Back Pain: What’s operable and what’s not

Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health.

This week I had an insightful conversation with Dr. Ken Smith about back pain, what is operable and what’s not. Dr. Smith is a good friend and well respected neurosurgeon in my hometown of Kingsport who, like myself, has a bad back. As a former weightlifter and powerlifter through college, Dr. Smith has been plagued with back pain for 25-30 years, with nothing operable.

If you have, or have had, any kind of back problem, you know how difficult it is to manage the pain. The question is, can it be fixed? As a primary care doctor, I can look at patients’ extremities, check to see if they have good reflexes and pulses, do straight leg raising tests, even get MRI’s, and maybe a plain film (if it still doesn’t get better), but only a neurosurgeon can tell you if the back can be fixed.

I encourage you to watch this podcast to see the visuals (the spine, vertebral, and disc models) that Dr. Smith used to explain how back pain happens, and what neurosurgeons can and can’t do to fix it. A fascinating subject.

PODCAST NOTES

Where To Go For Back Pain

Neurosurgeons get more and more referrals now because of the disparate types of treatments that are available. It’s hard to keep up with all of them, including the jargon on the radiographic reports.
Neurologists tend to get patients with non surgical/non spine back issues. Neurosurgeons and pain management specialists get the patients with back pain. Neurosurgeons take the ones they can operate on and pain management takes the rest. About 22% are able to be operated on, and the other 78% go to pain management.
If injections and ablations don’t work, the patient will end up seeing a neurosurgeon, like Dr. Smith, to get advice on whether or not they need surgery. Dr. Smith guides them through the maze and hopefully gets them to a place where their pain is controllable.
Dr. Smith looks at a whole set of issues: Where is the pain coming from? Is it out of proportion to the radiographic findings? Does the person have an autoimmune disease that’s amplifying it? Does the person have a past history of opiate use, which may amplify it? Did the person have a job in which the radiographic studies won’t accurately reflect what is wrong with them (i.e.,coal miners, truck drivers, airline pilots, stewardesses)? You have to investigate anything that may amplify their pain.

Getting A Good Picture

It was obvious, during our conversation, how much emphasis Dr. Smith put on getting a good quality picture of what’s going on with your back pain. There are a couple of different avenues you can go down. Here is how he looks at it.

First thing is getting an MRI. All MRIs are not created equal. Dr. Smith tries to guide patients to whoever has the best magnet and software package rather than the hospital or organization that has bought it. Many times people will buy older used magnets that aren’t very in tune and will turn out images that aren’t usable surgically. In general, the higher the tesla, which is the magnetic field strength, the better. Second is a software package, and does it get rid of artifacts? Do you have metal embedded in your back from a welding accident or from the military? Do you have implants? There are suppression packages that can be put on those patients in order to get a better picture of exactly what’s happening.
If an MRI doesn’t tell you, you can go to a Myelogram, which is a test where a needle is put into a sack (see video).
The purpose of plain films is to rule out something grossly immediate, like a fracture. They’re getting less and less useful.

Back Pain: What’s operable and what’s not

Where To Go For Back Pain

Getting A Good Picture

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