back pain

Tuesday, October 28, 2014

Fans always want to know the ins and outs of NFL injuries. Understanding what happens on the sidelines or in the locker room may help their fantasy football predictions or perhaps satisfy their prurient interest, like slowing down when driving by an accident, but it also engenders a false expectation of what the real world can bring to medical care. If technology was used on every person with a back injury like it was on the Cowboy’s Tony Romo, Medicare would be in a deeper financial hole than it already is.

Admittedly, even for an elite athlete, Mr. Romo’s case is special. Last year, he required surgery to repair a ruptured disc in his back and he has had to limit his practice time so that he could play on Sundays. Still, the Cowboy nation held its breath when he lay on the turf after taking a knee to his low back when being tackled. After x-rays in the locker room were negative for broken bones, he came back to play. But physical exam, those x-rays and clinical judgment weren’t enough. Technology and an MRI was required to confirm the decision as to whether he could return to play.

More than 85% of the United States population will experience low back pain in their lifetime and almost all will have it resolve within a couple of weeks without doing much special. Still, mechanical back pain is the most common cause of disability for those younger than 45 and falls only to number three for those who are older. Almost all are work related, especially for people who use their body as a tool or machine. While a single traumatic event can be the cause of the low back pain, often it is a series of minor traumas that add up to cause the pain. The numerous structures that make up the low back, the bones, ligaments, tendons, discs and nerves, all have to work together to allow the back to function. An injury and subsequent inflammation to any one structure can lead to pain.

The back has many responsibilities including maintaining an erect or upright posture. But perhaps, its most important job is to protect the spinal cord its nerves from damage. Most often the cause of back pain arises from the muscles, tendons and ligaments. The decision point for the care provider is to decide whether the spinal cord or nerves are at risk. If the answer is no, then imaging the back with plain x-rays, CT or MRI is a waste of time, radiation and resources.

Most often, the diagnosis is made by talking to the patient and performing a detailed physical exam. When the pain started is important. Was it acute onset with movement? Or did it arise hours later, perhaps after laying down or getting up in the morning. Understanding the mechanism…was it rotation or torsion of the lower back, or the lumbar spine? or was it flexing or bending forward. That information can help point to what stabilizing structure of the back might be damaged. If the physical exam isn’t exciting and the diagnosis made that it’s all soft tissue (muscle, tendon, ligament), there’s not much to do, except pain control, activity as tolerated and perhaps physical therapy or chiropractic manipulation.

Perhaps the questions that are directed to the potential for nerve impingement or irritation are most important. Is there sharp pain radiating into the buttock or down the leg. Is there numbness or tingling in part of the foot? Nerves that run from the spinal cord can present with pain that follow predictable dermatome patterns and can help determine at what level in the spine damage has occurred. The sciatic nerve is the accumulation of all those nerve roots that supply the leg. Inflammation of any one root can cause significant pain called sciatica. Still, there is little to be gained by x-ray or MRI. The treatment remains pain control and activity as tolerated.

lowerlimbdermatomes

It’s only when signs of impending spinal cord damage does imaging become and urgency. Has the patient lost control of their bowel and perhaps become incontinent of stool? Has he or she lost the ability to empty their bladder and urinate? Is there numbness around the anus or vagina? The questions may seem unrelated to the back but are harbingers of spinal cord disaster and emergent MRI is required.

For most other patients, the best diagnosis and care for low back pain is time and support. Often, symptoms resolve in 2-4 weeks with a combination of rest, ice, heat and anti-inflammatories. Activity as tolerated is always better in mending a back than lying in bed. In some patients, back pain is progressive and further diagnosis and treatment is required, but as opposed to Tony Romo’s x-ray within a few minutes and MRI within 48 hours, the time frame is a lot slower. To be fair, one indication for plain x-rays is in a trauma victim and suspicion of fracture, and being hit by a linebacker qualifies. For most people, however, their trauma is bending over or twisting to pick up a box and that isn’t enough to break bones. (There are always exceptions in medicine and we’ll offer one to little old ladies with osteoporosis who can get compression fractures with little or no trauma).

The stakes are high in the NFL and with player salaries in the millions, there is a want to return the player to the field of play as soon as possible. It causes doctors and trainers yo use technology to bolster their medical opinion. In the real world, the stakes for o every patient are just as high, but it is just as reasonable to trust high touch instead of high tech in caring for their back. If the 85% of the population that will one day experience back pain demand the Tony Romo level of care, unemployment in this country will fall to zero. Somebody will have to build all those MRI machines.

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low back pain

Monday, November 11, 2013

The shelf life of an NFL running back is much too short. The body is asked to absorb repeated hits and that is coupled with turf that is unforgiving on knees and ankles. The career life expectancy of an NFL player is about 6 years but running backs may or may not last that long. Last month, Houston Texan Arian Foster made news by offering fans the opportunity to buy shares in his future earnings, but that was forever ago and now his stock is dropping because of planned season ending back surgery for a bulging disc.

Mr. Foster joins the 40% of the American population who suffer from low back pain. Most often it is because of a pulled muscle and the pain resolves with a little time and TLC. But sometimes, the cause of the pain is damage to one of the structural elements of the back and surgery may be required. It is rare that surgery is emergent and often, an operation is planned when other options like physical therapy, chiropractic care and medication injections fail.

The spine is made up of stacked vertebrae that are supported by muscles and ligaments. In between the bones lay the discs that act as shock absorbers to cushion the force of walking, running, jumping and twisting. The vertebrae also protect the spinal cord and the nerves that enter and leave, transmitting signals to and from the brain. Over time, because of age or due to trauma, the spine can degenerate and arthritis can set in, limiting the function of the back to move and to absorb the shocks of daily life. This may cause the muscles and ligaments to become inflamed but it can also cause the discs to bulge or rupture.

spinal disc

While the damaged disc can cause pain because of the local inflammation of the injury, the potential complication is that the disc can irritate a nerve root as it leaves the spine. In the lumbar spine, the low back, these nerve roots come together to form the sciatic nerve and the pain can radiate into the buttock and down the leg causing significant distress. The disc can also bulge and press back into the spinal canal where the cord is located and press on the cord, causing the pain and numbness to be felt in both legs.

bulging disc

The initial treatment remains the same for most patients but when muscles begin to weaken or reflexes are lost, an urgency exists to consider surgery to relieve the pressure on the nerve root or spinal cord. This progresses to a true emergency if the ability to urinate is lost and the patient becomes incontinent of stool, a condition known as cauda equine surgery, and if there is hope for the spinal cord, surgery needs to be done within hours.

Arian Foster’s medical course seems to be following the urgent, non-emergent course.  His back pain has been diagnosed as a bulging disc and he is seeking opinions as to when it is best to have an operation. He may opt to have surgery sooner than later because he is reaching the halfway point of his NFL career and may not want to spend months waiting to see if therapy may work. Add to the equation is that his job is not sitting at a desk or standing in front of a classroom, it is being hit by 300 pound linemen who do not care that he has a fragile low back.

For most people, ice, heat, over the counter anti-inflammatory medications and activity as tolerated is the mantra to healing low back pain. Better yet is maintaining good back health by keeping weight under control, working on abdomen and back core strength, stretching to maximize flexibility and using proper lifting techniques. Unfortunately for Mr. Foster, he and his running back fraternity, are not like most people.

 

Illustration attribution: webmd.com, denverchiropractor.com

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