Low Back Pain - Carter Beck, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Carter Beck. Dr. Beck is a neurosurgeon. He did his medical school training at the University of Chicago School of Medicine. From there he completed a neurosurgical residency at Stanford University. Good morning, Dr. Beck.

Dr. Carter Beck: Good morning, Dr. Sechrest.

Dr. Sechrest: Well, thanks for joining us. Today I thought what we would discuss is really a general concept of the neurosurgical approach to back pain. Really, what I'm talking about is I really want to discuss how neurosurgeons view and approach the epidemic of back pain, and how you, as a neurosurgeon, tend to evaluate patients and then proceed with a treatment plan. How does that sound?

Dr. Carter Beck: That sounds like a big topic, but I'm happy to do so. It's an important topic and, as you eluded to, back pain affects a very large percentage of the population at some point in their life, upwards of two-thirds of people, at some point in their life, have back pain.

Dr. Sechrest: Let's talk a little bit about the disease of back pain. My understanding, in my experience as an orthopaedic surgeon, is that there is still an epidemic of low back pain in this country. Why?

Dr. Carter Beck: Well, that's a complicated question. I think there are many factors that contribute to a human being ultimately developing back pain. One of them is simply an evolutionary result of the fact that we have upright posture, and the mechanical stresses on the low back from the fact that we stand upright and walk around are significant. We also live much longer than perhaps at earlier points in history and that means that this mechanical device, the lumbar spine, is going to have to put up with a lot of wear and tear over a prolonged period of time. The other features of genetics or heredity may impact on which patient develops back pain and when they do in their life, and how severe it is, and what the cause is. Certainly, there is a genetic contribution to degeneration or deterioration in the lumbar spine. Lifestyle issues, smoking, we know are quite hard on the joints and, on the lumbar spine, cause a premature deterioration in the spine. Obesity, eating too much, poor physical condition, lack of muscle tone, lack of strength in the abdominal girdle from a desk job, say, or being a piano teacher, could definitely contribute. So it's a whole gamut of things that ultimately will result, one way or another, in a patient getting back pain. And, of course, there's trauma and injury. Sometimes you just twist wrong and pull a muscle. Other times, it's an amalgam of things have developed over years.

Dr. Sechrest: You know it's interesting that you mention that even having a desk job, in some ways, is a risk factor for developing low back pain. Because I think a lot of patients that come in, they're always looking for that cause of how they injured their back, and, in most cases of low back pain; it's not necessarily an injury. We tend to think that the laboring population, the people that are bending, twisting, lifting, are at more risk of developing back pain, and what you just eluded to is the fact that even people with desk jobs have risk that they may very well develop back pain and just having a nice easy job is not a protection against developing back pain.

Dr. Carter Beck: I think that's absolutely true. One of my observations over time in my career is that people, who have low intensity physical demands continuous throughout the day, probably have the healthiest spines. Custodial workers, for example, people who are doing some physical activity, moving in multiple ways, without high strain, but changing positions and doing basic healthy physical activity all day long, their spines tend to age pretty well. Whereas somebody who is either very sedentary or on the other end of the extreme, very active, say, a roofer, those people are more prone to developing a problem with their back.

Dr. Sechrest: You know, I totally agree with that, and I think I would put it a little different. I've come to believe that the critical issue is that people who have control over their ergonomics and, what I mean by that, is that people that can move around in different postures, they're active throughout the day, and it's not a static posture. So people on an assembly line, for example, they're active but it's in a static way. It's a repetitive way that the same forces are hitting the spine time after time after time. Same thing goes for sitting. If you're sitting all day, it's that same static posture. The people that you just eluded to, the people that, I would say, probably go back to our days as hunting and gatherers, who can move around and sort of do their own thing, and when they get into a bad position, they can move and do something different, they tend to age very well.

Dr. Carter Beck: Yeah, I think so. It's an interesting observation.

Dr. Sechrest: It's probably a lesson for all of us to sort of think about.

Dr. Carter Beck: Right.

