Clifford R. Stoller, MD is Board Certified in Physical Medicine & Rehabilitation and is a member of Liberty HealthShare. Having recently retired from private practice, Dr. Stoller contacted us and offered to volunteer his services in the management of spine disorders. In this guest physician post, Dr. Stoller draws particular attention to the pitfalls of conventional wisdom regarding back pain, a broad symptom that can lead to improper, expensive treatments, up to and including surgery.
Dear Liberty HealthShare Members,
Thank you for the opportunity to share some information that is important for patients who suffer back pain in general, and for healthcare sharing members in particular, as you seek to optimize your health while avoiding expensive, wasteful interventions that are today so commonly recommended in an increasingly dysfunctional medical system.
During my residency at Mount Sinai Hospital in New York, I was mentored by several physicians whose combined work laid the foundation for the modern management of spine disorders. Dr. Weinstein, the head of medical education for residents, specifically emphasized the need for critical thinking when approaching widely accepted but scientifically unproven medical concepts. The training I received under minds such as his continues to inform the way I approach my field even today.
Following residency, I was recruited by Lovelace Medical Center in Albuquerque, NM, where I went to work in the orthopedic department. As the first treating physiatrist, I treated the perplexing spine problems we saw. These difficult-to-treat cases were referred to us from internists, family practice physicians, neurologists, and orthopedists. In addition to the work I did at Lovelace, I also saw patients in a private practice.
What my work has taught me is that most back disorders will improve with proper, nonsurgical treatment—or what is often called “conservative therapy.” During the busiest time of my career, I estimate that only two or three of my patients a year had to undergo surgery. That may be surprising given many physicians’ propensity to opt for surgical intervention in the case of back issues, but I am here to say surgery should be the last resort.
As a Liberty HealthShare member who believes in the mission of this ministry, my aim is to share information that will help my fellow members avoid any unproven procedure that is likely to increase or prolong pain while also supporting members’ efforts to steward the finances of this community. By comparison to other developed nations, the amount of back surgeries in the USA is extraordinarily high. This is accompanied by a higher rate of failed back surgeries, which leads to a tremendous financial burden and a lifetime of intensified pain for individuals who were seeking a cure. My hope is to help Liberty HealthShare members make informed decisions as they discuss the best treatments with their doctor.
If you find yourself dealing with chronic back pain, here are a few things to keep in mind when seeing your doctor about it:
- You should expect them to take a thorough history of your pain, including:
- Activities that worsen pain
- Activities that relieve pain
- Is the back pain greater than leg pain, or is leg pain worse than back pain?
- Is pain greater at night?
- Associated bowel or bladder control problems
- Is pain associated with fever or weight loss? (could indicate a severe problem)
- Associated neurologic problems
- Associated radiating pain
- Associated numbness
- Associated pain or numbness down leg(s)
- Associated motor weakness
- Following your history, a full physical exam (undressed, with gown) should be done, including the following:
- Palpation for areas of tenderness
- Evaluation of flexion, extension, and notice taken of which position(s) improves or worsens pain
- Neurologic exam including:
- Testing for sensation to pinprick
- Evaluation of motor strength
- Checking reflexes at both the knee and ankle
- Raise straightened leg while lying flat on examination table – evaluation of ability and any associated pain
- Checking range of motion in the hips – evaluation of ability and any associated pain
If and only if this history and comprehensive examination have been performed, your physician should then give an opinion regarding the potential diagnoses underlying your back pain and a possible course of treatment.
Regarding diagnostic testing, many physicians will order x-rays as a first step, but you should know that there is no direct correlation between x-ray findings and pain. For instance, an elderly patient may have horrible x-ray results despite the absence of pain. On the other hand, the x-ray results for a younger person experiencing significant pain might yield only minor findings. The point is, if the doctor orders x-rays and then claims that the radiographic findings explain the cause of your pain, you should not accept this without further investigation and testing.
In the same way, doctors often also opt for an MRI study prior to back surgery. If your doctor tells you your MRI shows a herniated disc, you should come armed with the knowledge that a good percentage of people with herniated discs and other structural findings experience no pain. Statistically speaking, the majority of patients with herniated discs get better without surgery.
Again, keep in mind that only a minority of back disorders actually require surgery. Treatment should start out with medication and/or therapeutic exercise. If these fail, therapeutic injections, trigger point therapy for muscle pain, epidurals for nerve-mediated pain, and facet injections for mechanical movement-related pain should all be considered.
When injections are recommended, they should only be done after consultation with a spine specialist who should carefully examine you and locate what specifically is generating pain. There are no guarantees with injections, but after your physician conducts a thorough history, examinations, and diagnostic studies, he or she should have some confidence regarding whether injection is a wise next step.
As you can see, there is a wide range of treatment options available to those who suffer from back pain. What is the correct one for you depends entirely on the cause of your pain. As I have emphasized, the majority of patients get better with conservative care, not radical and invasive surgical intervention. The presence of pain does not, in any way, mean that surgery is the answer.
Sufferers of chronic pain may believe surgery is the only option available and then, post-surgery, find they must endure even greater pain as a result. Instead, proper exercise, medication, and other pain control techniques are likely to yield better pain management in the long-term.
Those patients who do ultimately require surgery must have true neurologic issues including pain, numbness, and motor weakness in one or both legs that does not respond to conservative therapy. For this subset of patients to experience a successful surgery, their history and clinical findings must match the structural findings on their MRI. If they do not match, it is very likely that the diagnosis is wrong, correlating to a high risk of failed back surgery and worsened chronic symptoms in the patient.
Only a small minority of patients with back pain truly require surgery, and the risk-benefit calculus of a procedure must be carefully considered by both the patient and his or her physician. I hope this information is helpful as you, my fellow members, seek to make informed decisions about your back health.
Clifford R. Stoller, MD