A pervasive pain

Of all the illnesses and ailments that primary care physicians encounter, lower-back pain ranks among the most common reasons people seek medical care. That may seem like a very specific, localized concern, but according to the National Center for Health Statistics, more adults point to discomfort in the lower back than any other place on the body.

“It’s a quite common complaint that brings patients in,” said Dr. James Westcott, a family practice physician at Mission Ranch Primary Care in Chico. “I see it every week, for sure—quite frequently.”

Typically, the doctor and patient identify a cause of the lower-back pain that’s physical: a specific injury that arose during an athletic activity or from a jarring, wrenching accident.

However, there’s also a possible overarching cause that’s physiological.

“My theory is, evolutionarily speaking, we’re not really meant to live past 30 or 40 years with a lot of stress on the lower back,” said Dr. Bill Whitlatch, a neurosurgeon at Enloe Neurosurgery & Spine, a specialty practice in Chico. “If you look at a lot of so-called normal people, with no back pain, when we do MRIs on their backs, over [age] 30 there’s almost always an abnormality, even if they’re not symptomatic….

“You just don’t see this much back pain in quadrupeds as you do in bipeds, bearing all that weight all those years on those discs. Certainly accidents, trauma, poor nutrition, poor conditioning and, concurrent to that, obesity and smoking accelerate that degeneration.”

The job of the physician—primary care or specialist—is, in Whitlatch’s words, “sorting out what’s actually causing the problem: the ‘pain-generator.’”

The first step is actually a process of elimination, ruling out what Westcott referred to as “red flag symptoms” such as cancer, infection or fracture. “That’s a very small percentage,” he said, “but that’s very important to check.”

Once the physician rules out a major condition, the next step—surprisingly—is to take a step back.

“Most acute back pain is going to go away in four to six weeks whether you do anything or not,” Westcott said. In fact, he added, often lower-back patients won’t return to the office after the first week because their symptoms have abated.

During this restorative period, they aren’t idle: “Most patients do better if they have a plan rather than waiting,” Westcott said. “We follow evidence-based care and encourage them to be as active as possible. People seem to do better if they move around more, so we tell them they’re not fragile and try to get them back to work as soon as possible.”

If pain persists, Westcott may order an X-ray, MRI and/or blood test, and perhaps recommend medication, physical therapy or chiropractic care. After that, it may be time to consult a specialist—namely, a neurosurgeon.

Ironically, though “surgeon” is in their job title, many neurosurgeons view surgery as the treatment of last resort.

“We’re really trained in the surgical treatment of back and neck problems, as well as brain and peripheral nerve, but we’ve had to learn conservative treatments from other specialties,” Whitlatch said. “Most of the time, surgery is not indicated, but the patient still hurts, and that’s the real conundrum: You want to help the patient, but you don’t want to put them through unnecessary surgery. A lot of times there’s a gray area.”

Whitlatch has three criteria for surgery: A clear target directly matching up with the symptoms; a progressive neurological deficit such as increasing paralysis; and it being the final option.

“In my mind,” he said, “not only is surgery the last resort, but the ethical thing to do is make it the last resort.”

Surgery may be indicated for a deformity, such as the spinal curvature known as scoliosis, which can throw body posture out of alignment. On the other hand, some patients “just learn to live with it.”

Two joints in the lower back commonly cause pain. The facet joint can cause an ache, accompanied by a popping or clicking sound, which grows worse with use or in cold weather. The sacroiliac (or SI) joint, which causes up to 20 percent of back pain, tends to spark pain when a person is upright.

A neurosurgeon may fuse the joint, though in the case of the SI joint, Whitlatch says the procedure is controversial and not performed in his group. He likely will refer a facet or SI joint patient to a pain specialist.

In the case of spondylolisthesis, a condition in which two bones slide over each other, surgery tends to alleviate the pain in up to 90 percent of patients.

Other causes of lower-back pain seen by specialists include complications from previous surgeries, inflammatory diseases such as rheumatoid arthritis and fibromyalgia, and osteoporosis.

Back pain isn’t wholly avoidable, but adults can reduce their odds with lifestyle choices such as exercise, good nutrition and quitting smoking.

“The most important thing is to be in good condition,” Westcott said. “Strengthen your core muscles, strengthen your back, and learn proper lifting techniques….

“People who are in poor health are at much higher risk for back pain problems, so if you are in good health, you should be avoiding that by staying in good shape.”

This story originally appeared in the July 31, 2014, issue of the CN&R.