The Great Back Debate

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 infamous 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."

Photographer Nancy Newberry vividly remembers the "kunk, kunk, kunk" she heard seven years ago when she slipped on some stairs at the Bronco Bowl arena in Dallas. After two years of persistent pain, she was floored by a searing jolt as she bent over during a photo shoot. She tried painkillers, hot and cold ultrasound therapy, cortisone injections, electrical muscle stimulation and a year of physical therapy. Nothing much helped. Frustrated, cranky and crazy from pain, Newberry reluctantly gave in to surgery. Doctors removed a cracked disc, then fused her vertebrae together with a bone graft. Five years later, the pain is duller but it lingers, and Newberry still keeps a stash of painkillers in her medicine cabinet. "I'll never be the same as I was," she says.

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 like Newberry's. 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, which could be FDA-approved as soon as next year. Dr. Jeffrey Goldstein, a spine surgeon at NYU-Hospital for Joint Diseases, has inserted dozens of the implants into patients as part of a nationwide 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 who has disc degeneration 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 nationwide (you're almost five times more likely to undergo an operation in Boise, Idaho, than you are in Manhattan, probably because of community standards of treatment and physician preferences) 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 Americans, complementary and alternative therapies are the way to go. Chiropractic treatment, the most popular nonsurgical back therapy, is booming, with 60,000 chiropractors practicing 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. "At this point, we don't really know," says Dr. Dan Cherkin of the Center for Health Studies in Seattle, who is now conducting the first large trial of the practice. Of course, in the grip of pain, patients don't necessarily care about data--they just want relief, and a lot of them get it from the "adjustments" chiropractors make to their backs. 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. Steven Smith, a physical therapist at the Schuldt Performance Center in Deerfield, Ill., uses massage on back-pain sufferers to loosen up tight muscles and increase blood flow. It's not exactly a spa-like experience--Smith uses an electrical vibrator to distract patients from the pain of his fingers pushing into their muscles. "You've got to get in there deep to break those spasms," he says. 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. Dr. Jeffrey Ngeow, an anesthesiologist by training, pushes the tiny needles into patients at New York's Integrative Care Center. He says acupuncture, which seems to stimulate the release of feel-good endorphins, won't provide instant relief, but it will have a cumulative effect. Patients describe a lingering euphoria--a nice state to be in whether you've got a lumbar problem or not.

It was a flood of interest in alternative medicine that prompted the Hospital for Special Surgery to open its complementary-medicine center four years ago. Now about 13,000 patients a year, many with bad backs, see its rehab specialists, massage therapists and chiropractors, as well as taking yoga and tai chi classes and working with personal trainers to help strengthen muscles--any noninvasive approach they can find to relieve the pain. Craig Jordan, 41, is a typical patient. He used to run six miles a day and thought he was man enough to pick up a leather club chair on his own; the gesture herniated two discs. Like so many others in the beleaguered-back population, Jordan tried every wacky thing out there. "Faith healing, hanging from the ceiling, clicking my heels together and wishing I was home--you name it, I've done it." Jordan now gets acupuncture twice a week and shots of anesthesia three times a year to numb the pain. Last week, feeling especially stressed by tax deadlines, he decided to start biofeedback, a technique that trains the mind to believe it can overcome pain. "You never get rid of the pain," says Jordan, though he says his treatments provide some relief. "You learn to live with it."