The Truth... What is it?





  Back & Leg Pain Problems

DISCLAIMER

I offer this information as a physician not much involved in pain cases, but in the practice of Pathology & Laboratory Medicine at Lexington Medical Center since 1975. I got into this info while helping two Aunts and some others. Most of the below relates to situations corrected by neurosurgeons, orthopedic surgeons, and interventional radiologists. Chronic neck & back pain syndromes are another arena of complex situations, and I note below a website that might be of interest as it discusses so many aspects & issues in good layman language.

CALCULATOR: For back problems, a calculator now exists to help a patient to look at odds of surgery or nonsurgery making things better, no change or worse, the SPORT calculator.

The term, dorsopathy, includes all disorders (spinal disease) of the back/spinal area. Pains can arise, in general, from four (4) areas: (1) the actual joint tissue, (2) non-boney tissues around a joint and between adjecent bones, (3) nerve "pinching" (impingement) in that anatomic area, (4) referred pain which is interpreted by the brain as arising in that area due to disorders elsewhere (maybe even bone near the joint). A quick test that a doctor might do is to first inject the joint with an anesthetic (pain numbing shot); and, if the pain disppears, the cause in is the joint itself. Prior to spending huge money on imaging studies, if the joint injection did not make the pain disappear, a few lab tests might be useful. A CBC and a serum CRP can detect infections that may not have caused a fever. In males above 50, a serum PSA that comes back normal is helpful. In both sexes above age 50, the blood test for serum protein along with electrophoresis that comes back normal is helpful. Going to expensive imaging (such as MRI) is then helpful if one is willing to undergo (1) major surgery if a definite problem is clearly identified or (2) radiation and chemotherapy if evidence of metastatic malignancy ("cancer") is discovered.

The "back bone" is a complicated structure containing the all-important spinal cord which lets out main nerves at regular intervals on both sides from the top of the neck to about the waist. Injuries, degenerations (bone spurs, cysts, bulging & degenerating discs, ankylosing spondylitis), and tumors can encroach (stenosis) on spinal cord and/or nerves and cause "entrapment pain syndromes" or nerve inflammations (radiculopathy). Associated muscles, ligaments, cartilage, disc, and bone can be strained, ruptured, torn, or collapsed; and the pain can, in turn, case additionally painful muscle cramps/spasm. For entrapment and/or stenosis syndromes not responding to non-surgical measures (such as epidural injections), surgery such as laminectomies, discectomies, decompressions,  fusions, and releases must be done surgically. And I like the idea of a nerve-oriented surgeon working on this...a neurosurgeon...if surgery is necessary. An old term for chronic low (lumbar area) back pain is "lumbago". Chronic low back pain with a prominent pain component running down the back of one or both legs is said to include "sciatica" (the leg-pain component).

For collapsed degenerated discs, orthopedic surgeons tend to be the repairers, at least in the low back...treated by surgical fusions. The more important the nerve and cord considerations (thoracic & cervical areas), the more I like the idea of a neurosurgeon. The end of 2004 saw the coming to market of an alternative to fusions: the artificial disc. The FDA approved CHARITE immobile disc (CHARITÉ™ Artificial Disc [DePuy Spine, Inc.]) is available in Columbia, and the MAVERICK mobile disc is open for clinical trials in Charleston (as of 16 Jan. 2005). ProDisc® (Synthes Spine), Maverick™ (Medtronic Sofamor Danek), and Flexicore™ (Stryker Spine) are others coming down the pike. They all will be compared with the CHARITÉ™ Artificial Disc, which has a 17-year track record outside of the US. See Sciatica, below.

Neck & shoulder pain due to neck disc disease (acute or chronic spinal disc herniation): Our neurosurgeons, between May 2006 and April 2007, caused (under a clinical trial) Lexington Medical Center to be the site of the largest number insertions of the new "PRESTIGE® LP Cervical Disc" by Medtronics in the USA.

All sorts of medical doctors (MD & DO), Chiropractors, psychological counselors, acupuncturists, physical therapists, massage therapists, medical & surgical physicians (including rheumatologists), orthopedic physicians, neurosurgeons, and radiologists are called on for diagnosis and treatment of all sorts of chronic pain, including back pain. Life-style modifications, medications, injections, electronic devices, and surgical corrections are used for treatment. For my money, I'd prefer to see a radiologist (specialist in all manner of body imaging anatomy & abnormal findings visible by such techniques) for the initial imaging studies to see if any obvious cause is visible by their techniques. That means that the key images (CT scans and/or MRI) need to be performed where the radiology talent & high technology is and where the doctors can discuss the images with your doctor (of whichever of the above type you choose). At Lexington, among our team of excellent radiologists, the group has a neuroradiologist (brain & nerve specialist...Dr. Chris McCarty). It may not work to your optimal, best interests if your doctor makes an appointment for CT or MRI studies somewhere other than where your doctor can have access to the consulting advice & be able to personally self-review imaging studies and with the imaging experts.

