Back pain is a complicated issue
Back pain — can’t live with it, can’t live without it.
That is, it’s no fun to live with back pain, but the chances of living your whole life without it are pretty much nil. About 80% of Americans suffer from the condition at some point, so if you’ve never had your back act up or seize up or go out ... well ... just you wait.
This explains why, in the U.S., back pain is the second most-frequent reason to go to the doctor — right after the common cold. But here’s the rub. In spite of all the knowledge and skill and experience and dedication your doctor may possess, not to mention all the high-tech diagnostic tools that can be brought to bear on your case, there’s a good chance you’ll never find out exactly what’s wrong with your back.
“Back pain is one of the most complicated problems in medicine,” says Dr. James Weinstein, professor of the evaluative clinical sciences and orthopedic surgery at Dartmouth Medical School. “It’s something I’ve been working on for 30 years, and I still don’t understand it.”
The pain can run the gamut from irritating to excruciating. It can include sharp twinges, dull aches and even gasp-inducing spasms that surge like gigantic electric shocks. It can last anywhere from a day or two to years and years. It is said to be “chronic” if it lasts several months. Treatments abound, of course, but they might not help.
“For some of them, at least, the evidence that they work isn’t that great,” says Dr. Matthew Butters, chairman of the department of physical medicine and rehabilitation at the Mayo Clinic in Arizona. Many people can hope only to reduce the length of time spent in misery, not prevent or eliminate it completely.
“Most back pain resolves itself in six weeks, no matter what people do,” he says. “We just try to facilitate recovery, to lessen that time.”
Whether and when to see a doctor for back pain is generally a judgment call. (See related story.)
Dr. Michael Ferrante, director of the UCLA Pain Management Center and professor of clinical anesthesiology and medicine at the David Geffen School of Medicine at UCLA, suggests one rule of thumb: “If it’s just a little ache or pain, take some Motrin. But if the idea crosses your mind that maybe you should see a doctor, then you probably should.”
Once in a while, back pain warns you about something urgent — a tumor, cancer, kidney disease, etc. In fact, one of the main objectives for doctors is to rule out those types of problems, says Dr. Sean Mackey, chief of the pain management division at Stanford University. “And in the vast majority of cases, they do.” But if they should happen to find a “sinister cause,” it will be that condition they treat you for. Getting rid of your pain will merely be a fortuitous side effect.
Still, most of the time — perhaps as much as 98% — even if your back feels like it’s killing you, you can rest assured that it’s not. Getting rid of your pain is the main goal of treatment. In fact, some treatments ignore the underlying cause altogether. They’re simply intended to eliminate, or at least ameliorate, the pain.
Clearly, this is an especially useful approach in cases in which the underlying cause is unknown — as it often is. Obvious suspects include ruptured or degenerative disks, spinal stenosis and arthritis, but matching the right one up with a particular patient’s particular pain can be tricky — so tricky, in fact, that many surgeons and pain specialists say it’s impossible 80% to 85% of the time.
It’s excellent news, then, that doctors can often treat back pain even when they can’t say exactly what’s causing it.
Surgery is the highest-profile treatment for back pain, and it should probably be used the least.
Dr. Richard Deyo, professor of family medicine and evidence-based medicine at Oregon Health and Science University, says it can be very effective for certain conditions: ruptured disks accompanied by sciatica (leg pain), spinal stenosis (narrowing of the spinal canal) and spondylolisthesis (slipping vertebrae).
But just because surgery works for these conditions doesn’t mean it’s the only treatment for them, or even the best. “You should exhaust all other options,” says Dr. Alok Sharan, chief of spinal surgery at Montefiore Medical Center in the Bronx, N.Y., noting any operation’s risk of complications. “Surgery should be your last option.”
Most people with a ruptured disk will get better without surgery. Over time — maybe months or a year — the disk will shrink back. “Some people will put up with that, wait it out,” Deyo notes. “But some people will say, ‘I can’t stand another day of this.’ The advantage of surgery is that it’s faster.”
Still, “a lot of spine surgery doesn’t yield the results that patients would like,” says Dartmouth Medical School’s Weinstein, who has conducted several large studies of back surgery. “They want relief from pain. And I don’t know that you can guarantee that any patient will get rid of pain through surgery. You have to be very clear about expectations before you go into it.”
At the very least, surgeons say, patients should be fully informed about the limitations of whatever procedure they’re considering. For example, surgery has proven to be successful in treating ruptured disks that are causing sciatica, but it’s most effective at treating the sciatica.
“Ironically,” Sharan says, “back surgery is more effective at relieving leg pain than at relieving back pain.”
