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------------------------------------------------------------ SURGERY, MEDICATION, CHIROPRACTIC MANIPULATION AND OTHER FORMS OF MEDICAL INTERVENTION ------------------------------------------------------------ Back pain responds to changes in posture and exercise, but other medical treatments are sometimes considered by patients. Surgery, chiropractic therapy, medications and injections are sometimes suggested to back pain patients. A brief background regarding these paths is probably in order.... Doctors of chiropractic and osteopathy attempt to manage back pain and several other medical ailments by manipulating the spine, joints and muscle tissues in an effort to relieve pain and restore nerve function. Chiropractic practitioners may also make recommendations regarding diet, exercise and rehabilitation therapies. Some surgeons and physicians consider forceful manipulation dangerous and of dubious benefit. Others consider it one of several possible beneficial therapies. The truth probably lies somewhere between the two views: it may have potential but within specific limits. The name chiropractic derives from the Greek language and roughly translates as "practice by hand." Chiropractic medicine was founded in 1895 by Daniel David Palmer of Davenport, Iowa - a town which is also home to the Palmer College of Chiropractic. By profession Mr. Palmer was a grocer who was interested in the possibilities of manipulation in the maintenance of health and relief of pain. As proposed by Mr. Palmer, certain diseases and specific pain have origins in pressures placed on the nervous system. The restoration of normal function and relief from pain could be achieved, he believed, by manipulation and treatment of the structures of the body - especially the spinal column and back. If pressure upon a nerve pathway is present, nerve impulses are believed to be blocked to and from the brain which causes the tissues served by these nerves to become more susceptible to disease and pain. Disorders believed to be treatable by this system, according to practitioners of chiropractic, can include lumbago or back pain, high blood pressure, asthma and arthritis. In chiropractic theory, dislocations and subluxations of the vertebral bones cause pressures upon associated nerves which leads to pain and decreased resistance to disease. A subluxation is described as a partial separation or slippage of two joint surfaces while a dislocation is the complete separation of both sides of a joint, frequently with tearing or rupture of the joint capsule. Fourteen chiropractic colleges are accredited in the USA and Canada to award the doctor of chiropractic degree. Students normally begin study with at least a high school degree and in many cases an additional two year liberal arts college background. Training during a four year chiropractic college normally includes courses in chemistry, neurology, X ray diagnosis, anatomy and clinical practice. Currently all 50 states of the U.S. license chiropractic practitioners. Medicare, Medicaid and workers compensation usually covers the cost of certain chiropractic treatments. Osteopathic doctors are also skilled in manipulation but unlike chiropractors have attended a four year medical school of osteopathy which is similar to mainstream medical training. In most cases osteopaths are licensed to practice medicine like an M.D. Chriropractors are licensed to perform manipulations of the body, back and spine and are limited for the most part to that type of service. Chiropractic manipulation cannot push or move a ruptured disc back into proper alignment - once a disc has ruptured it is permanently weakened. Likewise a chiropractor cannot treat meningitis, tuberculosis of the spine or tumors of the spine. A herniated or ruptured disc cannot be treated by manipulation and may even be dangerous if manipulated improperly. Surgery may be the only course of action for cases of severe disc rupture. Chiropractic practice has limits and reasonable practitioners admit this. Mobility and recovery from muscle spasm and joint facet problems may, however, be benefits of manipulation. Beware, though, that overly frequent chiropractic manipulation sessions can sometimes cause swelling of tissues, delayed muscle spasm and a further visit to the chiropractor - a vicious cycle which serves to perpetuate further sessions. A prudent course following chiropractic treatment is to protect against further joint damage and embark on a program of exercise rather than additional chiropractic manipulations immediately. Manipulation of the neck or cervical region of the spine is extremely dangerous because the spinal cord lies within the spinal canal at that level of the spinal column. Manipulation of the lower lumbar region is less risky since the spinal cord ends just under the first lumbar vertebrae and is thus less likely to be damaged by manipulation. On balance, though, there may be benefits to specific manipulations especially when muscle spasm or facet joint movement is impaired. The American Medical Association recognized chiropractic practice in 1980 after many years of often heated debate about its validity. Current practice of chiropractic has also developed to include the study of kinesiology as proposed by George J. Goodheart in 1964. This branch of chiropractic practice proposes that it is possible to treat some disorders by locating muscular weakness and then manipulating the spine in a manner that directly stimulates and strengthens the muscle. A side effect of this development is the recognition that muscle weakness can be directly caused by allergy or nutritional deficiencies and is thus correctable in some cases by changes to diet. The discipline of chiropractic is served by the International Chiropractor's Association and the American Chiropractor's Association which promotes public education and provides continuing education and training to members. The most conservative course to consider if you are contemplating chiropractic treatments is to visit your physician or orthopedic surgeon and ask if muscle spasm or facet