August 2019 Edition. Volume XIX

That back pain is a societal scourge is unquestioned.  It has been well established that 80% of the population will be incapacitated by back pain atleast once during our lives and that back pain represents (after chemical dependency and psychiatric disease) the largest single expenditure of dollars in the health care system.  Despite the existence of good answers to this challenge spine care remains an “orphan” medical issue.  The reasons why this remains so continues to be a matter of conjecture but seems to relate to the difficulty of measuring the efficacy of different means of therapy from the objective standpoint.

It has been rightly pointed out that “back pain” is a symptom, and not a diagnosis.  A well-known spine specialist has consistently stated : “We do not know what causes low-back pain.”This nihilistic approach to spine care has produced an “open season” for myriads of medical mystics (some feral in nature) to advance their favorite therapeutic modalities.  The speculations regarding the etiology of back pain range from socio-economic deprivation, unhappy working conditions, psycho-social “disturbances” to organic etiologies ranging the gamut from musculo-skeletal dysfunction, “fibromyalgia”, to legitimate neurologic impairments.

The Burton Experience differs markedly from the belief that “We do not know what causes low-back pain.”  This Editor has chosen to not to join in this popular sport but to endeavor to make the point that the diagnosis of back pain is similar to the diagnosis of other medical problems.  The first step is to make a specific diagnosis based on quality medical information and a valid understanding of spine anatomy and pathophysiology.

Specificity in diagnosis is coming.  It won’t be long before each newborn will have a buccal swab submitted for DNA analysis.  The resulting voluminous computer readout will probably too specific for our present knowledge base and create new and different dilemmas for medicine and the insurance

In the meantime, the most helpful spine diagnostic aide in today’s world remains the high-resolution magnetic resonance imaging study (MRI). There was a time, only a few short years ago, when spine radiologists first began to recognize the wealth of important diagnostic information contained in a spine MRI.  Rather than being applauded for their efforts they were criticized for giving “surgeons more of an excuse to operate.”

In lieu of the impending “genomic era” of medicine MRI has allowed the appreciation of some of these congenital spine problems (something not always evident in previously available imaging studies).

It is now well appreciated that the greatest step forward in medicine in the 20th century was the introduction of antibiotics.  There can be little doubt but that the greatest step forward in the 21st century will be the sophisticated comprehension of genomics.  Genetic testing of the future will clearly assist in determining the likelihood of someone having back pain or requiring surgery but also be endowed with the associated gift of being given the preventive means of avoiding this disability.

 On The Subject of Degenerative Disc Disease 

Degeneration of discs reflects a “normal” process of aging.  The speed by which this occurs is contingent on many factors including heredity, accumulated physical insult and injury, as well as environmental and personal insults (i.e. cigarette smoking), etc. are relevant A disease, however, is something which produces incapacitation and disability.

For example, the process of mitosis is the normal means by which the cells of the body replicate.  If this replication process goes awry and produces incapacitation and disability it becomes a disease. The common name for this disease is “cancer.”
When degeneration of the spine goes awry and produces incapacitation and disability it then becomes most certainly, a disease.  Shown at left is a child with progeria.

Progeria is a genomic disorder characterized by accelerated aging. Progeria is a disease because it produces disability due to joint abnormalities, generalized arteriosclerosis, and cardiovascular abnormalities.  Progeria is a disease in the same way that genomic spine conditions can also promote advanced aging, neurologic compromise, and associated disability. The genomic condition “juvenile discogenic disease” not only becomes disabling but represents a significant population of those who require spine surgery during their lifetime.  The sooner that these facts are appreciated, and the sooner society is informed regarding it, the sooner will we be able to significantly prevent these disabilities and thus also dramatically reduce the overall burden of high health care costs.

Why Back Problems Cause Pain

Back problems are associated with pain when sensory nerves are adversely influenced.  In the clinical disease entity “adhesive arachnoiditis”  the spinal nerves are enmeshed in collagenous scar tissue impairing their arterial and venous supply and nutrition from blood and cerebrospinal fluid.  Their unhappy state results in streams of “nociceptive” information being transmitted to the brain.  The stream is aggravated by body movement as slight as breathingThere are many sources for back pain.  Back pain alone can be disabling but is typically best treated by non-surgical means. Multi-level instrumented spine fusion as a treatment for back pain has been the single most concerning abuse of spine surgery in the past although the advent of artificial discs appears to have the potential to take over this honor.  The existence of other options such as reconstructive spine surgery does not seem to be well known by patients.


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