Conquer Back and Neck Pain - Walk It Off! (16 page)

MRI stands for magnetic resonance imaging. In order to understand how it works, recall when you were in science class learning about how a magnet works. When you place a magnet under a paper containing iron filings, the little pieces of iron arrange themselves on the paper in the orientation of the magnetic field of the magnet. If you rotate the magnet under the paper, the iron filings re-distribute themselves to align to the new orientation of the magnetic field. Picture all of the trillions of water molecules in your body as iron filings, and place them in a magnetic field that is made to oscillate back and forth. The water molecules will orient themselves first one way and then another and begin to wobble. Given a few trillion molecules wobbling all in the same direction, they give off a signal, resonance, which can be detected and converted into a picture by a computer. The water molecules in your body will resonate differently according to where they are located in your body, such as in discs, spinal fluid, fat, bone, or muscle. MRI scanners are comprised of large magnets to make the water molecules in your body resonate, and computers that can detect the resonance and produce a clear picture of parts of your body such as the discs in your back.

This side-view MRI scan of the low back shows a herniated disc between the 4th and 5th lumbar vertebrae and a bulging disc between the 3rd and 4th vertebrae.).

Using an MRI scan, your doctor can distinguish different tissues in your body such as disc, bone, fat, muscle, blood, spinal fluid, scar tissue, and ligaments. It can distinguish normal from degenerated and herniated discs. You can see the degree to which a disc is degenerated on an MRI scan. The scan can tell you how far out into the canal a disc has herniated. Tumors, infections, and fractures can be detected by MRI scans.

No other diagnostic test can provide you with so much information concerning what is wrong in your back. And yet MRI scans are safe, accurate, cost-effective, create no x-ray exposure, and can be performed on almost everyone except patients who have metal implants in the exact area of their spine that must be seen. Stainless steel screws and rods in the spine will interfere with the MRI scan picture. People with a heart pacemaker should not have an MRI scan (magnetic fields can interfere with the function of a pacemaker). People who have some other magnetic metal foreign objects in their body should not have MRI scans. However, you can have an MRI if you have a metal joint replacement in your hip, knee, shoulder, or ankle. Also, most metal bone plates, rods, and screws for fracture fixation are compatible with having an MRI scan. Spine implants made of titanium steel do not interfere with the MRI scan as much as stainless-steel implants. People with a stainless-steel implant in their spine or who have a heart pacemaker should have a CAT scan and/or a myelogram instead of an MRI to diagnose their problem.

When the first MRI scan arrived in our clinic in the early 1980s, I volunteered to have one performed on me, in order to understand what my patients would experience and to be able to advise them about the study. I was also curious to find out if an MRI scan could tell me why I had suffered from periodic bouts of back pain. I was placed face-up on a thin stretcher on tracks and was slid into a tunnel in the scanner that was about 10 feet long and open at both ends. My face was less than a foot from the wall of the tunnel. As the scan began there was a loud, incessant thumping noise; I surmised this was the magnetic field being shifted back and forth. After a short period of time I became very anxious, my heart began to beat fast, and I started to breathe heavily. I felt afraid and shouted, “Get me out of here!” It seemed like an eternity, although it was probably only a few seconds, before they pulled me out of the scanner. I had suffered from a claustrophobic attack. I never had any clue before that time that I had claustrophobia (irrational fear of small, enclosed spaces). As a result of my claustrophobic experience in the MRI scanner, I developed some ways to prevent this from happening to others. I will pass them on to you.

Open MRI scans have been developed for the claustrophobic patient. Unfortunately, the pictures produced by the open scanners are not as clear and accurate as those from the closed scanners. I often see patients who come to my clinic with an MRI scan that was performed in an open scanner, and the scan is usually inadequate to clearly localize the cause of their pain. The patient ends up needing to have another scan performed in a closed scanner in order to make the diagnosis, much to their distress and to that of their insurance company.

To get the claustrophobic patient through a closed MRI scan without a reaction, I suggest the following measures. I first explain the importance of using a closed scanner to accurately diagnose their problem and the inadequacy of an open scanner for this purpose. I tell my patients to tell the technician who is performing the scan about their claustrophobia and that they want to be removed from the scanner at the first sign they become anxious. I recommend that they have a relative or friend drive them to the MRI facility and sit with them through the scan. Finally, I prescribe a sedative to be taken just before the scan. Using these measures, I was personally able to have an MRI scan of my spine several years after my first unsuccessful attempt. These measures and advice have proven to be very helpful for my claustrophobic patients who would not otherwise have been able to obtain an MRI scan. Even if you are claustrophobic, these recommendations should help you to successfully obtain an accurate MRI scan.

The picture of the spine obtained from a good MRI so clearly shows the reason for the pain that it is easy for my patients to see the problem when I show it to them (see page 53). The only problem with the MRI is that it sometimes shows too much information. A famous spinal surgeon and mentor once told me that the doctor who treats the image on the x-ray is a shadow boxer, and the doctor who treats the patient is a heavyweight. This means that the indication for surgery is not the appearance of a herniated disc in the patient’s MRI scan, but the patient’s pain and disability resulting from the disc herniation. The patient’s symptoms and disability must be confirmed by the MRI scan for the test to be useful. Many a time I have seen a disc herniation in an MRI scan that is on the side opposite of the patient’s pain. After further scrutiny the real culprit producing the pain becomes apparent on the correct side, and the disc on the non-painful side is of no consequence. We know from our discussion in the first chapter of this book that not all disc herniations produce pain. I have seen patients who were told they needed surgery because of a large disc herniation that was seen on their MRI. The patient seeks another opinion because their pain is not so bad, and they instinctively know that surgery is not completely necessary. I reassure them that they can safely avoid surgery and that they will eventually get better with time despite the appearance of a large disc herniation on their MRI scan.