joint impairment is involved. If that is the case would he or she recommend a competent chiropractor or osteopath to solve that part of the backache? Mainstream medical professionals are now referring selected patients to chiropractors and osteopaths for some treatments and therapies, so manipulation is no longer the "dark science" it once was. In addition, many chiropractors are now recommending specific back exercises following manipulation which represents a "mainstreaming" of chiropractic practice towards recommendations and continuing care generally followed by physicians. Nevertheless, ask questions of professionals on both sides of the chiropractic issue regarding exactly what a manipulation treatment can and cannot do for you since there are limits to what chiropractic practice can achieve. Medications are available for some types of back pain, but be aware that there is no magic pill which will provide a quick cure. Generally three classes of medications are available to back pain sufferers: 1) pain relievers or analgesics, 2) muscle relaxants and 3) anti-inflammatory agents. Analgesics or pain relievers treat the symptom of a backache - the pain - but not the source. Tylenol and aspirin are the most commonly prescribed medications and aspirin has the added benefit of also being anti- inflammatory. However aspirin and tylenol may be only partially effective at relieving severe back pain. Stronger pain relievers such as percodan, vicodin or codeine- tylenol are usually prescribed for severe back pain. Codeine is, of course, addictive if taken over longer periods of time. For the most part these strong pain relievers are only offered during the first few days to a week of a painful episode and then discontinued. The strongest analgesics such as demerol and morphine are used on patients suffering from back pain in a hospital setting or after back surgery. They are obviously quite addictive. Recent studies of patients recovering from a variety of surgical procedures show that these patients tend to have a more rapid recovery when correctly treated with stronger pain relievers. Strong pain relievers such as morphine are dangerously addictive, but over very short periods can actually hasten recovery. If you are in severe or chronic back pain, do not be afraid to ask the doctor for a stronger pain medication if a low level analgesic is not controlling the pain - you may be able to recover more quickly and begin a suitable therapy or exercise program that much sooner. Strong or addictive pain medications are usually best discontinued within two or three days - a practice followed by most physicians. Appropriate bed rest is usually just as effective at controlling chronic pain as most analgesics after the first day or so. A different class of drugs, anti-inflammatory agents, reduce swelling in the muscles, ligaments and joints of the spine. The most effective are cortisone and related medications. Cortisone is not without side effects and is used very carefully by most physicians who watch and monitor a patient closely. Other anti- inflammatory agents include motrin, advil, nuprin, ibuprofen, indocin, naprosyn, clinoril, felene and voltaren. Side effects of these anti-inflammatory drugs include stomach irritation, nausea, diarrhea and vomiting. Not all patients will experience these side effects when taking an anti-inflammatory, but if you are taking one of these drugs, watch for side effects. Some patients will have inadequate anti- inflammatory effect with one drug and may need to switch to another medication under a doctor's supervision. This is common with anti-inflammatory drugs and a period of "testing" may be required by patient and doctor to find the one which gives best anti-inflammatory result with little or no side effects. Muscle relaxants loosen tight, spastic muscles. Robaxin, flexeril, and norflex are common drugs in this classification. Valium, a common but potent tranquilizer, is also a muscle relaxant but can be addictive over long periods of time. Most muscle relaxants work indirectly by affecting the central nervous system or brain and NOT by working directly on the muscle. In most cases these agents are useful during acute episodes of back pain - especially painful sciatic attacks which radiate down the legs. Some patients remain on these medications for several months, but in most cases the drugs are discontinued within a week or so after muscle spasm has decreased. Medications administered orally are but one route to managing back pain... Local injections are sometimes used to relieve back pain. The injected medications may consist of anesthetics alone or mixed with cortisone. In most cases these injections are done routinely in the doctor's office and provide only temporary relief. They may be helpful in allowing a patient to overcome the first day or two of pain after which adequate bed rest and therapy or exercise is usually prescribed. Epidural injections and facet joint injections are a variation of the above idea. These injections are given into a much deeper area - typically the irritated facet joint or exterior layer of dura of the spinal cord. Usually these deep injections are given by a licensed anesthesiologist under orders from a surgeon or physician. Unlike a superficial local injection, the deep epidural injection usually provides prompt relief for several days. A combination of cortisone and anesthetic is usually administered. Conditions such as disc ruptures, spinal stenosis or compressed or irritated nerve roots are comfortably treated in this manner. Relief does not last more than a few days and further injections or other therapies and specific back exercises are usually required in the end. Ultrasound heat treatments are usually given by physical therapists prior to additional massage or exercise of the back. Diathermy likewise projects heat deep into the tissues of the back and serves a similar purpose. By themselves, these treatments have little permanent value unless combined with additional exercises, massage or other therapies. Surgical procedures for treatment of back pain are the most drastic course of action. Frequently