Rye, East Sussex, UK
|Illustration by Claude Serre.|
As a rheumatologist, now retired, I spent a good portion of my working life dealing with patients who had back pain. I reckoned over the course of thirty-three years in the specialty that I had back pain largely nailed. I developed an algorithm which enabled me to determine, with what I considered reasonable accuracy, whether back pain was from the bone (malignant or due to osteoporosis), muscular, arising from a disc prolapse, or due to a facet joint problem. I was hot on red flags. I was able to divert patients away from unnecessary investigations and treatment, working on the basis that well over 90% of mechanical back pain got better on its own, so long as you gave it enough time (around six weeks). Alternative therapies invariably undertaken within that time were no more effective than nature doing its own stuff. Brought up to immobilize back pain patients in traction, I learned that such treatment was harmful, and that patients should be kept moving as far as possible. In the end it became apparent that as my physiotherapy colleagues were just as good at taking a history and examining patients as I was, I only needed to see those where something was seriously amiss.
So you might assume that when I was seized with my first agonizing episode of severe back pain I would have no trouble self-diagnosing, would patiently wait for it to get better, and take the odd painkiller. I had felt my back “go” while sweeping up some leaves, so there was a typical mechanical trigger. Easy.
Wrong. After two days I was lining up for a GP appointment and an MRI scan. The first problem was that the pain did not fit my algorithm. It had elements of everything. It seized me when I bent forwards (disc), was even worse when I tried to stand straight from a bent position (facet), was bad at night (bone pain, possibly nasty), and was accompanied by muscle spasm so bad that I cried out. I had referred pain in my buttock. Painkillers did not work. However, I stood manfully by my “do nothing but try and keep moving if you can” mantra and sure enough, after about ten days, it gradually settled down leaving me none the wiser about what had given rise to it.
I was embarrassed by my pathetic behavior, at least internally and not least because my dear wife thought I was making rather a fuss. I should have been more robust. Did the exact diagnosis really matter? No. That said, when it took fifteen minutes to get down two flights of stairs, and standing for any length of time required a stick, it was no picnic.
Some six months later the pains struck again. But this time there was no trigger event, and the diagnosis was even less clear. Sometimes the pain was one-sided, confined to the back, sometimes there was referred pain, sometimes there was nerve root pain in the groin (L3/4) and sometimes in the back of the leg (S1) with an element of root claudication, so the leg numbness worsened as I walked. Once more there was intense muscle spasm. All positions were uncomfortable or worse. A sudden jerk was agony. The pain was up to nine on a scale of ten. Then it switched sides. Bladder function was altered (normally I get up once or twice in the night, but the urge to do so had disappeared). There was a burning element to the pain and I was beginning to wonder, as it got steadily worse, whether I had something malignant. At the very least, I thought, I had a disc prolapse, but the root symptoms were so widespread and variable I could not convince myself what level it must be.
Once more I geared up to seek an independent medical opinion and investigations. I did not care whether the result would alter management, I just wanted to know what was going on.
And then, ten days later, it stopped. Just like that. Over the space of an hour all of the root pain vanished, as did most of the back pain, leaving what one might call a residuum of “ghost” pain—just enough to remind you of where it had been, but barely at a level of one out of ten. And after a couple more days even that went.
Was it a disc prolapse? Did perhaps the prolapsed bit detach itself, drop into the spinal canal, and sink to the bottom where it caused no pressure effect and was gradually absorbed? That is my best bet. Sure, some of the pain came from the facets as the disc narrowed and the facets jammed together, but they too adjusted to the altered strains.
Since then I have had the occasional twinge with some muscle spasm, but nothing more.
The several morals of this tale are:
- However clever you think you are, when it happens to you your capacity to make a diagnosis is not as clear-cut as you might like to think.
- Mechanical back pain really does get better on its own but . . .
- When pain really grabs you, you will panic and want it fixed yesterday.
- Having worked yourself into a frenzy that you are about to die from a spinal malignancy, you will feel extremely foolish when the pain vanishes.
But the big question is—if it comes back, will your experiences help you to remain calm, rational, and professional? This is, in my view, a question to which the answer is no.
ANDREW BAMJI, MB, FRCP, is Gillies Archivist to the British Association of Plastic, Reconstructive and Aesthetic Surgeons. A retired consultant in rheumatology and rehabilitation, he lives in Rye, UK. He was President of the British Society for Rheumatology from 2006-8. He has written widely. He co-edited the Atlas of Clinical Rheumatology (Gower Medical, 1986); wrote a history of early twentieth-century plastic surgery (Faces from the Front, Helion, 2017); a book of personal recollections (Mad Medicine: Myths, Maxims and Mayhem in the National Health Service, KDP, 2019); and a collection of poems (The Doctor’s Doggerel, KDP, 2019).