Living Well with Back Pain: What Your Doctor Doesn't Tell You . . . That You Need to Know

LIVING WELL WITH

Back Pain

What Your Doctor

Doesn’t Tell You…

That You Need to Know

ROBERT B. WINTER, MD

MARILYN L. BACH, PhD

and The Twin Cities Spine Center

MEDICAL DISCLAIMER

This book contains advice and information relating to health care. It is not intended to replace medical advice and should be used to supplement rather than replace regular care by your doctor. It is recommended that you seek your physician’s advice before embarking on any medical program or treatment. All efforts have been made to assure the accuracy of the information contained in this book as of the date of publication. The publisher and the authors disclaim liability for any medical outcomes that may occur as a result of applying the methods suggested in this book.

CONTENTS

Medical Disclaimer

Acknowledgments

Introduction

    Why You Need This Book

1 The Good News about Back Pain

2 Where Does Back Pain Come From, and Why Do I Hurt?

3 Nonsurgical Treatments

4 Surgical Treatments

5 The Twenty-Five Most Common Questions about Back Pain and Its Treatment

6 Adopting the Right Mindset

7 The Benefits of Taking Charge and the Costs of Being Passive

8 Self-Care

9 Using the Internet

10 Face-to-Face with Your Family Physician

11 Tests

12 Step-by-Step: Using the Back Care Pyramid

13 Choosing the Right Treatment

14 Dealing with Your Health Insurance

15 Face-to-Face with the Physical Therapist

16 Face-to-Face with the Medical Specialists

17 Taking Control When You Need Surgery

18 The Mind–Body Connection

19 Recovering Quickly and Safely After Surgery

20 How Do I Get Back to Work?

21 Keeping Your Back Healthy and Strong

22 What Do I Do If My Surgery

    Doesn’t Seem to Have Worked?

23 Back Pain in Children and Adolescents

Appendix A: Resources

Appendix B: Glossary

Appendix C: References

Searchable Terms

About the Authors

Praise

Copyright

About the Publisher

ACKNOWLEDGMENTS

Many people have made substantial contributions to the development of this book. We thank Lorie Schleck, MA, PT, who provided technical and writing support and edited the entire draft manuscript. Special thanks to Scott Edlestein, literary consultant, who insightfully shepherded this project from beginning to end. We thank Linda Konner, literary agent, for successfully linking this effort to the HarperCollins Living Well series.

Members of the Twin Cities Spine Center, Minneapolis and Saint Paul, provided the backbone of this effort. Ron Anderson, administrator, facilitated the work of multiple contributors, adding patience and humor through the hills and valleys of this endeavor. We thank the surgeons of the Twin Cities Spine Center, Julie Abnet, RN, Lisa Butler, RN, and Cate Pandiscio, PT, PA-C, for their review and critique, and Doug Toft, writer and editor, Minneapolis, Minnesota.

Special acknowledgment to Lyla Westrup, education coordinator, for her tireless administrative assistance and coordination of the work. Stacy Claassen, education/research liaison, provided helpful administrative assistance.

We thank Janice T. Sacks, vice chair of the Scoliosis Association, Inc., senior editor of Backtalk, and past president of the Scoliosis Association, Inc., for her insightful and helpful commentary on the entire manuscript.

Dr. Bach wishes to thank Alice Erickson for her patient and highly competent research and editorial assistance.

We thank the editorial staff of HarperCollins, Sarah Durand and Jeremy Cesarec.

The illustrations are by Peter Lane, St. Paul, Minnesota; photography by John Lehn and modeling by Kristin Smith, KAS Fitness Training, Minneapolis, Minnesota.

Introduction

Why You Need This Book

by Joseph Perra, MD, of the Twin Cities Spine Center

Chances are you’re reading this book because your back hurts—perhaps badly—and you’re not sure what to do about it.

You’re not alone. Back problems are among the top ten most common ailments that people live with. More than 80% of all American adults suffer from frequent or chronic back pain at some point in their lives. Most of these people have no clue about what they need to get better. Should they have surgery? Do yoga? Exercise more? Will massage help? Can they trust a chiropractor? And of all these options, which ones will their insurance cover?

