80% to 90% of Americans experience low back pain at some point in their lives.
If you are in the 10% whom this does not happen to, then you have nothing to be concerned about. On the other hand, if this describes you or someone you know, then you may want to read the rest of this column. (Note: from this point, the term back pain will be used when low back pain is inferred).
We all take our backs for granted. Back pain will affect you no matter what you do: walking, sitting, standing, exercising, and even sleeping. So if you have back pain, it will be with you most, if not all, of the time. What to do about it when it gets to the "debilitating" stage is what we will address here.
The low back consists of the lumbar spine, the sacrum, and pelvis. Lumbus is derived from the Latin word limbos, meaning "lion," and the lumbar spine earns its name. It is built for both power and flexibility – lifting, twisting, and bending.
The spinal cord is housed in the vertebral column (spine) that protects it. The lumbar spine consists of five movable vertebrae. The complex anatomy of the lumbar spine is a remarkable combination of these strong vertebrae, multiple bony elements linked by joint capsules, and flexible ligaments/tendons, large muscles, and highly sensitive nerves.
The five vertebrae of the lumbar spine (L1–L5) are the biggest vertebrae in the spinal column, their size enabling them to support the weight of the entire torso. The lower the vertebra is in the spinal column, the more weight it must bear. The lumbar spine's lowest two spinal segments, L4–L5 and L5–S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury. The lumbar spine meets the sacrum at the lumbosacral joint (L5–S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when one is walking and running. Below the lumbar spine are the sacrum and the pelvis. Although not technically in the spine, these last two bony structures make up the low back complex.
In between the vertebrae are the discs. They are there to cushion the pressure between each vertebra. They support the pressure when compressed (standing or sitting) and allow movement between the vertebrae. The discs are firmly embedded between the vertebrae and are held in place by the ligaments connecting the spinal bones and the surrounding sheaths of muscle. The disc is sometimes described as a shock absorber for the spine. It has a tough, fibrous outer membrane (the annulus fibrosus) and an elastic core (the nucleus pulposus). Although discs start off as gel- or fluid-filled sacs, they begin to solidify as part of the normal aging process, making the outer protective lining weaker and the discs more prone to injury.
Four major ligaments of the spine are the anterior longitudinal ligament, the posterior longitudinal ligament, the supraspinous ligament, and the capsular ligaments of the apophyseal/facet joints. These last ligaments are arranged to provide maximum resistance to flexion. They can support about twice body weight in the young, although their strength decreases with age.
A fifth and very important ligament in the spine, which is frequently overlooked, is the iliolumbar ligament. It connects the last lumbar vertebra (L5) to the pelvis. It strengthens the lumbosacral joint and basically helps stabilize the spine on the pelvis. The iliolumbar ligament is one of three vertebral-pelvic ligaments responsible for stabilizing the lumbrosacral spine in the pelvis, along with the sacrospinous and sacrotuberous ligaments. Along with these three are the sacroiliac (SI) ligaments, which also help to stabilize the spine.
An important joint in the spine is the apophyseal joint, commonly called the facet joint. This is a synovial joint (containing fluid) between the superior articular process of one vertebra and the inferior articular process of the vertebra directly above it. This allows the two vertebrae "connect" to each other and glide/move together, and also limits motion. There are two facet joints in each spinal motion segment. In the lumbar spine, for example, the facet joints function to protect the motion segment from anterior shear forces and excessive rotation and flexion. These functions can be disrupted by arthritis, injury, trauma, and surgery. Due to the mechanical nature of their function, the facet joints undergo degenerative changes with the wear and tear of age, commonly known as facet joint arthritis, or facet arthropathy.
There are many important muscles that affect the lumbar spine's motion. They are divided into the extensors, forward flexors, lateral flexors, and rotators. There are too many individual muscles to name, but the groups are (1) extensors: stabilize posture and increase the efficiency of larger muscle groups; (2) forward flexors: their primary action is hip and trunk flexion; (3) lateral flexors: lateral flexion is normally a combination of side bending and rotation; (4) rotators: rotation is brought about by the unilateral contraction of muscles.
What Causes Back Problems?