a physician will try other courses to remedy the pain since surgery is useful only in limited specific cases such as disc rupture. However, if a disc has failed, an orthopedic surgeon may attempt to remove its core via a variety of procedures. Percutaneous aspiration of a disc describes the removal of the pulpy core through a hollow needle which is inserted into the disc. A modification of this method adds a tiny spinning burr or reamer which is inserted through the needle and aids in breaking up the disc core. It is important to note that only the core is removed, not the entire disc structure. In most cases this surgery will relieve direct pressure of a ruptured disc upon adjacent nerve roots. However, the procedure has some risks such as possible disc fragments remaining near the spinal canal. Also, if back pain derives from nerve pressure due to overlying ligaments and muscles or narrowing of the bone through which nerve roots pass, this operation will have little beneficial effect. A surgical variation of disc removal is chemonucleosis which makes use of an injection of the chemical chymopapain into the core of the disc. This enzyme is derived from the papaya fruit and can selectively dissolve the tissue collagen which is contained within the disc core. Normally the needle is guided to the injection site by X ray image. Once the injection has been made, the core will slowly dissolve and in most cases relieve pressure on irritated nerves. Side effects to this procedure is the possibility of allergic reaction to the injection and the possible irritation of nerve roots if the chymopapain leaks out of the disc and comes into contact with nerve or muscle tissue. The procedure has limits in other ways: completely ruptured or extruded discs are not good candidates for this procedure. Likewise, elderly or arthritic patients are not usually recommended for chemonucleosis. The most aggressive surgical method for treating a herniated or ruptured disc is direct surgical dissection and removal of the affected disc core. In most cases back pain which focuses on irritated or compressed nerves may also derive from several sources in addition to the damaged disc. Removal of the disc core may thus be accompanied by surgical investigation of bony growths between vertebrae, stenosis or narrowing of bone canals through which nerves pass and compressed muscles and ligaments. Typically removal of the disc by direct surgical intervention is accomplished by direct incision over the affected spinal area. Overlying muscles and ligaments are retracted to reveal the disc space. The affected nerve root is usually revealed after additional bone is removed. Finally the nerve root is retracted and protected and the ruptured disc material is cut and suctioned from the site. Other bony spurs which have grown in proximity are trimmed with the idea of relieving pressure on the irritated nerve root. Bed rest and specific therapy exercises are usually prescribed depending on the recommendations of the surgeon. A different operation is attempted if a narrowing of spinal canal places pressure on nerve roots or the spinal cord itself. Sometimes this narrowing is a result of a disc rupture. Other times it is a matter of aging or other disease processes. This surgical procedure essentially opens a space around the nerve by removing some of the bony surrounding tissue which encases it. Foraminotomy is a similar processes but instead involves enlarging the smaller bony canals through which nerves pass - not the central spinal canal. Bony growths or spurs adjacent to the facets of the vertebrae may also be trimmed to reduce pressure on nerve roots during the surgery. Stenosis or narrowing of the spinal canal or smaller foramen through which nerves pass is more frequently seen in elderly patients over age 55. Spinal fusion is another surgical procedure which is sometimes attempted to relieve back pain. Sometimes damage or injury causes the movements of one intervertebral bone to become misaligned in relation to an adjacent bone or disc. The lower lumbar area is notorious for instability and vertebral injury. Back braces may be suggested to limit the range of motion in the lumbar area of the back and prevent pain. However an external brace may not be sufficient and a surgeon will attempt to permanently fuse two vertebral bones together by taking bone grafts from the large pelvic bone and bonding them to two adjacent vertebrae. Bone tends to mend and grow together if fractured or injured and this procedure makes good use of this biological predisposition by grafting bone together at the site of two adjacent vertebrae. Occasionally metal plates or screws are added if the area is unstable or needs extra support during healing. Surprisingly, patients who have undergone spinal fusion still retain a considerable range of motion in the back and over several months may not even be aware of any decrease in flexibility or function. Years ago surgical removal of a ruptured disc core was accompanied by spinal fusion under the theory that removal of the disc core necessitated spinal fusion to strengthen the underlying area. However, today disc removal is not usually accompanied by bone-to-bone intervertebral fusion since appropriate rehabilitation and back exercises can compensate to provide strength and support to the back. It should be noted that surgical fusion requires several months of recuperation for the grafted bones to heal and strengthen the site while disc removal causes only a few weeks of recuperation for most patients. The majority of patients who undergo surgery are pleased with the results. However a program of exercise, rest and specific medications are usually required - surgery is only a foundation for relief from pain. Many months may be required for complete recuperation and a return to a normal work schedule. Fundamentally, removal of a disc or spinal fusion is NOT the normal structure for a healthy back. In addition to exercises, proper techniques for sitting, standing and lifting will have to be learned by the recovering patient. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter.