Your Office Visit
What to expect from a Medical Spine Specialist
Getting to the root of your spine problem, in my opinion, involves no short cuts. You should expect to fill out a pain diagram, a complete spine and medical history, get into a gown, (yes, the physician should LOOK at your back!) and have a comprehensive physical examination. Let’s start with a generic question: Where does it hurt? Some answers may surprise you. A patient may say that their tailbone hurts yet are actually referring to their lower back when asked to point to the area that hurts. Where is your tailbone? Where are your hips? How far up and how far down does the spine go? While these may seem like obvious questions, patients, especially pediatric patients, may give a variety of interesting answers since they may not know anatomy. When a patient tells a doctor, they hurt their tailbone (or another specific part of their body), it is ALWAYS helpful to make sure the physician and patient are talking about the same thing. It is important that the patient point to the place on their body where they feel pain or have been injured. Pain drawings are especially helpful as well. They illustrate what the patient feels and where on the body he feels it. There may be numerous imaging studies that may not be helpful or even indicated if the correct body part is not identified. Excess radiation can be harmful! Besides unnecessary x-rays, focusing on the wrong body part can delay treatment, send you to the wrong specialist and cost the patient time and money. Insurance costs will also be adversely affected. Patients – point to where you hurt! Your health could depend on it!
Then and only then, should your imaging be reviewed by your spine specialist. After that, the radiologist’s reports should be read. If any of these steps are skipped, or if any short cuts are taken, you are likely to be seeing a spine specialist who will be influenced before they see you. In general, we do not treat imaging, we treat patients. The history and exam will tell the treating physician how each patient is affected by their spine problem.
During the history we should focus on which body positions (i.e. sitting, standing, etc.) cause your symptoms to worsen or improve. This is helpful because you may have multiple imaging findings (i.e., disc herniations, stenosis, disc degeneration, and normal wear and tear). The only way to know what is symptomatic is to know which body positions cause your symptoms to worsen or improve.
Your Physical Exam
The physical exam should reassure the patient that there are no neurologic deficits, such as weakness, loss of reflex or sensation. Fortunately, only about 3-5% of patients with low back pain and sciatica will present with neurologic deficits. Another important part of the exam is to determine if the patient has a directional preference to movement. What this simply means is, if you present with low back and leg pain, can we find a direction of motion that reduces your leg symptoms toward your back or so called “Centralizes” the pain. Usually the patient will feel worse sitting and bending forward at the waist while standing and better when they bend backward. This is a typical presentation when a disc herniation is present, one of the most common causes of low back pain and sciatica. The most effective medical treatments include exercises that centralize your leg pain toward your back. Bridges and planks that build strength and endurance while not placing a high load on the injured tissues. Mobilizations and manipulations have been shown to be most effective in the first month from onset of symptoms and when symptoms are not below the knee level. Other commonly used treatments, but that carry a low success rate, are traction, acupuncture and massage.
If imaging is not done when you see your spine specialist then there are very specific indications when this should be ordered. If there is any weakness, in particular, progressive weakness, loss of bowel and/or bladder function or any “red flags” or a reasonable period of time for medical treatments to have been tried, then imaging is indicated. These so called “red flags” include a history of cancer, unexplained weight loss as well as urinary retention, weakness ore loss of bowel and/or bladder function.
Once imaging has been ordered, it should confirm what our history and physical exam has already told us – the most likely diagnosis. This information will help to guide the patient’s best options for treatment. Failure to respond to the most effective medical treatments such as exercise, mobilizations and manipulations then imaging and more invasive treatments may be indicated. Epidural steroid injections performed under fluoroscopic (x-ray) guidance with contrast (x-ray dye) enhancement should be considered. Blinded injections without these benefits carry a much lower success rate and should not be done any longer now that this simple and safe technology is readily available. A trial of oral anti-inflammatories, oral steroids as well as pain medications and muscle relaxants have a limited role and often help temporarily when exercises are not enough.
The indications for surgery are very clear. If the patient presents with progressive weakness, loss of bowel and/or bladder function or failure to respond to medical treatments such that your lifestyle and work status is unacceptable to you then surgery should be considered. Surgery, when indicated, is only one step in the rehabilitation process. Studies now confirm that patients who receive physical therapy after surgery will do better in the long run than those that do not. Interestingly less than 10% of spine problems require surgery. Surgery for a disc herniation carries a high success rate and with microdiskectomies available, much of the normal anatomy of the spine is preserved. When fusions are considered or artificial disc replacements are offered, the indications and results are much less predictive with a higher complication rate as well.
A step-wise approach is always prudent. It is generally thought that medical treatments may take a little longer to improve your disc herniation but will still restore you to function within a reasonable period of time.