Back pain is universal.

Almost all adults will experience it at some stage of their lives. The majority can get through it.

Unfortunately for about 20% of cases, it becomes chronic. The back degenerates and the patient experiences repeated episodes. This can lead to persistent and ongoing pain.

Two major causes of chronic back pain

Chronic back pain is caused by one of two conditions: degenerative or mechanical instability.

Degenerative conditions are the most common and surgery has a limited role to play.

Much less common, mechanical instability is a result of a structural change. An accident or an advanced degenerative condition. In those cases, surgery can be effective. Mechanical instability can be easily identified with usual spinal imaging studies, X-ray, and CT scan.

But does degeneration relate to pain?

In the absence of major changes on spinal scans, it can be difficult to diagnose the exact cause of back pain. This is termed ‘non-specific’ back pain. Something that the medical profession is still trying to understand its causes.

An MRI can show a degenerative disease of the spine. Yet we be cannot be certain that what we are looking at is causing the pain.

For example, a black disc showing up on the scan is not conclusive. Yes, the disc is unhealthy, but black discs are common in people without back pain. The literature does not support surgery as the treatment for them. Although this is still offered to patients.

The further complication

Compounding the issue is the impact of psycho-social factors.

A person’s own world view about pain will impact their experience of it. People prone to catastrophic thinking are at a high risk of developing chronic pain.

Their perceptions can create their reality. Negative attitudes: such as back pain is harmful, or severely disabling, are a yellow flag. An indicator of potential long-term chronic conditions and disability. *

Surgery has a low chance of success with people that catastrophise. They react badly to the pain and discomfort and things become worse. For these people, Cognitive Behaviour Therapy, allied with physiotherapy, is the best course of action.

For the majority

Most patients do not have major pathologies, either physical or psychological.

The recommended course of treatment is to provide some basic advice and reassurance. Typically, the pain subsides and then goes away. Exercise is also proven to reduce pain in lower backs.

If the pain is more intense then you can recommend a pain management clinic. Exercise is also proven to be an effective treatment. Physiotherapists can advise and develop a personalised movement program for your patient.

Some patients though will insist on seeing a specialist. In which case do send them to me for assessment.

However, I will operate on very few of them. I do not advise surgery for degenerative disease unless there is:

  • Evidence of instability
  • Advanced single level degeneration
  • Neurological symptoms

In which case surgery makes sense. Then depending on the patient, I offer fusions or disc replacement.

Surgery is not a panacea though and carries its own risks. Once one level of the spine is fused there is an increased risk that adjacent discs will need to be operated on.

* For further information about this fascinating area of the impact of mental perceptions on the back refer to https://www.sheffieldachesandpains.com/back-and-neck/professional-resources/learning/in-detail/yellow-flags-in-back-pain

Keele University in the UK also developed an effective diagnostic tool: STarT Back Screening Test https://www.physio-pedia.com/STarT_Back_Screening_Tool

Also see my article on Why I only operate on 17% of my patients.

As always if you have any questions about a patient, please feel free to call me on 02 9650 4893.    

I will return your call and discuss how we can help.

You can also reach me via ralphstanford@powspine.com.au.


Posted 20 November 2020


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