World Wide Spine Web
Puget Sound Spine Institute
Common Sense Back Doctor
PreHab Program
Virtual Spine Center
If you have back pain you are certainly not alone. Estimate the 66% of
adult Americans have recurring back pain. The question is; do you have to
live with it or can you manage a way to live without it? The fact is that
most types of back pain are manageable or treatable with some simple principles.
Like a computer program, there are many menu options that you can choose
for individual tastes and needs. The question is, are you in the right program?
The first step is a simple list of questions to decide what the underlying
cause of back pain is.
List of Questions
Do you have:
- Back pain that stays in your lower back?
- Back pain that goes to your buttocks or posterior thighs?
- Back pain that goes to your leg and to your foot?
- Back pain that only comes with activities, bending, or lifting?
- Back pain that comes only when walking?
- Leg or foot pain and little or no back pain?
- Cramping in the buttocks or legs that only comes with walking, relieved by sitting or bending forward and helped by leaning forward on a shopping cart?
- Leg cramps the come with walking, only relived by stopping for a
few minutes but reoccurs at the same distance of walking especially repeatedly?
- Back Pain with Leg Pain and/or Leg Numbness and/or Leg Weakness?
- Leg Pain with or without Back Pain, Numbness, or Weakness?
This is an indication that a nerve is being effected. Usually the effected
nerve is in the lower part of your back and goes to a special part of your
leg. Doctors refer to this as radiculopathy or sciatica. Basically, the
nerve is pinched by a disc protruding into the spine or the ingrowth of
bone from the joints (bone spurs). For either reason, the nerve is pinched
or squeezed and is not getting enough blood flow. If it is a disc that is
doing the squeezing, you may be in luck, since discs are 85% water. After
they protrude, they can shrink in size and therefore stop squeezing the
nerve. You know that people get shorter as they get older; that's because
the discs are 85% when you are eighteen years old, but by the time we near
our sixties, the discs should be down to 60% water. This is good. When we
are eighteen years old we are strong, energetic, and flexible. But as we
get older we want a more self-supporting spine so we don't have to spend
as much energy to support our spine and keep it stable. We naturally become
less flexible as we get older, but this has minimal effect on our function
since we still have flexible hips and knees to stay active. This natural
loss of water in our discs has somewhat inappropriately been called Degenerative Disc Disease (DDD). It is not a disease, but a natural condition or process of aging, and, as any doctor will tell you, is not necessarily associated with back pain or leg pain. The problem is your need to listen to the messages your body is sending to you. If your back doesn't want to bend but you keep bending it or try to keep it flexible, it will hurt. If you learn to relieve the stress in your back by having strong abdominal and back muscles and
flexible hips, quads, and hamstrings (lumbar stabilization exercises), you
can get rid of the pain.
If pain is caused by a disc pinching the nerve, the disc can be:
- bulging
- protruding
- herniated/extruded/ sequestered
Bulging Disc
If the disc is bulging, this is not necessarily a problem. The disc is
a unit with a tough fibrous outer layer (annulus) like the outside of a
radial tire. The inside is filled with something kind of like toothpaste.
As your disc begins to lose water (going down from 85% to 65%) it is like
letting air out of a radial tire; the sides begin to bulge. This can either
cure itself as the annulus tightens up with time, or as the joints in your
spine enlarge and add more stability. Most of the time these bulging discs
are treatable by exercise (Lumbar Stabilization or aerobics) and/or anti-inflammatories (ASA, Ibuprofen, or Aleve), and learning not to over stress these bulging discs. Usually this can get to a pain-free situation. Occasionally a disc bulge can get so big that it squeezes the nerves and denies them nutrition (blood supply), and causes continuing leg and posterior thigh pain. This is called Central Disc Syndrome. Even still, this often gets better with exercise and medications. If you smoke, the chances of getting better are
much less due to multiple factors.
Herniated Discs
If the disc is herniated it can be protruded/extended or sequestered.
This is basically when the tough annulus part of the disc has gotten a
tear or blowout in it, and some of the inside of the nucleus has come out.
This is Herniated Nucleus Pulposus (HNP). Even still, when the nucleus
material (which is kind of like toothpaste) comes out, it too tends to
shrink down with time. (Have you ever squeezed out toothpaste and left
it on the sink overnight? The next morning it has shrunk as the water dried
out of it.) If the herniated disc material shrinks enough, the squeezing
and irritation to the nerve root gets less and the nutrition and blood
supply return to the nerve root, and it stops complaining. The pain, numbness, and weakness goes away. How do you get this to happen?
