Questions/Answers

What is scoliosis?

Scoliosis is an abnormal curvature of the spine.  There are usually two components to scoliosis, a rotation and a lateral bend.  Most scoliosis is primary, i.e., the patient is born with a genetic abnormality that leads to the incorrect development of the spine.  In severe cases, scoliosis can interfere with a patient’s ability to breathe or his heart to beat.

Secondary scoliosis occurs when an injury to the back or legs, such as a fracture to the spine, or a leg fracture that shortens one leg.

Scoliosis can lead to abnormal motion of the spine, which in turn can lead to pain because of damage to cartilage, ligaments, and disks.  Muscles can be strained because of the abnormal work they do.

Fortunately most scoliosis is minor and does not cause problems.

Do back injuries heal?

Most of the time a back injury is a pulled muscle (strain) or stretched ligament (sprain).  These heal.  We’ve all had minor strains and sprains and they have all healed nicely and we never think about them again. 

Some strains and sprains are more serious.  In that case you may be left with a significant amount of scar tissue in the muscle or ligament.  These become weak areas that are susceptible to re-injury in the future.  For these injuries healing is not complete.  You can avoid repeat injury by strengthening the muscle or ligament fibers that weren’t injured to help protect the damaged area.

If the injury is to cartilage or disc, then healing is less certain.  Neither has a good blood supply and so the damage usually is not completely repaired.  Recovery takes a long time.  Damaged nerves take a long time to heal also.  Fortunately severe damage to cartilage, disc, or nerves is rare.  On rare occasions surgery is the only remedy for an injury that won’t heal on its own.

In general, when do patients need surgery?

In general, a patient needs surgery when surgery can save his life, repair an injury the patient’s body cannot, or shorten significantly the recovery from an injury or disease.  When it comes to the lower back, there are five absolute indications for surgery, but several elective reasons.  The absolute reasons are the following:

1.  Cauda equina or conus medullaris syndrome.  These situations happen when there is a very large central herniated disc that compresses severely the nerves in the lower spinal cord.  Without surgery, the compression would lead to eventual loss of function of those nerves, paralysis of muscles, and/or loss of sensation.

2.  Intractable pain, i.e. unremitting, severe pain.

3.  Progressive neurological deficit, loss of sensation, proprioception, muscle control, etc.

4.  New incontinence or retention, bowel or bladder.

5.  Hemorrhage into the spinal cord.

The relative indications generally center on the relief of discomfort (less than intractable) and the shortening of recovery time from various problems: herniated disk, compression fractures, etc.

I have been told that my discs are dehydrated.  What can I do to rehydrate them?

If it is obvious on the x-ray or CT that your discs are dessicated (dehydrated), then there is little you can do to reverse that process.  These changes only show up on x-ray after years of progression.  They are a result of aging and trauma.  An intact disc annulus keeps fluid within the nucleus, but as we age the disc annuli crack and the nuclei deteriorate, leading to dessication.  Just as it would be impossible to unfry an egg and pour it back into the shell, it is impossible to return the discs to their previous younger and healthier state.  The same is true with cataract formation in the eyes, wrinkled skin, and a host of other changes in you body brought about by aging.  That’s not to say that one day we won’t be able to reverse those changes through genetic or stem cell therapies.  At the moment we can’t, though

I had an episode of severe back pain.  My doctor ordered an MRI and I have four herniated discs!  The surgeon wants to operate, but my pain is getting better.  What do I do?

If you take your age and change it to a percentage (say you are 55, that equals 55%), that percentage is the chance you will have an abnormal lower spinal MRI, including herniated discs, arthritis, etc.  Doing surgery for the sake of doing surgery makes no sense.  If you have a specific unresolving problem, say pain down the back of your right leg AND there is a disc herniation or extruded disc fragment on the right side of your spinal column at the L4-L5, or L5-S1 levels, then that disc abnormality MAY be causing your pain.  Otherwise, these abnormalities are not causing you a problem; they are incidental findings.  Without the MRI you would not know they existed and would have gone to your grave convinced you didn’t have a bad back.  Don’t over-react.  See if your pain resolves.  Surgery also traumatizes your back; avoid it if you can.

The doctor says I have severe spinal stenosis.  I can only walk fifty feet without my legs getting weak and having to sit down.  He says surgery will help.  Will it?