Dr. Sechrest: Well, the other piece that people are always interested in is the notion of what's causing my back pain. Now, again, my approach to this is that, in the vast majority of cases when back pain starts, we really don't know what is causing your pain. We don't know the structure that is responsible for causing the pain, what we sometimes term "the pain generator", and trying to track that down and decide what structure is causing your pain, it can be a long and tedious process. Give us a little bit of a run-down from a neurosurgical standpoint, what neurosurgeons think about the causes of back pain, the source of back pain, and how you try to fit that concept into your thought processes as you're evaluating a patient.

Dr. Carter Beck: Well, I think that you've eluded to what is really, I think, the most important element of my role as a spine physician, and that is making some correlation between the symptoms a patient experiences and what we can discover from an MRI scan, a CAT scan, a set of x-rays, or any of the other diagnostic tools that we have at our disposal. I always tell patients I could pick anyone off the street today, put him in an MRI scanner, and find something that is abnormal in their spine. Does that mean that it is symptomatic and requires surgery? Usually not, in fact, the person walking down the street who I asked to have an MRI scan may not have any symptoms at all even though we find multiple things on an MRI scan. So, by that logic, if you have somebody come in the office and they say, "My back hurts and my back hurts when I sit, or my back hurts when I stand, or my back hurts while I'm at my workplace." Just because there is something abnormal on an MRI scan doesn't mean that that's the cause of the pain, and, so, that correlation is very important. The way to do that is by, I think, a very, very traditional organized and disciplined approach to clinical medicine. That is to take a careful history and listen to the patient, listen to what they're complaining about, listen to how it started, what the chronology is. Has it been bothering them for years? Has it just been bothering them for 2 days? Did it come on after a minor accident? People often tell me about tripping on their small dogs or a little stumble on the ice. So, basically, a careful history is important, a careful physical exam is important. Figuring out where it hurts, touching it, palpating it, examining the nervous system and finding out if any spinal nerves aren't functioning properly; and, then, a battery sometimes of confirmatory tests. In a 25 year old, who strained their back lifting something very heavy, perhaps all that is necessary is a set of x-rays. In somebody who has repeated episodes of back pain that may be associated with leg pain or numbness in the leg, sciatica, something that suggests that a nerve is involved, then often an MRI is indicated, and we can go from there. There are three or four other tests that are often needed in order to develop a really clear picture of the whole patient and what is going on.

Dr. Sechrest: You know, it's interesting that you've gone back to the basics of medicine. I think it is so critical in this day and age when we think that everything is about technology. Patients come in every day almost demand an MRI scan to tell them what's wrong with their back, and that whole thought process of somehow an MRI scan can tell you what is causing the back pain is the first error that a lot of physicians make, I think, and, I think, a lot of patients make. The importance of listening, of understanding the natural history of low back pain, and then understanding how to evaluate a patient physically, to really try to get a feel for what are the possible causes. As you said, you used a key term, and, I think that everybody should understand this, the tests are then confirmatory. The old adage is that 85% of diagnosis is made on the history, and everything beyond that is trying to confirm our thought process as we go down the path of trying to say, "Are the tests, is the research I'm doing, the MRI scan, and that sort of stuff, are they confirming my hypothesis of what is wrong with this patient?"

Dr. Carter Beck: Yeah, I completely agree. As I said, a lot of patients who come to my office have had an MRI scan, and when I ask them what's happening, what's bothering them, what brings them into my office today, they tell me that there is something on their MRI scan, and as far as they're concerned that's the diagnosis, and that's the end of the discussion, and what are we going to do about what we found on the MRI scan. I usually have to rewind quite a bit at that point and say, "I haven't looked at your MRI scan." I have a personal habit of not looking at a patient's film until I've taken the history, because, as you say, that's 85% of it, and it doesn't really matter scan what the MRI scan shows, I need to be developing a diagnosis based on talking to the patient and then we look at the MRI and find where the consistencies, where the inconsistencies are. I do that as a rule, and I think it leads to better patient care.

