The Great Back Pain Debate

Stop rubbing your sore back for a minute and take a quick tour of Mother Nature's engineering masterpiece: the human spine. Pretend you are Alice, so tiny you can climb among the muscles, nerves, bones and ligaments that make up the very core of your body. Crawl down the 24 vertebrae that encase and protect the spinal cord, from the cervical spine to the thoracic area to the lumbar region, that pesky lower back. Note the 23 rubbery white discs: the cartilage inner tubes that cushion the vertebrae. Observe the dozens of spinal nerves threading out from the cord between the bones. Poke the bands of muscle that wrap and support the bony column. Now focus on the tugs and thuds of daily life. The quick bend when you pick up your sobbing 2-year-old, the pounding of your feet as you run to catch the bus, the steady pull of your untoned belly, the dull pressure as you sit bleary-eyed in front of your computer, the sudden twist of your golf swing. Feel, too, the constant emotional stress we all live with: worries about aging parents, the kids' grades, a tax audit. Finally, imagine (or recall) that knife-in-the-back moment when something suddenly goes wrong with all that gorgeous spinal anatomy: Owwwwwww!

Like an expensive but temperamental sports car, the human spine is beautifully designed and maddeningly unreliable. If you're a living, breathing human being, you have probably suffered the agony of back pain. It strikes almost everyone at some point, regardless of nation, culture or income--in any given year, about one person in five will struggle with back pain of some sort. In developed countries, it's one of the top reasons for doctor visits (after coughs and other respiratory infections). In America, back-pain sufferers wrack up more than $100 billion annually in medical bills, disability and lost productivity at work. As the world follows the American lead into sedentary and stressful lifestyles, this kind of spending will become more common.

As legions of new back-pain sufferers, many desperate and even disabled, seek relief, they'll quickly discover just how complicated their problem really is, with its mystifying mix of physical symptoms and psychological underpinnings. The reality is that the torment will usually go away on its own--impossible as that may seem when you're writhing on the kitchen floor. But pain is pain, and most people want a quick fix. The result: spinal procedures have been rising steadily in recent years. But many of these surgeries simply don't work. Doctors, worried that far too many patients seem far too willing to go under the knife, are now actively looking for simpler, more effective ways to treat one of the most vexing problems in medicine. "We've come to the point where we have to think out of the box," says Dr. David Eisenberg, head of Harvard Medical School's Osher Institute. "The time is now."

Back pain can originate anywhere in the elaborate spinal architecture. Degenerated discs, which may lead to herniation and compressed nerves, are a common problem. Then there are those wrenching spasms provoked by muscle, tendon and ligament injuries, which can drop grown men to the floor. What's most mysterious about back problems is the disconnect between anatomical defects and pain. Unlike blood pressure and cholesterol, which can be easily measured with arm cuffs and blood tests, lower-back pain has no objective way--the volume of tears? the intensity of a grimace?--to be gauged. In many cases, the precise cause of pain remains unknown. Imaging tests have found that two people with herniated discs can lead radically different lives: one spends his days popping painkillers, the other waltzes through life like Fred Astaire. In one well-known study, researchers sent 98 healthy people through an MRI machine: two thirds had abnormal discs even though none complained of pain. In other research, experts compared a group of patients who reported back pain with a control group who didn't. Close to two thirds of the pain patients had cracks in their discs, so-called high-intensity zones, or HIZs. But so did 24 percent of the noncomplainers. "The real issue," says Dr. Eugene Carragee, the study's lead author and director of Stanford's Orthopaedic Spine Center, "is, why do some people have a mild backache and some have really crippling pain?"

The answer, Carragee and others believe, has as much to do with the mind as it does with the body. In the HIZ study, the best predictor of pain was not how bad the defect looked but the patient's psychological distress. Depression and anxiety have long been linked to pain; a recent Canadian study found that people who suffer from severe depression are four times more likely to develop intense or disabling neck or low-back pain. At the Integrative Care Center of New York's Hospital for Special Surgery, physiatrist Gregory Lutz says he routinely sees men who have two things in common: rip-roaring sciatica and an upcoming wedding date. The problem in their back, possibly a degenerated or herniated disc, probably already existed, says Lutz, but was intensified by premarriage jitters.

Each year, 600,000 spinal-fusion procedures are performed--at about $34,000 a pop. Most of them are used to treat disc problems. When they're young and healthy, discs are plump with water, which keeps them hydrated and buoyant--the perfect consistency to work as shock absorbers for the vertebrae. But over time, the daily stress of walking, sitting, twisting and just plain aging dries them out. As discs deteriorate, their tough outer shell weakens. One swing on the tennis court or even just lifting a briefcase can burst the interior gel through the casing, like jelly squishing out of a doughnut. The result is the famous herniated disc. Some go unnoticed, but when a disc bulges against one of the two long sciatic nerves, which run from the spinal cord down the leg, the pain can be excruciating. Teri Klein, 45, describes it as going through childbirth "for all three of my kids at once."

