer muscle.

To prevent back pain, you need your stabilizer muscles to have endurance. They protect your spine. If they work as long as you do, everyone is happy. If they quit before you do….ouch!

These muscles don’t need to be strong, but they need to be able to keep going and going….and going.

The problem with exercises for strength is that they tend to work the “movers” more than the stabilizers. And, when they do work the stabilizers, they can change them from slow-twitch (endurance) muscle to fast-twitch (powerful) muscle.

Studies of back pain patients show that high percentages of patients with chronic back pain have a different mix of fast vs. slow twitch muscle fibers. Studies also show that those with back pain tend to have very low endurance of their stabilizers – particularly the multifidus.

Tomorrow: preventing back pain with endurance exercises. Stay tuned!

What do surgeons say about disc replacement?

While reading this morning about the first spinal disc transplant, I was reminded of the excitement over the artificial disc a while ago. It was a big deal! It was revolutionary! The Seattle Times did a big piece on a woman who was miraculously cured, etc. etc.

I was skeptical, partly because it made sense to be and partly because………hey, I was born that way. About this time I talked to a local neurosurgeon and asked him about it. He didn’t think it was very effective. But, people will want it….”so I’ve got to offer it.”

More recently I was at a continuing education meeting with a group of mostly local spine surgeons. The presenter gave a clinical vignette (i.e. a made up patient case, describing a patient with intense, persistent back pain). He then asked how many, by a show of hands, would opt to get a disc replacement surgery if THEY WERE THE PATIENT. Not one hand went up. 50-75 spine surgeons in the room and not one would subject themselves to a disc replacement!

Do unto others as………..?

Adult Scoliosis: The Real Story

Earlier I wrote a mild rant about doctors scaring adult patients with mild scoliosis (click here to read).

After finding out that some of the common fears are overblown, some of you wanted to know what is a realistic expectation. I am glad you asked. Some Swedish researchers followed a group of patients with adolescent idiopathic scoliosis, who were treated with bracing as adolescents, for more than 20 years.

Over this time, the average increase in the size of the scoliosis curve was 7.9 degrees. One scoliosis patient out of 127 had a large increase of 27 degrees and ended up with surgical treatment. The odds of having a large curve increase were 0.079% in this study. Or looking from the other side, the odds of having mild curve progression were 99.21%.

The scoliosis patients did have more degenerative disc disease and more mild back pain. Of those with scoliosis 75% had back pain compared to 47% of those without scoliosis. Remember, the pain was mild and only 24% had daily pain.

Clearly this is not the horror story that some clinicians are selling to patients with scoliosis. And, if you are one that has a very mild curve, these statistics don’t even apply to you.

If you had scoliosis as a teenager – enough to require bracing – you can expect to have mild back pain and some extra spinal degeneration. Not great, but not too bad either. (click here for the study)

What does your doctor know?

There is a famous basic competency test to test doctors’ knowledge of musculoskeletal medicine (necks, backs, shoulders, knees, etc). Many studies have shown that most medical school graduates fail this test.

In one particularly galling study, 70 out of 85 orthopedic residents – students who had graduated from medical school and were doing a residency in this very subject – failed.  There are many, many more studies like this. Osteopathic school students, who study spinal manipulation and would be expected to have a decent passing rate, showed a 70% failure rate. In other specialties it is worse.

So, when a study came out testing chiropractic students came out I was pretty interested and thought you might be as well. They used the same test as previous studies, but did not count 5 of the questions which were outside the scope of a chiropractor. The average score was 80% (vs. 55-59% in the studies of medical students.

Does this mean that MD’s are idiots? No! The graduates that failed these exams are bright and have vast knowledge in many other areas. This expectation that a doctor should know everything is crazy and dangerous.

It doesn’t matter too much what your doctor knows. Every doctor knows some areas well and others less so. The question is, does your doctor know what he doesn’t know?

Scoliosis: Be Afraid…Be Very Afraid!

On a regular basis, patients come into my office with big worries about their scoliosis. The thing is, most of these patients DON’T HAVE SCOLIOSIS….never had it, never will. But, someone, either at school or some doctor (often, I am ashamed to say, a chiropractor) has told them falsely that they have a scoliosis.

As a result, they carry these visions of future pain and disability around for years. Sometimes they even avoid activities they love because they think it will be bad for their scoliosis.

Here is an example of a mild case of scoliosis. He has probably had this curve for decades. I would guess that his curve is about 20 degrees. Looking at his back, you can see he has a curve. But if you didn’t know to look for it, would you notice it? Probably not.

Even with this long-standing scoliosis, he does not have much disk disease. Looking on his x-ray (it is a little hard to read on the computer at this size), I don’t see any more degeneration than I would expect in someone who has gray hair.

He is doing well. Most of the patients who come into my office have a curve that is half the size of this curve and usually more like 1/4 or 1/8. They have no more reason to worry about their backs than anybody else – at least not related to the curve.

So, what about people with a real scoliosis – as big as the picture or more?…………I’ll put that in another post.

Smoking hurts….your knees?

A new study at the Mayo clinic shows that smoking makes arthritis worse. They followed a group of patients with arthritis pain in their knees for 2 1/2 years.

The smokers in the group were younger, skinnier and had more worn out cartilage. They also had more pain. This is bad all the way around. Their pain started earlier, hurt worse and we cannot just blame their weight (which is a typically overblown cause anyway).

Does this make sense? Or, is this just researchers picking on smokers again? Unfortunately, for the smokers, it does makes sense and the research is pretty good.

To understand how this works, let’s use an analogy of a coal-fired furnace. This furnace (in our analogy) makes the energy that powers the rebuilding of our bodies.

So, when you damage the cartilage in your knees, which we all do from time to time, your body fires up the furnace and mends the damage.

However, your body does not use coal. Your body uses oxygen to make energy.

When you breathe in, the oxygen from your lungs is put into hemoglobin molecules. You can think of these hemoglobin molecules as semi-trucks. These semi-trucks (the hemoglobin molecules) then take the oxygen to the rest of your body where it can be used to make energy needed to repair damage to your body.

One component of cigarette smoke is carbon monoxide (CO). The problem with CO is that it fills up some of the semi-trucks (hemoglobin molecules). So when they go make their deliveries, they have nothing useful to drop off.

If the CO fills up too many of these semis (hemoglobin molecules), you die. We saw this in the news recently when some local (pacific northwest) folks ran generators in-doors during the windstorm and associated power outage.

In a less dramatic case, as we see with smokers, it slows down the healing process. In fact, if a surgeon tries to fuse the spine of a smoker, the body won’t heal well enough for the fusion to work. On a side note, if the smoker quits for six weeks, the fusion will heal, but the patient won’t get pain relief.

One more reason to kick that habit.