Say Goodbye to Back Pain

Marian Betancourt, Emile Hiesiger

• Publisher: Pocket Books
• Year: 2007
• ISBN:
  9781416595816
• Topic: Medicine
• Subtopic: General Health

DON'T LET BACK PAIN RUN YOUR LIFE! Anyone who experiences chronic or even minor back pain knows there are plenty of remedies for temporary pain relief -- but how do you know you're treating the correct problem in the most effective way? Top neurologist and pain management expert Emile Hiesiger draws on the newest medical information to target back pain at its source. From whiplash and sciatica to osteoporosis and spondylolysis, from faulty facets to herniated disks, Dr. Hiesiger identifies the origins of common problems, and arms you with essential information on

• Diagnostic tests and what they mean
• Key questions to ask your doctor
• Medical and surgical options from nerve blocks to vertebroplasty
• Exercises and lifestyle changes for pain relief and prevention
• Physical therapy
• Prescription drugs
• And much more
  

Practical and accessible, this one-stop resource will take you
from symptoms to diagnosis to cure, so you can say goodbye
to back pain -- forever!

Part I

The Basics

The Mind-Body Connection of Chronic Back Pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience that we primarily associate with tissue damage or describe in terms of such damage.” The definition of pain has two parts. One part deals with the sensation of tissue damage: A burn is perceived as different from a blow from a hammer to your thumb. Its intensity is rated, and it is localized. However, the experience of physical pain involves an emotional response to that injury, a feeling about its unpleasantness and a reaction to the pain. Those who have experienced extreme anxiety or depression recognize easily that mental dysfunction may also elicit an emotional response that is experienced as painful.

If you are under increasing levels of stress, you will be more sensitive to pain. If you twist a back muscle while picking up your child after an enjoyable weekend when you are well rested, it won’t hurt much at all. But if you twist that same muscle with the same force after a stressful week at the office, when everything went wrong, you may find the pain excruciating. The same amount of “injury” is felt with a different intensity of pain. I learned this myself as I was writing this book in the final days against the deadline.

Pain signals the brain, and its perception as pain can be modified by a number of mechanisms. Our body produces its own narcotic-like pain relievers, endorphins. These chemicals block transmission of pain. Endorphins also are released by regular exercise. Feeling good and reducing stress also can release them.

When physical pain is long standing, it often results in psychological pain of anxiety and depression. People with chronic moderate-to-severe pain become irritable. Many become listless or depressed. Some feel useless and unable to cope. People have ruined their lives because they enter—or are forced into—a downward spiral of incorrect diagnoses, untreated pain, disability, depression, and more pain and suffering.

Most of my own patients are not disabled; I won’t let them go out on permanent disability unless they have a condition that is likely to worsen with time, such as progressive cancer. This is not because I am cruel or dispassionate but because I am very aware of the economic, social, and psychological downfall of disability. Most Americans disabled for a year never return to work—or full enjoyment of life. And, as you know, life is not getting any easier or cheaper. Your disability payments of today may not be as helpful ten years from now. But in all likelihood you’ll still be alive, in increasing financial distress, depressed, and in pain. Because of what chronic disability creates, you’ll have less financial and logistical means of finding and using high-quality medical care, including new, improved, but invariably expensive drugs and other pain-relieving treatments.

I hope that this book will help you avoid or get off disability. Of the patients on temporary disability I have worked with, I have been able to put the overwhelming majority back to work, sometimes with a different job from the one they previously had. The vast majority don’t even go on temporary disability.

Chapter 1

Understanding How Your Back Works

You don’t needto go through medical school, but a little knowledge about how your spine works may go a long way in helping you understand what can go wrong, what to do about it, when to see a specialist, and how to prevent pain. Your spine is your main means of support and keeps you upright. The ingenious design of this large organ includes bones, muscles, ligaments, and nerves. It’s also the guardian of your spinal cord, which, along with your brain, makes up the central nervous system.

Your spine moves like a semirigid gooseneck lamp, with the greatest movement in your neck—which might move three hundred times a day—and your lower back, which supports the weight of the top half of your body as you bend and straighten up, rotate, and pick things up from the ground. The gooseneck shape serves an important purpose, curving to allow room for the heart and lungs in the chest while keeping the head centered over the lower body and the pelvis. This shape is well balanced, the structure strong.

Whether you run a marathon or pick a book up from the floor, the disks lying between the bones (vertebrae) of your spine absorb the shocks of pressure and cushion those bones to protect you from injury and pain. The wear and tear to the joints connecting these bones, the disks, and related structures is at the root of most back pain. Joints become arthritic, disks tear or protrude and press on a nerve, supporting ligaments harden, and so on. We can face these risks at any age. Young people as well as old can get muscle spasms, stress fractures, and a variety of sports injuries to the spine.

