By Angela Spivey

When patients talk to Paul Tawney, MD, about their aching backs, they can be sure he knows the lay of the land.

His own journey with back pain began in college, when he was in the gym lifting 365 pounds.

"My foot slipped about half an inch, and I felt pain in my back, the back of my thigh, and my calf," says Tawney, assistant professor of orthopaedic surgery at Duke.

"I put the weight down and I passed out."

Doctors told him he was fine neurologically, but later, his foot started giving way whenever he'd get out of his car.

Imaging studies showed that Tawney had a ruptured disc and previously undiagnosed congenital spinal stenosis (narrowing of the spinal canal). Surgery to remove the disc and correct the stenosis helped, but didn't heal all. Tawney's back has gone out several times, including while he completed a surgery rotation in medical school. During a marathon operating room session, Tawney spent hours with his arms in one position, holding up a retractor.

"I twisted to wheel the patient out of the operating room, and that was it," he says. He was bent over for days.

Tawney decided the physical demands of being a surgeon were too much for his back.

"So I researched a bunch of different medical specialties and found the field of physical medicine and rehab," he says.

Today Tawney still has flare-ups but controls them mostly with exercise.

"I feel it's most under control when I'm staying on top of my workouts, running as well as keeping my core muscles strong," he says.

As Tawney's experience shows, no single treatment, not even surgery, is a cure-all for back pain. And if you haven't yet had your own experience with it, chances are you will. Eighty to 90 percent of adults will have at least one episode that limits their activity for at least 24 hours.

The good news is that it will be brief -- most of us will return to normal within six to eight weeks, no matter what the treatment. But we spend a lot of money on the problem. According to a 2004 Duke study, patients with back trouble rack up over $90 billion in health care expenses annually, with approximately $26 billion of that directly attributable to treating the pain.

A 1991 study from researchers at the University of Vermont showed that most of the money is spent on those few who have chronic back pain (that which lasts for more than three months).

"Part of the art of taking care of people with back pain is identifying that small group of people who may have something truly, seriously wrong.

"And for the group of folks who have traditional back pain, it's helping them to be as comfortable and functional as possible while they're recovering, while at the same time trying to not inappropriately use health care resources," says Joe Minchew, MD, associate professor of orthopaedic surgery.

Duke's physical medicine doctors, orthopaedists, physical therapists, anesthesiologists, and neurosurgeons work together to guide people through back trouble. For most patients, the focus is temporarily relieving pain so they can get moving -- and healing. Patients with chronic, hard-to-treat pain can get advanced pain therapies at Duke that are available at few other places.

And for the few conditions that respond well to surgery, Duke offers traditional procedures as well as minimally invasive ones that can get patients out of the hospital in just a few days.

Pictures Don't Always Show the Way

Tracing the spine's parts, it's easy to see why they're vulnerable to wear. Each of the 33 vertebrae has two joints, one on each side. Just like your hip or knee, these facet joints can develop arthritis. Or the vertebrae can enlarge over time, which narrows the spinal canal and puts pressure on nearby nerves (spinal stenosis).

The discs that cushion the space between each vertebra can age too. They're made of a tough outer coating and an inner jelly-like material that can take in and release water. But over time the disc loses some of that ability to absorb water, so it doesn't cushion so well anymore. And as a disc wears, it can bulge like a lip bruised from a punch, putting pressure on spinal cord nerves and causing pain, says Winston Parris, MD, director of Duke's Pain Clinic.

All the fancily named back problems -- facet joint disease, spinal stenosis, disc degeneration -- are not really diseases, but a normal part of aging, Minchew says.

If people were randomly given an MRI at age 25, a quarter of them would show aging-related changes in their discs. By age 65, 85 percent of people would show changes in their spine that a radiologist would label "not normal," Minchew says.

If an MRI shows such changes, but your pain doesn't come from that particular area, then your "disease" probably isn't what's causing your pain.

"Nine times out of 10 you cannot look at an x-ray or an MRI or any other test and tell the patient with any absolute certainty why they're having back pain," Minchew says.

William Richardson, MD, professor of orthopaedic surgery, says that in their first weeks of back pain, most people don't even need an x-ray.

"Imaging is not indicated in the first six weeks of pain unless you have some suggestions that the person has had trauma, has a fever suggesting infection, has a major neurologic deficit, or has any history of a tumor or suggestive of a tumor, such as weight loss," he says.

Studies show that 70 percent of people get better in the first six weeks, and 90 percent in the first 12 weeks, he says.

Because imaging can be inconclusive, the dialogue between doctor and patient can be just as important as an x-ray or an MRI. In many cases, non-operative doctors steer patients toward using medications and adjunctive treatments that will relieve the pain enough that patients can do the physical therapy that will help the body heal itself.

Physical Therapy Paves the Road to Healing

While physical activity may seem daunting to someone whose back twinges or throbs with every movement, doing appropriate exercises as soon as possible can be very effective.

"We try to enable the patient to achieve early success," says Matt Roman, PT, practice manager for Duke Physical Therapy. "We tend to have people do a very high frequency of activity, but at low intensity, so they're not provoking symptoms."

