This article isn't for people with slight low back pain--like you can "kind of" feel it when you sit down or get up. This article is written for people are in a great deal of pain. The kind that has you worry about the ability to get off the toilet. The kind that makes you worried that you'll never get any better. Bad. That kind.
Here's a common course of events when you get an acute episode of 10/10 Low Back Pain:
1) You get really scared and either ask a friend what to do or look up your symptoms online
2) You schedule an appointment with your Primary Care Physician (or Urgent Care)
3) They recommend you get an X-Ray
4) The X-Ray shows nothing
5) The doctor gives you anti-inflammatory medication or pain medications and says if the pain persists for 2-3 weeks, then an appointment with an Orthopedic doctor is indicated
6) The Orthopedic doctor offers you some sort steroid (oral or injection) and orders an MRI
7) If the doctor sees a herniated disc (and depending on his personal skills and experience), he/she recommends surgery and/or a referral for Physical Therapy
8) Meanwhile you've been in pain for a few months now and the chances that this becomes chronic pain grows larger by the day
Well there's another way, let me explain....
There are some common questions and concerns that people have when they get an episode of acute Low Back Pain. Especially if it's your first episode. This article is designed to provide you with comfort and some helpful tips to help you get better quicker and stay better. Also, hopefully it provides you with proof and evidence that you should seek out conservative, rehabilitative intervention to help you through this time. For the purposes of this article, conservative rehabilitative intervention is defined as:
- Physical Therapy
- Physical Medicine MD
Know that this is known as an "Acute Episode." 100% of people will experience them. The vast majority of the time, they are short-lived and infrequent but painful and scary nonetheless.
About 4 years ago I got a stomach bug that wiped me out for about a week and a half. It was awful. I couldn't go to the bathroom that whole time. I was alternating all my time between writhing on the couch and sitting, ineffectively, on the toilet. I knew something was really wrong. I went online and read WebMD and found that I might have an intestinal blockage which would require immediate emergency surgery. I considered maybe I had diverticulitis with painful out pouching of the intestines that would also require major intervention. Finally, after a week of misery and WebMD-induced anxiety, I broke down and went to Urgent Care. What did she diagnose me with? Constipation. What did she recommend I do? Eat crackers and drink ginger ale. After questioning her about the severity of my symptoms, what did she say? "This too shall pass......."
What was the lesson that I needed to be reminded of? We tend to fear the worst and catastrophize when we're in unfamiliar pain. It's completely normal.
Getting An X-Ray or MRI Probably Won't Help You Get Better Any Quicker
As human beings it's very normal to think that when you're in pain that there must be some visible physical cause that would be apparent by getting imaging of your low back. For some reason, we also need proof that something is causing this pain. Unfortunately, when it comes to back pain this type of thinking isn't really helpful. All pain in the body is caused by chemical inflammation that creates the emotion of pain in the brain. (THAT'S RIGHT--I said chemicals and emotion even though it feels 100% physical). Now, I'm not telling you that you're pain is in your head. What I am saying, is that the complex phenomena that is Low Back Pain can't always be found and described by imaging your low back. In fact, it's quite the opposite.
Medical studies are now showing that early MRI is associated with WORSE outcomes in chronic Low Back Pain and disability (Graves, 2012). Why? I suggest, that when you can visualize an abnormality in your back there is a psychosomatic effect that propagates the emotional cycle of back pain, whether that abnormality actually causes your Low Back Pain in the first place or not. Did that make sense?
So what I'm telling you is:
1) Don't be so quick to want to take an X-Ray or MRI. It's expensive and it probably won't change the outcomes of your Low Back Pain episode anyway.
2) X-Ray or MRI is appropriate at two times:
a. Upon initial exam you are showing signs of "Red Flags" such as possible fracture, infection, neurological findings; or
b. You've attempted a course of conservative management (chiropractic, physical therapy, etc) and haven't gotten good results after approximately 1 month.
It's not always smooth sailing. Sometime you'll feel worse after a visit. It's okay and doesn't mean something is wrong or not working. Stay the course.
