Oh, My Aching Back

If you have an attack of back pain, don't just keep working. An orthopedic surgeon offers advice on easing the pain and preventing recurrences.

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When back pain strikes entrepreneurs and other hard-driving people, they often bear it -- to a fault.

"I find entrepreneurs tough patients precisely because they tend to tough it out," says Dr. Hugo A. Keim, associate professor of clinical orthopedic surgery and chief of the scoliosis clinic at New York City's Columbia-Presbyterian Medical Center.

Gene Pepe, 51, is a classic example. In 1970, Pepe, the owner of a sales agency for American cars in White Plains, N.Y., decided to expand by opening a foreign-car dealership. Although business was brisk, Pepe's enthusiasm was dampened by recurring back pain.

"I was spending two months a year in bed, as much as three weeks at a clip, because my back was killing me," remembers Pepe. "It was crazy. I couldn't even plan a business trip." Even though his back hurt, Pepe continued to work. "Somebody had to run the business," he says, "I didn't have anyone I could turn it over to."

Pepe's pain wasn't consistent; sometimes he felt fine. Then he would get out of a car the wrong way, or step off a curb, and suddenly his back would go out again, and he'd be back in bed. "The pain was so strong, I ripped sheets with my hands," he recalls. Despite pills, hot baths, visits to chiropractors, and massages, Pepe's on-again, off-again suffering continued for years. Finally he decided to go to an orthopedic surgeon, Dr. Hugo Keim.

Keim discovered that nerves coming out of Pepe's spinal column were being squeezed by a large bony spur on one of the lumbar vertebrae and by a disc between vertebrae that had herniated, a so-called slipped disc.

The only treatment he could recommend was surgery to remove the spur and the disc. Pepe, however, wanted no part of an operation: "I had heard all the horror stories and the advice, even from doctors, against ever letting anyone operate on your back," he says. So he kept putting it off until January 1973, when the pain became so severe he agreed to the operation. Since then, he says, he has felt fine.

Unlike Gene Pepe, most people with back trouble -- as many as 96% estimates Keim -- don't require surgery. That should give some cheer, if not relief, to the many millions of people with aching backs. The American Academy of Orthopedic Surgeons calls low back pain "the single most costly medical problem facing society." It afflicts 80% of all people at some time during their lives and, according to Liberty Mutual Insurance Co., the country's largest worker's compensation insurer, leads to a loss of 93 million working days a year.

Columbia's Keim sees as many cases of back pain among office workers as among factory workers, and as many women with back problems as men. There are many causes of back pain, but the kind most people complain of -- chronic lumbar strain -- can be traced to the time humans took their first steps in an upright position. "Biomechanically, we weren't built for that," says Keim. "The upright position puts a great deal of strain on the lower back."

Although disorders of the discs between lumbar vertebrae get the most publicity, fatigue of the lumbar muscles causes the most trouble. Keim compares the spine to a radio transmission tower and the lumbar muscles to the cables that hold it erect. If the cables are strained or break, the tower may twist or fall. In his book How to Care for Your Back (Prentice-Hall, 1981), Keim observes that "just as we keep a car engine in tune, our spine must be kept in tune by keeping the muscles properly toned" though a daily exercise routine.

Most back problems can be blamed on obesity, lack of exercise, and emotional stress, or a combination of these. Even an extra 15 pounds can strain muscles supporting the spine, especially if muscles are already weak from lack of exercise. However, Keim cites stress as the most important reason for back pain: "If mental anxiety can actually punch a hole in your stomach wall, as it does in people with duodenal ulcers, it certainly can cause damage to your back by making muscles form a tight, painful knot."

Although stress and resulting back pain are common among people who run businesses, bosses don't usually run to the doctor when they are grabbed by back pain. "They work like hell, even when they're away from the company," says Keim, "and they sure don't want to take two weeks off to come into the hospital for such 'silliness' as traction, or even longer for surgery. Instead they tell themselves it's nothing and they take a pill or have a drink and go back to what whey were doing. But that's definitely not the remedy," he argues. "The more you push, the tighter your muscles become.

"When you feel a stab of pain," he says, "try not to fight it. Sit back and relax. Taking pain medication, such as aspirin, Anacin, or Tylenol is fine, and a little Scotch or brandy will help. If you're at the office, get yourself home. 'Working out' the pain doesn't usually work."

Keim recommends spending several days with your feet off the ground, preferably lying in bed in a semisitting position -- as you would on a chaise longue -- with a couch pillow behind your head and back and a couple of bed pillows under your knees. Many people also find they can get a night's sleep, despite the pain, if they stay in that position or lie on their side in the fetal position (with the knees pulled up). He also recommends warm -- not hot -- baths three times a day, an occasional drink, a heating pad, and muscle-relaxant drugs. This routine aborts most attacks in 8 to 10 days.

After an attack, there are several steps you can take to make yourself more comfortable and help prevent recurrences:

* Use a chair that's not too low, is fairly firm and gives support to the lower back. A small pillow shoved into the hollow of the back also supports the back when you sit.

* When you sit, get your feet off the ground and rest them on a footstool or even a cigar or shoe box, anything that lifts your feet several inches. If you have to stand for a long period, take one foot off the ground and place it on a support.

* When you have to sit for extended periods, whether at work or on a long plane or car trip, get up at least every 45 minutes, stretch, and walk around.

For the small minority of back-pain patients who aren't helped by any of the conservative methods of treatment, surgery is the only recourse. If a doctor recommends an operation, you should get at least one other opinion from a qualified orthopedic surgeon. The success rate in curing disc problems, says Keim, is more than 90% when the operation is done by a spine specialist at a major medical center.

Patients usually stay in the hospital for 12 days, recuperate at home for two or three weeks, and then return to work (though Keim tells patients to put in no more than half a day at first). He also likes patients to wear a small corset for six months to remind them that they had an operation and that they should avoid doing anything that puts strain on the back.

"More important over the long haul, he emphasizes "is to minimize mental stress, eat properly, and exercise regularly. If people did that, we could prevent 90% of all back pain."