‘Conquering Back Pain: The Myths around Back Pain Surgery’
Mr Sam Lynch

My name is Sam Lynch I’m a consultant spine surgeon working in the Sports Surgery Clinic in Santry and I have got public appointments at the Mater Hospital in Dublin and the national Orthopaedic Hospital in Cappagh so I’m going to speak to you about innovations in back surgery but the first thing I’m going to do is address some of the myths that surround back surgery.

The reason we’re going to talk about this is because if you don’t understand the right way to treat it and the causes behind it’s very difficult to get to the bottom of it right and I think everybody accepts that it’s a complex issue and it involves more than just surgery or more than just physiotherapy, everybody has to be involved but there’s an awful lot of disinformation out there surrounding back pain both in the causes of it and the treatment of it and I’m going to hope to address some of these for you tonight.

So, the first myth of which there are seven is that if you have a slipped disc you must have surgery, it sounds like I’m trying to talk myself out of a job here now but I’m not. 50% of people with a slip disc regardless of the size of it provided that they don’t have any weakness in their legs or any alterations in their bowel or their bladder, so if they can go to the toilet normally because after the disc prolapse they improve without surgery, and that improvement happens within 12 weeks to six months. Of the 50% that don’t improve provided that they’ve had the proper treatment which would be physiotherapy, movement, non-steroidal anti-inflammatories and in very specific cases injections, if they don’t improve within 3 to six months it’s reasonable to consider surgery. The reason we consider surgery to take the pressure off the nerves the disc is like but I like to describe it as in the clinic is like a cod liver oil tablet it has a hard shell and a soft centre. When the disc bursts the hard shell around it splits and the contents of the disc spill out into the canal. You can see it up here in the diagram on the right, you can see that blue part of the diagram is pressing on the yellow bit which is the nerves, so you can see that that’s what causes your pain, most of the time and 50% of the time your body will resorb that disc it’ll just dissolve it away over time. If that doesn’t happen it’s reasonable to consider surgery for it because you can develop a chronic pain syndrome which is very debilitating. So, the first myth around surgery is that if you have a slip disc you must have surgery that’s not true you may need surgery but there are other things we can do first.

The second myth that we often encounter is that when you have back pain an MRI scan or an x-ray is going to give you a cause for that pain, in the main that’s not true and this is my worst nightmare and any medic’s worst nightmare in the clinic is you’ve got someone with real and debilitating back pain and absolutely normal scans that doesn’t mean that they don’t have pain or that their pain is in their head or it’s not a real entity it’s a very real entity it just means that from a spine surgery point of view there isn’t a surgical target for their pain and oftentimes the patients history what they tell us when their pain comes on what makes it worse what makes it better and how they examine so when we examine people and ask them to move to bend, to examine the power and tone in their legs that will often give us more information than imaging. So just because you have a normal MRI scan and a normal x-ray doesn’t mean that you don’t have a real problem it just means that it’s a more difficult problem to fix.

The third myth and this is one we hear all the time and it’s one that you your mother would have told you back in the day, is if you’re back hurts you should rest until the pain goes away. That’s the worst thing you can do, when you’ve got an acute flare up of back pain you need to take some painkillers to try and get you over that pain and then you need to start moving gradually as quickly as you can, the more movement you can tolerate the better and the quicker you get back moving the more likely you are to recover. This is especially true in an elderly population because the older you are the less likely you are to regain movement once you’ve stopped moving and that’s the same for anything, it’s the same for back pain, it’s the same for hip pain, it’s the same for knee pain, once people stop moving as they get older it’s very difficult for them to start moving again so the take away from this is that back pain is helped by movement after the initial day or so of acute pain.

The fourth one we have is that most back pain is caused by injury or heavy lifting, right that’s also not true. Back pain is so common that we’re starting to consider it as normal, if you don’t have back pain in the in the course of your life you are in the minority not the majority and this lady on the right she’s an Olympic champion weightlifter and I’m quite certain that she doesn’t suffer from debilitating back pain so the fitter you are, the healthier you are, the more active you are the less likely you are to have back pain. If you obviously go into the gym and lift weights with bad technique you’ll injure yourself but it’s not a direct relationship between activity and lifting and back pain.

