TRADITIONAL APPROACH/EXPERIENCE

Despite the fact that back pain or neck pain represents the second most common problem affecting humans after the common cold, we have very few spine specialists. We do have a lot of generalists who see patients with back or neck pain and triage them to an army of proceduralists. The result is assembly line care for back or neck pain. What do I mean by this?

Let’s look at the traditional journey of a patient with back or neck pain. The journey usually starts with a visit to a primary doctor or chiropractor. Back or neck pain is rarely a life-threatening problem, but it can put your life on hold.

After the initial visit and prescription of pain meds or a steroid pack, the patient goes to get an MRI. Unfortunately, very few patients receive a thorough neurological and musculoskeletal evaluation. It is a sign of our times that we rely more and more on other studies than the history and physical exam. Some doctors don’t even see a patient initially and their nurse practitioner or physician assistant perform the initial encounter.

The MRI scan is performed by a radiology technologist, who submits the images to a radiologist. The radiologist describes the images without ever seeing or talking to the patient. In a majority of the cases the only information the radiologist receives is “back pain or neck pain”.

A written report (most often two to three pages) arrives to a primary physician or chiropractic practice. Most primary physicians or chiropractors are not trained and equipped to review MRI images themselves and cannot correlate the findings on the MRI with relevant clinical findings. I find it ironic when radiologist report includes the statement “clinical correlation recommended”. This is an impossible task when four different providers have seen the patient each focusing on different aspects of the problem. The image of an elephant in a dark room, with four people touching different parts of him and trying to guess what it is, often comes to my mind. 

In addition, most adults have age appropriate changes on an MRI and a significant portion of them has discreet pathology that may not cause any problems. All of this together makes it less likely that a patient will receive the correct diagnosis and an individualized treatment plan. Most often he or she receives a new prescription for pain killers and is transferred further along the assembly line.

Subsequently, patient is referred to physical therapy or pain management specialist. The question why their back or neck hurts is still not answered. The pain, once a symptom, becomes a diagnosis that is passed along the assembly line. A new treatment plan is developed to tackle the elusive back or neck symptom. Why or how a medical practitioner can develop a treatment plan without knowing what they are treating remains a puzzle to me.

In a case of physical therapy, a patient goes through four to six weeks of exercises. Very often they get even more confused as therapists tend to add to the list of problems terms like: your pelvis is out of alignment, your core is weak, or you have bad posture. I have a problem with this as back or neck pain causes a muscle spasm, which is a defense mechanism to minimize the motion of the affected segment and postural changes are often a consequence of the pain and will not change until the source of the pain is addressed.

In a case of pain management, this is a new sub-specialty that has spun-off from Anesthesiology (the branch of medicine that deals with the study and application of anesthetics). Granted anesthesiologists know a lot about acute pain and how to quickly block it with medication or injections; however very few of them know about the musculoskeletal or the neural system and their associated diseases presenting as back or neck pain.

 I assume you have already guessed what will come next. The anesthesiologist (aka pain management specialist) sees the patient. No attempt is made to diagnose the problem. The focus is on treating the pain as quickly as possible. Hence, the patient receives several pain blocks to mitigate the debilitating pain as well as narcotics pain meds.

The epidural steroid injection is the king of all pain blocks. Initially it was developed as a way to anesthetize the lower abdomen and lower extremities for surgeries by injecting a local anesthetic around the spinal cord and nerves. Later it evolved into a miracle procedure to help women with labor pain. Most recently the epidural injection of steroids dominates the pain management field.

The application of the mixture of the local anesthestic and steroid into an epidural space (space around the spinal cord and spinal nerves) quickly suppress the pain. The positive side of an epidural block is that it provides almost immediate pain relief and the patient gets a needed break from the debilitating pain. The problem is that this is only a sophisticated Band-Aid. The pain will disappear, but only temporary. As soon as the medicine wears off the pain will come back.

The biggest problem is that source of the pain remains unknown and thus an effective treatment and recovery is again postponed.  The patient usually gets several pain blocks with varying effect. Sadly, once a full battery of blocks is exhausted, the patient often receives a dreadful message “I am sorry, I have done all that I can. You need to go back to your primary physician who will prescribe you pain killers as needed”. A few unlucky patient develop arachnoiditis (inflammation of the membrane covering the spinal cord) which causes chronic neurogenic pain. There is no cure for this problem.

I often ask myself what patients would do if they would have the same experience with a toothache. The “dental specialist” would numb their tooth several times. Pain would come and go again and again. Eventually the patient would make the following request “Please doctor can you fix my aching tooth”, but instead of getting an affirmative response, they would hear “I am sorry, I am only managing the pain.  I can numb your tooth, but I am not dentist. You need to go back to your doctor to get more pain pills or find another doctor, preferably a dentist”. I bet this patient would never return to this fictitious dental specialist.