Dr. Sechrest: I think you're absolutely correct. I think that is so easy to get biased by either other people's impressions that sort of poison your own ability to view things from a clean slate, and then especially if you've seen that abnormality on some sort of imaging test you tend to do things that confirm that rather than the other way around, and it is definitely a trap.

Dr. Carter Beck: You know, family, friends of family, people often call me and ask for an informal consultation. They say, "Will you take a look at my MRI scan?" and I say, "Sure, I'll take a look at your MRI scan but that doesn't help me." I need to talk to the patient and if it's Joe's uncle's brother's best friend, then Joe's uncle's brother's best friend needs to come see me, because I really can't do any patient a service just by looking at an MRI scan.

Dr. Sechrest: Agreed. Let's go back a little bit about the actual physical exam. As a neurosurgeon, what are the things that you're evaluating when you actually begin laying hands on a patient, after the history. What sort of things are you going to do with that patient in the examining room and what are you looking for?

Dr. Carter Beck: The physical exam starts when I go and greet a patient in the waiting room. I watch them stand up. I watch them walk into my office. I watch how they sit while we take the history, and I'm really beginning the physical exam at that point because I'm looking for signs. We talk about the distinction between signs and symptoms. Symptoms are what the patient says are bothering him. Signs are what you can objectively observe. So that's really part of the physical exam. Patients who are sitting-intolerant, that will give me some indication as to what might be going on in their back versus somebody who is standing-intolerant. Very classically, patients with a big herniated disc will come in my office and they'll stand while we take the history, and I consider that really a physical finding, a sign. When I bring them back to the exam room and start really laying on the hands, we're going to go through a bunch of basic things: take their blood pressure, listen to the heart and the chest because some systemic disorders, general medical illness can result in back pain. Patients need to be healthy otherwise for me to get a clear diagnosis of what's going on with their back. Then we go into basic examination of the spine. Can they bend their leg? Can they extend their leg straight in a sitting position? Is there muscle spasm in and around the lumbar spine and the paraspinal muscles? Then, of course, is a thorough neurological exam. As a neurosurgeon, I think I'm probably a little more focused on that, but I think all spine surgeons, from whatever their training tradition, focus a lot on the nervous system because the spine is intimately associated with the nerves and we're going to look at how the nerves function and to do that we look at the basic functions of the nerves. Is there sensitivity to touch, to pressure, to pain? We use a little sharp wheel that will simulate a pinprick, and then basic muscle function. Nerves, spinal nerves, go to predictable muscle groups. If you have an L5-S1 herniated disc and pressure on the S1 nerve, there will be typical signs. Or if you have an L4-5 herniated disc, patients often have a foot drop. So we look for the clinical exam from the knowledge of the anatomy of the structure and function of nerves and muscle groups.

Dr. Sechrest: Yeah, you know, it's interesting because I think both orthopaedic spine surgeons as well as neurosurgeons do tend to focus on, what we would consider, signs and symptoms that the nervous system is involved. Over the years I've found that sometimes physical therapists and other types of providers who focus much more on the mechanical aspects, the pattern of posture, the pattern of gait, the pattern of muscle recruitment, and those sorts of things which I don't think we know a lot about, are very good at trying to look at those other components of the back, you know, the muscle, and the way the back moves, and that sort of stuff. I do think that we, as spine surgeons, tend to get a little too focused sometimes on the nervous system, and the problem with that is that if we don't find anything wrong with the nervous system, and we tell the patient that is okay, they sort of assume that everything is okay, and that's not the case. I mean, so much of back pain is really mechanical pain in the spine rather than problems with the nervous system, and that probably gives people more trouble than the numbers of patients, or the percentage of patients, that we see who actually have nerve problems that may need surgery or something like that.