*** Get your diagnostic imaging (CT or MRI) radiology pain studies at LMC (for the reasons just stated above)!!!

If there is a "disc" problem that less-than-surgery management or treatments (see below) fail at, I'd seek the opinion of a surgical repairer: neurosurgeon (especially if evidence of spinal cord or nerve entrapment and problem location in neck or thoracic spine) or orthopedic surgeon.

Among the imaging studies are "plain film" X-rays, CT scans, MRI, and myelograms with post-myelogram CTs. The last is an additional test some want prior to final decisions for surgery because it allows computer reconstruction and more exacting detail as to the configuration of the suspected surgically-curable lesion. If there is any doubt as to whether your symptoms match exactly with what is seen by imaging and proposed to be surgically repaired, I'd tend to hold back on surgery and try all of the more conservative treatments possible. I'd be VERY reluctant to "have my back cut on" in the absence of an almost "slam dunk" certainty that there is a definite cause of the pain which is curable by surgery!

vertebral-body compression fracture...VCF:

If the vertebral body has recently collapsed (vertebral compression fracture...VCF), I'd seek an interventional radiologist to determine that the posterior cortex is intact (radiologists are the "imaging" experts...a non-intact posterior/dorsal cortex is a contraindication for vertebroplasty and kyphoplasty because the cement could exude through to compress the spinal cord) & then perform a non-balloon, local-anesthesia, through-the-skin transpedicular (or parapedicular) vertebroplasty (this website is general and not our hospital's). The stabilizing "cement" is injected & spreads in around the fracture fragments to variably fill the marrow spaces within the vertebral body...seldom restoring height. However, when vertebral bodies are long-ago collapsed (and/or "dried out" nucleus pulposus discs have reduced the spaces between vertebral bodies and/or annular ligaments have been traumatized) for many months to years, they begin to have repairing and stabilizing bony growths (osteophytes) which attempt to bridge and stabilize "gaps" and or to stabilize injured non-bony tissue. In doing so, the growths impinge on nerves and/or spinal cord.

In our area, some orthopedic surgeons & neurosurgeons perform the high-pressure "balloon kyphoplasty" (this website is general and not our hospital) which theoretically (and sometimes actually) can restore some height to the collapsed body. Kyphoplasty is also via transpedicular or parapedicular approach & more likely under general anesthesia. The expanded balloon displaces bone fragments & creates a void into which the stabilizing cement is injected.

Vertebroplasty & kyphoplasty compared here.

My aunt has had miraculous relief between January and June of 2004 for 4 or 5 instances of osteoporosis-caused collapsed vertebral bodies treated by our radiologists using vertebroplasty.

Doctors Chris McCarty & David Knight are the radiologists performing the vertebroplasties at Lexington Medical Center (Chris is our interventional neuroradiologist & David our special procedures interventional radiologist). Ask your doctor to request an evaluation or referral by FAXing an order to 803-791-2519 (or you may call for information, 803-791-2461). Report to the east-side main entrance (same side of hospital as the ER) on hwy #378 @I-26...hospital's main number is 803-792-2000...2720 Sunset Blvd., west Columbia, S. C. 29169. And feel free to call our hospital's medical staff office (803-791-2200) for names of neurosurgeons & orthopedic surgeons using Lexington Medical Center as "active staff". As of 2008, neurosurgeons tend to do the neck & back surgery at Lexington Medical Center and orthopedists all other bone & joint surgery.

Sciatica (lower back pain that radiates through buttock & down same leg):

This back & leg pain may be problematic to cure as it involves 3 spinal nerves & may be caused by one of the above-mentioned "entrapment" problems (radiculopathy). See Mayo Clinic's file about sciatica. (The following goes for other types of lower back pain not clearly requiring surgery for relief) A maximum-allowed 24-48 hours of Advil might give relief. If not, a trial of oral steroids might give relief. However, regardless of cause, when relief from disabling pain is the major acute/urgent desire, anesthesiologist delivered pain-management epidural steroid injection (of a "depo steroid") can be an initial...sometimes permanent...help (and can help in some of the above radiculopathy situations). That is, if you've been diagnosed with sciatica and need pain relief which has not happened with your doctor's initial medication advice, get some injection relief...surgical correction can come later, if needed. And, injection may provide all the treatment that is needed in 10-20% of cases. It is a regional injection not requiring ultra-precise localization. These injections can be repeated as needed (you schedule another injection if it becomes certain that too much pain has really returned...as of 9/04, Medicare will allow payments toward 6 per year). Another aunt of mine and several of my mother's friends have gotten relief with this technique.

***YOU MUST HAVE BEEN FREE OF ANY MEDICATION CONTAINING ASPIRIN OR ANY TYPE OF NSAID (check here) FOR SEVEN DAYS PRIOR TO INJECTION***

Drs. Jim Knight and John Caskey (anesthesiologists) used to provide these services in our Hospital system, usually at our branch hospital on hwy. #1 & #378 just west of the town of Lexington, S. C. until ceasing in November 2005. From about then to 2010, I have had friends and relatives be highly pleased with very prompt appointments for pain consultations, injections,  & other treatments at Columbia Neurosurgery and Lexington Brain and Spine Institute.