Unfortunately, the answer here is almost anything. We are bipeds (walk on two feet), so there is a lot of pressure on the spine whenever we are upright. Gravity alone takes care of this. Generally speaking, the lower back is subject to a lot of mechanical stress and strain. The reason is the weight of the upper body, which always puts pressure on the low back. There is also pressure on the spine in the seated position. Most sports, hiking, yoga, driving, sitting, standing, and most other activities cause pressure on the back. At some point or other, this will build up, and one gets back pain. Being overweight, poor physical condition, decreased flexibility, poor posture, poor sleeping position, weight gain during pregnancy, and stress may also contribute to low back pain. The list goes on and on.
You've Tried Everything: Is Surgery the Answer?
Chiropractic, physical therapy, acupuncture, medicines, TENS units, muscle stim, distraction techniques, stretching, Pilates, and more. Now what do you do? Have surgery?
Simple answer: no. Let's see why.
600,000 Americans have back surgery each year. $30.3 billion is spent on treatments to ease the pain. But while some of that money is spent on chiropractic visits, physical therapy, pain management, and other noninvasive therapies, a big chunk pays for spine surgeries; and complicated spine surgeries that involve fusing two or more vertebrae are on the rise. In just 15 years, there was an eightfold increase in this type of operation, according to a recent study.
The rate of back surgery in the US is at least 40% higher than in any other country and is more than 5 times that in England and Scotland. Back surgery rates increased almost linearly with the per-capita supply of orthopedic and neurosurgeons. Research suggests that of the 500,000-plus disc surgeries that are performed annually (a significant increase of late), as many as 90% might be unnecessary and ineffective. A US medical school professor notes: "It seems implausible that the number of patients with the most complex spinal pathology [has] increased 15-fold in just six years" and mentions that one strong motivation includes "financial incentives involving both surgeons and hospital." One article evaluated worldwide surgical attitudes. There were twice the number of surgeons per capita in the US compared with the UK. Sweden, despite having a large number of surgeons, was conservative and produced relatively few surgeries. The most surgeries were done in the US. In the UK, more than a third of nonurgent patients waited over a year to see a spinal surgeon. A lower rate of referrals in the UK was found to discourage surgery in general. Fee for service and easy access to care was thought to encourage spinal surgery in the US, whereas salaried position and a conservative philosophy led to less surgery in the UK.
Studies show that at best 50% will get relief (this may be all or just some) from back surgery, 25% will stay the same and 25% will get worse. These are not great odds. The ICD-9 codes (soon to be the ICD-10) are all the medical codes that insurance companies use to categorize illnesses, procedures, and surgeries. There are over 20,000 of them. But there is only one for a failed surgery. Guess which one? Yes, low back. It is called "failed low back surgery syndrome." Every year, there are 50,000 documented cases. This category should not even exist; but, sadly, after years of failed low-back surgeries, they had to put it in.
Of course, other problems that might happen with back surgery are device failure, loosening of a screw, infection, improper wound healing, and more. Then there are months and months of therapy afterwards, with no guarantee as to the outcome. In addition, many must take pain medicines. In what might be the most troubling study finding, researchers determined that there was a 41% increase in the use of painkillers, specifically opiates, in those who had surgery. Some of those go on to become addicted to these dangerous medicines and then need a pain management physician to help them. And if the surgery that you have does not come out to your liking, you cannot have the surgeon put it back the way it was. Surgery once done cannot be "undone."
I recently was treating a patient for his shoulder. One day he asked me if I worked on low backs, to which I replied yes. He then reminded me about his three low-back operations. Several years prior, they did surgery to fuse his L3–L4, L4–L5, L5–S1. This was done at a major medical center with some of the top surgeons in the US. Two days after discharge from the hospital, he developed severe pain going all the way down his leg. He was told by the surgeon to go to the ER. An X-ray confirmed his worst fear: a screw had come loose from the apparatus that they put in his low back. So it was back to the operating room for him. This time, he stayed in the hospital for a week. Several days after this second surgery, he again began to have pain. And guess what? They found that another screw had come loose. This time the surgeon called in an "expert" to assist him, and they finally got it right. Total time in the hospital: 47 days! And the reason that he is asking me about all of this? Because he still has a lot of pain three years later. That is why he is now seeing me: to fix the cause and not just the effect.