Since I was a young girl, I have had frequent bouts of back pain and I swear I can feel my back move.  When it moves the pain goes away.  My family practitioner ordered a CT scan that shows I have spondylolithesis.  He wants to send me to an orthopedic surgeon.  Will surgery fix my pain?

Spinal stenosis and spondylolithesis can be treated conservatively with medications, Physical Therapy, and exercise.  However, they sometimes progress to the point of intractable pain or nerve compression and then fall into one of the five indications for surgery.

Besides your book (What Your Doctor Won't Tell You About Your Lower Back) do you recommend any other books on treating back pain?

There are thousands of books!  There are also thousands of exercises, programs, treatments, etc.  Sometimes, it is tough to find what works for you.  I think Robin McKenzie's Treat Your Own Back is a good place to start.  Provided you don't have an anterior disc rupture (rare), spinal stenosis, or a problem caused by a Red Flag disease (see Appendix 1, on the page Initial Post and Blog Information), the program he offers generally helps.  If, however, exercise makes your pain worse, then STOP! Or at least cut back; it's possible to be too flexible and to do too many exercises.

How can I tell if I have spinal stenosis?

Lumbar spinal stenosis is usually experienced by men more than 60 years of age, but anyone can have it.  Common complaints include:  Pain on standing erect, walking long distances, or leaning backward that goes away when seated or leaning forward (as when pushing a shopping cart); pain in both buttocks and/or upper leg pain; some patients have difficulty with balance and walk with a wide-based gait.  Lumbar spinal stenosis can necessitate to surgery if symptoms are severe.

My doctor didn't take x-rays or order an MRI, should I find a new doctor?

As long as your physician took a good history (listened to your story) and did a reasonable physical exam (had you bend over, walk on your heels and toes, checked your reflexes, etc.) then you are probably in good hands.  If you do not have any Red Flag symptoms, neurological deficits, or intractable pain, imaging studies (x-ray, MRI, or CT) are generally unrewarding.  In other words they don't help in making the diagnosis, but they do expose the patient to radiation, or enormous expense with little information gained.  If you don't improve by following your doctor's suggestions, imaging may be necessary in the future.

What are the symptoms of a herniated disk?

A majority of people will have minimal or no back pain.  We found out about their herniated discs by accident years later when doing an x-ray or MRI for some other reason.  Some people have localized back pain that goes away after several weeks.  Some people have nerve pain that radiates into their buttocks and legs.  This is called sciatica and can be severe.  Some people have muscle weakness or numbness in the same are area that others experience sciatica.

I don't want to have back surgery.  What is the best exercise to do in order to avoid surgery?

The best back exercise is one that you will do.  Exercises or stretches that increase your pain should be avoided.  You may experience a little discomfort, but that should resolve when you finish.  If the pain persists, it is the wrong exercise.  All exercises use all the muscles, ligaments, and tendons in your back and therefore help strengthen them.  But, if those exercises increase pain dramatically, then your body is not ready to try them.  All stretching exercises will stretch the ligaments and tendons in your back thereby increasing flexibility.  DO NOT bounce.  A slow, steady stretch is better.  If stretching causes pain, then you may be increasing instability.  Stop!  Probably the easiest exercises for back pain patients to start with are walking and the Plank -- the position one takes before performing a push-up.  Holding that position for several seconds is a good start.  Try to progress to a complete push-up, then add to the number of push-ups as your back, core, and arm muscles get stronger.

What is inflammation, and what do anti-inflammatory drugs do?

Inflammation is your body's way of fixing things that are broken or diseased.  An inflammatory response is the result of the release of a cascade of hormones by your immune system.  These hormones direct the fight against infection and/or the rebuilding of tissue damaged by infection or injury.  In general inflammation causes four obvious responses: redness, swelling, warmth, and pain.  In some instances your body over-reacts and causes more swelling and pain than necessary for healing.  Most people are aware of these responses, easily seen with an insect bite, sprained ankle, or back strain.  Anti-inflammatory medications (also known as steroids or non-steroidal anti-inflammatory drugs, NSAIDs) interfere with this cascade of hormones and frequently reduce redness, swelling, warmth, and, most importantly, pain.