The fifth myth around back pain is that it’s usually disabling, we often see people in the clinic and they’re coming to you and they’ve been in pain for an awfully long time and pain is an absolute leveller for everybody. If you’re suffering from chronic pain for a long period of time it wears you down right and people get to a point of desperation where they feel that there’s nothing that can be done to help them, whereas the reality is that if you have a more holistic approach to the management of your back pain, treat it like it’s a chronic condition using a kind of a multi-disciplinary team approach so you involve spine surgeons, you involve Sports Medicine Physicians, you involve physiotherapists, you involve psychologists, all of these people combined can help you overcome your back pain. There is no one person that can do it but if you’re given the right tools by multiple people back pain can be conquered but it’s very difficult but it certainly isn’t a life sentence which is often what people feel by the time they get to see me.

The six myth is that everyone with back pain should have an MRI scan or an x-ray and the reality of it is that there’s only very specific reasons to get an MRI scan and that is back pain that causes leg pain or leg numbness or heaviness in the legs or weakness there’s normally no real need for imaging of any kind x-rays or MRI scans unless you have some of those symptoms or unless you’ve tried other treatments like your physical therapy, your physiotherapy, your pain regimes and your lifestyle modifications and you’re still having ongoing pain then it’s reasonable to start thinking about an MRI scan but because they’re so easy to get now and they’re not too expensive anymore we’re very liberal in their use and oftentimes I think they confuse people because they don’t highlight anything that we can target.

The seventh myth and it’s the worst one is that bed rest is the best therapy for back pain it really is the worst thing you can tell someone to do when they start getting back pain is to lie in bed for days at a time because your back needs to be in a curved position it assumes that position when you’re standing upright when you’re lying flat your back gets straight which straightens the muscles even further, it alters your posture into one that generates pain so it’s actually makes your acute pain worse. So people with acute back pain should stand as best they can and start gradually moving right a period of bed rest never helps anybody and it’s associated with increased and prolonged duration of your back pain, an increased risk of blood clots, depression and it just doesn’t help so bed rest is not the best therapy for back pain it’s one of the worst things you could possibly do. Although some people do say that it’s the only thing they could do, so I do understand that in the real world sometimes people have to take the bed for an hour or two but spending days in bed is not what you need to do when you’ve a bad back.

We’ve seen it now the epidemic of back pain it’s more prevalent in the States but there’s a huge issue now with opioid addictions as a consequence of indiscriminate prescribing of opioid medications and the treatment of back pain because and oftentimes not to vilify people but oftentimes that’s just because it was all that was available to people to manage their pain, but we know that it’s more than just Opioid medications, morphine based medications that’s not what people need people need a multidisciplinary team approach that are paying to help them manage every facet of their life because everything about your life impacts on your ability to cope with back pain.

You can see that and these are American numbers is well we don’t have the numbers Ireland right but there’s like MRI scans they’re over ordered by 300% that means that like one in four MRI scans, give us information that we can actually use in the opioid prescriptions I think they’re much less regulated where this data is coming from but opioid medications are dirty medications they’re really good for pain but they’re really bad for everything else, they cause addiction, drowsiness they cause problems with your digestion, they cause constitutional problems, they alter people’s mood so they really should be avoided and they’re a medication of Last Resort that should only be prescribed for short periods of time. Spinal injections these are really powerful when used properly they’re really effective and I do them in very specific instances in my clinic and I know some of my pain colleagues also use them to great effect but you have to be very discerning about their use there has to be a surgical target that you can see on the MRI scan and that is directly linked to the patient symptoms. So it it’s very important that you take a good history that you do a good physical examination, that you look at the x-rays and that everything matches up together before you start injecting because while they’re very low risk there’s still risks associated with them and there’s no point in doing any intervention on someone unless it works. Then spinal fusions again in America because their health services is very financially driven and so fusion procedures pay more over there so they do them an awful lot more and it’s almost a purely private system so their degree of fusions is much higher than it would be in Europe.

So what we’ve established here in the Sports Surgery Clinic in Santry is what we call an MDT a multi-disciplinary team and the reason we do that is that it is a complex problem all be it a very common problem it’s still a complex problem and the source of each individual’s back pain is different, the causes that are driving it are different the modalities that we use to treat it will be different and unless we give people long-term tools to cope with their back pain as well as the therapeutic interventions that will help get rid of it people aren’t going to get better.

