Conquer Back and Neck Pain - Walk It Off! (28 page)

Just as a herniated disc and spinal stenosis can recur, so can a facet joint cyst (illustrated on page 78). Recurrence of these conditions alone or together may be a cause for failed back syndrome. By now you undoubtedly have a better appreciation of how complex the spine is and how difficult the judgments are that must be made for surgical treatment of back pain the first time and certainly for failed back syndrome.

One of the most common reasons for failed back syndrome is adjacent segment failure, which is breakdown of the disc, ligament, and/or bone at a level proximal or distal to a spine fusion. I had recommended to a patient a decompression of multiple-level spinal stenosis and fusion with metal fixation to correct a complex deformity (slippage, tilting forward, and curvature) at four levels between L2 and the sacrum. The patient e-mailed me a copy of a paper entitled “Adjacent Segment Failure above Lumbosacral Fusions Instrumented to L1or L2” that was posted on the Internet. The author’s conclusion that long instrumented fusions were unacceptable because of a 30 percent rate of failure frightened my patient. My response to the patient was as follows: “The problem is that this extensive surgery is performed for people with extensive problems such as yours. You have curvature (scoliosis), slippage at two levels (degenerative spondylolisthesis), constriction (spinal stenosis), and osteoporosis of the spine. For you to obtain relief of pain and regain function requires a decompression of the constricted areas of your spine and stabilization with a fusion from L2 to the sacrum. If you do not have surgery I think your condition will gradually become worse and surgery will be more difficult. However, there is a 25 percent risk that you will require additional surgery at some time in the future because of the nature of your condition.”

Adjacent segment disease occurs because of two problems. Stress on the spine is shifted from a fused disc space to adjacent unfused levels. If the adjacent unfused discs or bony structures are predisposed to break down, they will not hold up to the increased stress. This is usually the case in patients who require fusions in the first place. It is difficult to predict who will develop adjacent segment disease following a spinal fusion and therefore how many levels to include in a spinal fusion. I have seen this problem require a second operation in fewer than 20 percent of my patients.

Failed back surgery can be caused by operating on the wrong level, incomplete surgery on the correct level, operating for the wrong diagnosis, and, when there are multiple sources of pain, failing to correct all of them at the time of surgery. It can also develop because of the nature of the disease. I have given you examples of each reason why back surgery fails.

I get this joke from my patients all the time: “Doc, since the surgery I can’t play the piano anymore.” To which I reply, “I am sorry, why is that?” And the patient answers, “Oh I couldn’t play it before the surgery either!”

Finally, back surgery can fail simply because the patient’s expectations were not met. Both you and your doctor must have a clear understanding of what the expected outcomes of the surgery are. You have an obligation to tell the doctor what your expectations from the surgery are, and your doctor has an obligation to tell you whether she or he can meet those expectations. I frequently tell patients that there is a high probability that the surgery will relieve their pain and improve the quality of their life but a low probability that they will be able to perform certain activities such as skiing, running, playing tennis, or, in some cases, golfing. It is best for both parties to have a clear understanding of these issues before the surgery to avoid a feeling that the surgery has failed when unrealistic expectations are not met.

I was in my late 20s when I had my first attack of back pain. I realized that I was not taking good care of myself. I had been a college lacrosse player but stopped exercising regularly after graduation. I also made the big mistake of taking up smoking — during medical school, no less! With a combination of sitting in classes for long hours, lack of exercise, smoking, and a family history for bad backs, it was inevitable that I would suffer an attack of back pain.

Although I had already stopped smoking by the time of my first back-pain attack, I had not yet resumed exercising. I vowed to begin a lifetime of exercise so that I would never suffer like that again. My father, who lived a sedentary life and smoked, suffered repeated attacks of back pain, whereas my mother, who exercised daily and did not smoke, never had back pain. I began to emulate my mother, and started exercising on a regular basis. To this day I have a propensity for backaches, but I have never suffered from a disabling attack like my first attack of back pain. My wife and I walk four miles a day several days a week, and I am also otherwise physically active. My MRI scan shows that I have multiple degenerated discs in my spine.

The medical literature substantiates what I have personally experienced and what I have observed from my patients: staying physically fit and not smoking are the two best things you can do to decrease the frequency and severity of back-pain attacks. It is that simple; and you have complete control over your own destiny!

There are a few other suggestions regarding your everyday activities that will help keep you from having an attack of pain. There are certain activities that can bring on attacks of neck and back pain that may not have occurred to you. You may not associate these activities with your pain because it frequently does not come on until a day or two after doing them. One of these is sitting on the floor. When I sit on the floor and play with my grandchildren, I invariably will develop back pain a day or two later. Other activities that will do this are lifting heavy travel bags into the overhead compartments of airplanes or, even worse, lifting bags off the carousels in baggage claim. Usually this requires that you quickly snag a heavy bag (if it was light you would have carried it on) and then twist as you lift. Lifting a heavy object while twisting and being off balance is a very bad move for your back.

It has been shown that, to prevent back pain, children should avoid carrying heavy book bags. Weight lifting is not good for children and adolescents, and hyperextension sports such as gymnastics are associated with back pain in adolescence.

Sleeping on your stomach can bring on neck pain, particularly if you are not accustomed to doing this. I have found that sleeping in this position is more difficult as I get older and develop more degenerative changes in my neck. Looking up for any extended period of time, such as by sitting too close to the stage in the theater, cleaning ceilings in your kitchen, or watching overhead fireworks, can bring on attacks of neck pain. Conversely, I almost always develop neck pain after reading an interesting book for a few hours at a time while lying in bed with my neck flexed. Many of these and similar activities are not associated with attacks of back pain because they do not hurt at the time you are doing them. The pain comes on a few days later.

