The Pain Business

On Sunday, I rode in a wheelchair through the Oakland Airport, experiencing a taste of humbling dismay. I’ve been dealing with a pinched nerve for weeks now, learning through my own complaints how many fellow sufferers there are. (Along with another participant in the meeting I attended, I got down on the floor during the break to do yoga to help relieve matching pains in our left legs).

They say it’s the tragedy of bipedalism: if only we’d remained on all fours like some of our ancestors, there wouldn’t be all this pressure on the lumbar spine. (On the other hand, our greeting rituals might involve sniffing around each other’s hindquarters rather than shaking hands, and I can’t imagine that would do anything for cultural development.)

Happily, I made a lot of progress while I was out of town. I walked on my own steam through two airports during my return journey. Perhaps sitting in a meeting all day and sleeping in a hotel bed are good for what ails me, but I have a feeling that the large organ sitting on top of my head had something to do with it.

You see, my wonderful friend who knows all about the body came to see me the day before my departure. In addition to a lot of good advice, unguents and healing hands, she brought along some food for thought: the chapter on “Marketing, Money and Medical Decisions” from Jerome Groopman’s recent book, How Doctors Think.

Groopman discusses spinal fusion surgery as a medical procedure that is widely prescribed but almost never efficacious. He reports that, “In 2006, more than 150,000 lower lumbar spine fusions were performed in the United States,” and that the “procedure is of tremendous benefit to patients with fractured spines or spinal cancer, but these make up a minuscule number of the total cases,” most of which are prescribed to alleviate lower back pain. He goes into some detail about the economic incentives medical equipment manufacturers aim at doctors to push this mostly useless operation, and about the high fees collected even by some doctors who perform the operation regularly while privately admitting it seldom helps.

This ostensible remedy is supposed to be grounded in observation of spinal changes that show up on MRIs, but Groopman points out that research shows that “36 percent of people over 60 had herniated discs, and some 80 to 90 percent of them had significant disc degeneration in the form of narrowing or bulging,” yet they “had no nagging back pain.” What’s more, even if pain corresponds with spinal changes, “more than 80 percent of people will recover with conservative measures, like anti-inflammatory medication, a short period of rest, and then progressive mobilization and physical therapy.” Groopman observes that with so many systems in play—muscles, tendons, bones, joints and ligaments—it is hard to say definitively why a patient is in pain, and that doctors tend to try to cope with this uncertainty by using the diagnostic tools and treatments characteristic of the medical specialty in which they’ve been trained.

I suppose it’s a little perverse to admit I found this comforting, but it did help me stop thinking about terrifying subjects like back surgery.

Elsewhere in the chapter, Groopman mentions an earlier and similarly lucrative medical mistake: “In the 1950s, many patients with angina and coronary artery disease underwent an operation that involved tying off an artery that runs under the breastbone…. [A]t the end of the decade, a clinical trial showed that patients who had a sham operation did just as well as those who had a real one. Apparently, the placebo effect accounted for the fact that many patients felt better after surgery.”

Perhaps it’s another type of mind-power that explains why the paragraph that helped me the most was the one that started out saying that “85 percent of patients who suffer from low back pain cannot be given a precise diagnosis,” then continued:

It turns out that the diagnosis is not critical, because the outcomes tend to be similar anyway. With acute low back pain, 90 percent improve within two to seven weeks without specific therapy. Even with an acute ruptured disc the prognosis is good, although recover is usually slower; 80 percent feel significantly better within six weeks without surgery.

I read this five weeks and four days after I awoke with searing pain radiating down my leg, at a point where chiropractic, physical therapy, acupuncture and an MRI followed by anti-inflammatories hadn’t done much to relieve it. Every day since has been a big gain. Nearly six weeks and counting.