So the MDT that we’ve set up here in the Sports Surgery Clinic in Santry consists of spinal surgeons of which I’m one, I’m really the last resort in the treatment of back pain and the skill set that I bring to it are only applicable to a small minority of patients. Most of the patients will be dealt with by the other members of the team these include the pain Physicians who have great expertise in targeted injections, non-opioid pain medications other pain strategies then we’ve got the physiotherapists who are the main stay of the treatment for most people with back pain. They tailor the exercise based rehabilitation programs to the patient needs and the pain generators that the patient has, psychology is very important in the management of back pain because especially if it’s been going on for a long time it can come to dominate your thoughts and people often come to us in a desperate state because their pain has been ongoing for an awfully long time and they feel disempowered by the by it just controls their life they don’t have any control over it. So CBT or cognitive behavioural therapy is a very powerful tool for people to learn to manage their pain it gives people back power and control over their own lives and it’s one of the fundamental tenants of what we’re trying to achieve and then the sports medicine physicians are very good for devising return to lifestyle programs for people they get people back to where they want to be back to where they started from be that playing sport, going for a walk, just living a normal pain-free life. So you can kind of see that the management of back pain is really complex it takes more than just a spine surgeon to do it and really a spine surgeon while they have an important role at the thin end of the wedge they’re not central to it they’re part of a team.

So the MDT will begin with a comprehensive physical and psychological evaluation of each patient, we look at the physical shape that they’re in how their exercise tolerance, their cardiovascular fitness but you’ll also look at the psychological stresses that they’re facing in their lives, we know that people who are going through any kind of psychological stress be it a bereavement, marital problems, general life stresses, job changes, moving house anything that diminishes people’s capacity to cope with any kind of pain and it also increases the likelihood that they will develop back pain so all of this is important and it needs to be factored into their treatment algorithms. Then based on this you get a treatment plan that involves either the spine surgeons if there’s a mechanical cause to their back pain are the physiotherapists, the psychologists, the nutritionists and the sports physicians, pain management is really important but we really need to not use opioid medications if we can because while they’re very good for pain as we said earlier they’re very bad for everything else. Over time then we try to give people back the power to get rid of their back pain but it takes time it takes buy in from everybody involved but the patients the GPS who are referring them to us and the members of the multidisciplinary team and once we get people back up and moving that’s what we consider a success.

So it sounds like I’ve spent the last 20 minutes talking myself out of a job right but like most of the spine surgeons across the city are very busy and for good reason because even though most cases of back pain don’t require surgery, surgery is a very powerful tool and it’s essential in some instances and they’re very specific instances so the first one is if there’s nerve compression so the nerves come off the spinal cord at the base of the spine and go down into your arms, go down into your legs, supply the power, the sensation and the movement to those limbs. If they’re being compressed by anything be that a slipped disc an infection a tumour any kind of injury then spine surgery is essential to take that compressing element off the nerve before it completely obliterates it permanently. The second indication for spine surgery is if when there’s any structural spinal instability, and this this sounds very fancy right but there’s a couple of instances where this is relevant. The first is scoliosis this is a progressive condition that gets worse when people are growing quickly which is why we see it in young adolescents during their growth spurt, we measure the absolute size of the curves and curves over 50° when we measure it on the X-ray they tend to progress into adulthood, curves under 40° they tend to stop when you stop growing and curves between 40 and 50 can go either way. So, we know that over time large curves in scoliosis get worse and it’s better to fuse them to fix them. The third indication for surgery would be serious conditions like fractures, infections or tumours we deal with a lot of these in the Mater spinal injuries unit which is one of my public appointments but and it’s not really relevant in an elective setting because these conditions they tend to require surgery immediately so we’ll often see these and we’ll operate them on the same day or the next day depending on when they’re referred to us but so spine surgery is important and it has a huge role but people have to be discerning about when they use it.

Just going to briefly touch on each of the indications we’ve discussed right so surgery for severe nerve compression comes with severe leg pain what most people would know as sciatica, which isn’t improving so if you’ve got a herniated disc it’s pressing on your nerve, it’s causing you severe unremitting leg pain that hasn’t gotten better in the first 12 to 24 weeks despite your best efforts at physiotherapy and pain medications then it’s probably reasonable to see a spine surgeon to get that disc removed before you develop a chronic pain syndromes. The surgeries that we would do would be a micro discectomy which is where we make a small window into the spinal canal to remove that bit of herniated disc that bit of disc protrusion that’s pressing on the nerves, in very big discs or discs that are in the centre of the spinal cord we’ll do a slightly bigger procedure called a laminectomy where we take the bony ach off the back of the spine to relieve the pressure. We tend to do that for what people will know as Cauda Equina syndrome and that’s when the disc is so big that it compresses the nerves that control your bowel and your bladder function, that’s a surgical emergency and we would do that overnight if I was referred a patient during the day I would do that operation the minute that patient arrived in my hospital, it’s very rare and it’s on the same spectrum as a herniated disc but it’s at the extreme end of it but in that in those scenarios you do the larger laminectomy.