You have been told that you have a herniated disc on your MRI scan and that you need surgery, but you are getting around all right and you do not have severe pain, weakness, or loss of bowel and bladder function forcing you to have emergency surgery. What are your options? Most people with disc herniations fall into this category. They can get around, but that is about it. Something must be done so that they can sleep, go to work, and eventually get back to normal.

First of all, it has been proven that if you can live through the pain without surgery, you have better than an 80 percent chance of full recovery (no pain, full function, no nerve damage) within one year and 92 percent in 10 years. This is the same chance of recovery that you can expect with surgery! It seems obvious that waiting is safer than having surgery. But that is not necessarily true if you develop a complication from non-operative treatment, such as becoming habituated to pain medications, developing a bleeding ulcer from anti-inflammatory medication, or developing an infection from an injection. So then what is the safest and most effective course of action: surgery or no surgery?

I advise my patients who have a painful disc herniation that they have three options. The first is to walk it off and be as active as you can be within the limits of the pain. I reassure them that there is a good chance the disc will shrink by itself, given enough time, and that the pain will go away within four months of onset. Our bodies have normal defense mechanisms that allow this to happen. If their pain is not interfering with their sleep and work, they usually take this option. After such discussions, many a patient has told me that understanding the problem was half the cure. Knowledge of the natural history of disc herniation gave them the reassurance they needed to discontinue medical care and walk it off!

If they require pain relief in order to sleep and function, I recommend a series of one to three epidural steroid injections (I will explain what epidurals are in a moment). Epidurals are very effective in relieving pain from a herniated disc. Pain relief allows you to walk off the symptoms and keeps you from taking narcotics and muscle relaxants (commonly prescribed pain relievers), which are habit-forming, make you drowsy, and cause depression (more about this in
Chapter 8
on chronic back pain). If the pain from a herniated disc is still significantly impairing their quality of life after three months of waiting for it to go away, then I recommend the third option, surgery.

Here is a further explanation for the three options in treating a painful herniated disc: walk it off, epidural steroid injection, and surgery.

We know from several classic studies that the natural history of symptoms from disc herniation is spontaneous resolution, if given enough time. As long as the disc has not caused progressive or severe nerve damage, it is better to try to walk the symptoms off. The secret is not to allow the pain to make you physically debilitated or mentally ill.

First you should consult a spinal specialist (see
Chapter 4
) who is familiar with disc problems and who should determine that your symptoms are really the result of a herniated disc.

Second, you should do only what is necessary to obtain enough pain relief so that you can get a night’s sleep and get around enough to take care of yourself. This means taking as few narcotic painkillers and anti-inflammatory medications as possible. Try not to take any muscle relaxants at all, which cause too many side effects, such as drowsiness and depression. Avoid traction, hanging upside down, manipulation, and especially passive stretching of the painful extremity. Remember how I made an enemy of a colleague by performing a straight-leg-raising test? Very light massage, heat and/or ice packs — well padded so as not to burn your skin — are good for pain relief. Most of these touch measures, as well as acupuncture, will relieve pain as long as you are not taking narcotic pain medications. I will explain the reason for this in the chapter on chronic pain. Try to remain as active as possible within the limits of your pain and stamina. Walking, aquatic exercises, stationary bicycle, and treadmill aerobics all help to keep you from becoming deconditioned (out of shape). Do
not
take pain medication so that you can exercise. Remember that the pain is a warning that something is wrong, and it is a normal defense mechanism. If, because of the pain, you cannot remain active despite these measures, then you should consider the following options for your disc herniation.

Epidural steroid injection (epidural) is a method of injecting a small amount of local anesthetic and steroid medication (the most powerful anti-inflammatory drug available) directly into the area of your spine where the nerve is being irritated by the herniated disc. The object is to place the potent steroid where it will do the most good. The local anesthetic is added to the injection to give you immediate pain relief and to confirm that the injection is at the correct location. Herniated discs can be a triple whammy to the nerve because they not only compress and stretch the nerve, but they leak irritants to the nerve. Epidural steroid injections are meant to block the irritants and reduce the pain. I prescribe them so that patients can get enough pain relief to avoid taking narcotic painkillers and so that they can get a good night’s sleep. One of the benefits of epidural injections is that only small doses of steroids are required to be effective.

I am not an advocate of giving steroids by mouth, the so-called “dose-pacs,” because it requires very high doses to get enough steroids to the area of the irritated nerve to be effective. The high doses of oral steroids required to be effective can cause some rare but harmful side effects, such as an increase in blood sugar (diabetes), loss of bone mass (osteoporosis), bleeding ulcer in your stomach, and destruction of the hip joint (aseptic necrosis of the hip). These bad side effects from steroids taken by mouth are not as common when they are given by epidural injection.