***************************************

Here are some other problems that may mimic sciatica (each numbered cause will result in a degree of pain along a spectrum from barely painful to distractingly painful and the degree of pain may slide back and forth on that spectrum depending on posture, position, time of day, etc.):

  1. Back strain (a back joint strain [sprain] of the joint fibrous & muscular interconnections): tends to be in age 20-40 group with low-back, buttock, and thigh pain and usually precipitated by some unusual physical activity. Likely to be tender if you mash the area.
  2. Sacroiliitis: degenerative (wear & tear) sacro-iliac joint irritation or "osteoarthritis" often comes to light or is precipitated by a fall onto the buttocks. That joint might be sore with deep pressure to it & its pain also might radiate to the groin on that same side. The leg raising test may cause pain before 60 degrees.
  3. Low back acute spinal disc herniation (rupture): onset might be related to incorrectly lifting too much weight. A friend can help you do the leg raising test to check.
  4. Spondylopathy (spondyloarthropathy): backbone disc joint or canal or other bone surfaces develope roughened surfaces, surface thickenings or protrusions of bone or narrowing canals that restrict nerves (could cause some numbness) or spinal cord (could cause some numbness) of smoothness of movements of the spine (or "back").There is no pain in the sacroiliac joint pressing test.
  5. Spondylolisthesis: this is the slippageof a backbone/spine joint out of alignment. Leg raising test might cause pain between 30-70 degrees.
  6. Trochanteric bursitis: This can be a spectrum of from low-grade irritation or outright infectious or noninfectious high-grade inflammation of the protective sac (bursa) over the upper thigh-bone ridge under the skin and muscle at the level of the thigh-bone ball-and-socket joint. Putting pressure on this site causes pain. Check HERE.
    7.
  7. Pyriformis muscle syndrome: This PMS pain is in an irritated or sore pyriformis muscle in the deep buttock that is located between the tail bone & behind the thigh-bone trochanteric area. Your butt cheek hurts! If the sacroiliac nerve runs through...or is so close to...that pyriformis muscle that the nerve gets squeezed or irritated, then this can resemble sciatica (seif test to diagnose, check HERE). Self treat, HERE.
  8. Cauda equina syndrome: Whether by sudden traumatic injury or gradual spondylitic tightening of the spinal cord canal around it, a squeezed cauda equina brings on lumbar area pain & partial (with abnormal gait) to totall loss of use of the lower legs a saddle distribution of loss of sensation sensation & function in the perineum (anogenital) area (HERE).
  9. Myofascial pain syndrome (MPS): If this syndrome (HERE) involves any of the above areas, MPS may seem to be related to the spinal (backbone) structures. And, MPS could co-exist with one of the other entities on this numbered list.
  10. Erector muscles low back pain: The erector spinae muscle group has (1) the obvious vertical, dorsal muscle group along each side of the backbone & with all having low-back anchoring on the pelvic bone girdle. (2) The quadratus lumborum (QL) is deep to the above component (anatomy video) and somewhat lateral and the inferior aspect is anchored along the deep margin of the pelvic girdle iliac boney edge...pain-causing QL spasm and irritation being more common in this muscle. (3) Just deep to this is the iliolumbar ligament. All of these are involved in verticle stability of the spine. Self treatment video, HERE. If bad enough, QL pain can recruit (add on) pyriformis and gluteus pain and even sciatica.

Ankylosing spondylitis (or a lessor amount of degenerative joint disease [DJD]):

This is a disease causing variable degrees of back stiffening (ankylosing = making it stiff...reduction of flexibility) fusion of the individual, originally separate backbone spinal components with pain and loss of bending & turning ability of the "backbone". It can mainly involve segments (say, just the sacral or lumbar region around the waist) or the whole back & neck. The office diagnosis can be proposed by demonstrating lack of elongation of the spine when attempting to bend or "curl up". Measuring of the amount of bending lengthening in the sacro-lumbar area is called the Schober test: the average normal increase of distance between the marks is 2 inches (5cm.), while an abnormal result is 1.6 inches or less (4cm or less).

Links (offered...not necessarily recommended):

  1. "Spine Universe" keeps up with all treatments and issues [here].
  2. WebMD's sources on dealing with chronic pain [here and then put your question in "search"], including the devices such as the one touted by Jerry Lewis (Medtronics).
  3. Adam Rostocki's = very interesting, very educational, & comprehensive website (now...2015...apparently in a book) about nonsurgical and non-drug treatments...by a non-physician for laymen [here].

***give me your comments about this page***

check out the Highest TRUTH

(posted 9 August 2004; latest addition 29 June 2018)

***********************************