Saved from the knife

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13 Nov 2018

At the time of writing this article, Elly is supposed to be on an airplane flying to the United States in order to get a very intricate and delicate surgery to repair a problem with the disk that sits in the lumbar spine between vertebrae L4 and L5.  Elly started to have severe lower back pain more than 18 months ago.  As time went on, the pain only got worse and after a while, he began getting a shooting pain down his left leg-sciatica.  As if that wasn’t bad enough, in the same leg, he began to experience tingling as well.  Needless to say, Elly’s quality of life wasn’t very good and he was taking a maximum amount of pain killers.  Even his family doctor asked him to try to cut down on the medications. 

Elly had business in America so on his last trip there, he consulted with someone who is considered one of the top surgeons to attempt to repair this protruding (possibly herniated) disk.  The cost of the surgery?  $31,000!   The recovery period?  After 5-6 days in hospital, if all goes well, there would be several more weeks of bedrest and light activity until a return to functionality. 

But just in time, with hashgacha pratit, a friend of his was speaking to him on the phone when he mentioned his plans.  The friend is a Rav here in Yerushalayim who had come to me a few years earlier for excruciating lower back pain.  We worked together to bring relief and then worked on his overall health and fitness.  Baruch Hashem, today he is fit and has no problems at all with his back.  He convinced Elly to come to me before subjecting himself to surgery and all the possible complications that can occur both after the operation and possibly years later. 

The biggest issue for me with Elly was that, unlike most of my clients who come with lower back issues, he had been living with this for more than a year and a half.  So, we began with low back specific stretches, icing and heat and then we moved into a more regular exercise routing, which included stretches, using a recumbent bike for aerobics, and some light weight lifting. 

Two months later his pain, tingling and weakness is 85% better than when we started and Elly is also generally fit.  His belt has even gone in a notch.  But what set off Elly and how can we potentially avoid going under the knife when we have back pain? 

Prominence of Lower Back Pain

After headaches, lower back pain is the second most common ailment in the Western World today.  At least 60-80% of the population will experience minimally one episode of lower back pain in their lives. It may range from a dull ache to a bout of intense and prolonged pain.  Not only is it painful, but it is costly as well.  Billions of dollars are paid in compensation and lost workdays, many due to on-the-job injuries. Let’s take a look at how to protect the health of your spine.

Nutrition for your back?

In order to keep your spine healthy, you need something we will call “good disk nutrition.”   When we think of nutrition, we generally think in terms of consuming the proper types and amounts of foods, nutrients and vitamins. The last connections we are likely to make in terms of nutrition are the disks that sit in between each of the vertebrae of the spinal column. Yet, without proper nutrition to these disks, trouble is right around the corner.

The inter-vertebral disks are located between the vertebrae and are ringed with a tough, fibrous outer material called the annulus fibrosus, and are filled with a thick, soft jelly-like material called the nucleus pulposus. When one of these disks ruptures and the jelly oozes out of the casing, the stage is set for chronic degenerative back disease, inflammation and/or impingement of nerves and can lead to back pain syndrome. It’s these disks, when healthy, which keep the vertebrae in place and keep them from degenerating. More importantly, the disks act as shock absorbers in between the vertebrae. This is of utmost importance when flexing, extending or rotating the spine – movements we all use in our everyday life. 

How do we nourish these disks so that they stay healthy? Early in our lives, they are nourished by direct blood supply. However, as we mature and the vertebral endplate closes, these blood vessels disappear and a different process begins to take hold. From this point forward, a combination of osmosis and imbibition supply the nourishment to the inter-vertebral disks.

Imbibition is the sponge-like action of soaking in the nutrients. It occurs during spinal movement and ensures the entry of the nutrient-loaded fluid into the nucleus of the disk. Imbibition cannot occur to any significant extent without alternating compression and relaxation of the disks. Douglas Books, M.S. uses the example of grapes versus raisins to create the image of a healthy disk versus and an unhealthy disk. When you bite into a grape, it is full of juice and there is a bit of a crunch. But when you bite to a raisin, which is the dehydrated version of the grape, the fruit is chewy and there is no juice. How do we achieve a healthy disk (grape) as opposed to an unhealthy, undernourished disk (raisin)? 

