Surgery and Back Pain: An Overview
Host: Dr. Linda Austin –
Dr. Linda Austin: I’m Dr.
Linda Austin. I’m interviewing Dr. John
Glaser, who is Professor of Orthopedic Surgery at the Medical University of
South Carolina. He’s one of our
specialists in the area of spine surgery.
Dr. Glaser, almost every human being has had a backache at some time in
their life. When somebody comes to you
with that complaint, how do you begin to think about and diagnose the actual
cause of that backache? What are some of
the first things you do?
Dr. John Glaser: Well, the
first thing we do, of course, is listen to what they have to tell us. We take a history. We want to find out what kind of pain it is,
how long they’ve been having it, where it is, where it goes, what makes it
better and what makes it worse. And,
many times, we can get a feel for what might be the source based on that. We, then, of course, do a physical
examination. And the primary purpose of
that is to see how much mobility people have and whether their neurologic
function is okay. After that, we will
often get some x-rays. We primarily look
at x-rays to see if there’s some deformity or some narrowing of the disc
space. There are the rare tumors and
infections, and things, that we see on x-ray.
But, it’s primarily to look at what the structure of the spine is in the
standing position and to see if there’s any deformity.
If that doesn’t tell us much, and if people are still miserable
enough, we often will go to an MRI, which gives us our best look, generally, at
the discs and the nerves, and the other structures in the area. Some of the other tests that can be done are
CAT scans and myelograms, which are invasive studies where we put a needle into
the spinal canal and shoot some dye in there, but the MRI has pretty much
replaced those. Many people, though, at
least of the folks that I see, don’t really need an MRI because it wouldn’t
really tell us what to do differently.
For many people with a backache, often the treatment is time and some
exercise, and some mild medication. And,
often times we can get people feeling better that way.
Dr. Linda Austin: Now,
let’s go back and talk some more, if you could, please, and I’m sure you can,
about disc problems. That’s such a
common problem. But I suspect that
people talk about having disc problems without understanding just what a disc
Dr. John Glaser: A disc is
the structure that’s between the vertebral bodies, which are the building
blocks of the spine, and the disc is sort of the bumper that allows for shock
absorption and allows for some motion in the spine as well. It’s made up of a number of soft tissue
structures; there’s no bone in the disc.
And, it is quite common to have disc problems. That’s probably the most common thing that I
see. Everybody’s discs degenerate with
age. That’s just part of the process
that we go through with aging. Some
people call it degenerative disc disease when it hurts. But it’s very difficult sometimes when you’re
looking at a picture of a disc that is degenerating to say whether that hurts
or not. We haven’t quite figured that
one out, exactly.
I prefer not to think of it as disease but as part of the aging
process. It would, to me, be the
equivalent of saying going bald is a disease.
But, the discs will wear out and, at times, they do cause pain with the
Dr. Linda Austin: So, in
other words, just to kind of get a picture of it then, the vertebral bodies are
actually bony structures that we think of as being kind of the core of the
spine, and then there are these more spongy structures, the discs, in between,
Dr. John Glaser: Yes,
Dr. Linda Austin: So,
explain, then, what happens when somebody has a so-called herniated or ruptured
disc, what’s going on there?
Dr. John Glaser: A
herniated disc is a somewhat different problem where the inner part of the
disc, the nucleus pulposus, actually pushes through the outer layer of the
disc, which is called the annulus fibrosis.
There are a lot of different names for disc herniation, slipped,
ruptured, protruded, sequestered, fragmented.
Basically, they’re all variations on a herniation of the disc. And I often tell people that it often looks
like the old inner tubes in a bicycle tire, where part of it has popped through
and is sticking out. When that happens,
it can often cause pain and irritation of the nerve roots in the area, because
when it pushes backwards, it often pushes up against the nerve roots.
Dr. Linda Austin: I
understand, then, that when that happens or when you look at a film and you see
that there, indeed, is a herniation of the disc, that doesn’t necessarily lead
to pain, is that right? And, one can,
likewise, have pain without that, so it tells you something. But it’s not an exact one-to-one correlation
between what you see and what the patient experiences?
