Our Philosophy on back pain
Back pain is a very common symptom, which can be severe and distressing but seldom permanent or crippling and can usually be managed by simple treatments.
There are many therapies and many therapists but not all are of proven efficacy.
Only occasionally is surgery required for back pain (usually fusion). Sometimes back pain is due to serious conditions including cancer (especially in patients over 50 or who have already had cancer).
The most important treatment is activity and exercise. Rest should be for a day or so only and never prolonged.
Back pain has a variety of causes and although certain changes within the structure of the spine are associated with pain it is not usually possible to categorically attribute the pain to these changes. We are all constantly aging and our spines all show the changes of aging. Radiographs (X-rays), CT scans and MRI scans as well as surgical and post-mortem (autopsy) studies confirm these. Pain studies performed at operation or by injecting discs, facet joints and nerves show that pain can arise in the outer aspect of the discs, in the joint capsules or in nerves when inflamed. These injections can be unpleasant so that we tend to rely on our experienced interpretation of radiographs and MRI scans to determine where the pain is likely to be originating. We know that many patients who are not in pain also have abnormal scans – our experience and the findings of physical examination help us decide when these changes are significant.
Pain in the back can be referred from other places, e.g., muscles and ligaments, sacro-iliac joints, abdominal or pelvic organs, aorta and arteries, and by other disease processes such as arthritis, infection or cancer.
Although we are familiar with these less frequent processes " common things occur commonly” and most patients with back pain will have abnormalities of the disc or discs.
There is new evidence which shows the benefit of certain exercises, especially abdominal strengthening, in managing back pain. Advice, reassurance and counseling can be useful. There are many unproven therapies available – see Non-surgical care - but we prefer to use validated methods.
Some work activities and hobbies such as gardening or sports such as golf, tennis or squash can cause back pain and may need to be modified. As I often say " it is better to change your job to suit your back than change your back to suit your job”.
Surgery for back pain is contentious (see www.cochrane.org) but our experience allows us to select some patients for surgery by means of fusion (an operation to stiffen the disc by placing bone in and around it), usually only at one or two levels.
This operation can be very successful but does not always work.
In offering a fusion (usually only to patients who have had longstanding back pain over several years) we make three assumptions:
1. that the abnormality on scan or other tests is the cause of the pain,
2. that the operation will achieve a solid fusion,
3. that the elimination of movement by fusion will bring about a reduction in the pain.
None of these assumptions is 100% true but in well-selected patients fusion can be beneficial. Obviously, the more levels that are abnormal the more difficult it is to obtain a fusion and the more movement that will be lost.