1) Stay active
Think of it this way. Your heart is a pump. It pumps the blood through
the arteries to the nerves. But, as the blood passes through, it needs
to enter the veins. The veins have very little pressure, about 5cm of water.
What pumps the veins are the muscles. When the muscles contract they pump
the blood through the nerve and back to the heart. If you stay inactive,
sit still, stand still, or lay in bed, you are stopping the muscle pump,
and just when you need it most. By doing Aerobic exercises and getting
the pump going, you get that blood to the pinched nerve and the nutrition
to the discs so they can heal. If you are inactive, not only do you stop
the muscle pump, but also you begin to get weak. Estimates are that you
lose 1% of your muscle strength for each day of inactivity. How many of
us can afford to lose 5-20% of our strength? But this is the effect of
5-20 days of bed rest. Bed rest also effects other body functions, such
as the ability to think, see, and hear clearly. Inactivity leads to all
these bad side effects, and begins to perpetuate the problem. Estimates
are that when we are forty-five years old we need 45% of our normal strength/power
to get through a normal day, but by age seventy-five, we need 90%. So the
effects of inactivity/bed rest are worsened with age. One day of bed rest
is okay while you begin other parts of the program (i.e. ice, anti-inflammatories),
but any more leads to problems.
2) Use Ice
If we had a medicine that would make blood supply/nutrition go to a
specific place in the body, we would give it to you. We don't. Most anti-inflammatories
work systematically, and all have side effects. Ice will increase the blood
flow to the deep structures (nerves, muscles, and ligaments), and help
get the swelling down. Both ways help to relieve pain and improve the healing.
The optimum is to use and ice pack twenty to twenty-five minutes and no
more. This can be repeated every two hours. Watch your skin so that you
don't get frostbite, but with the new form of packaged reusable soft ice
this rarely occurs. Heat does not work. While it makes it feel better for
a while by relaxing the muscles, it also makes the blood supply come to
the skin and takes it away from the deep structures. This perpetuates the
problem.
3) Medications
Anti-inflammatories: Aspirin, Ibuprofen, Aleve (not Tylenol)
These medicines help to decrease the inflammation if you can get blood
flow to the effected area. These need to be taken regularly and at advised
dosages. Some people respond like a miracle to some medication, others
do not. So, if an anti-inflammatory isn't working, it is often useful to
try another. Contact your physician. Many people get side effects form
antiinflamitories: Upset stomach, bleeding, eye, kidney, and other effects,
so you certainly should use them under the care of a physician. Antiinflamitories
are better at keeping the swelling down than at getting the swelling down.
So, start its use early, and it is more effective. Once the pain is gone,
it is rarely necessary or prudent to continue use of the medication.
Muscle Relaxants: Often useful for a brief time, but usually
cause sleepiness and depression. You should not operate a car while using
them. They do not relax the muscles in a direct way, but have a more central
effect. They are especially useful to get some relief for sleeping at night.
Muscle relaxants can be habit forming.
Narcotics: Usually are not very useful. When you take a narcotic,
you basically block the pain messages, but you are not improving the blood
flow or strengthening the muscle. It can be moderately useful if it allows
you to undertake an exercise program to improve blood flow/nutrition and
muscle strength. Remember, they are allowing you to ignore the pain signal/warning,
so they allow you to do things that are potentially damaging, such as sitting
or lying too long in one position. They also cause sleepiness, depression,
constipation, upset stomach, and are habit forming. They are not useful
for chronic pain because of the above cautions, and because even the good
effects diminish as the bad ones increase.
Chiropractic: Can be useful if it decreases the muscle spasm
or tightness of the muscle. If you are then able to undertake an active
exercise program and function improving the blood flow,this is very useful.
Basically, try it. If you feel improvement, it is useful to have repeated
manipulations. However, it does not make the disc slip back in. In the
long run it only works by improving blood flow. If a manipulation increases
the pain it may be actually pinching the nerve more. If numbness or weakness worsens, you need to try something else.
Massage: As with Chiropractic, can temporarily decrease muscle
spasm and increase blood flow, but will only be effective if you start
the exercise program and continue the blood flow.
PT/Exam: Aerobic Lumbar Stability. The idea is to improve the muscle pump without pinching the nerve by bending or twisting the spine.
