FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

"YOUR PAIN IS MY PAIN," DR. WOLF TELLS READER

Question: I've had quite a bit of back pain. My doctor has diagnosed my condition as lumbar instability. I'm taking some medication and doing exercises now, but he says that I may need surgery if my pain doesn't improve. I only want to have surgery if I'm sure it will make me better, particularly since I've talked to people who got worse after they had back surgery. How can I tell if surgery will work for me?

Answer: Have you been peeking at my medical record? You see, I also have lumbar instability. Hence, I have reviewed the literature about this problem with special enthusiasm.

I think I need to back up and explain the condition "lumbar instability" for those readers who are less familiar with it. The area of the spine that most think of as the "low back" is called the lumbar spine in medical terminology. Technically, the lumbar region is formed by the last five vertebra above the tailbone, which doctors call the sacrum.

Each bone in the spine, known as a vertebra, must be able to change positions relative to the bones above and below it in the spinal column. These movements taken together allow the wide range of body postures we humans are capable of assuming. While, as you can see, the spinal column has a great deal of flexibility, the vertebra have another important role. They must protect the delicate spinal nerve that passes through a cavity in the center of these bones known as the spinal canal. To accomplish this task they must stay in proper alignment.

In the condition that you and I have, the vertebra in the lumbar portion of the spine move one upon another in such a way that the spinal canal is not aligned correctly. That's why it's called lumbar instability. This compromised spinal canal causes either direct or indirect pressure on the spinal nerve and the nerves that branch out from it. The consequence of this is back pain as well as leg pain.

There is no easy way to tighten up the loose or damaged ligaments that support the back or to correct misshapen bones the underlying causes of instability. So, specific exercises to strengthen the muscles that control the bending of the spine are the first and usually only treatment necessary for this condition. Strong and flexible back, stomach and leg muscles support the vertebra in their proper position. When good strength and flexibility are accompanied with what we doctors call "good body mechanics" knowing how to safely bend, sit, lift, etc. most people with lumbar instability have only infrequent episodes of back pain.

In the most severe cases of instability, exercises and good body mechanics are not able to prevent chronic and disabling back pain. Surgery may be the best treatment for those with this degree of instability. This is particularly true when there is loss of strength or diminished reflexes in the legs as a consequence of nerve injury. So, it is premature for you to be considering surgery, since you are just starting your therapeutic exercise program.

The actual thought process your doctor goes through before recommending surgery for instability is more complicated than what I've outlined for you. You see, there are actually many causes as well as a significant variation in the degree of instability. For instance, 95 percent of the time, disability that originates from instability at one level of the spinal column, isn't caused by cancer and hasn't yet caused permanent nerve damage can be improved or cured by surgery. Instability involving more levels has a somewhat lower probability of success after surgery.

Only you can decide when it is time to have surgery. As a general rule, however, most surgeons only recommend it when they feel there is a high probability that you will feel and function be better after you've had the operation.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.