Question: How do I find a doctor to diagnose and treat my back problems? I've heard of a variety of treatments from epidurals and gel injections to surgery but don't know which is right for me, and I don't want to just go to a neurosurgeon who will just say I need spinal surgery. I have had a lot of therapy but no improvement.
Dr. Hibberd's Answer:
Investigating the cause of back problems has been revolutionized by the MRI and PET imaging. These non-invasive evaluations have saved many patients from the risk and discomfort of dye needed for myelogram studies, yet have identified a large number of patients with "bulging" discs who now worry about their "bad back." Just for the record, bulging discs as an isolated finding probably have little, if any, clinical significance with respect to pain but may reflect a recent injury or reflect a genetic or acquired predisposition to disc injury or protrusion.
Surgery should normally be reserved for intractable chronic pain, high-risk unstable acute injuries, or destabilizing conditions that, untreated, will result in paralysis, bowel or bladder dysfunction or permanent loss of nerve or muscle function.
Most back pain conditions associated with disc disease will self-resolve if given long enough, usually 6-12 weeks for the prolapsed disc material, a gel-like substance, to be dissolved and cleared away naturally.
Epidural narcotic and steroid treatments may provide comfort but DO NOT alter the recovery time needed for healing and dissolving the prolapsed disc material. Likewise, while physical therapy and manipulation in select cases do seem to improve comfort and allow earlier return to many activities of daily living, they do NOT accelerate healing or prevent recurrence as some claim.
Targeted exercise emphasizing strengthening of abdominal muscles, guidance on posture, and safe lifting technique instruction HAS been shown to reduce recurrent back pain and re-injury. Back supports marketed for prevention of back pain have been shown to be ineffective for prevention of back injury though they do increase the awareness of proper lifting and the potential for back injury.
Disc dissolution materials have been effective, although they put the patient a high risk for damage to spinal cord tissue, and hence have been generally abandoned.
I rarely approve of manipulation for neck injury because of the risk of permanent spinal paralysis. Selective manipulation of lumbar spine may have occasional usefulness for pain relief, but has no preventive role. There is no such thing as preventive manipulation unless you wish to fuel someone's retirement and vacation account!
I often see ads for various other "high tech" devices touted to "treat" disc disease with little true supportive data except for their expense. So if your local hospital or orthopedic/neurosurgery group does not have this device available, regard its use as suspect, probably experimental, and probably not as advertised.
There are kyphoplasty devices available to restore vertebral height after collapse, but pain relief is not universal, so cases must be carefully selected. Replacement disc material has been used but is hindered by concern the disc may migrate into the spinal canal causing paralysis of its own. Laminectomies and spinal fusions are aggressive procedures that provide relief to most but give chronic pain to some. I regard surgery for back conditions as second-best to conservative treatment for MOST chronic back conditions, accepting that some sadly will not be satisfied until they are cut.
Your best resource for your back should be your primary care physician. When indicated, consultation with orthopedic, neurology and neurosurgical consultants is appropriate. Surgery is normally a last resort for chronic pain.
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