Dr. Carter Beck: Yeah, I think it's a minority of patients who actually come to spine surgery who have an observable neurological deficit on their exam. Some people have neurological symptoms, say numbness or pain, going down the leg, the back of the leg, sciatica, but they may have a normal neurological exam. I think one of the reasons spine surgeons focus on that is, because when the nervous system gets involved and when there become objective neurological deficits, we know, at that point for certain, that the patient is likely reaching a point where it's not going to get better by itself. This is not a short-term episode and surgery is obviously more likely to be the right choice, and so we have a quick and easy screening in the physical exam as to how severe a problem may be and whether or not we need to proceed with surgery and at what sort of urgency. If the patient comes in and they have a foot drop, their foot is flapping on the street when they walk down the street because the L5 nerve root isn't functioning, that's an indication to do early surgery in probably or the next day, not something that we would like to wait around on for weeks and weeks because we worry that there is permanent neurological damage occurring, and that is, of course, frequently not recoverable.

Dr. Sechrest: I think we should, for the audience, I really want people to understand the difference between what we would consider, in some cases, let's say mechanical nonspecific low back pain, or nonspecific low back pain and the difference between that, in our minds, and neurological or neurogenic back pain. So, I guess, in general, separate those two for me. Separate nonspecific low back pain, how you think about that, and the neurogenic back pain. I think you just did to a great degree, but I really want it clarified.

Dr. Carter Beck: One of the most common diagnoses made in an emergency room is a lumbar strain, and we talk about how many patients have some type of significant back pain during the course of their life. The majority of those, we're talking about a lumbar strain, which is sort of one-time event. They pulled a muscle, they bent wrong, they fell down, and they've got some soreness in their back. That's a self-limited process that doesn't necessarily have any anatomically identifiable correlate. So you get an MRI scan and it's normal. Those patients, they have spasm in their back, they have limitation in their range-of-motion, they have pain which is interfering with their ability to sometimes even get out of bed. It can be very significant. But it's the first time it's happened, it's only been going on for 2 days, and the majority of those will get better by themselves and don't even require an MRI scan. When we talk about just back pain, without any neurological correlate, to start getting into talking about doing sophisticated testing, to get into talking about sending a patient to a neurosurgeon or an orthopaedic spine surgeon, we have to have a longer term. So I think the time course is important. Something that has been bothering a patient for 3-6 months is getting into a region where we're saying maybe this isn't just a muscle strain, it isn't just a soft tissue problem, and that there is something mechanical occurring. Positional aspects of the pain which, it comes on only when a patient stands, or only when a patient sits, and is relieved by changing position, that suggests that there is a mechanical problem with the structure and function of the lumbar spine, and so that can be important, too. A pulled muscle tends to hurt all day and be independent of position.

Dr. Sechrest: Now, I'm going to put you on the spot here because I think there has always been this controversy in terms of the notion of the a lumbar strain. Lots of people leave a practitioner's office with that diagnosis of a lumbar strain. What do you think is hurting in that case? I mean, what do you think is actually causing the pain when we diagnosis a lumbar strain?

Dr. Carter Beck: Well, I think it is an amalgam of things. I think that is relatively minor injuries to perhaps multiple structures, and I think the most important criterion for a lumbar strain is 1) we don't know, in fact, what's causing it; we can speculate but we don't know because there is no structural correlate on an MRI scan, and it gets better by itself. So not only do we not know, but it really doesn't matter because it's going to go away by itself. There are a lot of people who are diagnosed with lumbar strain and it's incorrect. Really what they have is a torn or herniated lumbar disc and in the course of time we figure that out. If I had to guess, I would say that of the thousands of muscles, which are very small muscles interacting with various points on the lumbar vertebrae, that a real, honest to goodness, lumbar strain is a pulled muscle.

Dr. Sechrest: Well, you know, it's interesting, you made a couple of comments that I want to really clarify, and that is, part of the problem is patients want an answer, and it is so difficult sometimes to have them be satisfied with the answer, "You know, here's what I can tell you. You have back pain, nonspecific low back pain; maybe it's a lumbar strain. We've looked at everything; we don't see anything dangerous going on, and it doesn't matter to us, at this point, what's causing your pain, because we're going to treat this empirically. Based on our experience, that most people get better, and the worst thing we could do is do a bunch of tests now and start putting you in a medical model. That somehow is counterintuitive to them. They really get concerned when you tell them you don't know, and they hear that, and they're not hearing the real message which is, "Look, this is probably a self-limited problem that's going to go away on its own. So let's watch it for a little while."

