The Great Disconnect

You are going through one of those rare periods in life. You are getting along with everyone, enjoying your job, losing weight and eating better when you suddenly tweak your back — doing something small — like lifting up a chair.

Later that day, your back is worse and the next day there is some leg pain as well. Now you’re worried. Five days later you see your internist or a chiropractor and get a lumbar spine MRI. You are told that you have a herniated disc.

Welcome to the great disconnect. Depending on the professional you see, your course of treatment will be different. At this point, everyone takes a different path. Maybe your internist recommends physical therapy. Another internist may recommend pain management. If you see a chiropractor, you may stick with the chiropractor for treatment.

Let’s follow one path as an example.

You are sent to physical therapy. You meet your therapist and she impresses you with her careful and detailed plan. She has successfully treated many patients with herniated discs. They didn’t need an injection or surgery and returned to their previous lifestyle after several weeks of treatment.

What she didn’t tell you was that she didn’t read your MRI. The internist who sent you to the therapist didn’t read your MRI either. Both of these providers relied on the MRI report.

The MRI was read by a radiologist. The problem is that you have no idea how reliable that radiologist is. Since there is no standardization in terminology, the report of a herniated disc means very little. Besides, herniated discs are common findings on MRIs done on people without any symptoms. What one radiologist would call a herniated disc another may call a degenerative disc or a disc bulge.

Let’s get back to the therapist again. Chances are, the therapist will apply the treatment that she prefers to start with. Is there any scientific literature to support this starting point? Perhaps the therapist decides to use therapy targeted to the herniated disc. Wouldn’t it be nice to have more detail about the disc herniation? For example, an extruded herniated disc should have a different treatment than a bulging herniated disc. But remember, the therapist has not seen the MRI — only the report.

You have failed physical therapy and now you are in pain management. The pain management doctor is recommending an epidural steroid injection. The chances are that she has not read the MRI, but similarly, relies on the report. The injection recommended will vary from provider to provider and is more connected to the preference of the provider than the architecture of the disc herniation.

Back to the chiropractor again. If that’s where you started, you may not be offered therapy or pain management, only chiropractic.

I think you get my point by now.

Here are my concerns:

  1. The treatment you receive depends on whom you see and not on what you actually have.
  2. What you actually have is best represented by either the arbitrary words of a radiologist who has never seen and examined you or by a clinician who cannot read the MRI.
  3. Even if the providers could more coherently put together the history and exam with the MRI findings, there is no scientific evidence to suggest the “best” treatment.
  4. Since we live in a fee-for-service world, the provider who sees you first is often motivated to apply his or her techniques.

This is the great disconnect of you getting the treatment you need. My website is dedicated to both highlighting and providing solutions (primarily non-invasive) to this ugly reality. Once you start your quest for back pain treatment, it’s essential to pursue an understanding of your condition and then, ultimately, to try to link that understanding with the correct treatment. It’s also important to realize that this doesn’t always work, or doesn’t work right away; treatment is often a process rather than a single event. To a large extent, settling on the best treatment is your responsibility.

© 2014 Patrick Roth, M.D., author of The End of Back Pain: Access Your Hidden Core to Heal Your Body