Lower back pain myths

Myth #1: Your imaging findings are indicative of your prognosis, or symptoms.  E.g. My MRI said I have a BULGING DISC!!! I will never be able to run or lift again!!

Fact: MRI findings in PAIN FREE populations:

At 20 years old:
37% had disc degeneration
30% had a disc bulge
29% had a disc protrusion

At 80 years old:
96% had disc degeneration
84% had a disc bulge
43% had a disc protrusion

(Brinjikji et al., 2015).

Myth #2: Having a disc bulge/herniation/rupture/extrusion/tear is BAD NEWS.

Discs have a bad rep. It is common for someone to present to me reporting that they have a disc bulge, or herniation, and as such need to be very careful with lifting or jumping.  The person may believe they have damaged their back forever, or that they have a potentially serious condition.

I think the most IMPORTANT piece of information here is that IMAGING FINDINGS ARE POORLY CORRELATED TO LOWER BACK PAIN. To the extent where having an MRI of your lower back is associated with WORSE outcomes, because of the fear that is linked with seeing what are actually NORMAL findings (Webster et al., 2013).

This doesn’t mean we don’t know how to treat someone with low back pain if we don’t know exactly the structure that is implicated, because we treat the PROBLEM not the finding (e.g. Person has pain to bend forward, which may be the case for someone with nothing on an MRI as well as for someone with a herniated disc on MRI).

Being referred for imaging for lower back pain in the absence of certain “red flags” that warrant further investigation is AGAINST best practice guidelines. And yet! Evidence shows 54% of people in the US are referred for imaging of their lumbar spine when they present with low back pain to the emergency department (Foster et al., 2018).

I understand why, because back pain is incredibly painful, and people must feel there is something horribly wrong with them when it comes on. But that’s the thing. The VAST majority of the time, the bark is worse than the bite.

Myth #3: My disc has slipped and my back is ‘out’. I know because it keeps getting stuck!

Truth: Acute low back pain can be extremely painful. Pain is the body’s alarm system. It is an evolutionary survival mechanism. A pain signal is sent in the presence of actual or PERCEIVED threat to our tissues. Our discs are very close to your spinal cord. It is likely that any strain or stress to these structures will produce a large pain response. Couple this with the idea that many people have a fear of badly hurting their back, which is likely to turn up the pain signal.

Pain is often poorly correlated to damage (think how much paper cut, hot water on sunburn, or stubbing your toe hurts when none of these cause actual damage). Inflammation and local swelling around a disc hurts like CRAZY, and if this inflammation and swelling contacts one of the spinal nerves that are right next to the discs, it can give you symptoms down your leg, often called ‘sciatica’). This high degree of pain, however, does not mean that the injury is necessarily severe.

Most of the time, acute disc-y pain eases within a few days, and you’re left with some residual pain and stiffness. Over time this gradually eases as well. Pain that persists for longer than the time you would expect can occur due a host of factors that I’ll discuss soon. It is rarely because you have something ‘really wrong’ with your back.

Myth #4: Backs that keep hurting, or keep ‘giving way’ and ‘going out’ are the small % that are really bad and must need surgery. The reason for prolonged pain is because of extremely bad damage.

There are so many reasons back pain can keep coming back, or never quite go. I do think that it is mainly the response to the episode of low back pain that will dictate this longer response.

HYPOTHETICAL: NEGATIVE PAIN EXPERIENCE LEADING TO CHRONIC SYMPTOMS
Imagine this. A fit and active young person hurts their back. Feels a giant terrifying snap and extreme pain. Goes to the hospital, gets an MRI which shows a disc bulge. Told it isn’t serious, yet, but it could get worse, and could progress onto the nerves, causing pain in the legs which might require surgery. Is told to go home and wait for it to get better, and if not return to see a surgeon.

Person goes home and googles back pain. Learns that flexion makes the soft inside of the discs ‘explode backwards’ like a jam donut. Thinks this will happen and lead to needing surgery. Becomes petrified of bending forward. Takes to bed for a few days to help the extreme pain go down, as the intensity of the pain must be linked to the severity of the injury.

While lying in bed, person becomes deconditioned, which happens rapidly if you stay lying down a lot. The person finds even any tiny forward bending hurts and is petrified that means more damage is done. Stops bending forward. Back starts to hurt all over, all of the time due to  being super stiff and rigid, and now hurts even to stand up, as has lost strength to stay up for long periods against gravity.

Back still hurts 6 weeks later, when it should have healed. By this time this person has had the whole time off work, unable to tolerate sitting up at a desk and having been told sitting is bad for disks. Has quit the gym as knows lifting will make the disc bulge more. Has started to feel depressed and isolate from friends, telling everyone that they have ‘totally stuffed up their back’ and starting to panic about maybe needing surgery.

HYPOTHETICAL: POSITIVE PAIN EXPERIENCE REDUCING RISK OF CHRONIC SYMPTOMS
Now imagine the same person from the scenario I posted a few days ago. A fit and active young person hurts their back. Feels a giant terrifying snap and extreme pain. Goes to the hospital. Is advised that there are no ‘red flags’ and that while the pain is severe, the injury is unlikely to be anything serious, the pain is related to inflammation. Person feels relieved, and pain even feels a little better knowing that there is nothing serious going on. Person is referred for physiotherapy to guide them back to movement safely.

Physiotherapist tells the patient that it is safe to keep moving as normal, even to bend and twist, as avoiding these movements is likely to make the back even more sensitive if it is to move in that direction. The patient is advised to try to stay active and avoid trying to sit up excessively straight, or hold their back rigid, as these things can make the whole back feel sore due to muscular fatigue.

The physio also shows the patient all the movements at the gym that are still ok to do, even in the acute phase of low back pain. The patient does a few of her usual gym exercises, gets some endorphins, realises she isn’t ‘broken’, and feels optimistic!

After a few days, the acute inflammation is less, and while the patient feels a bit stiff, she can still do 90% of her gym workouts, which helps her to feel strong and in control. After a few weeks, she gradually starts introducing the exercises she was initially told to avoid, and finds that after a few weeks of this, she is back to normal.

Obviously these are invented scenarios and the second one is very “textbook”. But both things happen. The EXACT same injury can literally end up as polar opposite as these two presentations at 6 weeks.

Reference:

1. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., . Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811-816. doi:10.3174/ajnr.A417
2. Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet, 391(10137), 2368-2383. doi:10.1016/s0140-6736(18)30489-6
3. Gugliotta, M, da Costa, BR, Dabis, E, et al.Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016.
4. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Underwood, M. (2018). What low back pain is and why we need to pay attention. Lancet, 391(10137), 2356-2367. doi:10.1016/s0140-6736(18)30480-x
5. Shamrock AG, Donnally III CJ, Varacallo M. Lumbar Spondylolysis And Spondylolisthesis. [Updated 2020 Sep 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
6. Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine, 38(22), 1939-1946. doi:10.1097/BRS.0b013e3182a42eb6