When you have a bad back, few things sound more inviting than taking to your bed — and few things sound less appealing than exercising. So, naturally, studies have shown that bed rest is exactly what you don’t need. It may actually make things worse. Your muscles weaken and shorten and no longer do their job of protecting and supporting the spine.
So if you hurt your back, go ahead and take it easier than usual for a few days — then get up and get moving. Dr. Daniel Mazanec, associate director of the Center for Spine Health at the Cleveland Clinic, calls a good exercise program “the cornerstone of most people’s treatment. The goal is to improve the strength and flexibility of the muscles that support the spine. And as long as they follow through with the program, most people will get significant relief.”
You don’t always need a special program, Weinstein says. “I tell patients, ‘Try to do what you usually do. If you’re a runner, I say, ‘Run.’ How can you run if you’re hurt? When people use the things that hurt, they actually get better faster.”
“I’m a huge believer in it,” Mackey says of behavioral therapy, summing up the feelings of many surgeons and pain specialists.
Not that they recommend it for everybody; it’s mostly for patients who tend to “catastrophize” their pain. Such patients are unwilling to exercise because they’re afraid they’ll hurt themselves further and end up permanently disabled. Behavioral therapy can help them think about their pain more objectively and see that in most cases their fears aren’t realistic, which makes them more amenable to getting the exercise that can help them get better.
Patients may sometimes take umbrage at the mere notion that they need psychological counseling to deal with their pain. But as Deyo explains, “We know the pain starts in your back, not in your head. It’s just that fear can aggravate it and make it worse.”
There is no dearth of drugs — both prescription and over-the-counter — for patients with back pain. These include ibuprofen and opioids, anticonvulsants and antidepressants (working in ways independent of their primary uses), and topical ointments and oral medications.
In general, doctors try to avoid opioids, especially for long-term use with chronic pain since they can be habit-forming and have serious side effects.
And many doctors encourage their patients to use as few drugs of any kind as possible. After all, they say, having back pain is a lot like having a cold: Sooner or later, it will usually get better on its own. “Let’s not over-medicalize it,” Weinstein says. “Take two aspirin and don’t call me in the morning.”
Two types of spinal injections are often used to provide temporary pain relief for chronic back pain — epidurals and facet injections.
In an epidural, a doctor injects cortisone near the spinal cord, in the area where the pain is thought to originate. In a facet injection, the doctor injects the cortisone into facet joints — which link vertebrae like hinges, allowing for movement — when those are believed to be the pain source. For both types of injections, the idea is to deliver the drug as directly as possible to the place it can do the most good.
Some doctors report success in using one or both types of these injections. But research has not found any significant effects for facet injections. And although epidurals have been shown to give some relief for sciatica, they have not been found to reduce the rate of eventual surgery down the road.
Patients who do get relief from a first injection can have another when the effects wear off … and then another ... and another.... Similarly, if a doctor gives a patient an injection and it doesn’t work, the patient may want to try it in some other spot.
“In fact, people will want to try over and over on different structures,” Mackey says. “But in general I prefer not to continue too many times if it’s not working.”
Then there’s radio frequency lesioning. It’s used when facet joints are implicated in back pain and works by cauterizing the nerves that send pain signals from the facet joints, thus blocking the signals from reaching the brain.
On average, up to half of the patients receiving this procedure get significant pain relief. Even when lesioning is successful, the nerves can grow back. In that case, Ferrante says, the procedure can be repeated “ad infinitum.”
Probably to no one’s surprise, some people can reduce back pain by losing weight, although the role of weight may be confounded by the relative inactivity that is often associated with it. Giving up cigarettes can help too; smoking is known to affect circulation, restricting blood flow to the cartilage that supplies oxygen and nutrients to the disks.
Others find that non-traditional treatments can provide relief, including acupuncture, massage, spinal manipulation and relaxation techniques.
“People should pursue as many avenues as they can think of until something helps,” Butters says.
After all, Weinstein says, “People respond differently to different treatments. We shouldn’t put everybody in one category. It’s important to work with individual people and their individual symptoms and make recommendations specific to them.”
And if patients start feeling discouraged, they should remember that healing is often a slow process, says Dr. Heidi Prather, associate professor of physical medicine and rehabilitation in the department of orthopedic surgery at Washington University in St. Louis. “They should expect the ride to be bumpy, full of ups and downs, good days and bad.”
They should also remember, Deyo says, that no matter what, chances are excellent that someday their travails will come to an end.
“Less than 10% of people with back pain will develop long-standing problems.”
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