Conventional “knowledge” tells us that we were not meant to walk upright and that backs typically degenerate over time which leads to chronic back pain. If back pain was caused by degeneration of the back and the discs between the vertebrae, then it would make sense that back pain would increase with age. This is not the case however. Back pain actually drops a bit after age 65. We have been told that back pain will occur more often in people who use their backs more often. However, in studies from around the world, more people have back pain in industrialized, modern societies than in rural, agrarian societies.
What is the cause of back pain? There are several serious medical conditions that can cause back pain, such as a vertebral fracture (usually a compression fracture seen in the elderly or those with osteopenia), cancer of the vertebrae (seen in those with metastatic breast, lung or prostate cancer), serious abdominal conditions such as rupture of an abdominal aortic aneurysm, pancreatic cancer, rupture of a duodenal ulcer, or infections such as osteomyelitis, epidural abscess or diskitis. Fortunately, these conditons are relatively rare and easy to diagnose with modern imaging techniques (X-ray, CT or MRI).
What about sciatica and disc herniations? Severe disc herniations can cause sciatic pain (pain radiating down the back or side of the leg), but these are usually associated with some clear neurologic evidence of compression of the nerve root as it exits the spinal canal. These would include weakness of certain muscle groups in the leg compared to the other side, an abnormal deep tendon reflex, or a reduction in sensation in certain areas of the affected leg. If any of these findings are present, that indicates pressure on the nerve root and if these findings progress or do not resolve over time, these people are candidates for back surgery to relieve that pressure on the nerve roots. If these findings are not present, i.e. the leg is neurologically normal, then it is likely that there is no significant pressure on the nerve roots and therefore no significant disc herniation. Many people have sciatic type pain, yet have no evidence of neurologic findings and therefore do not need surgery and fall into the category of back pain discussed below.
What about back pain that does not radiate down the leg? This is known as axial back pain and is best considered to be due to a combination of factors that is usually misunderstood by most medical doctors. See below.
Most back pain cannot be diagnosed by any doctor, using our current methods, including examinations, X-rays, CT and MRI scans. This is shocking to most people because if you have back pain and go to a back specialist of some kind, they will invariably tell you exactly why (in their opinion) you have back pain. Unfortunately, the data tells us that they will be wrong; they will unintentionally be misleading you and misleading themselves. How can this be the case?
MRI’s are inaccurate in diagnosing back pain, unless there is one of the serious conditions mentioned above or a disc herniation has lead to neurologic findings. Most people without back pain will have “evidence” of an abnormal back on an MRI study. Most people will show disc herniations or bulges, stenosis, disc degeneration and other findings. And when people with and without back pain are given MRI’s each year, there is no correlation between MRI findings and back pain. In some people the MRI improves and the back pain gets worse, in others, the MRI gets worse and back pain gets better. It is virtually impossible for a doctor to tell if someone has back pain based upon an MRI. Yet, in people with back pain, doctors are quick to point out the abnormalities seen on an X-ray or MRI and to presume that theses abnormalities are the cause of the pain. As mentioned above, they will be wrong in making such an assumption. Conversely, many people with chronic and severe low back pain show no abnormalities on an MRI.
What about surgical treatment?
The SPORT trial published in JAMA in 2006 showed that there were no clear differences between those with sciatic pain who received surgery compared to those who had physical therapy after two years. Surgery for sciatic pain is more likely to be effective than that for axial back pain. There have been no studies to determine if surgery is actually effective for axial back pain. In fact, one of the investigators for the SPORT trial stated in an interview that it would be appropriate to conduct a research study comparing surgery for axial back pain with a sham surgical procedure. A similar study for arthroscopic surgery for knee arthritis showed no difference between the real surgery and the sham surgery. It is possible that some (or even a great deal) of the response to back surgery is due to the placebo effect. Studies have also shown that the rates of back surgeries in different communities varies up to five fold, depending on the number and type of surgeons in those communities.
The next blog will focus on how back pain can be caused by MBS/TMS. Stayed tuned.
To your health,
Howard Schubiner, MD