“Specific” back pain: it’s not structure, except when it is
This article is an abridged excerpt from the e-book “The Complete Guide to Low Back Pain“, by Paul Ingraham.
The medical jargon for back pain without a specific explanation is “non-specific” back pain. It’s what we say when we can’t be any more specific than “it’s back pain!” It almost like saying “undiagnosed” or “baffling” back pain… and it’s not really clear why we don’t just say that.
This “non-specific” term is odd. It isn’t standard for any other medical condition; there is no non-specific headache, for instance. A headache without a specific diagnosis is traditionally called a “tension” headache, which is even worse, because it presumes a cause, which is probably usually wrong. Imagine if we called all puzzling back pain “tension back pain.”
Chronic low back pain is often classified as non-specific: that is, no organic cause of the pain can be identified. This happens a lot… officially, anyway. Most people will never hear the non-diagnosis of “non-specific” back pain from any doctor or physical therapist, although perhaps the occasional progressive one will trot out the term in the attempt to manage expectations and educate. But mostly it’s confined to discussions of back pain in general, in scientific papers and shop talk, formal and abstract.
Most back pain diagnosis in the real world attempts to be specific… and just screws it up.
“Specific” diagnosis is both common and wrong (and not even terribly specific, really)
Back pain is often prematurely and excessively but incorrectly blamed on a specific cause — much like the assumption that an undiagnosed headache is caused by “tension,” when we don’t even know for sure that tension can explain any headache, and there are many other known causes. Here are three common examples:
- Many professionals still default to assuming that undiagnosed back pain is “degenerative” in some way, with variable specificity and vehemence, and that is the problematic assumption that I have mostly focused on so far in this book.
- The most popular specific explanation for back pain among patients is probably “spasm,” which is more or less exactly the same as blaming headaches on tension. It isn’t terribly “specific,” but it is certainly more specific than “no bloody clue.” It is an idea! It is a specific hypothetical mechanism for pain. And it cannot be overstated how easily people take it seriously as the explanation for a new attack of back pain. I have personally heard people casually attribute back pain to spasm at least several hundred times in my career.
- And then there’s a specific explanation beloved more or less equally by both patients and pros: the assumption of injury — that some relatively innocuous physical stress is the culprit. For a specific explanation, it isn’t terribly specific: exactly what anatomy has gotten hurt, and how, is often not specified by this specific diagnosis. “Something in the spine got hurt somehow” is as specific as it gets… or perhaps “slipped disc,” because that’s s the only specific injury that many people have even heard of.
All of these things are possible specific explanations for back pain, but none are them safe assumptions, not by a long shot.
That unsafe assumption has an evil twin: the equally unsafe assumption that there is no specific cause, which is implied by the label “non-specific back pain.” Rather than simply being unknown, too many people (mainly clinicians) slip into overconfidently assuming that no specific cause actually exists — or that it is so perfectly unknowable that it might as well not exist.
The other side of the coin: just because we usually don’t know the specific diagnosis (or get it wrong) doesn’t mean it is isn’t there!
…degenerative disc disease is undervalued as a cause of chronic low-back pain by clinicians, patients and society.
Rustenburg et al, 2018, JOR Spine
Sometimes structure does matter. I have spilled a lot of “ink” in this book about the urgent need to back away from the pervasive idea that back pain is a structural problem (especially degenerative disc disease). I have demonstrated that specific, structural causes of back pain are over-emphasized, but not non-existent. Like violent crimes, they are far less common than the news makes people fear, but they do still happen.
In 2015, a perfect pair of papers by the same researchers pushed each way on this topic: one away from mechanical explanations… the other right towards them. The first was cited above (along with many other similar ones): Brinjikji et al looked at a whole lot of MRI pictures of spines, and presented evidence that signs of spinal degeneration are present in amazingly high percentages of healthy people with no problem at all. Good to know. It’s one of the best papers of that sort, highlighting the weird disconnect between back pain and spinal degeneration.
But Brinjikji et al didn’t stop there! Their second paper presented evidence that degenerative features visible on MRI are nevertheless “more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.”
Also good to know!
These papers aren’t actually at odds. The take-home message of the pair is just a nice, reasonable, and obvious compromise: degenerative changes matter less than many patients and professionals still assume, and are not an adequate foundation for many popular treatments… but they do still matter.
Duh? Surely no one is surprised by this!
Importantly, Brinjikji et al also showed that the disconnect between structure and pain is much less striking for some kinds of problems than others. Intervertebral joint dislocation (spondylolisthesis) is rarely asymptomatic! Some cases are, and that’s fascinating. But not most. 60% with bulging discs at age 50 are symptom free, but only 14% of 50-year-olds with spondylolisthesis are feeling no pain. It’s amazing that anyone can have a dislocated spinal joint and feel fine, but 85% do have symptoms.
So whether structure matters depends. Some spinal problems matter more than others. Some of them are worse than others. Duh again.
Neuroma: a very specific example of a very specific cause of back pain
🎶 M-m-m-my Neuroma
Ohhhhh my Neuroma
Ohhhhh my Neuroma
Ohhhhh my Neuroma 🎵
Obvious sources of acute and/or ominous pain like infections, aneurysms, tumours, fractures, and inflammatory diseases are all causes of some back pain, but they aren’t of much interest here because they are so serious (and often relentlessly progressive) that they mostly do get diagnosed. They are the kinds of things that mostly qualify as “specific” back pain.
But what about specific problems that tend to drag on and never get diagnosed? Sure there are also specific causes of chronic low back pain that get missed? Of course there are. The only real question is: how often does that happen? No one really knows.
A friend of mine — let’s call him Alex — suffered for about five years from slowly but steadily worsening back pain before a wee little tumour was finally discovered: it was “benign” as far as tumours go, but it was growing on a nerve in his back (a “neuroma”), and it had just about ruined him. Neuromas are tumours, but they aren’t the kind that kill you … they just make you miserable. My friend had dropped out of the sport he loved, ultimate, the Frisbee sport, which is how I know him — we had played for years together on a team called Afternoon Delight. (Fun fact: Our team symbol was a pair of humping unicorns.)
At his worst, Alex could barely walk. Eventually, after an easy surgery, he was entirely cured, just like that. Boom. Specific as it gets.
Alex had seen many, many healthcare professionals who had failed to diagnose the real problem, thrown up their hands, and chalked it all up to non-specific back pain. I know, because I was one of those healthcare professionals.(2)
Before the diagnosis, “sensitization” had been a major diagnostic option, a classic pseudo-diagnosis that means the problem is a false alarm. Although Alex likely was suffering from the phenomenon of sensitization, it was probably a sideshow, a complication of the real source of serious irritation in his back.
A chiropractor finally suggested the right kind of spinal imaging, which easily identified the neuroma. Once everyone knew it was there, that was the end of any discussions about how strange and unexplained chronic back pain is! He just needed surgery to remove a little blob of uninvited tissue from a nerve root. And that surgery worked immediately and permanently.
That’s probably the single clearest example I’ve ever encountered of a specific cause of back pain, no fine print.
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