Back Away


IVP Duplication

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There is probably no more frustrating problem for patients and physicians alike as persistent low back pain. For most people with back pain resuming their activity quickly, taking occasional muscle relaxants and acetaminophen, gets them back on their feet in no time. When back pain becomes persistent, it’s not unusual that patients become more concerned and want to know why it hurts and what can be done to completely relieve the pain.

Standard x-rays of the back are the first step. We look for obvious vertebral deformities that are congenital (inherited), or evidence of destruction of the spine by arthritis or cancer. Fortunately, the majority of the time we find nothing, or maybe some evidence of slight curvature of the spine (scoliosis). Although this provides the patient and physician some reassurance, it doesn’t address the problem of persistent pain. Moving up the scale of available tests, we start to get into neuroimaging and here is where it begins to get tricky.

CT scans of the lumbar spine are quick, painless for the patient—other than a little radiation of course—and usually approved quickly by insurance. They show bone and muscle relatively well and may give some information about the disc and the spinal nerves in between the vertebrae. MRI scans of the spine give a more detailed picture of the nerves and spinal cord. They’re also painless, use no radiation, and are usually difficult to get insurance approval due to their exorbitant cost.

A rupture of the discs in between the vertebrae can place pressure on the spinal nerves, what we typically associate with causing the pain. Most of the time however, we see only a bulging disc with no rupture, something that does not explain the pain adequately. We may also see lumbar stenosis; a tightening of the spinal column (usually caused by arthritis) around the  spinal cord. Spinal cord compression not only causes pain but muscle weakness as well.

Before we start singing, “Hi ho, hi ho, it’s off to surgery we go,” some new clinical studies throw new light on this subject. For patient’s without muscle weakness, conservative medical therapy consisting of low back exercises and non-narcotic medication was as effective as surgery. Epidural injections, where steroids, pain medication or both are injected around the spinal nerves might be affective, but only in very limited cases. The good news is when we use our crystal ball, most patients with low back pain, that doesn’t cause muscle weakness or other worrisome neurological signs, eventually do well with conservative therapy. That’s good to know if you’re feeling pushed to have surgery. Best advice: back away and give it time. When it comes to treating back pain, less is more.

About Steve P. Sanders

A general internist writing and sharing ideas and art.

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