Dr. Carter Beck: Yeah, pain is powerfully motivating for patients and back pain can be severe and it can be incapacitating, and, I agree, there's a disconnect between what a spine surgeon or a spine doctor understands about back pain, and that is the most important thing we can do is be patient, because a lot of patients will get better by themselves, and a patient who is feeling really uncomfortable and maybe is 32 and has never had a real medical issue in their life, they want an answer, and so education becomes a critical part of being a good spine physician, is to be able to sit back and tell a patient, "I know it bothers you, but one of the most important things we can do here is not get too jumpy, not get too reactive, and give it some time."

Dr. Sechrest: Now you had mentioned that one of the reasons to see a neurosurgeon and maybe take this nonspecific low back pain a little bit more serious is the fact that it is persistent and it's not going away, or it's continuing to occur, and it's the same thing every time or maybe a little different every time, but the bottom line is you're not getting back to normal and you're not living a normal lifestyle and it's gone on for a period of time; and, although there are no nerve signs or symptoms, maybe it's something that can be corrected by some type of an intervention surgery or injections or something like that.

Now let's move to the neurogenic or the neurological problems. You've eluded also earlier to the notion that if nerves aren't functioning, if we see a patient with a foot drop or weakness, what are some of the other things that you would caution patients that, if this is occurring in the face of back pain or maybe not in any back pain, you need to begin to think about seeing a neurosurgeon and have this evaluated.

Dr. Carter Beck: Well, that is a broad topic. There are a lot of nerves that are coming through and out of the lumbar spine. I think one of the things you are eluding to there is bowel and bladder function, and the cauda equina is the collection of nerves that go through the lumbar spine, and in that collection of nerves are the nerves that go to your bowel and bladder and control continence; and, in very bad disc herniations and very bad disorders of the lumbar spine, the continence can be affected and a deficit in the bowel or bladder function, numbness in the private areas is one of the scariest things for a spine surgeon to see. There are a lot of patients who have pain and have a little bit of urinary urgency that we don't worry about too much, but a real problem with the bowel and bladder is probably the biggest and scariest thing that we seen with lumbar spinal disorders, it is extremely rare. I can count on one hand, I think, in the course of my career the number of patients who really had bowel and bladder dysfunction as a result of a problem in the lumbar spine. Other nerves that exit in the lumbar spine or pass through the lumbar spine are nerves that go to the legs and, to some extent, the hip region, and real focal weakness in any of those muscle groups is an issue, so the classic example being the foot drop. If you can't raise your big toe off the ground and you're having pain that goes down the leg, sciatica, down the back of the leg, and maybe back pain, maybe not, that's an issue. We're concerned at that point that there's enough pressure on the nerve that the nerve is being damaged and maybe in a permanent way. That goes also with the muscles of the quadriceps, the muscles that go to the calf, and to the foot extensors. Those muscle groups are more complicated to examine, and usually a patient's perception of weakness, in that case, is more accurate than a physician's because there are multiple muscle groups with multiple nerves in each of those muscle groups. Numbness which is intermittent is less concerning than numbness which comes on and stays present 24 hours a day. At that point, we also think that that's an indication that there may be some permanent damage occurring to a nerve. Pain that goes into the leg but stops above the knee, sort of buttock and hamstring pain, is frequently not neurologic at all, it's related to muscle spasm and it can be easily confused with sciatica. But pain which stays above the knee, on the backside of the leg, is something that is pretty much normal even just with a lumbar strain which is going to get better by itself.

