Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, she reaches out to Dr. James F. Wyss, an Assistant Attending Physiatrist in the Department of Physiatry at the Hospital for Special Surgery in New York City, to discuss the importance of getting a specific diagnosis for that common affliction, “lower-back pain.”

 

Dear Dr. Pat:

I am 50 years old and suffer from chronic low-back pain. I am overweight, and my GP told me that since I don’t have any radiating nerve pain, this is likely due to my weight, and maybe muscle spasm.  I can’t exercise because of the pain.  He gave me a prescription for something to relax my muscle spasm, but it made me woozy, and I stopped taking it. 

This really affects my quality of life.  Lots of my friends have this problem as well.  Some of them see chiropractors or have acupuncture.  Spending money on treatment that might not help me is not in the cards right now.  I do have health insurance, but I have to get a referral from my GP.  Who should I see, and what might help?

Shelly

 

4040289919_99cbe7c3a2_zImage from Flickr via

Dr. Pat Responds:

Dear Shelly:

I worked with a very old, famous British pathologist when I was a medical student and did an externship in England.  It was in 1973, and he once told me, “a woman is a constipated biped with low-back pain.” That may have been the way women were thought of by overworked and curmudgeonly doctors who were trained in the early 20th century, but we have come a long way, baby.  Low-back pain causes much suffering and needs to be evaluated in a holistic way.

Your GP is right about one thing:  excess weight may have an impact on all joint pain.  And the weight affects other risks for disease as well.  So, since you can’t exercise while you have this pain, begin to cut back on portion size and avoid alcohol and desserts.  Pay attention to what goes into your mouth and the weight will slowly decrease.

The specialist that I recommend for patients with chronic low-back pain is a physiatrist.  These doctors evaluate the total musculo-skeletal system.  I have asked Dr. James Wyss, a member of our Medical Advisory Board, to answer your question.

Dr.  Pat

 

Dr. Wyss Responds:

Dear Shelly:

Is it time to have a more specific diagnosis of low back pain in women over 50?

Every week I see many patients for initial visits due to low-back pain (LBP). Most have had numerous medical evaluations, opinions, tests, and treatments; yet when I ask them “What is your diagnosis?” they tell me “low-back pain.” At that point, I explain to them that LBP is a symptom, not a specific diagnosis.

Next I usually ask, “What is the cause of your lower back pain?” Most patients describe their MRI findings of the lumbar spine—“I have a disc bulge, stenosis, and arthritis of the spine”—but they usually don’t know if any or all of these findings are responsible for their pain.

If I compare this conversation with patients of mine who have cardiac conditions, the conversation is very different. They never tell me they have “heart pain”; they usually tell me about specific diagnoses such as coronary artery disease, hypertension, or atrial fibrillation.

The reason that I and many other physicians routinely see patients with LBP is because it is an extremely common condition that almost everyone will experience during his or her lifetime. Fortunately, most episodes of LBP are self-limited and resolve even before the patient can see a physician; however, some people do go on to experience chronic LBP. This number may be higher than we originally thought; indeed, recent estimates suggest that nearly one in ten people suffers from chronic LBP. In addition, chronic LBP remains the number one cause of disability worldwide.  Many—dare I say most—of these chronic and disabling cases of LBP are labeled as non-specific lower-back pain.

The main problem with a non-specific diagnosis is that it fails to guide effective medical treatment. Non-specific diagnoses—such as LBP or TMJ disorder—often have a multitude of treatment options but lack a single effective treatment solution. For this reason, if you ask people how they treat their LBP, you receive several answers—“physical therapy, chiropractic care, acupuncture, massage, injections and medications for pain and/or inflammation or muscle relaxers,” to name a few. For years, many physiatrists like me have been trying to identify the specific cause of LBP in individual patients so that treatment can be focused on the specific cause, and therefore will, it is to be hoped, be more effective. At the upcoming North American Spine Society (NASS) meeting there is a course titled “Taking the ‘Non’ out of Non-Specific LBP.” Fortunately, the field of musculoskeletal medicine is moving in the right direction.

The most common sources of LBP are from the disc, joints, and/or nerves. Some health-care practitioners attribute the muscles to be the main cause of LBP, but in my opinion, muscular pain is usually a symptom, rather than the cause.

  1. Discs: the intervertebral discs—the shock absorbers for the spine—can tear, degenerate (wear down), and/or herniate, all of which will produce pain.
  2. Facet joints: these are small joints of the spine that help connect one vertebra to another, and they can wear down and develop arthritis like other joints of the spine.
  3. Nerve roots: they can be pinched or irritated by disc herniations or when spaces of the spine narrow, known as stenosis. The nerves of the spine more commonly cause leg pain (aka sciatica) than lower back pain, but are an important part of any discussion involving LBP.

Treatment options will be based on the source of your pain or your specific lumbar spine diagnosis. In my opinion, most conditions that cause chronic LBP are responsive to treatment, but finding the cause can sometimes be difficult. To identify the cause, your physician will begin with a detailed history and physical examination. Your physician should take the time to listen to your story, ask questions, and then thoroughly examine your spine, pelvis, and hips. Based on this information, tests such as x-rays, MRIs, or even blood work may be necessary. When the diagnosis still remains unclear, spinal injections can be used. For example, if your doctor believes the pain is coming from a specific lumbar facet joint, then that joint can be injected with the help of an x-ray and contrast dye. If the injection relieves the pain, then the diagnosis is confirmed.

If you are currently experiencing LBP, especially if your pain is chronic, then my recommendation is to make sure you understand the specific cause of your lower-back pain. Consider seeing a physiatrist (doctor of physical medicine & rehabilitation) for the initial evaluation. Alternative options are orthopedists, neurologists, or neurosurgeons that specialize in spine care.

Dr. Wyss

 

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