Then the surgery for structural instability and trauma so that would be severe scoliosis as we’ve discussed Spondylolisthesis is a big word for one vertebrae slipping on top of the other right so there’s just a little bit of a step there and that can sometimes cause pain especially when people are standing so that can sometimes need surgery and again fractures for trauma which is you know most often times you fracture your spine if it’s a road traffic accident or in elderly people with osteoporosis or soft bones they can get they commonly get spinal fractures from minor falls. The common fusion surgeries that we would do would be spinal fusions which removes all movement between the bones in the back using rods and screws or artificial disc replacements. The artificial disc replacements are again very powerful but they’re only relevant in a very specific population you wouldn’t do it in everybody you certainly wouldn’t do it in people who have got arthritis in the small joints of their back or arthritis in the small joints of their neck you tend to do it for younger people who have relatively healthy backs in every other way except for at that specific disc.

We’ve lots of very fancy High-tech tools to make this safer we have robotic surgery which combines your CT scan with your on-table x-rays during theatre to allow us to navigate the screws and the rods into exactly where we want them. So this is really powerful in that it minimizes the risk of any injuries to the nerves or to the spinal cord and allows us to do much more complex surgery much quicker and with much less risk to the spinal cord. Then the other one we the other options we have now are endoscopic surgery this would be for the micro discectomy the shaving the disc off in those in those herniated discs and that allows us to do a nearly Keyhole and this is a new technology that’s come on stream in the last 10 years that has really revolutionized how we can treat these common spinal conditions.

So the conclusions that the talk are that most back pain is not serious and it will go away, the key to getting better is to move as much as you can, while surgery is indicated it is the last resort in most cases, if you are having surgery it’s much safer now than it was in the past because we have an awful lot more technology at our disposal to make sure that the implants that we put in go exactly where we want them but really the more you move the better you’ll be when it comes to back pain.

So the GP will just write into to the spine service here at the clinic and then we’ll just triage out the referrals appropriately so you know we’ve got a lot of specialties available to us we’ve got surgery, we got the pain specialist Physiotherapy, the Sports Medicine so between us we kind of appropriately delegate the patients depending on the triage letter of the GP sends in and it’s very quick to be seen then after that.

It’s not long is the answer a lot of it will depend on the complexity of your surgery so if it’s a simple, let’s say the simplest thing I would do from an operative point of view would be a lumber decompression and the most complex would be a fusion procedure with disc replacements etc, so a lot of it will depend on the complexity of what you have done but if you have a simple procedure you’re talking within you know four to six weeks from consultation once we’ve gone through all the relevant planning and stuff it’s not an honours waiting list.

They’re powerful medications in people who are fit and healthy, if you’ve got any problems with your kidneys, if you’ve got any problems with your stomach, any ulcers they do have issues and taken safely like with within the recommended doses they’re fine. If you’re taking them for longer than a week I would always put somebody on a stomach protector just for that I would try to avoid them for longer than two weeks mainly because you get increased risk of ulcers and they can cause kidney injuries, they are a useful tool, they’re not addictive but they have side effects so you just have to manage them appropriately.

I would only use EMG if I couldn’t figure out where the radicular pain was coming from so radiculopathy in the main is relatively straightforward to diagnose, if it’s coming from your back. So the of EMG is to find out if let’s say you have a normal MRI scan but you have symptoms of nerve compression in your legs, normally that’s coming from your lower back but if it’s not in your lower back the nerve can be compressed elsewhere after it’s left the spine so that’s where I would get the EMG’s but I wouldn’t routinely use them unless there was some ambiguity about the source of the problem.

It does go away actually and it I didn’t put it in this presentation like it can be startling the change you can have an MRI scan taken let’s say a year ago and then a repeated interval at a year and it’s in some people it can be almost completely normal so the body does resorb them right like I mentioned it in the talk discs they kind of go one of three ways in the first six months so the pain either goes away, it gets better, or it gets worse. If it goes away you don’t need to do anything if it stays the same or gets worse after you’ve done everything right and you have some kind of a compressive component to it if there’s a disc pressing on a nerve or if there’s some other thing pressing on the nerve it’s probably reasonable to consider surgery at that stage. In the main your symptoms kind of in the first 24 to 36 weeks will dictate how it’s going to be long term.