The Scary Stuff:
When we have Low Back Pain we want to figure out why. When we're not confident that the source is a muscle or joint, sometimes our mind can start to wander on us. We get scared that the source of the back pain could be something more "sinister." Well, while there are times when the more sinister causes are at play, fortunately, the vast majority of Low Back Pain cases are much more benign. Here's a list of some "sinister causes" of Low Back Pain and symptoms/conditions that would usually accompany them. Keep in mind this list is not 100% and there are always exceptions to everything in life. This is no different:
- Neurological Involvement
- "Drop Foot" or weakness or atrophy (waisting away) of the muscle of your legs or feet
- Typically it doesn't involve specific movement that increases pain. So if you find yourself saying something like, "It hurts when I stand up from a seated position," then that wouldn't typically indicate a tumor as the cause.
- Broken Bones
- In the absence of a traumatic event, fractured bones causing back pain is very rare.
- Blood Clots
- Typically blood clots could be the cause if you:
- Take birth control medications
- Have a history of blood clots
- Have swollen foot/leg and you didn't recently sprain your ankle or injure your leg
- Have pin-point (the size of the end of your finger) pain in your groin, inner thigh, or behind the knee
- Typically blood clots could be the cause if you:
When Is It Time To Panic?
The vast majority of these incidents are episode that will pass with the right action. But sometimes it doesn't. When is it your time to panic and start seeking medical care? A general rule of thumb is if you are at 10/10 pain for more than a week and you don't feel like anything is improving, then it's time to seek out professional care. One week of 10/10 pain is too long to be dealing with this.
In my experience, back surgery should be avoided whenever possible. I see more research saying that conservative methods (non-surgical) get better long-term results than surgical outcomes (Delitto, 2016). Certainly, sometimes it is needed. When you have one of the more "sinister" causes mentioned above, such as neurological deficits or bad scoliosis, then there aren't many options other than surgery. The main types of spinal surgery are:
- Fusion - the spinal segments are fused to stabilize the affected area. Since the spine is designed to move, this spells trouble down the road for the segments above and below the fused area.
- Laminectomy - the back side of the vertebrae are removed in an attempt to decompress any pinched tissues.
- Disc Replacement - artificial discs are placed in the place of the injured segment.
- Microdiscectomy - the most modern and least invasive option we've seen lately. It involved cutting out the 'herniated' aspect of the disc.
What If I Have a Herniated Disc?
Many people have questions and concerns about having a disc injury. Now there are all sorts of possible disc injuries. There are:
- bulging discs
- herniated discs
- sequestered discs
- degenerated discs
- discogenic back pain
- endplate fractures
- degenerative disc disease
But to be frankly honest with you, it's not your job to know the difference and it doesn't benefit you, the patient, to know the difference in any way. The two most important things to know are:
1) Discs can resorb (heal) without surgery
Sometimes people treat a herniated disc like the kiss of death. All the time patients come into my office saying, "I herniated a few discs 20 years ago and I still deal with it." Well that's not necessarily true. Disc injuries can heal through proper physical rehabilitation, chiropractic, physical therapy, exercise, etc. Far too many people think that when you have a herniated disc that you need to have surgery. In my experience, for the majority of cases there are better, more conservative options that are successful.
2) A bad bulge/herniation/sequester can lead to a pinched nerve that could possibly, if they're bad enough, lead to surgery. But the majority of them don't.
Again, proper conservative care through a chiropractor/physical therapist/physical medicine MD, etc can adequately treat the majority of disc injury cases. Good luck!!!!!
(1) Delitto, A. "Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis." Journal Ann Intern Med. 2015;162(7):465-473. Doi:10.7326/M14-1420, n.d. Web. 20 July 2016.
(2) Chiu, CC and Chuang, TY. "The Probability of Spontaneous Regression of Lumbar Herniated Disc: A Systematic Review." Clinical Rehabilitation 29.2 (2014): 184-95. Print.
(3) Graves, JM and Fulton-Kehoe, D. "Early Imaging for Acute Low Back Pain." Spine. 37.18 (2012): 1617-627. Web.