Spinal Stenosi s/Pseudo-Cl audi cation Muscle Cramps in the Legs with
Activity, Relieved by Squatting or Leaning on a Shopping Cart
As you try to walk you get a pain or cramping in your buttock or posterior
thigh or calf that gets better if you stop, squat, or lean on a cart. This
arises because the cross section area inside the spinal canal has gotten
smaller. This can come about because of a herniated disc, but frequently
arises because the joints of the spine have enlarged and grown inwards,
taking away the space, squeezing the nerves, and therefore slowing the
nutrients or blood flow to the nerve. Frequently, there is no back pain
simply because as the joints enlarge, they sort of naturally stabilize
the spine and fuse it. The pain arises because the joints did this slowly,
often over the course of years, enlarging the joint and growing into the
spinal canal, taking away space for the nerve and causing resistance to
blood flow. This can effect you suddenly just like the straw that broke
the camel's back, the squeezing is too much to get the blood flow/nutrients
to the nerve and they begin to complain and not work. When you rest enough
blood flow gets to the nerves so you can walk a little farther. But when
you try to walk they just can't got enough blood flow so they begin to
hurt at about the same distance. This becomes a worsening problem because
if you can't walk you begin to lose strength in the back muscles, which
stresses the joints more and makes them enlarge further, causing more compression on the nerves and less blood flow. You can't stay healthy if you can't stay healthy. Therefore, early treatment with ice, anti-inflammatories,
physical therapy, chiropractic, and massage can help for a while, but if
the joint is squeezing the nerve and limiting the blood flow, the symptoms
will become more frequent and more serious. Once the joints have enlarged,
they can either stay that large or get bigger, but they do not tend to
get smaller without surgical intervention.
The enlargement of the joints is caused by Osteoarthritis. This is the
same type of arthritis that causes the joints of people's hands to enlarge.
Many people have very enlarged finger joints without much pain, only symptoms
of stiffness. The same process of stiffening up your back does not lead
to pain unless you continue to try to bend through. If the joints grow
outwards, you are okay. If the joints grow inwards, you only get into trouble
when they begin to limit blood flow and squeeze the nerves. This can be
made much worse if you continue to bend, inflame and stress the joints,
causing them to enlarge further. Fighting the natural tendency of your
back to stabilize itself can only lead to further problems.
When is Surgery Necessary?
Sometimes surgery is necessary to enlarge the spinal canal and remove
the part of the joint that has grown inwards. The surgery is particularly
successful if the spine has basically stabilized itself by shrinking the
disc to 60% water, and enlarging the joints outward. But, how do you know
when it is appropriate to go to the Surgical Option?
As we said earlier there are many menu options. At least some of these
should be tried before surgical intervention. Most people do respond to
one or more of these options. I basically ask patients on return appointments
if they are getting better, staying the same or getting worse. If they are
getting better we are obviously going the right direction. If they are getting
worse or staying the same we need to try something else. If none of the
easy things are working and the person is still experiencing significant
limitations then we may consider surgery. Remember, you cannot stay health
if you cannot stay active. For every day you are not walking at least 10
minutes 3 times a day you are losing strength. Estimates are that while
you lose strength at the rate of 1% per day, you can only gain it back at
the rate of 1 % per week. This means that somewhere relatively early on
it is important to get to the point where you have resumed at least some
level of exercise. If you are unable to get active Surgery should be considered.
It is important to understand that surgery does not remove your spine
and replace it with a new one. Surgery is always a patching up type of intervention. It often improves the anatomic problem by removing what is pinching the nerve or limiting the bloodflow,but it does not make you normal. It allows you to resume activity and improve the blood supply so your body can heal and get back towards normal. Surgery is a 90:10 deal. It can do about 10%
but you still need to do your 90%. It is not like carpentry where you can
go in and connect two things and you are done. It's more like gardening.
Surgery can prepare the area but it is the daily activity that restores
the blood flow and restrengthens the muscles. Just like gardening it takes
a season to get the results you want. If you plant your garden, but never
water it or care for it or worse yet poison it (by smoking) you wouldn't
expect much of a crop. However, if you take care of it everyday at the end
of a season you could expect a prize-winning result. As I said earlier,
you can only regain strength at the rate of 1 % per week and that is if
you exercise at least 5 days per week. I believe that while you may feel
pretty good after 6-8 weeks it will really be 100 weeks until you are back
to 100% of what you should be for your age. The real problem is that at
age 45 it only takes 45% of your strength to get through a normal day. Therefore, you may feel O.K. as you get to that level but given that you now have a patched-up back you need to aim for that 100% level to keep your back well protected to avoid problems as your increasing age makes increasing demands of the percentage of your strength it takes to function normally. |
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