A Surgeon's Own Back Story
by Leslie Berger
Dr. Caleb Kenna for the New York Times
Dr. James N. Weinstein is editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
Q. What's the most common reason for back pain?
A. Probably the most common causes of back pain are just - what's the best word? - life's events. People often go through life doing just what they normally do, and one-third of them on any given day will experience back pain. It's the second most common complaint after upper respiratory infections in the United States. Most times it's not related to work. There are some work-related risk factors like heavy lifting, twisting, or being exposed to vibrations, like a jack-hammer operator or a truck driver is. Obesity is thought to be a risk factor, and in our country, obviously, obesity is a problem. But even people who aren't exposed to these risk factors are subject to back pain.
Q. Is back pain on the rise?
A. With an aging population we are likely to see more spine conditions -- not the typical back pain you see in younger people, but conditions related to the degenerative process. Over age 65, you start seeing hip and knee problems and also back problems. In older people, it's most commonly related to spinal stenosis, a narrowing of the spinal canal associated with arthritis and aging of the spine. As the population ages, we are more likely to see more of that and to see more fractures of the spine related to that. We'll see more hip fractures and more complicated ones than we used to see, and more spinal problems and more complicated spinal problems as people live longer.
Q. What kind of patients find their way to a specialist like you?
A. Usually they're at the end of a long road. They may have gone to their local primary care doctor, a physical therapist, another surgeon, various specialists. They may have had surgery, and it hasn't worked. We, the health care system, make it complicated. When your back hurts, it's bad. It can take your breath away and make you totally immobile, and it's scary. In many cases, these are people who've been so taken aback by it. They are seriously looking for help, and they don't want to experience the pain again. And that's understandable, having had the problem myself.
Usually, 95 to 98 percent of the time, it will get better by itself without any intervention. But that's not the American way. We've built an incredible medical structure. People think, "I shouldn't have to suffer for one day -- there must be a pill or surgery that can help me." I agree with how they feel, but certainly there's over a 90 percent chance most people will get better with no intervention. That's an important message. People will say, "Well, what am I supposed to do when I can't walk or go to work?" Well, having surgery is going to keep you out of work. For the common cold, do you expect to see a doctor every time or expect surgery to make you better? Most people know it will take a week to 10 days to feel better.
Why don't we have that same approach to backaches? Stay active. Take aspirin or other over-the-counter drugs.
Q. What happened with your back?
A. I was going to pick up the mail at the post office, and I bent over, and I couldn't stand up again. Nothing brought it on. I wanted to laugh, but I was hurting so much I also wanted to cry. And I didn't want anybody to see me because I thought people would say, "What kind of spine specialist is he, anyway?"
I was hoping I could get out of the post office and back to my car and just get better. I could barely get back to my car. I went from meter to meter to get back, and I could barely breathe it was hurting so much. I drove home and lay down on the couch, and then realized I need to get up and keep going, because that's what I tell all my patients. I used ice, took a couple of aspirin and said to my wife, "I need to go for a walk." She said, "You can't even move," and I said, "I know, but it has to be."
I spent a week that way, and I did get over it. I've had several recurrences, and it always takes five to seven days to get over it, no matter what I do. I think I have some aging of the joints and discs in my back, and I think when I just move a certain way it causes the muscles to go into spasm.
Q. What do you do to prevent recurrences?
A. I keep up my running to stay in good condition. I think aerobic conditioning is extremely important. I do at least 20 minutes, and when I'm feeling good, up to an hour. I think that's incredibly important to keeping my episodes short and not as bad.
The point is, I live my own suggestions, and I think for most people they can work. The people I operate on don't have that ability to get better. In those 2 to 3 percent of cases, surgery can be a fantastic alternative.
Q. What do you find to be the best strategy for back pain?
A. The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible. That is the sine qua non of treatment. That means if you're normally a runner, you try to go running. If you're a walker, get back to walking. If you're not an exerciser, then you don't all of a sudden go out and become one. Then I'd avoid heat -- I'd use ice. I would use over-the-counter meds like aspirin or acetaminophen. I would avoid narcotics except in extreme cases. I would avoid bending or twisting during acute phases.
Q. How do you feel about the use of opioids?
A. I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances. Some people think antidepressants, the S.S.R.I.'s, can be helpful for treating pain. Long-term opioid therapy for some has been recommended, but the drugs can also affect your mood and cause depression, so we don't know that opioids improve function. Anti-inflammatories, like aspirin and acetaminophen, are the safest and just as effective. Even before the cox-2 drugs were taken off the market, I didn't prescribe those. And I've rarely had to use narcotics. Sometimes I've used steroid or Novocain injections, but rarely have I ever used opioids or other drugs.
Q. Any procedures that patients should avoid?
A. Having spinal fusion surgery -- you need the most information before making that decision. When you have the correct diagnosis, surgery can be very effective.
Q. What do you think of vertebroplasty and kyphoplasty?
A. For osteoporosis fractures, some people have gotten incredible relief, and others are no better and have just had more trouble. Those are a godsend to some people, mainly in people with metastatic disease. In some of my patients, the procedures have gotten mixed reviews. There's not one study as yet that suggests one -plasty is better than the other. We're still waiting.
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