WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

Transcription

1 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS? Robert Talac, M.D., Ph.D.

2 INTRODUCTION Three elements distinguish back and neck pain from other health problems and complicate their diagnosis and treatment: 2 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

3 1 2 This type of pain is incredibly common. In fact, it s the second most reported medical complaint after colds. It can be challenging for people to determine how serious their pain is. Back or neck pain is a symptom that could result from a broad spectrum of conditions some minor and others potentially life altering, if not treated quickly. 3 Back and neck pain is self-evident, meaning that when you experience it, you know exactly where the problem area is and that you need to see a healthcare practitioner who can examine it. The dilemma is that many professionals can do this. When you seek treatment for back or neck pain, you have numerous options. How do you know which practitioner is the best choice for you and will lead to the best outcome? All of this can create confusion and anxiety in patients. Remember: If you suffer from chronic or acute back or neck pain especially pain associated with a fever or neurological problems such as tingling, weakness, or numbness in your extremities you need to seek immediate medical help. If your pain is less acute, comes and goes in cycles, does not escalate, and is not accompanied by fever or neurological symptoms, you have more time to consider your options. Now let s explore the main types of healthcare practitioners you can choose from in seeking spine care, along with the pros and cons of each option. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 3

4 CHAPTER 1 Primary Care Physician Many people prefer to use their primary care physician (PCP) also known as a general practitioner as a first point of contact for any medical problem. By diagnosing and treating a wide range of everyday health issues, PCPs serve as their patients main source of care. 4 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

5 As generalists, PCPs have moderate knowledge about many topics as opposed to having deep expertise in a focused area. As a result, PCPs assess whether patients need specialist care for complex conditions and, if so, refer those patients to physicians with more extensive knowledge of that particular field. If you go to a PCP to report back or neck pain, there s a strong possibility the doctor will refer you to a spine specialist. About 80% of the time, patients with back or neck pain will visit their PCP and achieve a satisfactory outcome. The concern is with the 20% of cases in which diagnoses are more challenging to identify and generalists could easily get out of their depth. It s not that PCPs are incompetent as licensed physicians, this is hardly the case. Because they do not treat spine problems on a day-to-day basis or regularly engage in in-depth training focused exclusively on spine care, these generalists are not best equipped to recognize complex spine problems. The expertise required to provide high-quality spine care extends far beyond what is taught in general training. Then there s also the fact that, at least for an initial PCP visit, patients may not even get to see the actual physician. It s becoming increasingly common for physician assistants or nurse practitioners to handle initial patient encounters. This can further reduce the likelihood that patients suffering from back or neck pain will receive a thorough and expert musculoskeletal and neurological evaluation. Additionally, the diagnostic and treatment phases can take longer than necessary assuming the cause of the pain is identified at all. PCPs have obtained a fouryear medical degree (M.D.) and completed a residency program that typically emphasizes family medicine or internal medicine. Their residency program is a threeyear period upon graduation from medical school in which physicians receive basic training in each medical specialty. 80% of the time, patients with back or neck pain will visit their PCP and achieve a satisfactory outcome. 20% of cases, diagnoses are more challenging to identify and generalists could easily get out of their depth. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 5

6 CHAPTER 2 Medical Spine Specialists When you see a spine specialist, you can expect clear answers to your most pressing question: Why does my back or neck hurt, and what can be done about it? 6 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