Physical therapy eases back pain in three major ways.

Low-impact aerobic activity promotes fresh blood flow to the tissues and flushes out waste products. Strengthening core muscles such as the abdominals builds a strong foundation for the spine. And flexibility exercises help people go about their days without stressing their backs.

"If you bend over to reach a box, and your leg muscles aren't flexible enough to allow you to get there, the motion will occur through your spine where it shouldn't," Roman says.

Duke physical therapy researchers are working to fine-tune such interventions; researcher Chad Cook, PT, PhD, and colleague Adam Goode, PT, DPT, are testing a new scale that measures the outcomes of various physical therapy interventions for lumbar and cervical spine pain, in terms of how well these tactics improve patients' ability to go about their daily activities with ease.

Karyn Rahn, MD, an occupational medicine physician in the Department of Orthopaedic Surgery, says that physical therapy is as important as medication in treating back pain.

In fact, she says exercise therapy proved to be the magic ingredient for her patient Donald Hendrix, 79.

Because spinal stenosis made it painful to walk, Hendrix was using a walker all the time, and, for longer distances -- such as when he came for appointments at Duke -- a wheelchair.

In addition to spinal injections, Rahn suggested water therapy.

"I said, 'Look, water takes the weight away, you can work your body out and not put that pressure on your spine,'" Rahn says.

Now, Hendrix spends an hour in the pool each day doing back exercises, and another 30 minutes walking in the pool for aerobic benefit. He says he feels the best just after exercising.

"I felt so good last Tuesday, I got the lawnmower out and cut the grass, edged the yard, and blew the clippings off the driveway," he says.

Hendrix no longer needs a wheelchair or a walker.

"I've come a long way, thanks to Dr. Rahn and her encouragement," he says. Gloria Liu, MD, assistant professor of orthopaedic surgery, also emphasizes getting active early, before patients start to lose balance and sensation.

"I'm a rehab doctor," Liu says. "I want to help people get their lives back."

She also offers adjunctive therapies to ease pain, including acupuncture (two 2005 studies showed that acupuncture is moderately effective against chronic lower back pain).

Liu, Tawney, and others offer a variety of spinal injections to reduce inflammation and pain.

"If you can manage a patient with medications and physical therapy, then you don't really need to do an injection. But if they're still uncomfortable, and you want to try and calm down the nerve, then an injection is a reasonable thing to offer," Tawney says.

For patients with disc herniation or stenosis, epidural injections send steroids or anesthetic (or a combination) into the entire space around the spinal cord.

Such medications can also be injected into a specific facet joint under the guidance of fluoroscopy. Botox injections, which Liu performs, can temporarily stop the nerve signals that lead to painful muscle contractions.

Selective nerve root blocks (injecting steroids and anesthetics into a specific nerve where it exits the space between the vertebrae) can confirm the source of the pain as well as relieve it.

These blocks are performed by Liu as well as Duke interventional radiologists, who offer these outpatient spinal injections guided by CT scan. Imaging helps the injectionist place the needle precisely at the nerve or disc that shows degenerative changes.

Rahn says that these injections can aid in diagnosis if a patient may have problems in more than one area of the spine and the doctor wants to know which is causing the most pain.

"If an injectionist does a nerve-root block on one level and you don't get any relief, but on a different level you do, then that can provide some clues," Rahn says. "We're very lucky that we have several providers here who can perform this service."

A Destination for Tough-To-Treat Pain

For pain that doesn't respond to such treatments, patients can get comprehensive evaluation at Duke's Pain Clinic, which offers pain management specialists, neurologists, neurosurgeons, interventional anesthesiologists, psychiatrists, and psychologists under one roof.

Many of the patients seen at the clinic have "failed back surgery syndrome" -- persistent post-operative pain.

One of the causes is scar tissue that puts pressure on a nerve, says Parris, the clinic's director.

"Surgeons can't control the accumulation of scar tissue," Parris says. "Different people produce different amounts of scarring."

For such patients, the clinic offers specialized therapies, including a new procedure offered at only a handful of places -- percutaneous neuroplasty.

For patients with spinal stenosis and failed back surgery, this treatment involves injecting a 10 percent saline solution (hypertonic saline) that may dissolve scar tissue. Guided by fluoroscopy, the doctor injects the precise disc affected.

At the October 2007 meeting of the American Society of Anesthesiologists, Parris and colleagues presented results of a small study demonstrating the efficacy of this procedure [abstract available at www.asaabstracts.com].

Other treatments circumvent the nerve signals that cause pain.

For instance, ziconotide (Prialt) is administered directly into the spinal cord fluid through an implanted or external pump. Ziconotide is for patients who haven't responded to narcotics or for whom narcotics are contraindicated because of allergies or addictions, Parris says.

The clinic also offers nerve ablation for patients who have failed more conservative therapies, and for patients with nerve injuries, the clinic can implant a spinal cord stimulator that blocks pain "messages" using a small electrical stimulation that the brain doesn't perceive as painful.

"This is not for everybody," Parris cautions. "In the wrong patient it could be harmful."

In addition, psychiatrists and psychotherapists at the clinic treat the depression that can accompany chronic pain, and biofeedback is also offered.