Here’s the good news: More than 95% of those with acute back pain can be cured without surgery. In fact, 80% of all people with acute back pain can recover fully without seeing a doctor, chiropractor, or other health care professional. In this book you will also find out when to see a doctor as an emergency.

Now for the bad news: Whatever the cause of your back pain, the wrong treatment could make your bad back much, much worse. Making the wrong treatment decisions or choosing the wrong health care professional could cause you big trouble (see Chapter 7).

You can’t afford to let others make your health care decisions for you. You need to pick your own health care professionals carefully. You need to know what questions to ask, when to ask them, and whom to ask. You need to know about your choices and options in advance so that you are knowledgeable enough to make the right decisions. And you need to know when to say yes to a suggested treatment, when to say no, and when to ask for more information (and possibly a second opinion).

In short, in order to heal your back as quickly, completely, and safely as possible, you need to become your own best health care advocate. No one else can do this for you. Other people can and will help, but you must make all the most important decisions and choices. This book will show you how to make the right ones.

Living Well with Back Pain is designed to help you understand your back, ask the right questions, get the right medical professionals on your side, and do the right things at the right times. It has been written with three essential goals in mind: (1) helping you get the best treatment, (2) helping you choose the best and most appropriate health care professionals, and (3) advising you on how to enjoy the fastest recovery. You will be introduced to the Back Care Pyramid, a step-by-step guide to the complexities of back care options. You will learn exactly what to do every step of the way to make sure that you get what you need from the people who are most qualified to provide it. You will learn what to say and do to minimize the chance of something going wrong.

Because each person’s back is unique, there is no one-size-fits-all treatment for back pain. Your back must be carefully examined by a properly qualified and appropriate professional, and any treatment must be custom-crafted to suit your unique combination of body type, health history, type and intensity of pain, lifestyle, age, gender, and diagnosis. With some attention and effort, you can dramatically increase your chances for a fast and full recovery from back pain.

We do not offer simplistic (and potentially damaging) solutions. Instead, you will read about the most up-to-date evidence-based medicine that has been scientifically proven to heal your back better than a placebo and better than your body can heal itself. You can feel confident that we will not recommend any treatment for you that has not been proven effective.

We will help you pick the right professionals to get an accurate diagnosis. With the right people, you can then create the very best treatment for your own back, body, and personality. This book offers a user-friendly guide to your insurance options—a sine qua non in today’s medical world and a topic not commonly addressed by other back books. (Treatment information for children and adolescents is included in Chapter 23.)

Living Well with Back Pain will guide you through the maze of information, tests, diagnoses, and options for treatment. In down-to-earth language, it will

Explain all the many different causes of lumbar and thoracic back pain. (We have chosen not to address issues involving the neck, a very complex topic best left for another book.)

Help you understand what works, what doesn’t, and why.

Show you what you can do to reduce or eliminate your back pain on your own.

Outline and explain each different test for the causes of back pain.

Explain what each potential diagnosis means and what your treatment options are for each one.

Offer a comprehensive approach to treatment, with surgery being neither the answer nor the course of last resort.

Enable you to pick the right health care professionals for you and your unique situation.

Explain exactly what questions and requests to bring to each professional.

Give you all the tools you need to heal as quickly and effectively as possible.

Take the fear and mystery out of back pain treatment.

Show you how to keep your back strong and healthy after successful treatment.

In short, this book is your single best tool for healing, treating, and taking care of your back—and for becoming your back’s #1 health advocate.

Why should you read this book and pay attention to us? We offer a unique collaboration of experts: patient and wellness professional Marilyn Bach, physical therapist Lorie Schleck, and spine surgeon Robert Winter, all supported by an internationally renowned medical institution. The Twin Cities Spine Center, with locations in Minneapolis and St. Paul, is one of the world’s largest and most respected centers for the diagnosis and treatment of back problems. Dr. Robert Winter is a renowned spine surgeon, clinical professor of orthopedic surgery at the University of Minnesota, and a research consultant to the Twin Cities Spine Center. He has successfully treated thousands of people for back pain, both surgically and non-surgically, during a forty-year career. Dr. Marilyn Bach is a health and fitness writer, a wellness consultant whose clients include the 3M Company and the University of Rhode Island, a former faculty member of the University of Minnesota and University of Wisconsin Medical Schools, and the coauthor of the popular book ShapeWalking: Six Easy Steps to Your Best Body.

