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Back Pain Nation
How We Got into This Mess
Keeping to my plan, in the spring of 2008, I made an appointment to visit my primary care doctor,1 who suggested yet another round of physical therapy. He offered to write me a prescription for painkillers, to help me get through what he described as âthis rough patch.â Iâd already had three fruitless assignations with the local physical therapy clinic, I reminded him, and painkillers were out of the question, because even a single Vicodin addled my brain. Sighing, as if he had been through this routine too many times before, my doctor scribbled out an order for magnetic resonance imaging (an MRI) and the address of a private radiology clinic in the city rather than that of the local hospitalâs department, a few blocks away.
Several days after I had the scan, the Physician Assistant outlined the contents of radiologistâs report over the phone, mentioning two herniated discs and a condition called âdegenerative disc disease.â In a flash, my brain translated that diagnosis into âlife in a wheelchair.â I should come in immediately, she said, so that we could plan my next steps. In the interim, I should be careful of how I moved and what I lifted. That evening, I babied my ostensibly fragile spine through dinner and dishes. Then, I sat down next to my husband on the sofa and told him the news.
A week later, my primary care doctor read the same radiology report to me in person. The intervertebral discs in my spine, he said, had lost their resiliency. He did not explain that there was often no correlation between flat or black discs, as seen on an MRI, and pain, or that âdegenerative disc diseaseâ was a very controversial diagnosis.
It took a couple of weeks to get an appointment with an orthopedic surgeon, and no wonder: The reception area was jammed. The waiting crowd meant that the surgeon was tops, I assumed.
After an hourâs delay, however, I learned that I wasnât going to see the surgeon. Instead, the Physician Assistant would evaluate me. Although my more detailed spinal MRI was less than a month old, Iâd need a fresh set of X-rays, done right in the office, as soon as she finished asking me some questions. The X-ray technician aimed the camera at my neck. The pain, I reminded him, was in my hip and my leg and my low back. âItâs written right here that we need the cervical,â he said, and fired away. By the time I was dressed again, the Physician Assistant realized that sheâd checked the wrong box. I stripped for yet another unnecessary dose of radiation.2
On my next visit, I was sure I would see the surgeon. But the physiatrist, who scrutinized me as he darted around the exam room on a rolling stool, explained that the surgeon was booked three months out. In any event, slots in his schedule were reserved for patients who had already failed conservative treatment. (Physiatrists are often confused with podiatrists or psychiatrists, but they are MDs who specialize in physical medicine and rehabilitation. Those who work independently are worth their weight in gold,3 because theyâre expert anatomical sleuths and skilled in exercise physiology. Those who work for spine surgeons typically make a living performing spinal injections and other interventional pain management procedures, bolstering the surgeonsâ bottom line.)
After talking to me for less than five minutes, this particular physiatrist whipped out a prescription pad emblazoned with OxyContinâs boxy logo. Then he scribbled down a list of options for conservative care. He could perform a series of epidural steroid injections, or order more physical therapy. He could destroy the spidery nerves that grow around the facet joints of the spine. He could send me off to the affiliated pain management practice, where I could get a prescription for opioids.
When I asked him what he would do, and what it would cost, he invoked the phrase âshared decision-making.â4 Ideally, that term describes a very informed choice, made with the help of a physician who explains the risks and benefits of each option. Instead, this doctor said I should research my choices on the Web, and get back to him. If I wanted to talk about dollars, I should call my health insurance provider. He had a lot of weapons in his arsenal, he emphasized, and he was willing to try them all.
At that news, I grabbed my stuff and fled the exam room, with no plan to return. After a ten-minute wait, the receptionist handed me the films for two cervical and two lumbar X-rays,5 and a bill that included charges for both. She couldnât find my MRI, she said, but I was welcome to call in a week to see if the CD had turned up. To my dismay, I realized that a month had passed, with no discernible progress.
As I was leaving, I met an acquaintance who was parking the car after dropping off her barely mobile husband. I told her what Iâd just turned down. After many of the same interventions, she said, her mate had opted for a two-level lumbar spinal fusion. At the six-month follow-up, the surgeon noted that the vertebral bones had grown together just as heâd anticipated. Perfect union or not, the pain had not abated, the ailing manâs wife said. âHeâs still home on the couch, still totally miserable, and so stoned on painkillers he canât even take out the trash.â They were considering another operation.
