I'm Afraid This Is Serious

I'm Afraid This Is Serious

From Chicken Soup for the Soul: Say Goodbye to Back Pain!

I’m Afraid This Is Serious

The word pain comes from the French peine and Latin poena, which mean “a penalty or punishment.” The etymology of “pain” unfortunately reflects the historical belief that suffering was divinely imposed as penance for sinful acts. Many people still adhere to this idea, either willingly or not, and when they become ill ask themselves, “What have I done to deserve this?”

Saint Augustine claimed that the greatest evil is physical pain. Thankfully, over time we have developed many medications and other therapies that help to alleviate this evil. However, it’s no secret that despite significant advances in pain medicine, patients continue to suffer much more than they should. This is why relieving pain, and thus unnecessary suffering, has recently become such an important component of good healthcare that rating pain is now formally called the fifth vital sign (after temperature, blood pressure and heart and respiratory rates).

As a physiatrist, I spend a lot of time evaluating pain symptoms. Are they serious? What should I do to investigate the symptoms? How should I treat them?

Every time someone comes into my office with back pain, the first thing I do is listen to them explain what happened. Sometimes, they’ll tell me a very dramatic story, such as April shared, when she was thrown from her horse. Other times, the story is simply bending or twisting the wrong way. Still other times, my patients really don’t know what is causing their pain. In the chart, I will write down, “No inciting event.”

The next thing I want to know is more information about the pain itself. Since, I can’t see pain on physical examination, I have to rely on the patient to explain what he or she is experiencing. Pain is real, but only the patient is able to describe how it feels. In order to better understand patients’ pain experience, doctors are taught to ask a series of specific questions. We learn these in medical school, and they should be part of every initial consultation by a doctor who is treating someone for back pain. The information doctors need to know to make the right diagnosis includes:

• Location — Where is the pain and does it radiate anywhere?

• Quality — What does the pain feel like? Is it burning, sharp, etc.?

• Intensity — On a scale of 0-10 with 10 being intolerable, how bad is it at its best and worst?

• Frequency — When does it occur?

• Duration — How long does it last?

• Aggravating Components — What makes it worse?

• Alleviating Components — What makes it better?

Is My Back Pain an Emergency?

When I’m listening to the patient respond to each question, I’m constantly thinking about whether there are any “red flags.” Doctors use this phrase to mean “reasons to be really worried and do something right away.” There are three main reasons why doctors get really worried. The first reason is that we are concerned that there might be a tumor (either cancer or another type of tumor that is benign). The second one is that we suspect that there may be a bone fracture. The third reason is that we are worried about serious nerve injury (either to the spinal cord, cauda equina or nerve roots). Doctors think of “red flags” as either medical emergencies or as potentially serious problems that need a prompt investigation followed by appropriate treatment interventions — depending on the diagnosis.

The red flag symptoms that doctors worry the most about include:

• Recent trauma

• Numbness in your groin or anal area

• Weakness in your legs

• Pain at night, especially if you can’t sleep well due to pain

• Pain at rest, especially if it’s severe

• Fever

• Urinary or bowel incontinence

• History of cancer or immunocompromised state (e.g., organ transplant, HIV, etc.)

When to Call the Doctor

Most neck pain doesn’t stem from anything medically serious, making it safe to try self-care strategies before seeking medical help. However, if your neck pain is so severe you can’t sit still, or if it is accompanied by any of the following symptoms, contact a medical professional right away.

• Fever, headache, and neck stiffness. This triad of symptoms might indicate bacterial meningitis, an infection of the spinal cord and brain covering that requires prompt treatment with antibiotics.

• Pain traveling down one arm, especially if the arm or hand is weak, numb, or tingling. Your symptoms might indicate that a herniated cervical disk is pressing on a nerve.

• Loss of bowel or bladder control. This might indicate pressure on the spinal cord or spinal nerve roots, needing immediate attention.

• Extreme instability. If you can suddenly flex or extend your neck much farther than usual, it might indicate a fracture or torn ligaments. This usually occurs only after significant impact or injury, and is more likely to be detected by your doctor or on an X-ray than by your own perception.

• Persistent swollen glands in the neck. Infection or tumor can result in swollen glands and neck pain.

• Chest pain or pressure. A heart attack or inflamed heart muscle can cause neck pain along with more classic heart symptoms.

 

Reprinted with permission from the Harvard Health Publications Special Health Report: Neck and Shoulder Pain (2010)

 

As I mentioned, the vast majority of back pain can be diagnosed by history and physical examination. Medical tests, such as imaging studies, should be ordered only when there is a concern about a serious problem such as a fracture, the diagnosis is not clear, there is a progression of symptoms (for example, someone is losing strength in one leg), or the study is needed in order to direct treatment (for example, a doctor should always order imaging studies before recommending surgery).