Dr. Sechrest: So if I can paraphrase, I think you and I probably think alike. There's one emergency, one true emergency, that you don't even make a choice, and that's if you feel like that you've lost sensation in your crotch area, what we call saddle anesthesia, that's an emergency, and, especially if it's combined with inability to hold your bowels or your bladder. You're leaking, you don't know you have to go, whatever, that's a true emergency, rare, but a true emergency. I think the second thing you said was, if you're having progressive weakness, weakness is getting worse every day or just weakness that came and is not getting better pretty quick and numbness that has come and is getting worse by the day, or it's not getting any better. That's a relative emergency, that you might want to start thinking about calling the neurosurgeon and having it checked out.

Dr. Carter Beck: Certainly, I agree. Any time a progressive weakness, a part of the body is working, probably should be examined.

Dr. Sechrest: You know, the question always comes up, and I'm not certain ever how to answer this question, but the question always comes up amongst patients; if they have a neurological compression, so let's say they've numbness for 2 weeks, they've had a little bit of weakness for 2 weeks; the question always comes up, "How long can I watch that before I begin to do permanent damage if I don't have a surgical intervention?" What are your thoughts on that?

Dr. Carter Beck: Well, I think it's a continuum. I think a little bit of weakness for a short time in any muscle group has a very low risk of permanent damage. I think a lot of weakness for a long time has a high risk. So, I always tell patients, the longer a muscle group is weak, and the worse the weakness is, the lower our chances. There are some patients who will herniate a disc and have some weakness and it will go away by itself before they ever get to see the doctor. So there are not absolutes, but I think all we can do is look at statistics and think about it logically and that is, the more pressure on a nerve, and the worse the dysfunction, the more chance that it is permanent.

Dr. Sechrest: Now, what about the same for mechanical back pain, for people who are having problems with, maybe, some instability in the spine, or what we would consider maybe subclinical instability of the spine where the disc and the joints in the spinal segment are degenerated and that excess motion through that segment that's degenerated is causing pain. Are there any downsides to putting that off as long as you possibly can before you consider a surgical approach to that disease.

Dr. Carter Beck: I think that's the exception. I think it's unusual that we've really lost much whereas if you don't diagnose cancer, it can run away from you. Back pain, usually not. I think that a danger of chronic back pain that is underappreciated in the general medical community and with patients is the effect it has on a patient's psychology, on their lifestyle. Patients who have chronic pain get depressed, they can get addicted to narcotic medications, they can start having dysfunction or failure to perform in their job, in their marriage, and those sort of things start to snowball with chronic pain of any sort, particularly back pain, and that is a real danger. So, I think it's important to say, if you have back pain, to what level is it interfering with your overall lifestyle and your performance in life, your enjoyment of life. Are you getting depressed? Have you been taking narcotic medicines for weeks on end? And that's a real danger and that's when I start to get concerned.

Dr. Sechrest: It's interesting for a neurosurgeon to say that because, I think, that the traditional approach has been sort of a very stoic approach with the medical community in general, and surgeons are probably less likely to recognize the psychological impact of these diseases and what that does long-term. We're always focused on the notion that, if that nerve is pinched, then you're going to lose the ability to raise your foot and that's bad, and we need to stop that. We're not as focused on, if you have that amount of back pain, and you let this go on, you run the risk of divorce, you run the risk of losing your job, you run the risk of becoming addicted, and essentially spiraling down to the point where you're nonfunctional. It's all a psychological side effect of that first episode that then spirals into chronic pain, and I guess what you're saying is that, it needs to be taken into consideration. When you make a decision as to whether or not to let this condition go on and on and on, there are some ramifications there, there are some side effects.

Dr. Carter Beck: I agree. I think the most common complication, serious, permanent, or semi-permanent complication of a disorder in the lumbar spine is a personal psychological effect. I think the nerve that is broken is a much less frequent problem.

Dr. Sechrest: Any suggestions, other than surgery, about how to deal that situation, where you now have situation that the patient is in chronic, unremitting pain and it doesn't have a surgical solution? Any suggestions from the neurological side, what we, as physicians, should be focusing to try to manage that situation?

