Monday, April 23, 2012
There is never a good time to have back surgery but perhaps the best time is just before the nerves that leave the spinal cord stop working. A planned operation then becomes an urgent matter. And so goes the story for Dwight Howard of the Orlando Magic, whose season and Olympic team aspirations ended when he underwent surgery to repair a herniated disc in his low back. With his injury, Mr. Howard joins the two thirds of adults who have suffered with low back pain sometime in their lives and he becomes another worker whose low back pain and injury makes it the number one cause of work related injury.
Low back pain is a too common complaint and 80% of the time, the cause for the pain is not found. Usually the pain is muscular and gets better with ice, heat, ibuprofen and time. Sometimes the pain is due to inflammation of the nerve root that leaves the spinal cord to send and receive signals to the brain. Purposeful movement or motor nerve fibers send signals to the muscles to move while sensory nerve fibers return signals to the brain letting it know about things like pain, touch, pressure, temperature and position. If the space between the vertebra narrows in the back because of arthritis or a herniated disc (the shock absorber between two vertebrae), the nerve root can be pinched or irritated and cause symptoms.
There are 7 cervical, 12 thoracic and 5 lumbar vertebrae and the nerve roots are named for the space where they exit the back. Each nerve root is associated with a specific muscle and area of sensation in the body. Knowing the anatomy and matching it with muscle weakness and the area of numbness can help localize what nerve and therefore what part of the back isn’t working well. With a good history and physical exam, most people can have their diagnosis made clinically without need for x-ray or MRI. Basic treatment follows and most people have relief from their pain in a short period of time. Some people don’t respond and this is where we can learn from Mr. Howard’s injury.
Pro athletes tend to get many tests that are not offered to regular patients but that’s another column. Appreciate that Mr. Howard had a herniated disc causing his pain and he started the routine therapies that would be offered to everybody: rest, physical therapy, anti-inflammatory medications and steroid injections into the area surrounding the herniated disc. Urgent surgery was not recommended until his physical examination changed and he developed weakness in one of the muscles in his leg, a signal that the nerve was not just irritated, it was no longer working.
There are a few flashing lights that warn of impending disaster with low back pain and the need for urgent surgery. Pain is not one of them. It all has to do with the spinal cord and nerves that leave it. When the parts of the body that they control stop working, intervention needs to happen.
• If a patient loses control of their bowel or cannot urinate, this may be a sign of cauda equine syndrome, where the tail of the spinal cord becomes compressed and stops working. It may be due to arthritis and spinal stenosis that narrows the spinal canal or it might be trauma or a tumor that causes the narrowing. It is a true neurosurgical emergency because failure to fix the problem can leave the patient paralyzed.
• Another urgency occurs when there is painless weakness to the leg and the patient has difficulty lifting their leg against gravity. There may or may not be numbness but this is a sign that a nerve root is severely compromised.
• Extreme intractable pain is another indication for urgent surgery especially if a nerve root anesthetic fails to control the pain.
Without these situations and potential catastrophes, the common wisdom is that time and observation are important parts of the treatment plan for low back pain patients. This does not mean these patients should suffer but rather, their condition does not need an urgent referral for surgery. While surgeons do like to operate, they prefer to cut on people who have a high likelihood of getting positive results from their operation.
Dwight Howard taught us that knowing he had a herniated disc in his back, the first step to heal was rest and rehabilitation. Surgery was not the first step that he took towards recovery and it is unfortunate that he had to have any surgery at all. Now we get to wish him a speedy and full recovery.