Diagnosing Back Pain with Medical Tests

There are several types of imaging studies that doctors may order to evaluate back pain. These include:

• X-rays — These primarily show the bones in your back. They can give clues about other structures, too, but they don’t show the “soft tissues” very well. X-rays are very helpful when diagnosing fractures, changes to bones caused by tumors, infection and certain forms of arthritis. X-rays do involve radiation, but the amount from one set is quite small.

• Computed Tomography (CT) scans — CT scans are really sophisticated X-rays that take multiple pictures, each from a slightly different angle. They provide more information about the bones and can show subtle fractures, arthritis and narrowing of the spinal canal (called spinal stenosis). CT scans do not show the soft tissues, such as muscles, ligaments and nerves, very well. Similar to standard X-rays, CT scans do involve some radiation. So, it’s best to order CT scans only when it’s really necessary to see the bony structures in more detail than a plain X-ray will show.

• Magnetic Resonance Imaging (MRI) — MRIs use electromagnetic waves to create images of your tissues. Not everyone can have an MRI. For example, if you have metal in your body, the magnet from the MRI may damage the tissues around the metal. MRIs show soft tissue structures the best, such as a bulging disk that may be pressing on a nerve. Though this is not always true, you can think of a CT scan as showing the bones better and an MRI as demonstrating the soft tissues better. So, a doctor will usually order one or the other (not usually both) depending on which structures he or she wants to look at most closely.

• Myelography — This form of diagnostic imaging involves injecting fluid (a radiographic dye) into the area around the spinal cord and cauda equina and then looking at where it goes with a special X-ray machine called a fluoroscope. Myelography provides information about what the spinal cord, spinal canal, cauda equina and other structures look like and whether there is pressure on them for some reason. This imaging study is less commonly used today than it was in the past when CTs and MRIs weren’t readily available.

• Bone scan — Bone scans are performed by injecting a short-lived radioactive substance into the bloodstream. The bones absorb this substance at different rates — depending on the activity of the cells. A tumor, infection or healing fracture will appear as a “hot spot.”

• Electromyography (EMG) and Nerve Conduction Study (NCS) — Sometimes both of these tests are referred to as an EMG, but usually an EMG is done together with NCS. The EMG part of the test involves putting thin needles into the muscles and testing them. There are no electrical shocks given during an EMG, usually. The NCS part of the test usually involves surface electrodes that don’t pierce the skin. Small electrical shocks are used to see how well the nerves are working. This is an uncomfortable test, so it is usually done when there is a question about the diagnosis — either the cause of the problem or the severity. However, unlike some of the imaging studies, EMGs and NCSs are physiologic tests (so, they don’t take pictures, but rather tell the physician what is happening to the muscles and nerves and how well they are working)

In Caroline’s case, she likely had an MRI because her doctor was concerned about a serious problem and was considering surgery. This is precisely the kind of situation in which an MRI is recommended. However, just because a doctor orders an imaging test doesn’t mean that there will be a serious problem uncovered or that surgery will be necessary. In fact, a lot of times imaging studies are ordered to “rule out” a serious problem and the results don’t show anything too concerning.

Each of these structures may play a role in serious and not so serious back pain problems and sometimes more than one is causing pain. However, as the stories in the next chapter demonstrate (and you may already know this from personal experience), all back pain can be debilitating and hard to live with.

Pain Talks to You

What would it be like to live without pain? For many, this would be a huge relief. However, the reality of a pain-free life is very different for those with a condition called “congenital insensitivity to pain.”

Take the case of Edward Gibson. Gibson was known as the Human Pincushion. In his vaudeville act, he would allow audience members to stick pins in him anywhere except his groin and abdomen. During one show, Gibson decided to reenact the Crucifixion, and a woman in the audience fainted when a man with a sledgehammer drove the first spike into Gibson’s left hand. At that point, he wisely decided to cancel the show.

Edward Gibson likely had a congenital insensitivity to pain. This condition is part of a spectrum of hereditary neuropathies. People may experience altered pain and/or temperature sensations. They may have problems with regulating their blood pressure or excessive sweating (these functions are controlled by a part of the body called the autonomic nervous system, which may be affected by some neuropathies).

A major problem in people with congenital insensitivity to pain is their inability to protect their bodies. For example, a young boy in the Netherlands who had this condition suffered a series of minor injuries that ultimately led to the collapse and dislocation of both of his hips.

Congenital insensitivity to pain has led researchers to believe that there is tremendous survival value in experiencing pain. What happens every time we sit too long in the same position or we step into a shower that is too hot? We move. We protect our bodies.

Our pain tells us things about our bodies that we need to pay attention to. I call this listening to the voice of your body. Your pain is talking to you. What is it telling you? Whatever your pain is saying (whether it’s whispering or shouting), share this with your doctor, because he or she can’t hear it — only you can.

 

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