While new replacement disc surgery is available, nonsurgical and drug-free treatments also are gaining popularity

It's not too much of a stretch to say that to experience back pain is to be human. About 80% of people have back pain at some point in their lives, and it's second only to cold and flu in the number of doctor's visits it prompts.

Part of the problem is in our design. We're the only animals that get around exclusively by walking on two feet, and that places a tremendous amount of stress on our backs.

"The second and probably more important (factor) is that as a whole our society is more physically deconditioned and overweight," says Dr. John Klekamp, an orthopedic surgeon at The Bone and Joint Clinic in Franklin.

Back pain can be notoriously difficult to diagnose and treat, but advances in nonsurgical and surgical options make it more likely than ever that your pain can be tamed.

A LOT CAN GO WRONG
Your back is the most versatile collection of joints in your body, keeping you upright despite gravity, yet allowing you to bend to the ground to pick up a pencil.

It's made of 24 bony vertebrae that protect the delicate spinal cord and are cushioned by gelatinous, shock-absorbing discs. Passing through the spaces between the vertebrae are nerves that relay signals between the spinal cord and the rest of the body. Muscles and ligaments support the entire structure.

Such complexity brings versatility as well as the potential for many things to go wrong:

• Muscles and ligaments can be strained after an injury or through the accumulated effects of years of bad posture.

• Discs dry out and become less flexible with age, and can bulge out or break open (a herniated disc) and put pressure on nerves.

• Osteoarthritis, the progressive breakdown of cartilage, can cause joints to painfully rub against each other.

And that's just a sampling of what can go wrong. "The hardest thing about back pain is diagnosing what we call the 'pain generator,' " Klekamp says. "There are so many different entities that can cause back pain."

Getting to the root of the problem is complicated by the fact that many people, even those without symptoms, have some kind of back abnormality that's detectable by diagnostic tests such as MRIs. That means that if you look for a problem with your back, there's a good chance that you'll find one even if you feel fine.

SIMPLER SOLUTIONS
The number of people undergoing back surgery is booming. According to the federal Agency for Healthcare Research and Quality, the number of spinal-surgeries shot up 77% between 1996 and 2001. That year, 250,000 surgeries were performed, and doctors say the number keeps rising every year.

Still, the consensus is that conservative treatments are the way to go, at least initially. Losing weight can decrease stress on your back, and exercises can strengthen back muscles so that the spine is better supported. Small changes, such as sleeping on a medium-firm mattress or using a heating pad or a disposable heat pad, also can help.

Chiropractic care once was considered alternative medicine, but in recent years has become a mainstream option for back pain. A study published last year found that chiropractic care reduced back surgeries by 32% and cut hospitalizations among back pain patients by 41%.

"When I first started practicing (20 years ago) it was quite rare that a medical doctor would refer a patient to me," says Dr. Beth Barnett, a chiropractor and co-owner of the Green Hills Chiropractic Clinic. "Now, it's quite common."

The nonsurgical, drug-free option appeals to people such as 51-year-old Mary Dimoff of Mount Juliet. She has scoliosis, a condition in which the back has an irregular S-shaped curve in it. Her medical doctor told her that she could either have surgery, which carried the risk of paralysis, or she could take narcotic pain relievers, which carry the risk of addiction. Neither option appealed to her. "I said, 'So either I'm paralyzed or I become a junkie,' " Dimoff recalls. "And I walked out and never came back again."

She's been undergoing chiropractic care for five years and credits it with keeping her pain at bay.

Barnett's practice also incorporates massage and acupuncture, two of the most popular non-medical treatments for back pain. A 2003 review of the medical literature on the role in acupuncture and massage in treating back pain concluded that acupuncture is as effective as non-steroidal painkillers. Massage was found to be more effective than acupuncture and more cost-effective than chiropractic care, which was found to have "real, but modest" benefits.

PAIN SPECIALISTS
When traditional treatments don't work, patients can turn to pain-management specialists. Dr. Benjamin Johnson, director of the Nashville Pain Management and Pain Rehabilitation Center at Skyline Medical Center, stresses that pain management is an approach that uses techniques from many fields and isn't just prescribing pain pills.

It can involve physical therapy and psychology as well as outpatient surgical procedures. In a procedure called intradiscal electro-thermal therapy, a surgeon inserts a heated wire into a painful disc. The heat makes the disc contract to seal any tears or cracks while burning nerves to make them less sensitive. Nucleoplasty uses radio wave signals to remove bulging parts of discs.

Psychologists are increasingly being used to manage back pain because doctors are beginning to appreciate the role depression plays in back pain — as a cause and an effect.

"It's sort of vicious cycle," says Johnson, also an associate professor of anesthesiology at Vanderbilt University Medical Center. "The more depression a patient has, the more pain is perceived. And the more pain is perceived, the worse the depression is."

Narcotics still are the gold standard of pain relief, but antidepressants and new drugs used to treat nerve pain are playing a role in some patients' pain management.

"There's no one drug that seems to be helpful in all patients, so we have to use a combination including narcotics, antidepressants, anticonvulsive and anti-inflammatory medications," Johnson says.

NEW SURGICAL SOLUTIONS
The most popular back surgery is spinal fusion, where surgeons remove the disc that's causing pain and fuse the adjacent vertebrae together with rods, screws and a bone graft.

The benefit is it that can instantly eliminate disc pain by removing its source. The downside is that it puts additional stress on the discs adjacent to the fusion, which could set a person up for more back problems later.

"It never really corrects the problem," says 42-year-old Carter Ezell of Franklin, who has suffered back pain most of his life.

Ezell opted for total disc replacement, one of the newest and most anticipated surgical options. Doctors replace a diseased disc with an artificial one that mimics the natural motion and cushioning of a disc.

Disc replacement was approved by the Food and Drug Administration in October, and Ezell had the surgery done at The Bone and Joint Clinic in 2001 as part of a clinical trial. The clinic now is one of 15 centers in the nation training surgeons on the implant.

Ezell was back to work in 10 days instead of six weeks for the fusion surgery, and now is able to do everyday activities, such as playing ball with his children, without pain. "There are still aches and pains," he says. "But I think those are more attributed to just getting old."

Although the surgery is promising, Klekamp points out that it does have several limitations. It's only for people with a severely degenerated disc at a single level. It's not for people who are obese, have osteoporosis or have had previous major abdominal surgery.

And the consensus among doctors is that it won't likely replace fusion surgery. A survey of 133 surgeons conducted at a meeting of the American Orthopaedic Association found that only 7% said they'd choose disc replacement if they had unrelenting low back pain. Forty-seven percent said they'd choose spinal fusion and another 47% would choose chronic pain management.

When asked why they wouldn't want disc replacement, 59% said they were unsure about the long-term durability of the implants, 30% worried that surgery will be over-used and 9% worried about surgical complications.

Klekamp encourages patients to do everything they can before resorting to surgery. "It has complications and risks and it is not foolproof," he says.