Spine physician Q & A

Dear Spine-Health Member,

Over the past few years we have received over 7,000 questions from people researching their back conditions and treatment options on Spine-health.com. Each question is unique, but each has a common element too - that there are many complexities in understanding and treating spinal conditions and back pain.

To help you in your efforts to better understand your spinal condition and treatment options, we thought it would be useful to share with you a few recent questions we received and the doctor's responses. These clearly show how complex the situation is for many people with back and neck problems.

The following patient questions and spine physician responses have been edited for brevity, clarity and grammar, as appropriate.

Question

I have a herniated disk at C5-C6. I was recently in a car accident, and now the pain feels the same as before when I was in severe pain from the herniated disk. I had an MRI taken after the accident, but the doctor said there was nothing to do and would not give me anything for the pain. What might be the cause of the severe pain? Is there anything I should avoid doing to not aggravate the symptoms?

Spine Doctor's response

Keep in mind that the MRI scan does not always show you what is causing the back pain or neck pain. It is not a test for pain but rather a test for your anatomy. A disc bulge or similar pathology may be seen on a MRI scan but it is not symptomatic in 30-50% of patients. There are many other possible causes of pain, and after a car accident it is much more likely that you have had soft tissue damage to the muscles or ligaments that is not seen by a MRI scan. Thus, the disc may or may not be a cause of pain.

In general, the best treatments for back pain or neck pain after an auto accident are to keep the motion in the spine and strengthen the muscles. An active rehabilitation program with physical therapy, and time (it can take up to two years to heal), are generally the best treatments. See Rehabilitation and exercise for a healthy back [1].

A physical rehabilitation doctor (physiatrist) is probably best able to help you get through the rehabilitation process, and surgery is almost never necessary for a disc problem after an accident. See What is physiatry? [2] for more information.

Question

I am a 43 yr old male. My MRI shows degenerative disc disease and anterior and posterior disc bulge at L2/3, L3/4, L4/5 and L5/S1. I have constant lower back pain and have periodic bouts of right leg sciatica. I take regular pain relieving medication and use a TENS device. I have undergone physical therapy, osteopathy, several forms of chiropractic, pain relief therapy, and acupuncture. None resulted in more than a very short-term lessening of the pain. I have also had epidural and facet joint injections, which had no effect.

Are any options available which could lessen the pain and allow me greater control over my life?

Spine Doctor's response

Multi-level disc space degeneration is a difficult problem to handle because there are no surgical solutions. This generally leaves one with conservative pain management techniques. The good news is that it is not a crippling condition, and even if the pain seems worse at times it does not mean that your back or the condition is worsening.

Generally, your best bet is a strict home exercise program that emphasizes stretching your hamstring muscles as well as aerobic conditioning and stabilization exercises. This can help compensate for the bad discs, and even if it is not a cure it can keep you functional and keep the pain from getting worse. Unfortunately, the exercises themselves may be uncomfortable to do, but you should notice that as you get stronger and stretched out the pain will not be as bad and you will be able to function better.

It is best to work one on one with a physical therapist who specializes in the treatment of chronic pain. If you have had chronic pain you should also be under the care of a conservative care spine specialist, such as a physiatrist.

For more information, please read How a physical therapist can help with exercise [3] and Back exercise and physical therapy for back pain [4].

Question

I have spondylolisthesis of L5 on S1 grade 1-2. Two steroid epidural injections helped the back, leg and foot pain very much, but I had surgery four weeks ago due to increasing weakness and muscle atrophy of my right leg and foot and numbness of the lateral part of my right foot. The numbness has been present from the outset of problems last year. What is your experience with numbness being corrected with surgery and how long would you expect it to take if it does correct?

Spine Doctor's response

Usually the numbness is the first thing to start and the last thing to go away. It can take up to a year to get better, or even longer. The good news is that after surgery the numbness will usually either improve or go away.

However, if you had a lot of nerve damage (as would be evidenced by the preoperative weakness) I would probably expect that your numbness will not go away entirely and you may have some degree of residual numbness. The bottom line is that four weeks after surgery it is too soon to tell - you won't know until the nerve is done healing and this usually takes at least a year.

Question

After 2 years of lumbar pain on the right side above my hip. I saw a chiropractor who told me I have a congenital anomaly in that the L5 never fused with the last so I have 6 vertebrae in the lumbar spine. After 12 weeks of chiropractic treatment I did well for about 3 weeks, but my pain is severe once again. Should I see a spinal surgeon? Would spinal fusion in this area help my pain and keep me from going to chiropractic therapy for the rest of my life?

