Conquer Back and Neck Pain - Walk It Off! (14 page)

Some of the other specialties that your PCP, physiatrist, or chiropractor may refer you to, depending on the problem that is causing your spine pain, include: rheumatologist, neurologist, pain management specialist, urologist, vascular surgeon, and orthopaedic joint-replacement specialist.

A rheumatologist specializes in the diagnosis and treatment of arthritis and other painful diseases of the bones, joints, and spine. I refer any patient with back pain who I suspect of having specific types of painful arthritis of the spine such as ankylosing spondylitis (see page 101), to our rheumatologist. Painful spinal arthritis requires a lifetime of treatment with a specific supervised exercise program and anti-inflammatory medications, and is best managed by a rheumatologist working in conjunction with your PCP.

Rheumatoid arthritis, a potentially crippling form of arthritis, can dangerously involve the neck and other areas of the spine. Rheumatologists are aware of this and will frequently refer patients to spinal surgeons for consultation, and vice versa, when we see a patient who has rheumatoid arthritis involving the neck, we refer the patient to a rheumatologist for medical management.

I will occasionally see a patient who has difficulty walking because of leg pain that can be relieved by rest. When I examine them I notice that they have a shuffling gait and a tremor of their hands. I suspect that they have Parkinson’s disease as well as spinal stenosis (
Chapter 6
). I also see patients who have numbness in their feet and lower legs, who I suspect have peripheral neuropathy (see page 113). Neurologists, who are specialists in diseases of the brain, spinal cord, and nerves, can determine which disease is causing these symptoms and whether the person has a combination of diseases. They are qualified to treat these conditions medically.

I once saw a patient who had the spontaneous onset of a foot drop (see page 49). Foot drop, or other forms of muscle weakness of the extremities caused by a spinal condition, is usually associated with pain. Since the patient had no back or leg pain, I suspected another diagnosis and referred the patient to a neurologist. He performed an EMG (see page 82) and diagnosed Lou Gherig’s disease, (amyotrophic lateral sclerosis) a progressive, disabling condition that causes progressive muscle weakness and wasting. Neurologists perform many specialized tests, including EMGs and nerve conduction velocities.

Chiropractic medicine is primarily associated with the treatment of acute back and neck pain syndromes (
Chapter 9
). Chiropractic is based upon a concept of joint misalignment (subluxation), particularly of the spine. Chiropractic doctors diagnose and treat back pain with a variety of methods similar to physical therapists. They include musculoskeletal evaluation, adjustments, deep massage, stretching maneuvers, heat, ultrasound, braces, and traction devices (
Chapter 9
). They do not perform injections or surgery on the spine.

Physical therapists are primarily trained in the assessment of musculoskeletal disabilities and the restoration of function through pain management using physical methods such as deep message, heat and ice, as well as improvement in strength, stamina, and agility. They also use various other methods such as special stretching devices, traction systems, and electrical stimulation. In recent years, they are also assuming responsibilities for primary care of musculoskeletal conditions, including diagnosis and treatment, in some states. More will be said about the role of physical therapists in
Chapter 9
.

Pain management specialists are usually medical doctors who are primarily anesthesiologists. They perform special pain injection techniques, such as epidural steroid injections for herniated discs (page 58). They also manage long-term use of narcotic pain medications for chronically ill patients such as cancer patients. They usually do not participate in the diagnosis of the cause of your back pain except when they confirm the diagnosis of the site of nerve entrapment by performing local anesthesia blocks.

Massage therapists, acupuncturists, and personal trainers are not medically trained and do not assume responsibility for diagnosis or treatment of your painful spine condition. Your doctor should advise you when and if it is safe for you to be treated by these types of specialists (
Chapter 4
).

On rare occasions, back pain is from a kidney problem and requires the services of a urologist, or sometimes it’s a vascular problem that requires a vascular surgeon. Obstetricians and gynecologists will occasionally consult me for an opinion regarding the source of pelvic pain or whether it is safe for a woman who suffers from back pain to become pregnant. I have frequently been consulted to help a patient who suffers from back pain during pregnancy, and on very rare occasions have had to perform disc surgery on a pregnant woman (see page 47).

Your best approach to getting an accurate diagnosis and correct treatment of initial episodes of back pain is to consult a qualified PCP and have them determine what is wrong and who you should be referred to for further diagnosis and long-term treatment. Even if you are suffering from a recurrent episode of back pain after a pain-free interval, you should still go back to your PCP because the current episode may be caused by something different. It is not a good idea to have any form of treatment without first having a specific diagnosis by a qualified physician.

Contrary to the popular myth, discs do not slip out of place from between the vertebrae. What really happens is that the spongy central part (nucleus pulposus) of the disc actually squeezes through ruptures in the outer rim of the disc. Recall in the first chapter how I explained the analogy between a partially flat tire and a degenerated disc. Both the flat tire and the degenerated disc are susceptible to tears in their outer rim and subsequent blowout. In the case of the disc, the spongy center substance actually squeezes through the tears in the outer rim of the defective disc. This is what we call a disc herniation. There are varying degrees of disc herniation: bulging discs, prolapsed discs, extruded discs, and sequestered discs (free fragments).