"It's a very good adjunct therapy, to learn how to relax, how to cope with the pain," says Billy Huh, MD, PhD, associate professor of anesthesiology.

"The mind is a very important part of pain management."

Surgery: The Path Less Traveled

Patients shouldn't enter surgery territory until they've tried conservative therapy for at least three months, and more likely six, without success.

Even then, doctors reserve surgery for those with classic symptoms of particular conditions that also show up on imaging studies.

"Surgery can be very effective for back pain, but it needs to be directed to the diagnoses that clearly improve with surgery" -- such as spinal stenosis, adult scoliosis (curvature of the spine that's not congenital), and degeneration of a single disc, says neurosurgeon Rob Isaacs, MD, assistant professor of surgery and director of spine surgery.

To address the full range of patient needs, Duke's multidisciplinary spine surgery team includes both neurosurgeons, such as Isaacs, Michael Haglund, MD, PhD, and Carlos Bagley, MD, as well as orthopaedic surgeons such as Minchew, Richardson, and Christopher R. Brown, MD.

Brown, an assistant professor of orthopaedic surgery, says that the pool of surgical candidates has narrowed in the last 10 to 15 years.

"I don't do surgery for back pain. I do surgery for spinal instability," he says.

That's a broad term for any condition that causes the vertebrae and discs to interact abnormally, for instance when one vertebrae slips upon another (called spondylolisthesis). Patients with instability will often have pain that radiates into the legs and impedes walking.

A patient with a badly degenerated disc may be a candidate for fusion surgery, in which doctors remove the disc, then graft on bone and sometimes insert screws. The procedure stops the movement and reduces the pain caused by the lack of cushioning between the vertebrae.

The best candidate for a fusion is someone with degeneration in only one disc (single-level disease). Fusion does carry the risk that patients will later develop adjacent-level disease; by stopping natural movement of one vertebrae, the stress may be transferred to an adjacent one.

Artificial discs attempt to eliminate that side effect.

Disc replacements are approved by the Food and Drug Administration, and Duke does offer them, but many insurance companies won't pay for them.

Brown has performed one lumbar (lower back) disc replacement at Duke. But studies have shown that such disc replacement is only as effective as, not better than, disc fusion, he says.

Study results are better with disc replacements in the cervical spine (neck), but insurance companies often refuse payments for those as well, Brown says.

To provide more options for future patients, Richardson works with Lori Setton, PhD, professor of biomedical engineering and associate research professor of orthopaedic surgery, to engineer cells similar to the body's own that could be used to help regenerate discs.

And the researchers are trying to merge anti-inflammatory medications with proteins that will cause medications to gel around discs and stay there, reducing systemic side effects.

Richardson advises on the design of these experiments from a surgeon's perspective. But the use of such treatments is probably years away, he says.

Mapping the Best Route in the Operating Room

Isaacs and Richardson help patients now by offering minimally invasive procedures for virtually all back problems that respond to surgery, from disc degeneration to spinal stenosis.

While some traditional procedures require such drastic measures as collapsing a lung, minimally invasive surgery can be done with a few small incisions. That means fewer complications and a shorter hospital stay for patients.

"The short-term morbidity is dramatically less with minimally invasive procedures. The risk of being transfused is less, the risk of having a major medical complication is dramatically lower," Isaacs says.

Isaacs works to improve outcomes for all procedures through Duke's participation in the Degenerative Spine Study Group.

"We're linking up thousands of patients undergoing a certain procedure in the United States, and looking at the outcomes," Isaacs says.

Every time a patient has spine surgery at Duke, information about the procedure and outcomes are collected, along with that of patients at 30 centers around the country.

The data will tell surgeons whether minimally invasive procedures result in better long-term outcomes than traditional ones, and how to best perform procedures, such as whether to operate from the back or from the front.

Learning about Duke's minimally invasive procedures persuaded Carol Smith to take steps to stop hurting sooner.

She began having aching back pain around 1997. After an initial diagnosis of muscle spasms, an x-ray showed a curve in her spine.

Smith has adult scoliosis, which occurs more often in women and often worsens with age. As her curvature got worse -- in nine years it progressed from a 13-degree curve to a 33-degree curve -- the pain made it hard for her to walk and to do everyday things like shopping.

Another doctor had suggested a traditional procedure in which he'd have to cut along her spine and use a metal rod, screws, and bone grafts.

"It sounded horrendous to me," she says. "If there was no other option I probably would have gone that route, but not anytime soon."

Fortunately, she found an alternative -- and turned to Isaacs for a fusion surgery that required only three incisions in her side.

She had the procedure on a Monday and went home that Friday. Her predicted recovery time is three to six months, half the time predicted for the traditional procedure.

"Just thinking about the description of the other treatment, there's not a lot of comparison," Smith says.

"I'm so glad to have gotten it fixed. I was just really tired of hurting."

For more information about Duke's services for back pain, patients may call 888-ASK-DUKE (888-275-3853) and physicians may call 800-MED-DUKE (800-633-3853).

This article was first published in the Summer 2008 edition of DukeMed Magazine.