Jean was a middle-aged rancher who I saw for a second opinion from a neighboring state. She filled out an extensive spine pain questionnaire, which included many psychosocial questions in addition to a history and diagram of the pain. She was healthy and normally an extremely physically active rancher. Her low back pain started in the summer of 2005 after a lifting injury. The pain was constant and was located throughout most of her back. She was still functioning at a fairly high level in spite of the pain.
Her prior care
Jean’s care so far had consisted of six visits to physical therapy and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed any specific treatment plan or self-directed exercise program. On her second visit to a spine surgeon, it was recommended that she undergo a eight-level fusion of her lower back.
Jean’s x-rays showed that she had a mild curvature of her lower back. Other tests did not reveal any identifiable structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age. Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. There is also significant surgical risk associated with a six-level fusion. Also, with your entire lower back now turned into a solid piece of bone, you are just not the same person. There are long-term lifestyle limitations. At this point I was perplexed as to why surgery had been recommended when she’d undergone such little rehab. I also didn’t understand why she was continuing to experience such severe ongoing back pain without an obvious cause.
What was missing?
At this point, I knew to consult Jean’s intake spine questionnaire to look for clues. It revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention because marital troubles indicate significant stress. She then said her job had become much more stressful. Although she worked for the same employer, they had forced her to switch duties without adequate training. She was anxious about not only her performance, but also her ability to keep her job. This was another major stress.
I turned the page. A month before her pain began, her twenty-six-year old son had drowned.
Up until that point, I knew that outside stressors played a role in chronic pain, but this factor had never been so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances instead of just looking at surgical solutions. As I sat there stunned, I realized that I needed to do something different. Structured rehab started to become the main focus of my practice.
I have not taken my eyes off of that vision since that day.