Fusion surgery was originally designed to treat serious instability or deformity of the spine. Over the past 10 to 15 years, the patient pool has gradually expanded to include more run-of-the-mill disc problems. The increase in all spinal surgery has been prompted in part by technical advances promising better outcomes. Perhaps the most tantalizing new development is the artificial cobalt-chrome disc. Dr. Jeffrey Goldstein, a spine surgeon at NYU-Hospital for Joint Diseases, has inserted dozens of the implants into patients as part of a U.S. clinical trial. He believes the discs, like knee replacements, will give patients more mobility than traditional fusion. And they'll get out of bed a lot sooner, too. The key, he says, is "to be very specific and very careful about patient selection. Not everyone with bad discs should have an operation."

Perhaps too many already do, says Dr. Richard Deyo, a professor of medicine and health services at the University of Washington. In a paper published in The New England Journal of Medicine in February, Deyo and two colleagues issued a major challenge to the field. They charged that there are insufficient data to justify treating disc degeneration with spinal fusion. They also pointed to confounding issues like the variation in surgery rates and complications such as nerve injuries or infection. And then there's the quirky relationship between a surgeon's handicraft and how a patient actually feels: sometimes a first-rate fusion does little for pain, while a less impressive piece of work does wonders. Deyo's view: back pain "is part of living and being a human being."

For more and more people, complementary and alternative therapies are the way to go. Chiropractic treatment, the most popular nonsurgical back therapy, is booming, with 60,000 chiropractors practicing worldwide today, a 50 percent increase since 1990. Some happy clients visit their chiropractors more than their barbers. While experts generally agree that the treatment, which involves spinal manipulation and stretching, is safe for the lower back, there's not a lot of data on how effective it is in the long term. Massage has seen an increasing number of addicted patients, too, and research shows it can help knead out persistent pain; one study even found that patients took fewer medications during treatment. Acupuncture is also popular, though, again, there's a dearth of evidence about its effectiveness. But even conventional doctors say if it makes you feel better, go for it.

If a patient's attitude can help process the pain, can more creative thinking among the experts improve the odds of beating it? Harvard's Eisenberg is spearheading a pilot program to find out. Over 18 weeks, a diverse group of 25 specialists who rarely see each other in clinic corridors--orthopedists, neurologists, chiropractors, massage therapists, acupuncturists and others--met to educate one another on how they diagnose and treat back pain. The goal: to see if there is a more efficient, multidisciplinary way to attack the problem--and to make it cost-effective, too. Next month at Boston's Brigham and Women's Hospital, the first patients will meet with one doctor and one complementary-medicine provider, who will then consult with the rest of the team to devise a treatment plan.

In New York City, a lone crusader thinks he has another answer. Dr. John Sarno, a physician at NYU Medical Center's Rusk Institute of Rehabilitation Medicine, believes that almost all back pain is rooted in bottled-up emotions. In weekly lectures to his patients, Sarno uses a slide show and a pointer to explain how repressed rage--over your parents' divorce, sexual abuse, trouble at work--can stress the body, leading to mild oxygen deprivation, which he says will eventually manifest itself as muscle spasm, nerve dysfunction, numbness and pain. Recovery begins with recognizing the connection between mind and body.

Every new patient is required to attend Sarno's two-hour presentation, and by then most will have read his 183-page book "Healing Back Pain" as well. Alessandro Giangola, 28, says his hourlong office visit with Sarno felt like psychotherapy. The doctor performed some simple tests: running a paper clip up and down Giangola's arm to test sensation, checking his reflexes. "Your health is fine," he told Giangola. Then he asked questions: How was your childhood? What causes the anger? Patients are assigned "homework," which starts with listing every source of repressed anger in their life. Then every day, in a quiet place, they must meditate for 15 minutes on one item on the list. Tapping into the fury helps alleviate the pain. "Pain is created by the brain to make sure the rage doesn't come out," Sarno tells his patients. "It protects you by giving you something physical to pay attention to instead."

Sarno has published no academic research on his theory and can't prove that he's right. But his satisfied patients, who he says number in the thousands, swear by his methods. Skeptics say that Sarno is offering a placebo. Giangola says the man "is good for humanity."

After centuries of agony, humanity could certainly use some relief. But more important than the success of any given treatment is the good news that both back-pain sufferers and the medical establishment are embracing bold new ways to think about that most exquisite and frustrating work of art: the spine.

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