But it is more than just expertise that brought Bob, Marilyn, Lorie, and me together. In 2001, Marilyn began experiencing severe lower back pain that left her unable to work or exercise and barely able to walk. Knowing how harmful improper treatment could be, she developed an approach to taking charge of her own back care and becoming her own ideal back advocate. Using this process, she selected me as her surgeon, and I operated on her successfully.

Afterward, working together, the two of us designed a back recovery plan uniquely suited for Marilyn. By following this plan, Marilyn returned her back to complete health only seven weeks after her surgery—an astonishingly fast recovery.

After some discussions with Bob Winter, we realized that what worked for Marilyn—a combination of the careful selection of health care professionals, custom-tailored treatment and recovery, and assertive consumer advocacy—could work for anyone with back pain, potentially benefiting millions of people. Thus, this book was born.

Everything your back needs for the fastest, safest, and most effective healing is right here. So simply turn the page, and begin taking charge of your bad back.

1

The Good News about Back Pain

We begin with three pieces of very good news:

1. Acute back pain is one of the most common health problems. In fact, 80% of all adults have (or will have) at least one episode of moderate to severe back pain. Why is this good news? Because it means medical science has extensively studied back pain and knows a lot about it.

It also means you’re not alone. Millions of people have probably had the exact same problem you do and have healed successfully. With a little careful searching, you can find a medical professional who is very familiar with your specific problem and who has had repeated success in treating people for it.

2. Most back pain doesn’t require any professional medical treatment at all. Most cases of back pain are healed naturally by the body and thus go away on their own in a few hours or days. You don’t need to see your family doctor, a chiropractor, or a physical therapist (let alone an orthopedic surgeon or a neurosurgeon).

3. You can treat most back pain successfully yourself. Just do these simple things and there’s an 80% chance that your back will be better in a few hours to a few days:

Take it easy. Avoid heavy lifting and high-impact activity (jogging, tennis, golf, volleyball, etc.).

Avoid prolonged sitting. If necessary, do some of your work standing up, or take a ten-minute standing or walking break each hour.

Put ice on the painful area of your back during the first twenty-four hours of pain, then heat thereafter.

Take an over-the-counter pain medication such as aspirin or acetaminophen (Tylenol), or an antiinflammatory medication such as naproxen sodium (Aleve) or ibuprofen (Advil).

Do not spend a week in bed.

Rest frequently in the contour position, which is illustrated in the figure.

Figure 1: The contour position. The hips and knees are bent to almost 90 degrees in order to fully relax the spine and the strong flexor muscles.

Because most back pain is benign and goes away on its own, there’s usually no point in spending time and money on expensive doctor visits and tests. However, there are several circumstances in which you should immediately see a medical professional:

If the pain is so severe that you can’t sleep or function at all

If you lose control of muscles in your leg(s)

If you lose control of your bladder or bowels

Here’s the happy paradox: Many people buy this book, read this chapter, and follow its advice. As a result, they get better without seeing a doctor, save themselves the cost of a health appointment, and never need to read any of the remaining chapters. If this happens to you, that’s great! But if you are one of the 20% of back pain sufferers who need more help, read on. All the information and support you need are here.

2

Where Does Back Pain Come From, and Why Do I Hurt?

Understanding your back pain begins with a basic look at how the spine looks, how it works, and what can go wrong.

What the Spine Looks Like and How It Works

The spine is a complex structure. It performs several vital functions:

Supporting the weight of the trunk so that you can sit and walk upright.

Permitting trunk motion so that you can bend to tie your shoes.

Protecting the spinal cord (a structure that runs down from the brain and supplies nerves to the arms, chest, legs, and internal organs). Injury to the spinal cord can lead to paralysis.