Yeah so that’s like a type of conditions it’s very complex because and while like there’s loads understood about the connective tissue conditions, there’s a lot of evolving knowledge there so like and oftentimes the pain generators are hard to identify and as well as that person rightly points out a lot of pain medic medications don’t work so it’s it definitely that’s definitely one that requires an awful lot of input from more than one specialty. I don’t have an awful lot of experience like I have in terms of I’m a scoliosis surgeon as well so I have a lot of experience with people with connective tissue problems because they develop scoliosis as well but in terms of management of pain no it’s very complex and you need input from some fairly specialist people for it.

Yeah general advice is do exactly what you’re doing right which is all the right things and it’s very difficult to piece together exactly what’s going on there without seeing that person and their scan you know because if you have leg pain without a significant component of back pain that sounds very much like those nerves are being compressed which is why it’s worse when you’re standing up for example so there are surgical solutions to it injections in that instance do work as a general rule of thumb if you have narrowing at the base of your spine that’s due to just you know age related wearing tear it’s unlikely to get better over time it’s likely to get worse so it’s probably worth seeing somebody about that.

That’s a really good question and it’s one we have to deal with all the time so there’s two components to transferal nerve root blocks, there’s two ingredients in the injection there’s the local anaesthetic which does it’s just pain relief in the first 24 to 48 hours and then there’s a steroid. What the steroid does is it takes down any inflammation around the nerves because when I do a discectomy I’ve just done one and in the last hour or so you when you take the pressure off that nerve that’s been caused by the disc that’s pressing on it you see that the nerve is very hot and red and inflamed it looks swollen and irritated so the steroid takes down that irritation and that gives it a lasting benefit. So injections they’re not about masking the pain they have a therapeutic benefit as well and again it’s nearly like a rule of thirds with injections about 20% of people will get no response which means that you have to look for another source of their pain, if they get no response at all even if they don’t even get an hour’s response from the injection either the injection wasn’t put in the right place or it’s not the cause of their pain. The second group get a response but it’s transient which means that you have to revisit possibly doing a surgery on them and then the third group get a lasting response which means that you know the either avoid surgery or you can repeat the injection at an interval so it’s more than just masking pain it does have an anti-inflammatory effect that can be quite sustained.

Again like back pain in the absence of any leg pain is best treated non-operatively right if you have back pain and leg pain that are equal in measure there are subtleties to it this is these are all generalities you know but if you’ve got back pain and leg pain you can consider surgical intervention in this in the form of a fusion right if you’ve just got leg pain that’s bigger than your back pain tends to just need a decompression.

It’s a surgical emergency so if it’s left untreated like we I work in the Mater spinal injuries unit in Mater University Hospital as well and so we would treat Cauda Equina within hours of getting the referral to avoid long term consequences with their bowel and bladder function is the main problem right you can also have weakness in your legs but the long term consequences of untreated Cauda Equina are sexual dysfunction bowl and bladder problems so it’s a pretty devastating condition if it’s left untreated.

So it depends who you ask now and there’s a couple of ways to answer that question I’ll try be diplomatic about it but yeah so it with the common ground between orthopods and neurosurgeons is the spine right neurosurgeons do brain surgery and they go from the brain and they can go down into the spine, orthopaedic surgeons do surgery on everything else so every other muscular skeletal part of the body and we do spine. What we’re finding though is that for both neurosurgeons and orthopaedic surgeons spine is nearly a separate specialty now so I have an awful lot more in common with an orthopaedic with a neurosurgeon who does spine than I have with an orthopaedic surgeon who does foot and ankle like we very similar practices. So in real terms there’s probably no real difference depending on the level of training. We’re essentially spine surgeons there’s differences within those like a brain surgeon is different to a spine surgeon in the Neurosurgical side and like let’s say a hip and knee surgeon is different to a spine surgeon on the Orthopaedics.

Oh yeah definitely depends who fixed it now right but I’m sure they’ve done a good job yeah, the whole point the T6 to T10 is most of the mobility in your spine comes from your lumber spine so like yes is the short answer to that you should do provided it’s you’ve healed up and everything is good you should be fine.