Conquer Back and Neck Pain - Walk It Off! (13 page)

If you have had a recent urinary tract infection, tooth abscess, skin boil, or foot ulcer and develop severe back pain, do not forget to tell your doctor about the infection. That information will alert the doctor to the possibility that the infection has spread to your spine. Infection can spread to any disc and/or vertebra in the spine and therefore produce pain in any location of the spine: neck, thoracic, or low back. Severe pain in any of these locations in individuals who are susceptible to infection or have had a recent infection elsewhere in their body should be a warning that there could be an infection in the spine.

An aortic aneurysm is a blowout of the major blood vessel that leads from your heart to your body. The aorta runs alongside the spine all the way from your heart to your pelvis, and a painful rupture of this blood vessel can cause back pain anywhere along your spine from your chest to your low back. This condition occurs rarely, and usually is seen in older, debilitated individuals, especially those who have a long history of smoking. But it can also be seen in young, tall, and lanky individuals, like basketball players. Some tall and thin people have a genetic condition called Marfan’s Syndrome, which can be the cause of a rare form of aneurysm that can produce pain along the entire spine. Any older, deconditioned individual, man or woman, with acute back pain and/or abdominal pain should be treated on an emergency basis to rule out this life-threatening condition. The same can be said for young, tall, thin, and lanky individuals who have long, thin fingers and who complain of pain along the thoracic spine.

When should you see a doctor for back pain that is not acute and/or severe? A good rule is to determine the cause of any back pain attack that lasts more than two weeks, as the majority of acute attacks of benign back pain get better within the first week of onset. If the attack of back pain is associated with pain radiating down an arm or leg, with numbness or weakness of the muscles, or with loss of balance, stumbling, or tripping, then you should see your doctor. Anytime an adolescent or child experiences back pain or pain in an extremity, they should be seen by a pediatrician. Children and adolescents do not complain of pain unless something is wrong. Therefore, any time they have pain they should be seen by their pediatrician. Since babies under the age of two cannot express pain verbally, you should suspect a painful condition if they scream when you touch them or try to move an arm or leg. If you suspect pain in an infant, you should take the baby to an emergency room immediately. A child of any age who has meningitis may have severe neck pain, a stiff neck, and a high temperature. Early recognition of these symptoms and prompt diagnosis and treatment can save the baby’s life!

Much of what I have told you about acute low-back pain is true for neck and thoracic pain, with a few important exceptions. The cervical spine (neck) is more mobile than the lumbar spine (low back) so that you can move your head normally in a range of 180 degrees from side to side and from top to bottom. The discs in your neck are subject to the same degenerative process leading to spinal pain as described above. Also, the vertebrae in your neck are susceptible to the spread of cancer or infection, as are the vertebrae in the rest of your spine. Although acute neck pain is most likely to come from a worn-out disc, in rare cases infection or spontaneous fracture may be the cause. Also, you should know that chest pain radiating into the neck from the chest could be a symptom of a heart attack.

Most acute episodes of benign back pain occur when we are in our 20s and 30s, and most of these attacks are self-limiting and are not a symptom of anything seriously wrong. Back pain tends to become more of an annoyance as we get into our 40s and 50s; the attacks are not as severe, but they may be more nagging and last longer. However, it is during these years that we most commonly suffer from disc herniations. I will tell you all about disc herniation in
Chapter 5
.

If you have acute lingering back pain that worries you, who should you see for it? How do you choose between the many different types of doctors and therapists? I will explore this issue in the next chapter.

There are so many types of doctors and other health care providers who treat back pain that this entire chapter will be devoted to this subject. I also touch upon this subject in other chapters where it is appropriate to the problem, i.e., spine surgeon for surgery, pain management specialist for an epidural steroid injection, and physical therapist for pain control and improvement in strength, stamina, and balance. This chapter will be a specific description of the various specialties and services that are available to help you with your back problem.

Acute, intermittent, or chronic back pain may cause us to seek medical help in various ways. We can be carried to the emergency room of our local hospital in agony, or, if our back pain allows, we make an appointment to see a doctor at some time in the future. Depending on the type of medical insurance we have, HMO, PPO, or no insurance at all, we may go to our primary care physician, to the neighborhood chiropractor, or we may refer ourselves directly to a specialist such as an orthopaedic surgeon or physical therapist. Here are descriptions of most of the types of health care providers who manage back pain syndromes and the expertise that they can provide you.

If you seek help in an emergency room for acute back pain, the ER doctor will evaluate you to be sure you are not suffering from a serious life-or limb-threatening emergency such as cauda equina syndrome or an aneurysm (pages 30, 33). If you have a serious problem that requires admission to the hospital, they will immediately call in an appropriate specialist for your condition, i.e. a spinal surgeon for cauda equina syndrome, a urologist for a kidney stone, or a vascular surgeon for an aneurysm. If the ER doctor diagnoses you with an episode of acute back pain that is not life-or limb-threatening (idiopathic low-back pain, see page 29), he or she will then try to help you with pain medication, muscle relaxants, and/or anti-inflammatory medication and send you home with a recommendation to follow up with your primary care physician (PCP) or a specialist such as an orthopaedist.

Most people who have an acute attack of back pain do not require emergency care and have time to go to a PCP to determine how to get relief. PCPs are trained in general medical diagnosis and treatment. Traditionally, PCPs are medical doctors or osteopathic doctors who are trained in general medical care but do not have specialty training (they are also called general practitioners). Family medicine specialists are medical or osteopathic physicians who take at least two additional years of training following four years of medical school and one year of internship in general medicine. General practitioners and family medicine specialists, along with internal medicine specialists (who have three additional years of residency training in general medicine), comprise the category of qualified PCPs who can determine what is causing your back pain.