7 M edical spine specialists are experts in all spinerelated issues. They have extensive knowledge of the complex musculoskeletal and nervous systems that comprise the human spine, and they understand how to evaluate and identify the full spectrum of problems associated with back and neck pain using both advanced diagnostic techniques and their considerable training and clinical experience. The result is an expedited and accurate diagnosis. Once a precise diagnosis is made, spine specialists devise the most effective and efficient treatment course tailored to the particular condition and patient-specific factors. If the recommended treatment is nonsurgical, spine specialists oversee and lead the treatment, perhaps in coordination with other healthcare professionals such as physical therapists. If the recommended treatment requires surgical intervention, spine specialists refer patients to spine surgeons for the procedure. Typically, medical spine specialists are not qualified to perform surgery. However, a small number of spine specialists have undergone the additional training that allows them to perform some invasive procedures. You should ask your spine specialist about his or her qualifications if you are contemplating a diagnostic or surgical intervention. Spine specialists education and training involve obtaining an M.D. and then completing a residency program. Usually, spine specialists emphasize a study of physical medicine and rehabilitation (PMR) during their residency, which takes three to four years on average. Afterward, many spine specialists opt to complete a fellowship, which is an additional one to three years of specialty training focused on spinal care. In addition to this extensive training and their day-to-day clinical work, spine specialists regularly engage in continuing education to receive the most up-to-date information about diagnosing and treating spine conditions. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 7

8 CHAPTER 3 Spine Surgeons The main difference between a medical spine specialist and a spine surgeon is the ability to perform surgery as a means of resolving a specific mechanical problem with the spine, such as a compressed nerve, abnormal motion in a spine segment, or a fracture. Otherwise, a spine surgeon can perform the same evaluative and diagnostic functions as spine specialists. 8 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

9 You may ask: If a spine surgeon can do everything a medical spine specialist can and also perform surgery, isn t it more efficient to just see a spine surgeon first? In most cases, the answer is no. This is because spine surgeons are focused on performing surgery only on the small number of patients who need it. Consider that just 10 to 15% of cases of back or neck pain result in surgery. Surgeons don t typically spend quality time discussing nonsurgical treatment options with the vast majority of patients who don t require surgery because that is outside the scope of their role and expertise. Once it has been established that a patient doesn t need surgery, a surgeon will refer the patient to a medical spine specialist to discuss these other treatment options. Think of it this way you wouldn t take the drastic step of immediately seeing a cardiothoracic surgeon simply because you have high blood pressure. You d first need to understand why you have high blood pressure before you can know how to remediate the problem and identify who can help you. The recommended protocol is for patients to see a medical spine specialist first. If a patient has been diagnosed with a spine problem requiring surgery, then the medical spine specialist refers the patient to a surgeon for the procedure. In addition to obtaining an M.D. and completing a lengthy residency training focused on orthopedic surgery or neurosurgery (five to seven years), many spine surgeons opt to undertake a fellowship in spine surgery (one to three years). 10 to 15% of cases of back or neck pain result in surgery. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 9

10 CHAPTER 4 Physical Therapists Just as spine surgeons are integral in relieving mechanical-related pain for patients via surgery, physical therapists (PTs) are an important component of non-surgical treatment for patients with muscle-related back or neck pain. 10 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

11 Physical therapy is best suited for patients who can benefit from an exercise regimen. For example, patients with age-related arthritis often suffer from muscle spasms and decreased physical activity. Lying in bed for a week can reduce muscle strength by 4 to 10%. Physical therapy is critical in helping these types of patients avoid the vicious cycle of becoming weaker, decreasing activity levels, gaining weight, and experiencing recurring or increasing pain often referred to as the downward spiral. PTs help patients to strengthen their muscles so that they can provide more support to the spine and alleviate pain by gently moving patients muscles and leading stretches and therapeutic exercises in a controlled fashion to avoid further damage, massaging affected tissue, applying topical treatments, and deploying other techniques such as ultrasound or laser therapy. PTs guide patients through a treatment regimen that typically lasts six to eight weeks, with twice-weekly visits for a total of 8 to 12 sessions. However, patients cannot visit PTs independently because these professionals work under the supervision of licensed physicians similar to the relationship between physicians and nurses. PTs can handle a wide range of non-surgical treatments, but legally they cannot initiate any treatment without a doctor s order. Physicians prescribe a physical-therapy regimen based on a patient s specific diagnosis and then refer the patient to a PT. Because they are not licensed physicians, PTs also cannot prescribe medication, including pain blocks or muscle relaxants. To become a PT, candidates must obtain a bachelor s degree followed by a Doctor of Physical Therapy (DPT) degree from an accredited institution. The DPT program usually takes three years to complete. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 11

