Back pain won’t go away?
If your pain came on within the past 6 weeks or so, please see my page on acute back pain. What if you are one of the unlucky people who have back pain that won’t go away? What if the pain came on gradually and then just stayed? Sometimes it becomes clear that simply controlling the symptoms isn’t enough. Something needs to be done about the problem. Of course, in order to do something, we first need to come up with a diagnosis. There are several ways I can figure out what is wrong:
Although it may seem like a “duh” thing, it can be very helpful to get the answers to simple questions like “where is the pain?”, “where does it travel?”, “what makes it better?”, “what makes it worse?”, etc. Certain conditions have a classic presentation in history. For instance, if you have pain in your right hip and buttock area, it could be hip arthritis or sciatica (leg pain coming from your back). If you have pain in the groin area when first starting up from a chair or bed, it is more likely to be the hip. If you have pain that gradually gets worse as you walk, then it may be coming from your back. Obviously, history doesn’t clinch the diagnosis. But, it is important in providing the first clues.
Even though we have a lot of fancy tests these days, the simple “laying on of hands” can tell a lot. It gives us a general idea of where the problem is, and suggests what to get tests on. Without a physical exam, we could easily go “barking up the wrong tree.” An example: it is unfortunately not that uncommon for a patient to present to my office complaining of “sciatica” from his or her back. Often, they present with an MRI of the spine that has been read by other doctors as having no problem that needs surgery. Sometimes (and very unfortunately), he or she has had spinal surgery that failed to correct the problem. I do a simple physical exam to check the hip joints: when I rotate the hips, the patient yelps in pain. An x-ray confirms that the problem was the hip all along, not the back. The patient had never had a physical exam before!
We have an x-ray machine in our office, so it is convenient to get x-rays right at the time of your office visit. Very often, the plain x-ray alone is enough to tell us what the problem is. In this x-ray, the patient has severe bone-on-bone arthritis. If the patient’s history and physical exam is wholly consistent with the x-ray, we may be done with diagnosis. Fancier tests will not be necessary because the x-ray is so obvious. If there are other issues, more extensive testing may be necessary, but it is not a given.
HIGH TECH IMAGING
Most of the time here, we are talking about an MRI scan. It is noninvasive, it doesn’t use radiation, and it will be just about the most sensitive test for problems. There are other tests that could be necessary as well, such as blood work, CT, myelograms, bone scans and other such tests. Each patient will be unique in terms of what tests will be most likely to show the problem the best.
WE HAVE OUR DIAGNOSIS
So, we’ve done our history, our physical exam, and our testing, and now we know what’s wrong. What do we do now? Well, that depends on a few things: what the problem is, how bad the pain is, how long has it been present, and what treatments have been tried before. Even if you have a chronic condition, all of the treatments discussed on my acute low back pain page can be attempted if they haven’t been tried before. This is especially true for physical therapy. Many people have a chronic back problem that is too painful to live with, but not curable. In that case, therapy can be a useful tool to lower the pain from an intolerable range to a tolerable one. Hopefully, a range that you can live with.
But, let’s say that all of our conservative treatments were not sufficiently effective to eliminate the pain, or at least to make it acceptable. What then? Well, this may be a situation in which some form of surgery may be required to help with the problem. The specific surgery will depend on the specific problem.