Searching for direction, that night I called an old friend, an internal medicine doc. I described my chronically aching hip, leg, and low back and told her I was contemplating spine surgery. She asked if I was familiar with the term âiatrogenic.â I wasnât, so she defined it for me: It meant physician-induced damage, whether intentional or accidental. In the surgical treatment of low back pain conditions, she said, iatrogenic outcomes were far too common. There was evidence that recent-onset leg pain from a disc herniation6 could be alleviated with a simple nerve decompression procedure. But lumbar spinal fusion for chronic low back pain was an iffy proposition.
When I told her what was on my imagingâthe herniated discs, the diagnosis of âdegenerative disease,â she acknowledged that ordering that first MRI scan was the medical equivalent âof launching a Scud missile; it was hard to control and capable of causing enormous destruction.â Often, surgeons had investments in radiology clinics, so it was no surprise that the radiology report came back full of ominous-sounding things, panicking the patient, who insisted on his inviolable right to see the same local spine surgeon who had operated on his friends. Such âcommunity spine surgeonsâ tended to be cavalier, she said, operating on everyone who came through the door. Surgeons with academic affiliations could also be under pressure from their university hospitals to keep the OR (operating room) schedule full. In short, it was pandemonium out there.
Six months laterâand this was the worst partâthe patient for whom sheâd agreed to order the scan was back in her office, too often dependent on painkillers, overweight, and with the beginnings of type 2 diabetes and hypertension. âAnd from that moment,â she said glumly, âtaking care of him becomes my responsibility for the rest of his life.â
As I planned my next move, I tuned in to what I would come to call the âBack Pain Channelâ: populated by those fellow sufferers I encountered daily. Much of the time, I carried a plastic tractor seatâshaped device called a BackJoy, a $36 lifesaver that allowed me to abide even the most unforgiving perches in restaurants and theaters and on airplanes. When I bought one in DayGlo orange, it attracted a lot of attention. Before one flight, as I handed my license and boarding pass to the TSA (Transportation Security Administration) agent, he grilled me about this object and then held up a long line of passengers so that he might rest his back a moment.
The Back Pain Channel never stopped broadcasting news. Many victims were young. Ethan, a literary agent in his early twenties, gave up a bookstore job for a much more promising one that chained him to his desk chair. Heâd gone through two jumbo-size bottles of Advil in a few months. A friend requested that her daughterâs buff thirty-year-old fiancĂ© sit next to me at dinner, so he could fill me in on the details of his condition.
In midlife, people had just as many problems. Richard, an ad agency creative director, had taught his team to bring pillows to staff meetings, so that they could join him as he stretched out flat on the floor. Melanie, a writer, had bought and sold three used cars, but still had not found one she could bear to sit in for more than an hour. Roxie, an administrative assistant, had concluded that she and her partner âcould stay home and eat ice cream, or have sex and go to the hospital.â Jeannette, a middle school principal, admitted that she could not carry her own briefcase from the parking lot to her office. Simon reported that his back spasms had nearly caused him to skip his eldest sonâs bar mitzvah, while Pam said that on her long-awaited trip to the Vatican, sheâd had to sit and wait in St. Peterâs Basilica, while everyone else took the entire tour of the holy city. People in their seventies, eighties, and nineties cornered me with similar frequency, desperate to know what to do about the spinal stenosis that made it difficult to walk a block. âYou start to design your life to fit your pain,â said Barbara, who was extremely active until chronic back and leg pain made for agonizing days and nights. âItâs a hellish way to live, and you canât put it out of your mind. It always wins.â
Few people reported pain of recent onset, which is properly referred to as âacuteâ pain. For most, the problem had persisted for decades. That puzzled me, because early in my research Iâd come upon what is known as âthe 90/10 hypothesis,â7 which held that 90 percent of the 31.4 million people each year who see U.S. physicians about back pain recover on their own within two to three months, while only 10 percent develop chronic conditions.
Epidemiologist Peter Croft, who directed Keele Universityâs Primary Care Musculoskeletal Research Centre8 in the United Kingdom, made it clear that he did not trust the 90/10 hypothesis. In Croftâs estimation, only a quarter of back pain patients recovered within a year. It was true that 90 percent of back pain patients did not return to their primary care doctors within three months of a back pain episode, he noted in the British Medical Journal, but this did not mean that they had resolved their problems. Instead, theyâd abandoned primary care as a potentially helpful resource, and moved on to other types of practitioners and interventions.
University of North Carolina internist and epidemiologist Timothy S. Carey continued to dismantle the 90/10 hypothesis. In a paper...