Spine Doctor's response

Actually, a sixth lumbar vertebral body is not a known cause of low back pain. Rather, it is a variant of normal anatomy and is present in 5-10% of people.

There may be another correctable lesion that would be amenable to surgery, but the only type of surgery that is effective for back pain is a fusion. Because this is a large procedure, usually it is recommended that you first try to maximize conservative treatment.

It is encouraging that you did get pain relief with chiropractic manipulations. Besides just passive manipulations you should also be on a home exercise program, and it would be reasonable to also work with a physical therapist to come up with an exercise program that is right for you.

As your back heals, you may experience intermittent bouts of pain. If you continue to have pain or if the manipulations do not help this time you may want to first see a conservative care spine specialist (e.g. a physiatrist) to explore other non-surgical treatment options before seeing a surgeon. If conservative treatments are not successful, please read When to see a spine surgeon for lower back pain [5].

Question

I had back surgery in 1996 for a herniated disk at the L5-S1 position. Two years later, I had a severe episode of pain in my right calf and the right side of my right foot. The same severe symptoms returned a year later, and they have returned a third time this year. I have been in considerable discomfort for the last 3 months, and I have "twitching" of the muscles on my right calf when I am at rest.

I have been told that my condition is caused by scar tissue at the site of surgery compressing the nerve. My question is, how sure can we be that the problem is really scar tissue? Because of the long period after surgery before I had severe symptoms, and because I overcame severe problems twice in the past, I don't understand how the problem could be scar tissue.

Should my physicians be looking for something else? This year, I have seen a MRI specialist, a neurologist, and a neurosurgeon. Should I be seeing another type of health professional?

Spine Doctor's response

I would absolutely agree with you that the scar tissue is an unlikely cause of your pain. Scar tissue is an often over-diagnosed condition and much overrated cause of pain. Moreover, scar tissue would be highly unlikely to develop two years after surgery. If it is going to become a problem in and of itself it should do so within the first several months after surgery, which is when it develops.

There are more subacktalkle causes of pain, such as foraminal stenosis, where the nerve gets pinched as it exits out the spinal canal. This is especially likely to happen at L5-S1, and if you have a lot of disc space collapse on your MRI scan is a strong possibility. Also, although the scar tissue is not a cause of pain it does limit the motion of the nerve root, and even small discs or other lesions can then be painful.

If you want another opinion I would suggest seeing a surgeon who is fellowship-trained in spine surgery and for the most part does only spine surgery. These findings are again subacktalkle and sometimes it takes someone who specializes just in spine surgery (either orthopedic or neurosurgeon) to accurately diagnose your condition.

Another thing to consider is that the pain is not from your disc space at all and it could be from other causes such as sacroiliac joint dysfunction or piriformis syndrome. These conditions can mimic the symptoms of a pinched nerve, but require manual therapy and not surgery.

See also Specialists who treat back pain [6].

Question

I have been suffering from sciatica for a few months. I have not been to a doctor because I didn't really think there is anything that could medically be done. I guess my question is: could another type of back problem give me the same symptoms? Also, my back cracks a lot when I twist and turn. Is that OK?

Spine Doctor's response

The back cracking is not a problem and is nothing to worry about. Cracking in the back is natural and is not a cause of pain, and is not a known cause of any back problems.

If you have had leg pain for a few months it would be good for you to see a spine specialist. You need to be examined for the cause of your sciatica. Sciatica is not a diagnosis but a symptom (it just means that you have leg pain). Common causes of sciatica include spinal stenosis and lumbar disc herniation. The first step is to see a doctor for an examination, and you may then possibly need further testing such as a MRI scan.

Sometimes reading about questions from other people and how a physician responds can help by adding to your general pool of knowledge about back pain and neck pain. We hope that the above selection of questions and responses have been helpful to you in your quest to better understand and seek the right treatment for your condition.

Best regards,
Peter F. Ullrich, Jr., M.D., Medical Director
Stephanie Burke, President
Spine-health.com

About the Spine-health.com Newsletter: Each issue of the Spine-health.com newsletter, SpineNews Update, is written by the founders of Spine-health.com - Peter F. Ullrich, Jr., M.D., Medical Director for Spine-health.com and Stephanie Burke, President of Spine-health.com. The content in the newsletters is not peer reviewed by Spine-health.com’s Medical Advisory Board. The articles to which the Spine-health.com newsletters link have been peer reviewed by members of the Medical Advisory Board.