If the imaging is normal, some patients may respond to injections. Some patients may respond to bracing. Some patients may respond to physical therapy. Some patients may respond to Chiropractic, some patients may respond to nerve stimulation. Some patients may respond to tens units. Notice that I’ve used the same language for all of those. And the reason is is that some patients is this small amount of patients who respond to each one of those, but we don’t really have anything that tells us what will predict the response of each individual patient to each of those individual scenarios. And so it can be tough and it can be enormously frustrating for the patients because here they go from one thing to the next, looking for the holy grail to make their back pain better when indeed medicine may only be able to take a chunk out of it with one thing or another, and not actually as people would want curate. So it can be enormously tough.

One thing that I haven’t mentioned is that a minority of patients will find help in places such as in they’re characterized as back stores, places where there may be changes in ergonomics. For instance, seats, chairs. Personally, I tried one of the no bad chairs with my knees down. That did terrible things for my 60 year old knees and I’m not sure it made my back feel all that much better. But there are a lot of things that people can do that are relatively simple that may make a change in their back pain, but it’s hard to predict which one is going to be made better, for instance, by losing weight, which one’s going to be made better by going to the mattress store, which one’s going to be made better by going and getting inserts in their shoes. That one’s an interesting one because there was a recent military study that looked at back pain and shoe inserts and the bottom line was is that there was absolutely no difference whether they got shoe inserts or not, whether that can be generalized to the regular population. Hard to say, but also, English from that claimed their shoes, made people’s back pain better, and a nice English study that looked at that and people actually abandoned wearing the shoes for the most part because they weren’t happy with the improved lack of, I should say, the lack of improvement in their back pain.

We look for all these different things to try to make chronic back pain better. There are some certain instances in which surgery can help people with chronic back pain. The first instance is when people have true instability in the spine. Instability is a fancy medical term and even defined by the experts can be very tough to pin down exactly. It’s almost like the Supreme Court justices. I know it when I see it, but stability refers to the fact that the vertebra is which sit one on top of another may slip forward generally. Slipping backward is usually not such a big deal, but if it slips forward and it moves a lot, sometimes you can help back pain by taking away that slip in the sense of making it solid. That’s a fusion and in this day and age that usually is accompanied by screws and rods or another mechanism of holding the bones until the fusion can get solid. The other thing that sometimes with chronic low back pain that you can help or things that maybe grow in the bone, and these are more esoteric and probably not appropriate for this audience, but the imaging defines that and if you operate on those. And the whole spectrum can be everything from simple kinds of surgeries to very complex kinds of surgeries for things that grow in the bone.

In a patient with a normal study, surgery has really no place. Normal pictures don’t get operated on. Very important principle. Sometimes patients in their frustration will want to have something done, just do something, but it’s about the same as saying, well, you know, I couldn’t get this watch to run, so I’m going to go out in the garage and I’m going to get my hammer and chisel and we’ll see if doesn’t help. It doesn’t make much sense. The right surgery for the right problem, results in good outcomes. The wrong surgery for a particular problem when it’s wrong, very, very unlikely to help people.

Chronic low back pain is also often addressed with physical therapy and chiropractic. The problem is is we don’t really have good data about either one. And just recently I was fascinated to read an article in spine that talked about people with chronic low back pain that it occurred at work and whether or not physical therapy that was specifically designed to sort of look at their work and then tailor the physical therapy appropriate to their improvement, showed absolutely no difference over generic physical therapy in terms of improvement. So it can be tough. And that brings us back again to where I started that some people will get some better by some of our interventions.

If you’ve been listening along, you know that there’s one category that we haven’t been talking about yet. And that is chronic back pain with leg pain. And that typically instead of being just in one leg, is usually in both, although not always, most often that’s a function of bony overgrowth and that’s called stenosis. And the demographic for that is people who were sometimes in their forties but most often you’ll see it in late fifties, sixties, seventies, eighties and you’ll actually see it in 90s. And what happens is, is the bone just gets thick and the center of the bone and the vertebrates, which is where the nerves run and higher up the spinal cord, that that just gets tight. People start having a very stereotyped presentation. And that is, Ooh, Gee, my back starts hurting when I’m walking or standing. And if I’m going through Walmart or Costco that I have to use a grocery cart. Or, Gee, I need to park really close to the front of the store because when I’m trying to get into the front of the store, I got to have the shortest distance possible. Or, Gee, I’m standing in the checkout line and you know what? My legs are starting to hurt. My back is starting to hurt and I got to find a place to sit down now. Not everybody actually hurts with spinal stenosis and I’ve seen a number of patients and it’s been described where patients actually will have troubles, but it’s not that it’s painful, it’s that their legs get woody. They sometimes feel like their legs are numb, the legs won’t want to do what they want them to, and those symptoms will start in the back and extend down the legs. Although some patients will tell you, it seems like it starts in the legs and actually goes up into the back. There was a recent article published a couple of years ago. We used to think that stenosis in particular didn’t cause nighttime pain, but if I remember right off the top of my head, about 56% of patients in that study that they looked at who had stenosis also had trouble sleeping at night because they had leg pain. And so that tells you that sometimes we can learn something over time and looking backward at patients and be a little smarter about symptoms. So those are the four major groups, and there are four major presentations.

Back pain is really present in almost every gender, every occupation, and every age group to varying degrees. At any one time, 40 million Americans are seeing their doctors with complaints of back pain. And so thinking that somehow back pain is special to one particular group or another, just as a jive, people are visiting their doctors, talking about back pain, and it comes in many different types and sizes.