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Patient Discussion Handout 2:  Seeking a reason for slow recovery ... 
  Special tests may be needed.  If your back problem is slow to recover, your health care provider may consider special studies (tests) to find the reason.  They may include blood tests; or an imaging study may be needed to view your spine.  Nerve tests may help identify certain leg problems.  The chances are good that your problem will not be serious.  In only one person out of 200 do low back problems have a serious cause. 
  Why wait to do special studies?  You may have read or heard of tests like MRI, CAT scan, or myelogram for patients with neurological leg problems.  These are special imaging equipment studies.  They provide different views of body structures like your spine.  You may wonder why your health care provider did not order these tests in the first place.  There is a good reason.  Imaging studies can be confusing.  By themselves, they cannot tell the difference between possible causes of a back problem and common changes in the spine because of aging. 
  As we grow older, the spine changes.  Almost half the population has aging changes in the spine as early as age 35.  Yet most people who have such changes will not have a back problem lasting longer than 1 month. Remember that nine out of 10 people who have low back problems recover within 1 month.  For these persons, imaging studies are unnecessary and confusion can be avoided.  The tests could show a condition that is really not a problem and has no connection to back symptoms. 
  Imaging studies are seldom used alone.  Surgery is never based on imaging studies alone.  The studies could find something that is not really the cause of your problem.  Before deciding whether imaging studies are needed, your health care provider should review your physical examination carefully.  He or she may also do other kinds of tests to find evidence of a problem.  Ask your health care provider to explain what tests are needed for you. 
  Table 1 lists a number of terms that are commonly used to describe (diagnose) the cause of low back symptoms.  However, scientific studies have not been able to show a connection between these diagnoses and back symptoms.  In addition, there is no evidence that these conditions benefit from surgery or other specialized forms of treatment. 
Table 1. Common terms used to describe back symptoms are not necessarily a diagnosis 
Annular tear                                             Adult spondylolysis                 Myofascitis         
Fibromyalgia                                            Disc syndrome                        Strain         
Spondylosis                                             Lumbar disc disease                Facet syndrome         
Degenerative joint disease                         Sprain                                    Osteoarthritis of the spine 
Disc derangement /disruption                    Dislocation                              Subluxation                     
  When is surgery a choice?  If your back symptoms affect your legs and are not getting better, a herniated lumbar disc (what many people call a "slipped disc") may be the reason.  The disc can press on a nerve root in your back and can either irritate the nerve or affect its function.  If tests show strong evidence that this is happening, surgery to take the pressure off of the nerve may speed your recovery. 
  If your health care provider tells you that surgery is a possibility, ask about your choices.  Ask what would happen without surgery.  Before agreeing to surgery, get a second opinion from another health care provider.  Also, ask about the tests that were done to suggest that surgery is the best approach for your back symptoms.  Table 2 lists some conditions or diagnoses that sometimes benefit from surgery or other special treatment. 
Table 2. Diagnoses that may benefit from surgery or other treatment 
 Leg pain due to herniated lumber disc.  Surgery is sometimes used to relieve the pressure on the nerve and can speed recovery if the diagnosis is based on strong evidence.  Surgery should not be expected to make the back brand new.  
 Leg pain due to spinal stenosis.  Spinal stenosis is an uncommon cause of walking limitation in the elderly.  It is very rare under the age of 60.  Surgery to take pressure off the nerves can improve walking distance and leg pain. 
 Leg pain with spondylolisthesis.  Spondylolisthesis is measurable slippage of one vertebra upon another.  In extremely rare cases, the slippage may be great enough to affect nerve root function.  Surgery is sometimes used to take pressure off of the nerve and to fuse the vertebrae to prevent future slippage.                                     
 Fracture or dislocation.  Surgery is commonly used to repair a fracture or dislocation if the fracture or dislocation affects the spinal nerves.                                                            
 Spinal arthritis.  If the condition is verified by a positive blood test and is not osteoarthritis or degenerative joint disease, nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, may be used.                                                                  
  Tests cannot always tell you the cause of your symptoms.  Medical science cannot always explain the exact cause of most common low back symptoms.  But medical science is very good at finding out if you have a dangerous condition causing your symptoms.  If your problem is not caused by a serious condition, you can continue looking forward to recovery. 
  Exercise is important.  Remember to continue to exercise as you were instructed by your health care provider and as described in Handout 1.  It is important not to neglect your muscles.  Exercise regularly! 
Points to remember: 
 -   Special studies are not needed for early detection and care of low back problems. 
 -   Special studies can be misleading without other strong findings.  They can give additional information about a problem if used with other evidence. 
 -   If your health care provider suggests surgery, ask what the evidence is for surgery.  Ask about risks, your choices and what would happen without surgery.  Get a second opinion from another health care provider and ask about reliable science and what evidence based medicine suggests.  Your surgeon will understand how important it is for you to be sure. 
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