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[RC] Back Surgery - Bruce Weary

Hi Sherman-- This could get a little long, so I'll apologize in advance. Far and away, most back pain and sciatica has a mechanical origin. This means that "joint dysfunction" or jammed joints are usually the culprit. Even in the presence of disc bulges and herniations .I know that sounds bizarre, so let me explain. About 60-70% of Americans have bulges or herniations in their spine, and don't even know it. This is because certain other parameters must exist for them to express symptoms. So, when a patient has back or leg pain and is also found to have a disc lesion, it's very tempting to blame the pain on the disc. This is often a mistake in logic, and a trap that can send you down the wrong road of treatment. Over the last 25 years, 70% of my patient load has been dealing with low back pain and/or sciatica. Probably 90-95% of these cases can be treated successfully with skilled (and I emphasize that word as not nearly all manipulators are skilled) manipulation. The remaining 5-10% will respond to spinal decompression therapy, which is a relatively new, but very effective, tool for even the most painful and degenerated spines. I have been using one since the beginning of 2007, and wish I had had it over the entire course of my career. We have a Veteran's Hospital here, and they refer many patients to me, several of whom are on disability retirement for their backs, and they are actually recovering with decompression, when nothing else has worked. Some of them have recovered, and still receive a disability check! Go figure. A few percent of patients will respond to epidural injections (which are relatively safe and work about 50% of the time), and very rare cases of instability and intractable pain then become candidates for surgery. Surgery is, and should be, a very rare option for treating back pain or sciatica these days .The medical profession is in some pretty hot water over the abuse of spinal fusion surgeries, as they are expensive and have a high failure rate. To keep this on track, there is a situation that calls for immediate emergency surgery, and that is when a disc blows out in the lumbar spine and causes spinal cord pressure, resulting in numbness in the "saddle area" of the thighs and pelvis, weakness, and loss of bladder or bowel function. This is called a "cauda equina" syndrome (named after the "horse's tail" appearance of the lumbar nerves) and the results will be permanent if surgery to decompress the area is not performed within a few hours. I have never seen a case in 25 years, so it is very rare.
There are some general rules of thumb about treatable back pain. If it is below the belt line and off to one side, worse in the morning and improves with activity, hurts to rise and sit from a chair, doesn't radiate below the knee, and doesn't really hurt when you cough or sneeze, the news is good--it's very treatable. If it hurts a lot on cough/sneeze, is better in the morning and worse with activity, radiates below the knee, with numbness/weakness/loss of reflexes/loss of muscle mass and is accompanied by significant imaging studies (MRI confirming a disc herniation, for example), you're in for a longer ride. Either way, a really good chiro (and I am more aware than anyone how hard they are to find) is still a good place to start. Manipulation isn't used at the level of the disc damage, but rather above and below it, and sometimes the disc will heal. If not, then decompression, epidurals, and surgery, in that oversimplified order. Good luck, Dr Q


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