AMSA's 2015 Annual Convention
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February 26 - March 1, 2015 

Back Pain? Big Deal!

Suffering medicine’s most boring complaint

The New Physician January-February 2007
My back hurts. It has been hurting since the morning of April 24, 2006. The day before, I’d done my usual workout: stretching and sit-ups first, then 20 minutes on the stair climber and 45 on the treadmill. Light weights followed—lat pulls, curls, triceps extensions—but nothing too challenging. No sense pushing it. I’ll never have huge arms; not with a herniated cervical disk, but that’s another story.


Afterward, I had my usual shower, spa and sauna, and went to bed that night feeling fine. The next morning, however, I awoke with an intense low backache—fierce, as though someone had grabbed hard and squeezed. The juice from the central cramp ran down both legs, largely bypassing my thighs, but pooling in my calves and feet, which felt leaden. It hurt to stand. It hurt to sit. It hurt to kneel or squat or lie supine or prone. It hurt before two extra-strength Tylenol and three aspirin, a hot shower and rest, and it hurt just as much after.


I’m a doctor in the emergency department of a large teaching hospital, working with physicians-in-training. There is supposedly a teaching moment in every case we see, and it’s my job to find that moment and expound upon it. But back pain bores every doctor I know. It’s as common as white bread and just as dull. Were I cloned and became my personal physician, even my own back pain wouldn’t interest me.


Back pain is the mechanical equivalent of the common cold. If you don’t see a doctor, your symptoms will drag on for an entire week. If you do see a doctor, he’ll clear it up in just seven days. Likewise, the natural history of a back-pain bout is resolution. Usually it’s unclear what causes it and unclear why it goes away—which is fine because, mostly, treatment doesn’t matter. Rest or activity. Heating pads or cold packs. Massage or immobility. Pain medications? Sure, just pick your poison—there’s no difference in outcomes, although some drugs are notable for their unpleasant side effects like dysphoria, itching, gastrointestinal distress and constipation, not to mention narcotic tolerance and dependence.


Then so on and so forth, through muscle relaxants, yoga, imagery, curative spirits and voodoo. Relief eventually occurs in 80 percent to 90 percent of patients regardless of treatment protocol, offering no challenge or satisfaction for the professional healer.


Yet certain presentations of back pain can elevate it from tedious to intriguing. For example, fever and back pain is one fascinating combination, since it may imply that serious, even life-threatening, pathology lurks. More than likely, it’s just a kidney infection, but the possibility of something enthralling does suggest itself. Back pain in a cancer patient is never good, but it is attention-grabbing. So is back pain with concomitant abdominal pain; leg weakness; constitutional symptoms like weight loss, anorexia and fatigue; bowel or bladder dysfunction; progressive symptoms; or in any patient over 55.


I carried none of this exotic baggage, which was nice for me, but not so entertaining for my doctor. About six weeks into my ordeal, after trying everything myself and finding no relief, I called him for an appointment, and he reluctantly squeezed me in. Even the tone of his voice gave away his deep sense of ennui at having to see me. But I had reached my personal desperation point, and didn’t care if I was boring.


I get the sense that even without having to face me, my doctor leads a pretty dull existence, so I always try to spice up his day with stories or humor. But during the exam, as he monotonously ran down the standard list of questions—“How long has it been there? Where does it hurt? What have you tried to make it better? Do you have fasciculations, weakness, incontinence, blah, blah, blah?”—I had nothing electrifying to offer him. When he was through poking and prodding, forcing me to jump and bend, and banging on my spine, he sat back and hmmmmd. That’s when I took the opportunity to jump in with, “Did I mention my cyclical fevers to 103?”


He wheeled around so fast I thought he’d topple from his stool. When I had his undivided attention, I added, “Just kidding.”


Many physicians believe an MRI can help diagnose the cause of back pain, and while this is true in a select few cases, it’s false in most. Most back-pain patients have no discernable abnormalities on imaging, and alternatively, many individuals getting CT scans, X-rays and MRIs for other reasons reveal hideously disordered backs, chock full of bulging disks and collapsed vertebrae, but no back pain.


I myself question what I will do with the imaging information. If I have bulging disks, will I consent to surgery and two months of postoperative pain added to the discomfort I’ve already endured? Besides, the stats on lumbar disk surgery are grim: Only half of patients have sustained relief following surgery; the other half continue to have pain, as bad or worse. But I want the MRI because I want answers. I’m not entirely sure why I do, but I do.


In the end, my doctor agreed to do the MRI, grudgingly. “The insurance company will have issues with this,” he grumbled. I’m sure they will. They will (rightly) question the decision to do an expensive test to possibly diagnose a self-limited process, and I don’t care. Maybe, though, they’ll find cancer or some other unexpected treat on the MRI. That’ll be interesting!


But I predict there’ll be minimal to insignificant findings, and my back pain will simply go away in time. In short, a resolution boring to most doctors, but not to me—not anymore!


As I now await my MRI date, I am aware that it has been almost two months since I awoke in pain, and my back hurts just as much as it did on day one—sometimes worse. But now I appreciate why people seek attention from me in the emergency department for their mind-numbing low-back pain. There’s a certain desperation that takes hold after awhile. If the long, relentless search for diagnosis, relief and cure crescendos at 2:00 a.m. on Sunday, then they find me and plead for relief and answers. I understand that anguish now.
Michael D. Burg is an emergency physician at the University of California-San Francisco Fresno Medical Center. He can be contacted at michael.burg@fresno.ucsf.edu.