PATIENT-CENTERED APPROACH/DIFFERENT EXPERIENCE

By now you know that I am not a fan of assembly line medical care especially assembly line spine care. You may ask is there any other way? Do some of the people who suffer with back or neck pain have different experience? The answer is yes. There are physicians who specialize in the treatment of the entire spectrum of spine problems. They tend to develop a focused team addressing the various aspect of care. However, the care is planned and progresses towards clearly defined goals. The journey in this case may look like this.

The patient is promptly seen by a spine specialist, not by a nurse practitioner or assistant. They are important members of the physician team, but a physician can’t delegate his or her core function – diagnosing the problem and devising the treatment plan.  The spine specialist clearly understands the importance of getting accurate and comprehensive information from the start,  especially if so much rides on the interpretation of subjective symptoms such as pain.

The initial interview and physical exam provides sufficient information about the possible causes of the problem. At this point, the spine specialist asks about the goals that the patient wishes to achieve as well as the circumstances pertinent to a patient’s life style. Obviously each patient wants to get rid of their pain, however there are no mass produced human beings and thus each patients journey to recovery may be different. It is a well known fact that the engaged patient actively participates in his or her care and the result is a quicker return to normal life. However, before we can start any treatment, the spine specialist must answer the essential question – why does the patient’s back or neck hurts?

The initial visit is all about gathering full and comprehensive information about the problem, the patient, and the formulation of differential diagnosis (a list of two to three most probable causes of the pain) and a well defined plan of action before the next visit. If the pain is the only symptom and no neurologic deficit is present, no further work up may be necessary and physical therapy or manipulative treatment may be the best initial treatment.

However, let’s assume that the spine specialist detects a subtle neurologic deficit, i.e. loss of deep tendon reflex or finds a positive provocative maneuver suggesting irritation of the sciatic nerve, and they order and MRI. Once this is done, the patient comes for a follow up visit. The specialist reviews the images with the patient and sorts out the incidental findings from the relevant information. It is imperative to explain to the patient what information is extracted from the study and why some is more important than others. Given the high sensitivity of a spine MRI scan, each MRI finding must be correlated with the clinical findings from the initial clinical exam and further confirmed or ruled out by specific maneuvers performed at this time. The goal is to identify the specific tissue or structure responsible for the symptoms. The previously devised treatment plan is then adjusted to reflect the new information and findings.

If the specialist suspects a mechanical cause of the pain (i.e. ruptured disc pressing on the spinal nerve) an invasive procedure or surgery may become a part of the treatment strategy. In this case, a selective diagnostic block is often recommended. Why is this important? Each invasive procedure or surgery is an irreversible act. In other words, the physician can’t undo it. Hence, it is prudent to prove beyond a reasonable doubt that the structure in question is indeed causing the pain.

This is done by a selective blocking of the tissues or structure in question. It is an injection, but not the same as I was discussing earlier. There are several important differences that are beyond the reach of this text, but there are two specific differences that require further explanation. First, a local anesthetic is NOT injected around the spinal cord filling the entire epidural space with local anesthetic and steroids, but a minimal amount of local anesthetic is applied only to the very small area on or around the specific structure that the specialist suspects as a primary source of the pain.

This requires active patient collaboration. I can’t emphasize this enough. To properly interpret the effect of a selective block both positive and negative results are equally important. Moreover, as a physician can’t feel the pain or effect of his or her treatment, it is essential that the patient understands what the physician is looking for. If the pain does not significantly change after the selective block, it is safe to assume that the injected structure does not contribute to the pain even if there are changes on MRI image.

Obviously, if the pain disappears, even temporarily, we have found the culprit. The patient who was not informed about what the physician is looking for usually returns after the injection stating “doctor the injection did not work”. The patient may not recall the details and the entire diagnostic procedure has to be repeated.

This brings up a second important point. The patient must clearly understand that the goal of the selective block is not treatment, but a further refinement of the diagnosis.  It will prove beyond a reasonable doubt that the targeted tissue or spinal structure is truly the source of the pain. This is very important as the patient who believes that the injection will be curative will soon be very disappointed and may loose faith in their doctor’s ability to help. Once a patient mentally checks out, it is very difficult, if not impossible, to make any significant progress.

In many cases, the diagnostic phase of this encounter takes two to three visits. I tend to push my team to do everything possible to accomplish this within a week from the initial visit. This approach leads to an identification of the source of the pain in a majority of cases. Once the diagnosis is established, it is way easier to address it. I will discuss the treatment options in another chapter of this book.

Again, each plan must be individualized, taking into consideration the patient’s goals and specific circumstances. The treatment of back and neck pain is a team sport and the patient is a critical player.

It has been my experience that using this approach my patients enjoy positive results three to four times faster then using assembly-line care model. In addition, patients are more satisfied.

Now you know how to recognize different treatment approaches to back and neck problems. If you have a trouble with finding right spine specialist check this article. HOW TO CHOOSE THE RIGHT SPINE SPECIALIST.