Defining the Source of the Pain

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Identification of a potential “pain generator” is always the first step in dealing with low back pain.  It is the role of your surgeon to order the appropriate tests to define your anatomic problem.  If there is a definable structural source of pain, then there is the option of having it surgically treated.  If there is not a discrete anatomic problem that has a high chance of being the “pain generator,” then the pain must be originating from the soft tissues supporting the spine.  The terminology I use is “non-structural.” (I talk about this in the video: Is Your Pain Structural or Not?)

There are two factors that, if present, mean your pain is caused by a structural problem. These are a clearly identifiable lesion and clinical symptoms that MATCH the lesion. Both must be present. The presence of an anatomic abnormality alone does not constitute a structural problem.

It is critical that you understand the concept of a structural versus non-structural problem so as to have an informed discussion with your surgeon in regards to the surgical options.  It is not feasible to push rehab in the presence of a significant anatomic problem. It also is not a great idea to engage in a major surgical structural procedure for soft tissue pain. These concepts are discussed in detail in the surgical section of the book.

Most of the time, in the context of low back pain, there are no identifiable structural problems.  The two areas then remaining to be addressed are the soft tissues and the central nervous system.

One of the major obstacles in truly moving forward is your feeling that “something is being missed” or that “there just has to something that can be fixed.”  Surgeons also feel the same way, which is one of the reasons there is so much surgery performed.

We don’t want to miss anything either.  It is our responsibility to make sure that there is not a solvable structural issue and then to clearly explain it to you.  It is important for you to have that reassurance before you can move forward.

However, if you have been told several times that there is not a surgical solution, then you have to let go.  With the level of diagnostic testing in this day and age, not much is missed.  If you cannot let go, you cannot move on.  You will also find a knife-happy surgeon willing to do surgery if you look hard enough.  I can not stress enough how bad an idea this is.