Disc herniation can occur in any of the 23 discs throughout our spine and in any direction at each disc, backward toward the spinal canal and nerves, sideways, or forward. The most common level of disc herniation in humans is the lowest disc in the low back, between the fifth lumbar disc and the sacrum, the bone that attaches your spine to your pelvis. Most commonly this disc, the L5-S1 disc, herniates backward into the spinal canal and compresses the sciatic nerve, causing pain to radiate down the back of the leg from the buttocks to as far as the bottom and outside of the foot and little toes (sciatica). An L5-S1 disc herniation in your low back can result in leg pain that is worse than any toothache!

One day I received a call at work from a doctor who lived next door to one of my neighbors. My neighbor had called the doctor for help because he was experiencing severe back and leg pain. The pain was so severe that the doctor was concerned that my friend had something terrible, such as a ruptured aneurysm. On the phone I instructed the doctor to slowly lift my neighbor’s painful leg to see if it made the pain worse. The doctor could only lift his leg a few inches from the bed without my neighbor screaming with pain shooting down the back of his leg. I suspected that my neighbor had a herniated disc in his low back, pressing on his sciatic nerve.

When I saw my neighbor in the emergency room, his pain was so severe he could hardly move, and after examining him I ordered an MRI scan (more about this test later in this chapter), which confirmed my suspicion that he had a herniated disc. In surgery I found that the disc herniation was pressing directly on the nerve that goes down the back of the leg to the foot. After the surgery, that same day, my neighbor was able to get out of bed by himself without leg pain. He went home the next day and was playing tennis six weeks later.

He has never forgotten how much pain his disc herniation caused or how much relief he had from the surgery, and has remained grateful for my quick diagnosis and treatment. He gave me permission to use his story in this book as an example of how painful a disc herniation can be.

One of the worst scenarios that can occur from a massive disc herniation in the low back is cauda equina syndrome (page 30). The patient goes to an emergency room in agonizing pain, only to be placed on a stretcher to wait for a doctor who is totally overwhelmed with one or more life-threatening emergencies, such as a heart attack or bleeding trauma victim. Then the pressure of the disc causes all of the nerves to the legs, bowel, and bladder to stop functioning, and the patient feels relief from the horrible pain but fails to realize that he cannot urinate and that the pelvic area is numb and the legs weak (cauda equina syndrome). The patient is indifferent to the severity of his condition because the terrible pain has gone away, so he lies quietly on the stretcher, not complaining. The doctor, exhausted from taking care of the life-threatening emergencies, glances at the patient, lying quietly on the stretcher, sees that he is no longer in pain, takes a much-needed coffee break, and later realizes the severity of the patient’s problem.

Fortunately, fewer than one in 1,000 individuals who suffer from a herniated disc in the low back have cauda equina syndrome. But it can occur, and when it does, the symptoms may be ignored by the afflicted person and overlooked by those who they seek help from. Massive disc herniation resulting in paralysis can occur, and although it is extremely rare, everyone who suffers from back pain should be aware of this possibility. If you have any of the symptoms described above, get help immediately!

The severe pain my neighbor experienced and the massive disc herniation that leads to cauda equina syndrome are fortunately rare.
Most
people with a disc herniation suffer moderate pain that is not crippling, with or without loss of sensation, and/or mild weakness of one leg or arm. These grumbling symptoms cause deterioration in the person’s quality of life but do not endanger function to the point of permanent disability.

For example, I saw a patient who was complaining of severe pain in the front of her thigh, associated with a patch of numbness and loss of sensation, and a feeling of weakness in her knee. She had been suffering with these symptoms for two months, but she said the pain had been gradually becoming less severe in the past week. An MRI scan (more about MRI shortly) showed the culprit to be a disc that had squirted into the spinal canal, pressing on a spinal nerve and causing her pain. She was taking a muscle relaxant, had been on bed rest for a few days, and was told that surgery was the only way to get relief from the pain. From my previous experience, however, I was certain that she would get better without surgery. I suggested that she stop taking the muscle relaxant that was not relieving her pain anyway. For pain control I prescribed an epidural steroid injection (more about epidurals later in this chapter). She returned to see me two weeks later, saying that she had stopped the muscle relaxant and not taken the steroid injection because the pain had subsided on its own shortly after she had seen me. She continued to improve, and the last time I saw her she was completely pain free.

The majority of patients who suffer from a disc herniation will get better spontaneously and fully recover their strength and feeling within four months of onset of the symptoms. This is because the body has defense mechanisms that dissolve the disc away. Only a few disc herniations cause intractable pain, nerve damage, paralysis, or loss of bladder and bowel function. You should not be frightened when an MRI scan indicates that you have a disc herniation unless it is causing you to have severe symptoms, such as weakness in your legs or arms, or loss of bladder and bowel function. In this case you do need surgery, and surgery can help. If you do not have such drastic symptoms, and your pain is getting better or it is not crippling, you have time to see if it will go away by itself. If the pain from a herniated disc anywhere in your spine does not go away with time (at least three months from onset) and it interferes with your quality of life, you can always have surgery later to remove that part of the disc that is pressing on your nerve (disc excision).

In my experience, the symptoms from a disc herniation rarely get worse after the initial attack. If the person is getting better after the peak of their pain, and does not have nerve damage, they rarely get worse later. It is safe for you to wait out the symptoms of a disc herniation as long as you do not have the symptoms of disabling nerve damage described above.