Some people who are suffering from back pain go directly to a chiropractor, physical therapist, massage therapist, or acupuncturist for relief. Although their main concern is usually to obtain relief from the pain, it is actually more important for them to find out what is causing the problem first. I would advise them to go to a PCP initially, and once the PCP has determined what is wrong, ask them to prescribe initial pain-relief measures, e.g. pain medication, physical therapy, adjustments, or acupuncture. If you do not obtain relief from these initial treatments, then your PCP should refer you to the appropriate specialist. I have seen people who have been treating their back pain by going directly to an acupuncturist or massage therapist only to find out that in doing so they delayed getting a timely diagnosis and treatment for a serious problem.

Any time a child or young person under the age of 18 is suffering from spine pain you should take them to a pediatrician or to a PCP if a pediatrician is not available. Do not take them for chiropractic or physical therapy treatment before their problem has been properly diagnosed.

Your PCP should listen to your medical history, perform a physical examination, and, when appropriate, order x-rays, laboratory tests, and an MRI to help diagnose your problem. Some states license chiropractors and physical therapists to assume the role of primary caretakers for musculoskeletal conditions such as back pain. They are allowed by law in these states to perform the same diagnostic tests as PCPs to determine why you are having spine pain. I think PCPs who are trained in general medical diagnosis and treatment are better qualified to initially manage your back pain. It is not in your best interest to directly consult a chiropractor, physical therapist, pain management specialist, acupuncturist, personal trainer, or massage therapist before the actual cause of your spine pain is diagnosed. You must be sure the pain is not a warning of a serious problem that requires referral to another type of specialist, such as a vascular surgeon.

Depending on the diagnosis and severity of your back pain, your primary care provider may refer you to another specialist, such as a physiatrist for rehabilitation or a spine surgeon for surgery.

Physiatrists are specialists in physical medicine and rehabilitation. They are diagnosticians as well as organizers and coordinators of various treatments aimed at relieving pain and restoring function. To be designated a physiatrist you must be a medical doctor or osteopathic physician and complete an accredited residency-training program in physical medicine and rehabilitation and pass certifying board examinations. The physiatrists who I work with in our multi-specialty spine clinic perform careful patient histories, physical examinations, order appropriate diagnostic tests, refer patients when necessary, and formulate and coordinate a plan for treatment. They perform some diagnostic tests, such as EMG (electromyography, which is a test performed with a needle electrode to evaluate certain types of muscle and nerve diseases, page 82). They are oriented toward non-operative rehabilitation treatment. They coordinate referral to other specialists, prescribe medications and physical therapy, and perform special pain-relieving procedures, such as epidural steroid injections (see page 58). When it is appropriate, they refer patients to the spinal surgeons in our group and manage their pre-operative preparation and post-surgical follow-up.

If it is determined that you are significantly impaired from a herniated disc, spinal stenosis, trauma, deformity, tumor, and/or infection of the spine, you should be referred to a spine surgeon. Spine surgery, per se, is performed exclusively by neurosurgeons and orthopaedic surgeons. The exception is that interventional radiologists and physiatrists are performing some procedures such as vertebroplasty and kyphoplasty, (injection of bone cement into collapsed vertebrae caused by osteoporosis and tumors).

In the past 20 years, most spine surgeons are fellowship trained. To be designated a fellowship-trained spine surgeon, the physician must complete special training in diagnosis and surgical treatment of spinal conditions in an accredited spine fellowship. This year or two of special training in spinal surgery usually follows four years of medical or osteopathic school and between five and seven years of specialty training in orthopaedics or neurosurgery, respectively. Specific board examinations in spine surgery or added certificates of qualification are not currently required for designation of fellowship training.

Orthopaedic and neurosurgical spine surgeons are cross-trained in each other’s specialties with some exceptions. Orthopaedists are more oriented toward correction of spinal deformity and spinal fusion with metal fixation devices, and neurosurgeons are oriented toward the treatment of spinal cord diseases, injuries, and tumors. However, most spinal surgeons today who have been trained in a well-known spine fellowship program are qualified to perform all aspects of diagnosis and surgical treatment of spinal diseases.

Most pediatric orthopaedic surgeons have had special training in non-operative and operative treatment of scoliosis (curvature of the spine) in patients up to the age of 18. The first spinal surgery I learned how to perform in the 1960s was from a world-renowned children’s scoliosis surgeon. The children’s scoliosis surgeons were the ones who developed and taught all of us — orthopaedist and neurosurgeons — how to effectively correct deformity and stabilize the spine.

I was also trained by orthopaedists and neurosurgeons in spinal surgery, but no organized fellowships in spine surgery were available until the early 1980s after I had already trained. I have participated in the training of spine surgeons since that time.

I am often asked by patients to whom I have recommended spine surgery if it is necessary for a neurosurgeon to be present. Only rare, difficult, and painful spinal problems require that both a neurosurgeon and an orthopaedic spine surgeon be present at the same time for a surgical procedure. These difficult cases usually involve tumors, infections, some spinal deformities, or spinal cord diseases and require the expertise of both specialties. The vast majority of operations for painful spinal conditions, e.g. herniated discs and spinal stenosis, can be managed by a qualified spine surgeon, be they orthopaedic or neurosurgeon.