Dr. Carter Beck: I think it's important for a patient who has a real back problem, a chronic back problem, whether or not it's ultimately a surgical issue, to have professional help. Backs are very complicated, and it requires the interaction and the cooperation of multiple specialists to care for a patient with a back problem. I think that sometimes that is underestimated and people get sort of a quick and dirty cure in the bottle, and it's viewed that that's the extent of the treatment that is necessary. Taking pills are one part for caring for a patient with a chronic back problem, but it is only one part, and I think that really what patients need are to be in multidisciplinary care where they have access to psychiatric care, the physical therapists, to injection therapies, the pain physicians are an increasingly important part of caring for patients with backs. People should have access to alternative medicine such as chiropractic or acupuncture. There is a significant number of patients who have back pain or back problems for years, that their primary treatment is chiropractic, and I think it's valid and needs to be part of the armamentarium.

Dr. Sechrest: Any other areas of the neurological approach to low back pain that we have not covered during this discussion that you would like to have people know about, either primary care providers, other providers of spine care, or patients?

Dr. Carter Beck: Well, I think the point that we're just discussing is probably the most important, and that is, apart from a lumbar strain, something that goes on for a week or two at the most, patients with chronic back pain need help. One of the primary things that we, as physicians, can do for patients is help educate them as to how to manage something which may not need any direct or interventional treatment. So, patients in pain need help, and they need to be cared for, and they need to be cared for in a timely fashion, and I think that we, as a community of physicians and as a community at large recognize that and deal with it in an upfront manner then we can reduce the scope of this problem in America.

Dr. Sechrest: I agree. I think this goes back to that disease management sort of paradigm in the sense that, if we treated diabetes, and in the past we did. I mean the Type 2 diabetes, the type that occurs in older folks, if we approached it just sort of saying, "You know, your blood sugar is too high. You need to do something about that", and said, "There's nothing I can do about it." If we did that, we would have an epidemic, which we did for a while. Now people are taking a very proactive stance to some of these disease processes to really try to manage them well, as you said. We still don't do that with low back pain. We basically tell people, "You've got low back pain. You need to deal with it." We don't offer them any ways, strategies, we don't offer them any sort of approach to that or help with that in a large number of cases. So I think we're seeing the results of that, of this epidemic of people who feel that they've been disabled by this condition and there's nothing they can do about it, and they're just left to sort of wander through the system.

Dr. Carter Beck: I agree. It's funny you say that. I often tell patients, "Back pain can be a lot like diabetes, more like diabetes than appendicitis. You have to manage it." Sometimes the answer with diabetes is a pill. Sometimes it's diet modification. Sometimes it's injections. Sometimes it's a varying mixture of all three, and back pain is like that. Sometimes you need surgery. Sometimes you need a good counselor. Sometimes you need an injection, and it really takes a sophisticated back spine care professional to help a patient through that maze.

Dr. Sechrest: One thing that I would like for patients to know is that for years I see patients in my office who come in who have been to a specialist, a neurosurgeon, an orthopaedic spine surgeon, someone who has left that office basically saying the surgeon has told him that this may not be a surgical lesion. The surgeon may have said, "I cannot help you." They take that to mean there is no help for them, and, I think, the one thing that they need to understand is that what the surgeon is saying is, "I'm not the right person to help you and you need to seek out someone who can help you manage your pain." Obviously, in communities where that capability is present, it's easier, and people are aware of that. But I would like for patients to understand that you shouldn't stop there. When a surgeon or someone says, "I can't help you", that doesn't necessarily mean there's nothing to be done. It means that you're in the wrong place. You're not in the right place at the right time, and you may need to be at a different place.

Dr. Carter Beck: Right. I would take that even a step further and say there are many patients who are referred to a surgeon, say first or second, on their list and they may ultimately require surgery, but now is not the time. So there are many patients who I'll send off to have an injection or to have some other multidisciplinary approach to their pain knowing that they may well end of having surgery. But to have a good outcome in spine care, it must be the right treatment at the right time for the right reason on the right patient.

Dr. Sechrest: I think that's excellent advice. I don't think I could say it any better. That's a very good sort of tag line as we close. Thank you very much.

Dr. Carter Beck: Thank you.