Dear Dr. Lowell,
I’ve had lower back pain for 4-5 years. MRI’s show “degenerative changes” and “disc desiccation” with some bulging discs. I’ve had two epidural blocks and a lot of facet injections but they don’t work for long or sometimes not at all. I’ve been treated mostly by pain specialists. The last one said that surgery is not in order and suggested that I take methadone, possibly for the rest of my life. I saw an orthopedic surgeon, who did not advocate back surgery. A neurosurgeon said back surgery to remove or shave part of disc in lumbar region MIGHT provide relief but no guarantees. Are there any tests not already given or treatments not given that might provide relief on extended basis? I am a 65 year old man in good health.
This is not an easy thing to advise you on without looking you over and reviewing your studies. However, your MRI seems to indicate that your main problem is a form of arthritis in the back called degenerative disk disease. Your pain is most likely coming from the deteriorated disks themselves. Probably the general reluctance of other doctors to recommend surgery on you is because the surgical treatment of degenerative disk disease is a controversial topic. Some doctors have claimed good results treating it surgically, but many others believe that the odds of failure are too high.
Whether or not to undergo surgery in your situation depends mainly on your pain level. If it is so bad that your lifestyle has altered, you can’t do the things you love, and you are miserable, then surgery may be a worthwhile risk even if the odds of failure are higher than you might normally accept. If you are fairly functional in your daily life despite the pain, then surgery would not be a good idea. A new nonsurgical method of treating degenerative disks has recently come out in which a thin electric probe is inserted into the disk to heat seal the tears and cracks which are causing the pain. This method is called IDET, or Intradiscal Electrothermal Therapy. In appropriate candidates, IDET can relieve back pain up to 70% of the time using local anesthesia and without a hospital stay. The surgery for degenerative disk disease is called a fusion. The degenerative disk is eliminated entirely and the two adjacent vertebrae are fused together to eliminate movement. This takes a long time to heal from, but it can work well in very carefully selected patients.
Dear Dr. Lowell,
I am a 39-year-old female with the lower back of an 80-year-old! I originally hurt it by “lifting and twisting” at work. It got better and then I was in a small fender-bender and it hasn’t been the same for 1½ years now. I do not have pain that radiates anywhere else. My doctor said he suspected a ruptured disk and arthritis. He says I should get an MRI. I am looking for “THE CURE.” I don’t want to live this way forever! Do you think this could be a ruptured disk even though I don’t have radiating pain? What might your course of treatment be?
I’ve found that most people who have primarily chronic back pain after a lifting injury or after a car accident end up having disks which are injured or degenerative, but not truly ruptured (herniated). This is because most ruptured disks cause more leg pain than back pain. They produce their pain by pressing on a nerve, which produces pain mostly in the one leg that the nerve goes to – that’s the symptom we call sciatica. If the pain stays mostly in the back alone, usually that means that a nerve isn’t being pressed on. Most ruptured disks large enough to cause symptoms will end up pressing on a nerve, so in your case I doubt that you have a herniated disk. Occasionally, however, a disk can have a massive rupture in just the right spot to cause severe back pain but not much leg pain. I must warn you that this is rare. However, I would recommend an MRI or CAT scan on most people who have chronic back pain just to make sure that this isn’t the case.
If we find such a massive rupture, then if you have been having pain for so long, surgery to remove the rupture may be your best option. More likely, we will see that your disks are injured or degenerative, but no so far gone as to have ruptured. In this case, surgery is not a very good option because the success rate in dealing with this problem is much lower than when we are dealing with a ruptured disk. Unless you are in so much pain that getting out of bed is a chore, then treatment should stay non-surgical. This consists of some combination of medicines, physical therapy, bracing, and attitude adjustment. If you have a degenerative back that is annoying but not incapacitating, there is a definite possibility that surgery could make you worse, so stay away from the knife! The bad news is that in these situations, sometimes we can’t really make the pain go away completely; we can only help alleviate it somewhat.