White Coat Underground

Oy, my back

So, what’s up with low back pain? Well, here’s what’s up with mine:


To quote from The Book of Pal:

Just below the L4-L5 disc, behind L5 vertebral body on the
right side, there is evidence of a large extradural soft tissue density
measuring approximately 1.5 x 0.8 cm in its maximum vertical and
anteroposterior dimensions respectively. This has the appearance of a large
extruded disc fragment within the epidural space, compromising the right L5
nerve root.

And we say, “Amen.”

An MRI of the lumbar spine consists of hundreds of images; I’ve pulled one out for you. It turns out that science is still beating superstition. Visible on the MR images is a disc fragment pushing on nerves that happen to correspond exactly with my symptoms. If someone were to view this MRI without my story, they would predict how I feel correctly. Conspicuously absent from the pictures—subluxations, qi, worms.

What does the evidence have to say about my treatment and prognosis?

Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month.
Self-care education books based on evidence-based guidelines, such as The Back Book, are recommended because they are an inexpensive and efficient method for supplementing clinician-provided back information and advice and are similar or only slightly inferior in effectiveness to such costlier interventions as supervised exercise therapy, acupuncture, massage, and spinal manipulation. Other methods for providing self-care education, such as e-mail discussion groups, layperson-led groups, videos, and group classes, are not as well studied.

Basically, there are no particularly strong recommendations to follow for the treatment of low back pain, primarily because it gets better on its own most of the time. This isn’t just great news for patients, but also for doctors and quacks. It’s good news for patients for obvious reasons—there misery will go away on its own. For doctors and quacks, it’s hard to screw this one up. Whether you prescribe ibuprofen, physical therapy, homeopathy, or goat sacrifices, your patient is likely to improve, and you get to take the credit.

At this point, I’m staying away from the woo, and I’m going to let nature take its course.


  1. #1 leigh
    February 4, 2009

    i’ve looked at plenty of spinal MRI images… that’s definitely irritating a nerve root. ick. take good care of yourself, ok?

  2. #2 D. C. Sessions
    February 4, 2009

    I think in another Universe I might have gone into radiology.

    Damn, that is a sweet picture. Crappy for you, but the image is awesome.

    Be well.

  3. #3 wet blanket
    February 4, 2009

    Obviously, you are in the pocket of “Big Back” pushing your “MRI images” and “nerve roots”.

    Only Dr. Sarno understands the real cause of back pain.

  4. #4 Tsu Dho Nimh
    February 4, 2009

    Dude … your chakras don’t have enough energy. That blob to the left of the spine should be glowing more brightly.

  5. #5 Comrade PhysioProf
    February 4, 2009

    I remember reading somewhere that there is not really a great correlation between morphological MRI evidence of disks impinging on nerves and actualy symptoms: that many people with symptoms of impingement have no visible disks bulging onto nerves, while many people without symptoms who have MRIs for other reasons show visible disks bulging onto nerves. Is this true?

  6. #6 PalMD
    February 4, 2009

    That is essentially true, with patients with “low back pain”. Imaging is rarely useful, unless there are red flags or significant neurologic symptoms. With clear neurologic symptoms with an anatomic correlate, it’s different.

    Scan everyone, and you’ll find little disc and facet abnormalities, but they don’t correlate well with generalized LBP.

  7. #7 PalMD
    February 4, 2009

    i didn’t have the patience to poke arrows at the abnormal bits…sorry bout that…im sure a radiologist will point it out (if i got the right image, which i did).

  8. #8 Art
    February 5, 2009

    I think you need to get a doc to prescribe a hot tub and sauna for home therapy. One local lady got a large enclosed and heated swimming pool for therapeutic reasons.

    You look like a scotch man. I wonder if you could get the insurance company to cover a selection of fine scotches? Purely for therapy.

  9. #9 Bob O'H
    February 5, 2009

    Can someone explain what bits you’re all looking at. I don’t have much of an idea about what would look abnomal.

    Well, I guess if your abs were on the picture, it wouldn’t be normal.

  10. #10 Joe
    February 5, 2009

    I have extensive experience with chiropracty. You clearly need daily adjustments for a week, alternate days for a month, twice weekly for two months, weekly for the rest of the year, and then monthly maintenance adjustments for the rest of your life (more often in case of exacerbations).

    How many chiros does it take to change a light bulb? Just one; but it takes 40 sessions.

    Sometimes I slay myself.

  11. #11 melospiza
    February 5, 2009

    I’ve been an MRI tech for nearly twenty years, and I say, “Ow, ow, ow.” Yes, you show a bingo image, and I hope you don’t need surgery. Good luck.

  12. #12 Danimal
    February 5, 2009

    You must be getting better already, not a single F*bomb or cussing in this post.

  13. #13 leigh
    February 5, 2009

    CPP, local inflammation can also come from extruded nucleus material. that’s why epidural steroids help some people with herniated discs. that might not always be visible on MRI- and when it isn’t, you get charged several hundred dollars for the specialist to call you an addict and tell you to fuck off.

  14. #14 PalMD
    February 5, 2009

    Yes, we’re quite good at that. Dealing with addiction, pain management, and all of the attendant bullshit is a challenge, and not everyone is up to it.

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