You cannot prevent the fact that you are human and that our species is prone to disc degeneration and back pain. However, you
can
stack the odds in your favor by keeping in shape. My surgery resident had three disc herniations requiring three operations before the age of 26. Despite having such a bad back, he stays in shape and enjoys an excellent quality of life.

In
Chapter 9
I went over three clinical studies that substantiate the benefits of exercise for the treatment and prevention of acute and chronic back pain, but why does it work? It seems to work in three different ways.

First, exercise contributes to the healthy nutrition of the cells in your discs. Remember how the nutrients diffuse into your discs, and waste is squeezed out (
Chapter 1
)?

Second, it is known that controlled exercise stimulates your body to rebuild injured parts faster than rest does. Years ago a sprained ankle was treated in a cast for six weeks, following which it took forever to rehabilitate the ankle. Today we treat sprained ankles in functional braces for protection so that you can “walk it off.” It now takes half the time to return to full activity following an ankle sprain. The same thing is true for acute and chronic back pain. Controlled exercise makes the discs and ligaments in your spine heal faster.

Finally, exercise stimulates your endorphins, which in turn enhances healing. Exercise, exercise, exercise is the answer to prevention of acute and chronic back pain. The same reiteration applies to not smoking.

Why is smoking so bad for your back? How does it increase the likelihood of suffering from acute and chronic back pain? Let’s first explore the bad things that smoking does to your body in general, and then to your back in particular.

Some of the multiple toxic chemicals in cigarette smoke are potent immunosuppressive agents. Smoking the equivalent of one pack of cigarettes a day is like voluntarily taking cancer chemotherapy drugs. No one would do that voluntarily! They suppress your own body’s normal defense mechanisms. This is why smokers are much more apt to develop post-operative wound infections than non-smokers. Second, some of these toxic chemicals inhibit normal wound healing. That is why plastic surgeons insist that their patients stop smoking before having plastic surgery. The inhibition of healing applies to all of the connective tissues in you body: bone, ligaments, skin, tendons, and yes, spinal discs!

As if suppression of your immune system and inhibition of healing were not enough, smoking also asphyxiates your tissues! The carbon monoxide in tobacco smoke attaches to your red blood cell hemoglobin (the red chemical in your blood that carries oxygen from your lungs to your body) more firmly than oxygen. Ten percent of pack-a-day smokers’ hemoglobin bonds to carbon monoxide, which makes their red blood cells less able to carry oxygen from their lungs to their discs. When your spinal discs are robbed of oxygen, the cells die and leak painful chemicals into your disc. Both acute and chronic back pain is made worse by the toxic effects of tobacco smoke as the result of a combination of these factors.

There isn’t
any
way that smoking is good for your back or for the rest of your body, for that matter! Smoking is responsible for an increased risk of almost every known form of cancer: lung, stomach, breast, prostate, bladder, bowel, and many others. Ladies, smoking causes premature wrinkles and osteoporosis. Gentlemen, smoking causes heart disease and premature impotency. If this litany of horrors doesn’t convince you to quit smoking or never take it up, I don’t know what will!

If you are a non-smoker, don’t even think about starting if you want to be free of back pain. If you smoke, quit as soon as you read these words. In my experience with helping hundreds of smokers successfully stop, the best way to quit is cold turkey. It takes two weeks for the nicotine cravings to subside, and in six months you will hate the smell of tobacco smoke. It has been my observation that people who substitute nicotine patches, gum, and/or food have a higher relapse rate than the folks who just stop. Try to convince a lady who gains weight when she stops smoking not to resume the habit! That is why I also recommend going on a diet at the same time you quit smoking.

A late relative of mine was a heavy smoker and finally quit late in life when she developed terrible back and leg pain from severe spinal stenosis. I advised her that the pain would go away within 48 hours if she stopped smoking. She stopped, the pain went away as predicted, and she was relatively comfortable for the remaining days of her life. When the carbon monoxide from the cigarette smoke cleared out of her system, more oxygen was able to get to the nerves in her constricted spinal canal, and that was enough to relieve her pain. Unfortunately, she quit smoking too late in life and subsequently died from emphysema.

How can you keep from having painful deformity (kyphosis and scoliosis, see
Chapter 7
) of the spine as you get older? Start young, and advise your children and grandchildren to do the same. Never smoke, and if you do, stop now. Smoking is one of the most potent causes of osteoporosis because it turns off the bone-building cells, the osteoblasts. Smoking also inhibits the absorption of calcium from your gastrointestinal system. Excessive intake of alcohol and caffeine will also do this and should also be avoided. The combination of bone-building cells that don’t work and no calcium to work with weakens the vertebrae in your spine.

Weight-bearing exercises, like walking and light weight lifting, stimulate your bone-forming cells to make stronger bones. An adequate intake of calcium and Vitamin D (minimum of 1,000 mg calcium/day and 1,000 IU vitamin D) are also necessary for strong bones. A lifetime of regular exercise and adequate calcium and vitamin D are the two most important things you can do to ward off osteoporosis, painful vertebral fractures, and deformity of the spine.

For women who have premature menopause, that is, they lose their ovarian function at a younger-than-average age, it is important to have adequate estrogen replacement until the time of normal onset of menopause, in the early 50s. Estrogen replacement is not as important after menopause for the prevention of osteoporosis. Since estrogen replacement is also associated with a slight increase in risk of blood clots in the legs, lungs (pulmonary embolus) and brain (stroke), it is no longer recommended for prevention of osteoporosis after menopause. However, the decision for estrogen replacement should be made in consultation with your primary care physician or gynecologist.