SPINAL BONES: VERTEBRAE

There are thirty-two horseshoe-shaped vertebrae in your spine. The vertebrae and interspersed disks not only support the weight of your spine; they protect your spinal cord. They are organized this way, starting at the top of the spine. (Seefigures 1 and 2. )

• The first through the seventh vertebrae, called C₁to C₇, support the head and neck. This is the cervical spine and permits motion in all directions: forward, backward, and rotational.
• The eighth through the nineteenth vertebrae are called T₁to T₁₂and go down the back of the chest and connect to the ribs. This is the thoracicspine. It helps support the ribs and allows limited body movement in all directions.
• The twentieth through the twenty-fourth, L₁to L₅, make up the lumbar spine or lower back. These are the source of most back pain. Lumbar vertebrae support the upper part of the body and, like the cervical spine, allow significant motion in all directions.
• The sacrum, the twenty-fifth through the twenty-ninth vertebrae, is referred to as simply S₁. It consists of five fused vertebrae that fit between the pelvic bones and act as the anchor of the spine.
• The coccyx, or tailbone, is the last three fused vertebrae (the thirtieth through the thirty-second) at the bottom of the sacrum. (Very rarely, a person is born with an additional fused vertebrae in the coccyx.)

FIGURE1.Left: Front view of spine. Cervical area C₁to C₇. Thoracic area T₁to T₁₂. Lumbar area L₁to L₅. Sacrum S₁. FIGURE2.Right: Side view of spine.

SPINAL JOINTS: FACETS

A system of interlocking small joints, called facets (fah-CETTES) located on the side of each vertebrae, prevent us from turning our heads all the way around like the girl inThe Exorcist. Each vertebra has four facets that hold it to the one above and the one below. The vertical orientation allows us to bend forward and backward but limits the twisting motions of the spine. The greatest rotation of the spine occurs in the chest, the thoracic portion. Think of how your spine moves when you swing a golf club.

Facets are similar to many other joints in the body, such as knees or hips. The bony surfaces are covered with cartilage, and the entire facet is covered with synovium, a thin membrane that produces lubricating joint fluid. The cartilage and lubricant allow the facets to slide on each other without bone rubbing on bone.

Pain from Facets

As we age, we lose height, primarily because the disks that separate the vertebra dry out and shrink. The vertebrae become more closely opposed, and the facets take on undue weight. Facets are designed more to create stability than to bear weight. This excess wear causes them to degenerate, and some become arthritic and hurt, at times chronically. As they become arthritic, they may also calcify (harden with deposits of calcium from the body) and become deformed. The excess calcification of these joints may bulge into the spinal canal and foramen (see below), pressing on the nerves there. This may contribute to spinal stenosis, the narrowing of the spinal canal. (See Chapter 12. )

SPINAL DISKS

Disks are also joints, but unlike facets, they have no synovium or lubricating fluid. The twenty-three disks between each of the vertebrae work like universal joints, allowing motion in a number of directions. If the vertebrae were in direct contact with each other, the range of motion would be severely limited. Disks play an important role in the gradual process of spinal degeneration, pain, and disability. These semiflexible shock absorbers resemble checker pieces with a leatherlike covering, called the annulus. They are filled with a firm gel-like substance, called the nucleus.

A disk’s cushioning ability depends upon how well the gel remains filled with water. At birth, about 90 percent of the gel is water, but by the time we are thirty, the nucleus and annulus have begun to desiccate and become brittle. They crack and fissure. This degeneration results in the disks losing height, the vertebrae coming closer together and slightly wiggling over one another, and our height diminishing. The annulus may tear, allowing disk material to protrude through and press on a nerve root. This may cause pain, weakness, and numbness.

It is the degeneration of the disks that ultimately results in a series of changes of the spinal structures, varying degrees of spinal instability, and the compensatory thickening of the ligaments that support the spine. Later in life, the disk protrusion and thickened ligaments result in spinal stenosis. Significant disk degeneration, especially in the young, may also contribute to spinal instability and cause pain and disability.

Pain from Disks

Discogenic paincomes from a tear in the annulus, with no disk material oozing out onto a spinal nerve. This kind of pain usually is described as deeper than facet pain, but the two frequently coexist. Disks are deeper in the spinal structure than the facets and pain from them cannot easily be provoked by poking the area around the spine. Both facet and discogenic pain may be one-sided but often affect both sides of the back.

Lumbar-disk-related pain (either discogenic pain or pain from disk herniation) is usually worse during the day. It may exist at night and impair sleep. Many postures and activities make it worse: standing, walking, sitting, rising from a bent position, and bending down. Less commonly, lying in bed, with the spine curving into the mattress, may irritate the torn disk or a lumbar nerve compromised by a herniated disk. Anything that puts vertical or bending-related stress on a degenerated, painful disk may worsen the pain.

Cervical-disk-related pain is worse at night because you often turn your head while you sleep. It may also cause pain during the day when you turn your head to look around. When your head bounces around on your neck, such as when you are riding in a car over a rough road, it may also cause pain if you have cervical disk problems.

Thoracic-disk-related pain is rare. When it does occur, it may cause pain in the back or even travel partway around the chest along a rib. Thoracic disk herniation sometimes results in pain that may be confused with other ailments, like heart disease or reflux of the esophagus.