Another misconception about back surgery is that if you have a disc bulge or herniated disc (most are partial and not complete), then surgery will solve your problem. A retrospective study looked at over 5000 backs. About half of them had bulging discs. The other half did not. In each group, about half of the people had pain and half did not. So that meant that there were people with bulging discs who did not have back pain and there were people without bulging discs who did have back pain. The conclusion of the study: a disc problem was no indication of whether someone would have back pain. So having surgery to fix the bulging disc would be of no consequence in resolving the problem.
As I stated in a recent column (October 2013), an MRI will show a problem (e.g., disc bulge) but not if that problem is the cause of the pain. And many times, that disc bulge is not the cause of the pain. An MRI will most commonly be used to determine the need for surgery, yet does not accurately diagnose ligament and tendon laxity, since they frequently do not show up on an MRI. In addition, MRIs have frequently shown problems when there are none. Over 50% of adults over age 45 will have some sort of disc problem but not any pain. The most likely suspect is ligament or tendon laxity not holding the structure in place, which needs to be addressed.
Although there are many reasons to avoid surgery, there is a place for back surgery when dealing with chronic pain. Patients who have excruciating pain from a truly pinched nerve causing weakness associated with decreased muscle mass, or in cases where there is evidence of bowel or bladder difficulties along with the pain, require a surgical evaluation. In addition, complete tendon/ligament ruptures usually require surgery as well.
What Regenerative Medicine Has to Offer
Prolotherapy, the main form of regenerative medicine, looks at fixing the cause and not just the effect. I have already addressed the three main forms of prolotherapy – dextrose, PRP, and bone marrow/stem cell – and will not go into it here (please see the June 2013 issue of the Townsend Letter on my website: www.DrFields.com). As stated above, many low-back surgeries address what is seen on the MRI. This is just the effect; an MRI does not address the cause. Again, thousands of people have bulging discs but do not have a problem. And when those who do have surgery to address it, guess what happens? It does not go away. Weakened or damaged ligaments and tendons are the most likely cause of many low-back problems, especially those not alleviated by conservative care mentioned above. Plus, one must look at all the supportive structures of the back, which include the ligaments and tendons of the sacrum and the pelvis. Most, if not all, low-back surgeries do not address this.
Prolotherapy is a better treatment than surgery, as it stimulates soft tissue repair of ligaments and tendons to alleviate pain. This is because most people have chronic pain due to ligament and tendon weakness.
Prolotherapy is the safest and most effective natural medicine treatment for repairing tendon, ligament, and cartilage damage. It stimulates the body to repair painful areas in the weakened attachments through the spine, pelvis and sacrum, and the SI joint. In the simplest terms, prolotherapy stimulates healing.
One Last Thought
I would like to share a story about a patient. He had been having back pain on and off for many years. Twelve years ago, it came back, and this time it was debilitating. He had tried chiropractic (several forms), acupuncture, physical therapy, muscle stim, pain medicines, and more. None of it relieved his pain. After 6 months of continued pain that radiated down his legs, sometimes awakening him up to four times a night, he finally decided to get an MRI. It was read as: desiccated (dried out) discs, bulging disc (9 millimeter), bilateral foraminal stenosis (closed-down holes where the spinal nerves exit the spine), arthroses (spinal arthritis), and more. He then went to see three different neurosurgeons, who all independently agreed that without surgery his athletic days were over and he would have trouble walking from time to time. This sounded like a death knell to him, as he was extremely athletic; he just could not accept it. He found out about prolotherapy and got treated. After three treatments, he was feeling better; after only seven treatments, he was pain free. He continued sports and his love for triathlons, finishing eight half (70.3) Ironman events. And last August, he finished his third full Ironman Triathlon, which consisted of a 2.4-mile swim, 112-mile bike ride, and 26.2-mile run. And this was after he was told by three surgeons either to have surgery or give up sports.
I guess he proved them wrong.
And I should know, as this is me.
So believe me when I say: Prolo first – surgery last.
Peter A. Fields, MD, DC, "The Athletic Doc," is an expert in the field of orthopedic/sports medicine. He is both a board-certified medical physician and chiropractor, one of only a handful of physicians in the US with both these degrees. Dr. Fields is the director of the Pacific Prolotherapy and Medical Wellness Center in Santa Monica, California. Orthopedic/sports medicine is the main focus of his practice. He also practices holistic medicine, which includes bioidentical hormones, anti-aging medicine, IV nutritional therapy, IV chelation therapy, natural alternatives to prescription medicines, and more.