Oh, My Aching Back!
Patient stories tell the doctor what's wrong
By Robert Bernstein, MD
What brings you here today?
Doc, it's my back...
Tell me more about it...
Well, I think it is muscular, or maybe I bruised something.
Stop!! Don't tell me what you think it is, we'll get to that later, tell me what actually happened.
Oh, OK. I woke up with pain in my low back a week ago, and now it is going down to my thigh.
Which side, and where in the thigh?
The right side and down the front to my knee.
Tell me more...
It hurts every time I move and I can't get comfortable at night. Sometimes I can get comfortable in one position for awhile but it doesn't last. I can't sit much. Mind if I stand?
No problem. Any numbness or pins and needles?
Hurt to cough or sneeze or have a bowel movement?
When I sneeze I have to brace myself.
Any pain or numbness in the saddle area?
Ever had this before?
Yes, 10 years ago but not as bad.
Any injury? What were you doing the day before?
Hmmm. I was helping a friend move, felt a small twinge while lifting a box, but nothing more till the next day.
Taking anything for it?
Just some ibuprofen- helps for a few hours but that's it.
Feeling well otherwise?
Yes, fit as a fiddle.
What does it stop you from doing, and what are you worried about?
I'm having a hard time going to work and sitting at my desk all day, and I'm worried it might be serious, like cancer or something.
OK - let me review your chart and examine you . . . .
Let's comment a bit about the story process. When I see a patient with a new complaint, 90 per cent of the time I know what the diagnosis is just from the story. One of the most difficult parts of taking a history is when a patient tells me what they think they have, and goes on at length about it. Meanwhile, I often have no idea what part of the body hurts. Studies have shown that the doctor interrupts the patient on average about 12 seconds into the interview, and this is one good reason why. I don't mean to be unsympathetic; I am actually VERY interested in the patient's ideas, just not at the beginning. I don't want to be biased... to quote the cop in the old Dragnet show, "Just the facts, ma'am."
In this case, the patient told a typical story of a third lumbar disc problem. The physical exam confirmed it (notice I don't say "slipped disc"). No red flags to make me think of something sinister underneath, and I will expect it to start to get better in a reasonable time – two weeks for the acute phase to settle down then four to six months for it to heal completely. MRIs and x-rays are needed for only a very few who have red flags or don't get better as expected. When treatment fails, question the diagnosis.
What red flags do I look for? And let me say that in 35 years of practice I have had exactly two patients whose back pain was due to something serious, and literally thousands of the usuals. Red flags are things that suggest serious diseases like cancers, vascular problems, fractures and infections. Smokers may get lung cancer with lesions in the spine. The story will not be typical nor will the exam, but I'm careful with smokers. Both of the two were smokers.
A disc is not a hockey puck; a disc is a jelly doughnut and acts as a shock absorber. It doesn't "slip." One of three things commonly happens.
The first, with a story just like this one, is that a bit of jelly has leaked out of the doughnut through a crack in the crust and is pushing on some pain sensitive structures.
The second is a story like this: "I was lifting a case of 24 out of the trunk, felt a sharp excruciating pain in my back and couldn't move without terrible pain after." This is a story of the crust breaking and moving out of place. The crust is just cartilage. If this were your knee we'd treat it with arthroscopic surgery. In the back, we let nature take care of it - it gets absorbed eventually.
Lifting is typical – why? Because of the way the back is constructed. We humans were not designed to walk upright. Our ancestors who walked on all fours had a very thick ligament develop in front of the spine to prevent the back from collapsing forward. The ligament behind didn't need to do much. But the nerves from the spinal cord and all the structures that can produce pain are behind the discs. As we walked upright and bent forward to pick things up, we started to squeeze the discs backwards – right where the ligament is weakest, and boom – jelly leak or broken crust. By the time we reach our 40s, if we do MRIs on normal people without back pain, almost everyone has tiny tears in their disc crust.
The third is a pattern of leg pain without much back pain that fools the patient into thinking the problem is in the leg, so they don't protect the back. This happens when a disc protrudes out sideways instead of backwards, and is difficult to diagnose unless I am suspicious of it. These too heal with time, and often the pain migrates to the back before it gets better.
How can you avoid disc problems? First, bend from the hips not from the back and use your legs to lift. I can tell I'm bending my back too much when papers fall out of my shirt pocket. You'll look like an old person - too bad; it's the price to pay. Second, keep your hamstrings limber and stretched. People with tight hams like me tend to bend the back because they can't bend much from the hips. Avoid prolonged sitting, and your mother was right; don't slump. Use a towel roll to keep the back arched slightly backwards, especially when flying – airplane seats are just awful. Remember what it is like to walk on all fours – some swayback is good for you.
Above all don't worry. Backs heal with time. If something changes for the worse, or it just doesn't begin to get any better in a couple of weeks, see your doctor again.
Robert Bernstein is a family physician praticing at the Bridgepoint Famiy Health Team.