Dr. John Glaser: That’s
absolutely right. We can be comfortable
that it is the source of pain when that herniated disc is irritating or
compressing a nerve and the person complains of pain in the distribution of
that nerve. But, there are many people
walking around with disc herniations, if you were to get an MRI, who don’t hurt
at all, and many people who hurt that don’t have a disc herniation. So, it’s not the only thing that causes pain,
and it is somewhat nonspecific, unless we can be comfortable that it is in that
nerve root distribution.
Dr. Linda Austin: So, I
gather you don’t find it terribly alarming. You know that it may be very uncomfortable,
but it’s not alarming, is that right?
Dr. John Glaser: To have a
Dr. Linda Austin: Exactly.
Dr. John Glaser: That’s
right. It is very rare for it to be an
emergency. It’s not impossible. But the true emergencies, where people are
progressively becoming weaker from a disc herniation, are very rare. There was just a very large, recent, study
published where they compared surgical versus nonsurgical treatment for disc
herniations, and no patient treated nonsurgically ended up paralyzed or in a
wheelchair, or anything like that.
Dr. Linda Austin: You
mentioned that regardless of what you’re seeing, if there’s a disc problem, the
first thing you recommend is conservative treatment with bed rest and
exercise. Can you describe what that
course of treatment is like?
Dr. John Glaser: The course
of bed rest, or decreased activity, over time, has shortened
significantly. Back when I was in
medical school, people went to bed for two weeks and didn’t get out. And, now, for the acute phase, or right after
it happens, when someone has a disc herniation or just that severe episode of
back pain, we generally say two to three days of minimal activity. And then we like to get people going and as
close to normal activity as possible. We
often will ask our physical therapy colleagues to help us in putting together
an exercise program to work on flexibility and strengthening and increase their
Dr. Linda Austin: What
kinds of exercises do you recommend?
Dr. John Glaser: There are
a lot of different forms of exercise. I
like the ones that
work on strengthening the muscles around the spine, which, in the
front of the spine, are the abdominal muscles, or your belly muscles, so, simple
things, like crunches, which are half sit ups.
You can then flip over onto your stomach and work on arching the
back. Sometimes those are too painful
initially, so you have to work on some stretching exercises to work your way
into those things. It’s something that
is quite debated, and most of the experts you talk to will all have their own
particular form of exercise that they like.
Dr. Linda Austin: Anything
else that you recommend, such as something for pain relief? What kinds of medications might be helpful?
Dr. John Glaser: Generally,
we like to try the milder ones first, of course, Tylenol, Advil or aspirin, if
your stomach can handle it.
Occasionally, we do use some muscle relaxers, and every once in awhile
we use some of the narcotics, stronger medication, for a very brief period to
get people over a severe phase.
Dr. Linda Austin: Is it
likely to be a recurrent problem?
Dr. John Glaser:
Unfortunately, it is. If you’ve
had a severe back pain episode at some point in your life, you’re more likely
than the rest of the population to have another episode. But, we don’t know whether that will be next
month, next year, or in the next decade.
That’s something we haven’t been able to predict.
Dr. Linda Austin: But, it
sounds as if disc problems are really just part of normal aging, so most of us,
probably, will have a disc problem at some time in our life. Am I overstating that?
Dr. John Glaser: No, not at
all. A large majority of people will, at
some point in their life, have a backache that can even, at times, be
disabling. And, fortunately, a large
majority of people will recover from that within a few weeks.
Dr. Linda Austin:
Sometimes, I know, people get steroid injections for disc problems. When is that helpful?
Dr. John Glaser: Generally,
I feel that the injections are best for when people have the sciatic pain, the
pain that runs down their leg or their arm from the nerve irritation,
generally, from a disc problem, or other problem that may be irritating a
nerve. I think injections can be quite
effective at that time. They’re not a
cure, but they often can buy people some time to get better while their body is
helping the process.
Dr. Linda Austin: Dr.
Glaser, thank you so much.
Dr. John Glaser: Well,
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