The spine is a column of twenty-four bones called vertebrae. Seven of these vertebrae are in the neck (cervical vertebrae), twelve are in the chest (thoracic vertebrae), and five are in the lower back (lumbar vertebrae). The sacrum sits at the base of the spine and is part of the pelvis.

Figure 2a: A frontal view of the whole spine and pelvis. There are seven cervical (neck), twelve thoracic (chest area with ribs attached), and five lumbar (lower back) vertebrae. The sacrum is at the base of the spine and is part of the pelvis.

Figure 2b: A side view of a normal spine. The cervical (neck) and lumbar (lower back) vertebrae are in lordosis (a curve with the apex forward), and the thoracic (chest area) vertebrae are in kyphosis (a curve with the apex backward).

The disc is a firm, rubbery cushion that sits between the front (or body) of two vertebrae. Because it is compressible, the disc allows the spine to move in several directions. It also absorbs vertical loads such as the jarring your spine feels if you suddenly sit down hard.

The center of the disc is gel-like. The outside is a tough wall called the annulus fibrosis (often shortened to annulus). The annulus is thicker and therefore stronger in some areas than in others. The annulus has small nerve fibers, but the center of the disc does not.

Along the back of the spine are small joints called facet (fuh-set) joints. These joints are formed by parts of adjacent vertebrae. In the lumbar spine, the upper vertebra forms the inner part of a facet joint while the lower vertebra forms the outer part. The facet joints allow for spine motion and help protect the spinal cord.

In the chest area, the ribs attach to the spine with little joints that allow the ribs to move up and down as we breathe in and out. Ligaments are important supporting structures. They run along the front, side, and back of the spine and add stability.

Several muscles control spine movement. The most obvious are the big muscles that run up and down the center of the back. These are called extensor muscles because they help extend the trunk (bend it backward). Beneath the extensors are the multifidi, a group of smaller muscles that help rotate the trunk and play an important role in dynamically stabilizing the spine. The psoas is a big muscle in front of the lumbar spine and hips. It helps flex the trunk (bend it forward) and flex the hips (bringing the knee toward the chest).

The abdominal muscles play an important role in spine function. They stabilize the trunk, preventing unwanted motion. They also rotate and flex the trunk. Several muscles make up the abdominal—or abs—muscle group:

The rectus abdominus is the most central muscle of the group. It runs from the chest to the pelvis.

The internal and external obliques run diagonally to the rectus abdominus.

The transversalis is a deep central muscle.

The quadratus lumborum is a deep posterior muscle.

Figure 3a: A frontal view of the lumbar spine and sacrum. Each vertebra is separated from the next by a disc (intervertebral disc) that has a tough outer layer called the annulus fibrosis (cross-hatched areas). The sacrum is a single bone with holes in it where the nerves come out.

Figure 3b: A posterior (looking from the back) view of the lumbar spine and sacrum. In between each vertebra are ligaments that strengthen the spine and protect the nerves. The ligamentum flavum has fibers running up and down the center of the spine, and there are facet joints where each vertebra comes in contact with the next. The facet joints also have strengthening ligaments (the capsular ligaments or capsules).

Figure 3c: A side view of the lumbar spine and sacrum. The vertebrae are lined up in lordosis (sway-back) and are separated from each other by the discs. In the back are the spinous processes, which are the bumps you can feel when you touch your back.

Figure 4a: A view of the back of the spine showing the large muscles running up and down. These are the long extensors of the spine, which are critical for stabilization and backward bending.

Figure 4b: A view of the back of the spine showing the short, deep muscles responsible for segmental stabilization and rotation.

Figure 4c: A view of the deep muscles in the front of the lumbar spine and pelvis. These are responsible for spine and hip flexion.

Figure 4d: A view of the muscles of the abdominal wall. In the center are the abs, and off to the side are the obliques and the tranversalis muscles.

Nerves run from the spinal cord to various body structures through openings in the spine called foraminae. As we shall see later, it is very important that the foraminae remain open for these nerves to function properly.

