I will answer the commonest questions on back pain that patients search for on the internet.
When I went to medical school low back pain was a Pandora’s box. I didn’t understand it. I couldn’t unravel it and I couldn’t very well treat it. Over the past 3 decades I’ve spent 8 hours a day listening to patients tell me about their back pain, thought about, treated it and learned a lot from my patients. Sometimes I help, sometimes I don’t. My dad had two back surgeries and was miserable with pain until he died. I’ve said before, don’t have surgery for back pain. Low back pain is a commonly googled topic. When I looked today there were 1,220,000,000 results. that’s 1.2 billion pages. Clearly there is a lot out there! I thought the easiest way to tackle this topic was to select the Top Five Questions asked on the web about back pain. I will give you my thoughts and a summary of the scientific evidence we have.
Question 1: Back Pain Without Leg Pain
Ok. This is common and usually self limiting. Up to 80% of us will get back pain at some stage. It is usually the muscles
(so called ‘strain’). It can be other things (see the list at right but don’t let your eyes widen!) but in 90% of cases, it’s not.
It is usually gets better. Simple tylenol and over the counter anti inflammatories help. Cold packs can help. Bed rest is no longer advised. Avoid activities that stress it. In the old days we said stay in bed but no more. Just avoid the things that make it worse:
Massages feel great and may help sore muscles. Great for acute flare ups.
Lots of people go to chiropractors and feel good. I think it’s one step above massage. The data on chiropractic for back pain is not good:
Physical therapy is great. It makes you do the work. Finish the course and do it at home.
I think physical therapy should be the initial cornerstone of managing back pain.
I hate needles but acupuncture plays a role. I’ve seen it in my own patients. The mechanism is probably endorphin release by why is it sustained after a series of visits?
Doing nothing is also ok. It’s not cancer. It’s not a broken leg.
Question 2: Back Pain Red Flags
Red flags are things to watch for- things that may be a harbinger of something bad. Look at this list:
Loss of bladder or bowel control that is sudden onset or progressive is bad and at the least needs an MRI scan. Old men get prostate cancer and it can spread to the spine. If an older male patient has sudden onset of back pain with no incident that brought it on, at the least they need x rays and maybe an MRI scan. Pain at night is rare- most people get rest in bed. I’ve seen patients with purely night pain where they sleep in recliners have benign tumors. Pain that is not able to be controlled with medication needs assessment. Fever with back pain, particularly in diabetes and drug users and those people with compromised immune systems needs an MRI scan to rule out an infection in the spine. Weight loss that is not expected with back pain can suggest that there may be underlying cancer. Recent trauma needs an xray at the least if it does not settle, if the trauma is severe or pain out of control. Finally if there is weakness in legs, shooting pain down the legs that won’t settle, need a closer look. OK. so if it’s plan old my back hurts when I do stuff or play golf, your first step should be moderation, then PT and don’t ask for an MRI off the bat.
Question 3: Back Pain For Days/Weeks/Months
This is tough. You do the basics. Lifestyle modification, simple pills, PT. If your still not good then see your GP who may send you to a specialist for assessment.
Do yourself a favor: stop smoking, lose weight, don’t do heavy bending, lifting and twisting and see a PT to learn and practice core strengthening.
Question 4: Radiating Back Pain
Ok. If it’s just back pain and that’s it, sit tight. If you get pain down the leg that means a nerve in the back may be pinched. Sciatica means shooting pain down the leg. The actual sciatic nerve is at the back of the thigh. It does not get pinched. The nerves in the spine get pinched. You can get pain, weakness, numbness and tingling. If it persists for more than a few days, see your GP. If it’s uncontrolled or the weakness is severe, go to the ER. Ditto if you get numbness in the crotch, loss of bladder and bowel control or can’t feel it when you pee.
We order a boatload of cortisone injections for back pain. I order them and they often work. It’s interesting that the scientific data on injections is not great:
Simple injections into the muscles also have not been proven to scientifically work but we order them:
We underplay the risk of getting soft bones and possibly a compromised immune system from cortisone shots:
Some data even suggests if you have shots before surgery, you do worse!
There is also no proof out there that parachutes work so take what’s in research with a pinch of salt:
I think shots are fine, just not too many.
Question 5: Surgery for Back Pain
I’ve said it before- don’t do it!
Most back pain should be managed nonsurgically:
Surgery is pretty good for leg pain, sciatica, tingling and weakness in the legs:
This is what I teach GPs to do:
Surgery is way down the list.
I’ve told you before my dad had back surgery and did not do well. When I went into practice 20 years my back would kill at the end of a long day. I wondered how I would make a career of it when I hurt so bad at the start? My secret?
I became careful
with bending, lifting and twisting. I learned core strengthening. I bought these two on amazon (a Roman chair and andbench for crunches) and 3-4 times a week strengthened my core. My back does not hurt:
Ok so it sounds like most people on the internet want reassurance and to make sure nothing major is wrong. Read the red flags list, follow the good living tips above and you should be ok. If we walked on four legs or were fish we’d be fine!
Agree? Disagree? Feel free to comment below or share!