Hi everyone, it’s Medicine Mondays again and I had promised to rewrite my post about “Experience Matters” because it was lost. However, I woke up this morning with some back pain, kind of like mid-lower right back pain. For this reason, I’m going to talk about me being an Old Man with Back Pain. This is only circumferential related to Medicine, but just bare with me. This should be a short post. (Spoilers: It ended up being long.)

Stock Photo from: Pexels

Back Pain?

So yea, first things first, I’ve had back pain before, so this is nothing new. However, there is like an achy back pain and then there is the “I can’t move” back pain. The worst back pain I ever had, was back in New Jersey when I was moving from Rhode Island to Hawaii. Most of our stuff was in New Jersey, at my in-laws house and I was helping to get it packed up and moved out. Trying to be a “manly-man” I told everyone to leave all the heavy lifting to me. Admirable right?

Admirable? Perhaps. Bad idea? Yes.

Of course in the last 6 years of my life (residency/fellowship), and maybe even the 4 years before that (medical school), my physical prowess was… not great. As you would expect, by the end of that day my back was aching a bit. However, I figured a few Advil and some Icy Hot and some sleep would take care of it, right?

Wrong.

I woke up, and the pain was still achy, but also with certain movements I felt tinges of lightning-sharp pain. There was no radiation to the left leg or right leg or anything like that. However, the pain was most certainly different from before. It was difficult (read: impossible) for me to even get out of bed without help. I realized I was going to have to “take it easy” for at least today.

So I had my wife help me move to the couch and turned on the TV, watching whatever movie was on at the time. I positioned myself on the couch as comfortably as possible. Their couch was one of those super-plush couches that you kind of fall-into. I felt kind of worthless while my wife and in-laws continued to try to pack things into bins while I sat on the couch like a lump.

That was my morning.

So, I decided, (in my infinite wisdom), that I had rested long enough and was “fine”. So, without any help, I positioned myself to get up off the couch. I rested my hand and the couch’s right arm, left hand on the couch cushion to my left, placed my feet firmly down on the floor, and pushed off. I made it about 15-20% off the couch…

Then it happened.

I felt shooting pain across the whole left side of my back, yelped out, and essentially crumpled on the couch. So what I think happened is that the whole left side of my back decided to spasm, causing pain, making me involuntarily lose support of my left arm, which resulted in me falling back on to the couch.

My wife and in-laws came running over to check on me. I assured them that I was “ok”. The shooting pain had subsided but the aching was significantly worse than before. What made this even worse is that after this happened, no position was comfortable anymore.

And this is how that moment felt:

Long story short, it took about a week for me to get some semblance of recovery.

Also, bonus clip from Scrubs about Dr. Cox’s Back Pain for those who haven’t seen it:

So more back pain today?

Yep. I’m actually not sure why this time. I don’t really have back pain unless I’ve been doing something strenuous like lifting heavy objects (read: moving). To be honest, it may just have been that I slept funny last night or something. (By the way, don’t worry, I’m fine now, which is why I’m writing this post.)

Long story short, take care of yourself everyone and always “bend from your knees and keep your back straight“.

Also, for those of us who do a lot of sedentary work, make use of your height-adjustable desks.

Anything else?

Yes.

Back pain is an extremely common complaint in healthcare and uses a lot of healthcare dollars. Unfortunately, the options available to chronic back pain sufferers aren’t all that great. They boil down to medical management, pain management, and surgery.

Ideally, everyone would improve with medical management and physical therapy. However, that is not the case.

It may be difficult to imagine for those who have not yet had an episode of back pain to understand what it really entails. However, if you have had even one episode of severe back pain, you are able to imagine the plight of those who have chronic, debilitating back pain. These patients would be willing to try anything in order to get some sort or relief.

Spinal surgery is an option, but in my opinion, it should really only be a last resort. It is difficult (or impossible) to predict which patients will benefit most from spine surgery. Some may have a miraculous recovery and complete relief of pain, while others may have no relief, and still others may have an increase in pain and/or complications. All patients will hope they are in the 1st category, but so far, there has been no real way to differentiate which patients will get the most benefit.

So what are you going to do?

The best thing to do is prevention, in my opinion.

• Make sure your workplace is as ergonomic as possible.
• If you have a height-adjustable desk, make sure to utilize it as much as you can.
• Exercise, or do Yoga, or whatever. Just be active.

This post serves as a reminder to me to do do the above.

I had a colleague in Rhode Island who had back pain when he was in his mid 30s. He was a taller guy, probably around 6’4″ maybe. He was a radiologist like me, so of course during the work day we are pretty sedentary. Back pain was something he had dealt with on and off through the years. However, one day the back pain suddenly became severe. He had sharp, shooting pain, with elements of “lightning-like” pain which would radiate down his right leg (radiculopathy).

His MRI demonstrated that he had a right paracentral disc protrusion with some mass effect on the right L5 nerve root. After some consultation with his neurosurgeon, he opted for a microlaminectomy and microdiscectomy to remove the part of the protruding disc. He recovered well. However, I must be clear that this will not be everyone’s experience. Every patient is different and just because it worked for him, does not mean it will work for everyone.

Recovery

His neurosurgeon advised him to try to stand up for part of the day since we didn’t have height-adjustable desks. His monitors were propped up on some stands to bring his screens to eye-level while standing, and he became accustomed to just standing while at work. There was an office chair of course for sitting down once in awhile, but most of his day was spent standing.

Also, he was advised to try Yoga, so he began doing something called “Hot Yoga” where you sit in almost a sauna-like environment doing Yoga. I guess this is kind of nice in Rhode Island where it can get super cold in the Winter. Either way, it’s helped him I think.

I am not necessarily a strong proponent of microlaminectomy and microdiscectomy. However, if I was to have the same issue that my colleague had, it is one of the few interventions that I would consider. The other (more invasive) options of decompressive lamiectomies, fusions, interbody disc spacers, etc. would be difficult for me to ever consider.

I haven’t talked to him in awhile, but I think he’s doing well since I still see pictures of him fishing once in awhile.

What about spinal neurostimlators?

Spinal Cord Stimulation (SCS), while not “new”, aren’t very common yet. This may be because they are expensive and may be potentially cost-prohibitive if your insurance does not cover it.

The idea is that you are able to “mask” the pain at the source (the spinal cord). This may help people to cut down on the amount of opiates needed, or potentially wean themselves off of opiates completely. However, this is a not a cure-all, as it doesn’t address the cause of the pain. It simply helps to decrease the amount of pain felt. From my understanding, it serves as an adjunct to pain management.

More studies need to be done.

TL;DR

Back pain is very common, and it can be chronic and debilitating.

Prevention is probably the key – Ergonomics, Height-Adjustable Desk, Active Lifestyle

If intervention is absolutely necessary, one of the few I would even consider is the microlaminectomy and microdiscectomy. (See above)

Spinal Cord Stimulation (SCS) is a potential adjunct to pain management.

Sensei’s Note:

I’m not a neurosurgeon and I’m definitely not your neurosurgeon. The above are simply my experiences with back pain and my opinions.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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