THE SACRUM AND COCCYX

The sacrum is a large triangular bone formed by five fused vertebrae wedged between the pelvic bones. It contains the end of the spinal canal and therefore nerves. The coccyx, or tailbone, consists of three or four tiny fused vertebrae located between the cheeks of the buttocks. It is well padded, so is difficult to fracture.

Right and left sacroiliac joints are formed between the sacrum and the iliac bones of the pelvis which attach to the upper leg at the hip. The sacroiliac joints are not mobile like knees or elbows. If they are injured or degenerate, they cause pain at either side of the upper buttocks. Sometimes sacro-iliac-joint pain travels down the leg.

Spinal facets and disks are not differentiated by sex. However, the sacrum is tailored differently for each sex. In men, more of the sacrum is attached to the ilium (part of the pelvis); in women, the sacroiliac joints widen during childbirth. These differences also affect how we walk. The male hip structure tends to be stable during normal walking while women have a natural swaying of the hips when they walk.

Pain at the End of the Spine

The sacrum itself is rarely a cause of pain unless it is fractured or its connection to the lumbar spine is altered. In people with normal bones, sacral fracture may occur from a severe fall. People with severe osteoporosis can fracture the sacrum even from minor trauma. Various types of sacral tumors can cause local pain and damage to the nearby nerves that control bowel, bladder, and sexual function.

Pain in the area of the sacrum also occurs after fusion surgery in which the lumbar spine is surgically fused to the sacrum at L₅– S₁. Sacral pain following this type of fusion is perhaps the most common cause of severe chronic sacral pain in the noncancer patient population. Occasionally, sacral pain is due to sore or tight muscles. It may exist while walking, standing, or sitting.

Chronic, severe tailbone—coccyx—pain is rare. This is fortunate, since it is often difficult to treat. Most people with such pain—coccydynia—complain of pain in the tailbone while sitting. It usually develops following a fall on their rear end, usually squarely backward, as on an icy sidewalk. The tailbone can also be invaded by tumors, which cause pain and often bowel dysfunction.

THE SPINAL CORD AND SPINAL CANAL

The spinal cord is like a fiberoptic cable of nerves, about the thickness of your finger, that carry messages up and down the cord to and from the brain. The cord rests in the hollow space formed by the vertebral arches. This space is the spinal canal. (Seefigures 3 and4 .)

FIGURE3. Side view of cervical or thoracic spine and top view of cervical spine.

As the principal collection of nervous tissue in the spinal canal, the spinal cord constantly sends messages from the brain to various parts of the body and back. Moving your finger voluntarily, for example, begins with electrical signals that are relayed from your brain down the motor nerve column of your spinal cord to a nerve root and peripheral nerve and into the muscle in your lower arm that lifts your finger. Signals from sensory nerves in your finger go back up the same nerve through a different sensory column in your spinal cord and report to your brain that the job has been accomplished. Reflexive involuntary reactions, such as lifting your finger from a hot stove, are carried out at the level of the spinal cord well before pain signals reach your brain and cause you to say “ouch” and consciously react to the burn.

This exceedingly complex, interconnected system of nerve signals that spreads ...

Table of contents

• Cover
• Living with back pain?
• Title Page
• Copyright
• Dedication
• ACKNOWLEDGMENTS
• DISCLAIMER
• Contents
• Introduction
• PART I: THE BASICS
• Chapter 1 Understanding How Your Back Works
• Chapter 2 Why a Good Diagnosis Is Hard to Find
• Chapter 3 Will Pictures Tell the Story? What to Know about Diagnostic Tests
• Chapter 4 Finding the Doctor Who Can Really Help You
• Chapter 5 How to Get and Pay for the Best Treatment for Back Pain
• PART II: COMMON CAUSES OF BACK PAIN
• Chapter 6 Muscle Injuries and Myofascial Back Pain
• Chapter 7 Facet Syndrome: Painful Spinal Joints
• Chapter 8 Chronic Whiplash Pain
• Chapter 9 Pain from Spinal-Disk Herniation
• Chapter 10 Discogenic Back Pain
• Chapter 11 Spinal Slippage and Instability: Spondylolisthesis and Spondylolysis
• Chapter 12 Spinal-Canal Narrowing: Stenosis
• Chapter 13 Osteoporosis of the Spine
• Chapter 14 Benign and Malignant Spinal Tumors and Cancer Pain
• Chapter 15 Recognizing and Treating Other Causes of Back Pain
• PART III: TYPES OF TREATMENT FOR BACK PAIN
• Chapter 16 Physical Therapy and Exercise
• Chapter 17 The Challenge of Finding the Drug— or Drugs—That Will Ease Your Back Pain
• Chapter 18 Radiofrequency Lesioning and Other Interventional Treatment for Back Pain
• Chapter 19 Treating Back Pain with Surgery
• Chapter 20 Eastern Needling and Other Integrative Means of Pain Relief
• PART IV: PREVENTING BACK PAIN
• Chapter 21 Watch Your Back! How Lifestyle Can Hurt or Help
• GLOSSARY
• Appendix