Many of my patients come because they have pain in their spine. The pain may be high up in their neck or down in their lower spine (such as in the lumbar region, sacrum or coccyx).
Being a physiotherapist in the area for nearly 25 years I have treated many hundreds of people with back pain. I think the proportion of people having spinal pain in my surrounding suburbs is probably similar to many other suburbs in Australia located near cities such as Brisbane. Research indicates that over 3.5 million Australians (that’s one in six) had chronic back pain in 2014-2015. More than 3 out of four of these 3.5 million people were between the ages of 15 and 64.
Patients with spinal pain have had imaging studies such as X- rays, CAT scans and MRIs before their first physiotherapy appointment. Patients often believe that these studies can reveal which part of their spine is causing their back or spinal pain. This is a perfectly natural idea as if we see a cut on our finger we know that is the cause of the sudden pain in our finger. However, the link between the experience of pain and the damage we can visualise is actually not always straightforward.
The following patient’s story (case-study) is given to help demonstrate that images do not always provide ‘the truth, the whole truth, and nothing but the truth’ when it comes to understanding why we sometimes have spinal pain. But first a quick orientation to how our spines look on x-rays, CAT scans or MRIs.
This side view of a mature adult’s spine shows how it is made up of bony blocks stacked on top of each other with a gap between each block. The blocks (vertebral bodies) are fairly rectangular looking. The gaps in between the blocks are where the discs are located, and it can be seen that they get thicker the further down the spine you look.
A 69 year old patient presented to my clinic in December 2017, and after observing his spine I referred him for an x-ray. Apart from complaining of pain he was otherwise healthy.
Here are some of my patient’s side-on view x-ray images (lateral x-rays):
As you can see, instead of all the blocks being rectangular, one is quite pointed at the front edge. This is because the entire front section of this vertebral body has collapsed down. This fracture would have happened suddenly. We know from previous research that this type of fracture is due to the bones being weak, which in turn is due to a deficiency of their bone mineral density (BMD). This condition is called osteoporosis, and about 2.2 million Australians have this problem. In fact about 11% of men and 27% of women in Australia who are over the age of 60 have osteoporosis, even though they may be unaware of their dangerous situation.
I say dangerous as they have a risk of developing these wedge shaped osteoporotic crush fractures. The fractures can occur spontaneously, for example just while they are walking around. Sometimes a fall is responsible. The fractures are often said to have caused a large amount of pain at the time they occurred and for long periods afterwards. Surgical techniques (such as percutaneous vertebroplasty) have been developed to ease the pain.
Getting back to my patient and his x-ray images, first impressions are that he has back pain, and that this was due to a sudden and severe fracture. However nothing could be further from the truth. He denies ever having had back pain. The reason he came for a physiotherapy consultation was because of recent right hip pain. I quizzed him at great length and despite being able to recall several snow skiing falls he denied that any of these involved his back and was emphatic about never having back pain. He was able to recall in great detail his few snow skiing falls.
The reason why I referred him for an x-ray of his spine was not because I thought his back pain was referring to his hip, but because he could not adopt an upright posture, which is something every physiotherapist is keen to achieve. Correct posture helps prevent painful conditions and often helps mitigate spinal pain, including low back pain.
By the way, his hip pain responded well to physiotherapy treatment he is heading off for another skiing trip in early 2018.
Does this just mean that x-rays, CAT scans and MRIs are never helpful? Not at all. But it is common to find that patients who present with very significant spinal pain, and with images showing very obvious degeneration, or spondylosis (generalised degeneration of parts of the spine), or bulging discs (sometimes called prolapsed discs), will get completely better. Yet a re- imaging of their spine when they are fully better would be very likely to show that no change can be seen on the images. By the way, you will see the discs of the spine sometimes spelt as disks. Also sometimes health professionals will refer to a bulging or prolapsed disk as a herniated disc, but I think it is best to confine the term herniated disc to those discs where the middle portion (nucleus pulposus) has extruded out of the disc; these often require surgery.
The good news is that even though imaging of your back may reveal a lot of changes that look significant, often these changes do not indicate that you need to have surgery to get pain relief. Most of the time spinal pain can be fully relieved without surgery.