Two areas of the utmost importance are maintaining proper posture and getting the proper amounts of exercise and stretching for the back. LBP (low back pain) typically is located in the lumbar region of the spine, with L4 and L5 (like with Elly) being the most common place.  Undoubtedly, you have probably heard of slipped, herniated, shattered, protruding, and crushed disks.  These are some of the ramifications of LBP. But what brings on these conditions and how can they be prevented and corrected?

Causes of Lower Back Pain

The main causes of LBP are weak abdominal muscles, tight hamstring muscles, poor posture, stress and poor biomechanics do to flat feet or high arches on the bottom of your feet.  Also, a simple thing like a worn-out pair of shoes can bring on back discomfort.  Prevention of LBP includes a well-balanced exercise program that incorporates flexibility training (stretching) and abdominal strengthening.  A pair of good, functional orthotics can correct a biomechanical problem.  And, aerobic exercise is known, amongst its many benefits, to be a great stress reducer.  Being overweight is most certainly a big contributor for LBP, as is smoking. 

Many years ago, the common thinking on treatment for LBP was to prescribe bed rest.  There is now strong evidence that this treatment is ineffective. Numerous studies have indicated that bed rest of more than 2-4 days can start to weaken muscles, actually delaying recovery.  The current thinking is that a person with LBP should be physically active.  Walking, even if somewhat painful, is considered essential. 

To operate of not to operate?

Any time you operate on the spine, there is some risk of injuring the spinal cord. This can lead to serious injuries to the nerves or the covering of the spinal cord – the dura. The spinal cord is a column of nerves that connects your brain with the rest of your body, allowing you to control your movements. The nerve fibers in your spinal cord branch off to form pairs of nerve roots that travel through the small openings (foramina) between your vertebrae. The nerves in each area of the spinal cord connect to specific parts of your body. Damage to the spinal cord can cause paralysis in certain areas and not others, depending on which spinal nerves are affected.

Some spinal operations are simply unsuccessful. One of the most common complications of spinal surgery is that it does not get rid of all of your pain. In some cases, it may be possible to actually increase your pain. Be aware of this risk before surgery and discuss it at length with your surgeon. He or she will be able to give you some idea of the chance that you will not get the relief that you expect.  Some pain after surgery is expected, but if you experience chronic pain well after the operation, you should let your doctor know.

As with any surgery, risks caused from anesthesia and getting blood clots exist.  In addition, the risk of excessive scar tissue can occur. All patients will heal with scar tissue after back surgeries as this is the only way to heal. Clinicians often use the explanation of scar tissue as the cause of continued pain, whether or not there is any evidence that this is in fact the patient’s pain generator. Often, a better explanation for continued pain after surgery is that either the patient has a secondary problem that needs to be addressed, or that the lesion operated on was not in fact the source of the patient’s pain. I can tell you that I personally have a relative who after several back surgeries is a incapacitated today because of scar tissue. 

Whether surgery is necessary will greatly depend on who you speak to.  Orthopedists may be inclined to recommend surgery.  Physical therapist will almost always tell you to try therapy first before invasive procedures.  It certainly is less dangerous as far as potential complications.  Surgery, no matter how routine or not, always carries certain risks!  Let’s take a look at some recent data regarding NOT doing surgery.  Regarding lower back surgery—it is estimated that in the United States, of the 56 million people with lower back pain, no more than 5% really need to have surgery.  As a matter of fact, in the United States there are roughly double the amount of back surgeries as a percent of the population than any other developed country.  There are times when surgery is necessary and there is no choice but as one who encourages trying other options before resorting to surgery, I can tell you that like our client Elly, there is a lot to do before one has surgery.  The complications from back surgeries can be devastating and crippling if they occur.

Happy endings

This story had a happy ending, as have others who have been helped with this problem.  There are some that might really need surgery, but most don’t.  And the best thing is that after the type of treatment we give, you will know exactly what to do if your lower back starts acting up again without taking pain killers, seeing your doctor, chiropractor or physical therapist.  Achieving success without surgery will add hours to your days, days to your years, and years to your life.” 

The words of this author reflect his/her own opinions and do not necessarily represent the official position of the Orthodox Union.