In the thoracic spine, nerves run along the ribs to the intercostal muscles (the muscles between the ribs), which allow us to move our ribs up and down as we breathe. In the lumbar spine, nerves go out to the legs, bowel, and bladder, controlling the movement and function of these structures. The nerves that control movement and function are called motor nerves. When a motor nerve is affected, you might experience muscle weakness in the legs or disrupted bowel or bladder function. Sensory nerves run from the legs, bowel, and bladder to the spinal cord and up to the brain. They register pain, touch, and other sensations. If you step on a sharp stone, the sensory nerves send a pain signal to the brain. Sensory nerves also tell the brain when your bladder is full. When sensory nerves are affected, you might experience numbness in the legs or an inability to sense a full bladder.

During your back examination, the medical specialist will check for motor nerve problems by testing your leg muscle strength. He or she will also check for sensory nerve problems by looking for areas of numbness.

What Can Go Wrong

Back pain can come from many different parts of the back and even from places outside the spine. Once your doctor finds the source of your back pain, he or she will give you a diagnosis. In this section we will describe common back diagnoses: what they are, what causes them, what you might feel or experience with a certain diagnosis, and how a given diagnosis might be treated.

Muscle and Ligament Strains and Sprains

What is it?

Just like our knee and shoulder joints, the spine can suffer a strain or sprain. These conditions occur when muscles or ligaments in your back are overloaded or stressed. A strain is a pulled muscle, and a sprain is a pulled ligament.

What causes it?

Strains and sprains are most often caused by lifting or twisting. For example, you might strain your lower back by carrying a heavy suitcase or picking up a heavy package. Minor falls and other injuries can also cause this problem. Major trauma such as an automobile accident or a fall from a significant height can cause complete ligament tears or ruptures, which can be seen on X-rays, CT (computed tomography) scans, or MRI (magnetic resonance imaging) scans. Strains and sprains cannot be detected with these techniques.

What does it feel like?

Pain in the injured area is the main symptom of a back sprain or strain. You will have muscle tightness and soreness, but you will not have pain in the legs.

Muscle strains can become a chronic (long-lasting) problem if the cause is not addressed. For example, a woman with large breasts may have chronic upper back muscle strain. In this situation, breast reduction may be a way to diminish muscle strain and relieve back pain. Chronic bad posture can also cause muscle strain. This can be corrected with proper exercise and good posture training.

How might it be treated?

Most muscle strains and sprains resolve themselves in a few days without any specific treatment.

Disc Herniation

What is it?

Almost everyone has heard of a ruptured or herniated disc. This occurs when the outside part of the disc (the annulus) ruptures and the central part of the disc seeps out or herniates. A partial tear of the annulus causes only back pain. A complete tear of the annulus can cause the ruptured disc material to press against the spinal cord (rare) or on the spinal nerves (much more common). Pressure on the spinal nerves causes acute back pain and acute leg pain going down below the knee. The diagnosis of disc herniation is best made by MRI examination.

What causes it?

Usually but not always a sudden stressful load causes disc herniation. For example, Dr. Winter suffered a disc herniation when he lifted a heavy patient by himself. Mrs. Winter suffered a disc herniation from violent vomiting due to a kidney stone. Disc herniations are most common in the 30- to 50-year age group (though they can occur in teenagers). Disc herniations are less common after age 50, as the discs naturally dry up and are no longer prone to rupture.

What does it feel like?

Pressure on the nerve can vary from mild to severe; consequently, the symptoms can vary in severity, too. With a more severe disc herniation, you may have numbness in the leg or foot, muscle weakness, and changes in your reflexes (which your doctor will check with a reflex hammer). With smaller herniations, you may feel only back pain.

Sometimes a very large central disc herniation (where the middle part of the disc ruptures) can cause a loss in bowel and bladder function along with numbness in the genital area (called cauda equina syndrome). Emergency lower back surgery is indicated in this situation. Emergency surgery is also necessary if a thoracic disc rupture causes paralysis.

How might it be treated?

Most disc herniations are treated nonsurgically. When your pain is acute (indicative of a recent injury), pain medications including narcotics may be necessary. Spasms in the back muscles are common with this condition and can be treated with heat or cold, whichever one you respond to best. Resting on your back with your hips and knees flexed (the contour position) can be most comfortable and beneficial (see Fig. 1).

In a few days, your symptoms should subside. In this subacute phase, you