12 CHAPTER 5 Chiropractors Chiropractors play a complementary role in the management of non-acute or muscle-related back and neck pain that is isolated from other, more serious symptoms. 12 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

13 There is some overlap between the work performed by PTs and chiropractors. Like PTs, chiropractors are not licensed physicians and cannot prescribe medication. For this reason, they focus on natural techniques for pain alleviation. They aim to eliminate patients back or neck pain with manual manipulation of the spine and extremities, massage of affected tissues, exercise programs, nutrition and lifestyle advice, and other modalities such as heat, ice, vibration, cold-laser, and electricalstimulation therapy. Unlike PTs, chiropractors are more independent in that they work at their own clinics and at their own pace, and using their own methods without any physician supervision. Additionally, patients do not need a referral from a licensed physician to visit a chiropractor. However, patients should exercise some caution. Chiropractors methods are not as rigorously evaluated as those of licensed physicians. Nor do chiropractors have the equivalent training or expertise of a medical spine specialist or other physicians; therefore, chiropractors are more restricted in their capabilities and treatment methods. Additionally, keep in mind that not all practitioners are created equal and it s up to patients to do their due diligence when selecting a care provider. Good chiropractors will perform all necessary diagnostic work before attempting to identify and treat the source of back or neck pain. They will also be able to recognize when a spine condition is more serious and will promptly refer that patient to a spine specialist. Bad chiropractors will cut corners, treat pain as a diagnosis, and attempt to eliminate pain when they don t fully understand the underlying cause, which could delay more effective treatments and risk causing patients with serious spine conditions more harm and even irreversible damage. The training to become a chiropractor involves obtaining a bachelor s degree followed by a Doctor of Chiropractic degree from an accredited chiropractic college. This program takes three years and four months to complete. Good chiropractors will perform all necessary diagnostic work before attempting to identify and treat the source of back or neck pain. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 13

14 CHAPTER 6 The Case for Comprehensive, Specialist-Led Spine Care For the last several chapters, we ve provided an overview of the different types of healthcare practitioners that patients suffering from back or neck pain may see. Now let s examine the typical patient experience when a patient opts to see a generalist, such as a PCP or chiropractor, and compare it to the patient experience with a specialist. 14 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

15 The Usual Scenario: Assembly-Line Care After the initial patient visit which, as we ve noted previously, may not even include the PCP the doctor or chiropractic office usually recommends that the patient undergo magnetic resonance imaging (MRI), a diagnostic technique that uses magnetic fields to produce detailed images of organs and tissues. A radiology technologist obtains the MRI scans and submits them to a radiologist. In most cases, the radiologist receives little patient information alongside the scans other than the vague complaint of back or neck pain. The radiologist describes the MRI scans without ever seeing or talking to the patient and submits a written report to the PCP or chiropractor. Most PCPs and chiropractors are not equipped to review MRI images themselves, which significantly diminishes their ability to correlate MRI findings with relevant clinical symptoms, as radiologists often direct them to do. Compounding the problem is that most adults have age-appropriate, non-problematic changes that show up in MRI, which creates confusion. MRI is a very important diagnostic tool, but its high sensitivity makes it a double-edged sword. Reading only an MRI report may lead to unnecessary treatment or an incorrect diagnosis. Unfortunately, many practitioners overly rely on such studies instead of emphasizing the collection of a thorough patient history, physical exam, and neurological and musculoskeletal evaluation. All of these factors make it less likely that a patient will receive an accurate diagnosis and individualized treatment plan. At this point, patients usually are transferred further along the assembly line of healthcare practitioners to physical therapy. Without a clear directive on what they are treating, PTs can create further confusion in patients by telling them they have additional problems, such as a weak core or bad posture. However, back and neck pain causes muscle spasms, which is the body s defense mechanism to minimize motion of the affected area. These additional problems are usually the consequence of pain and will not cease until the source of the pain is addressed. Patients are then shuttled along to pain-management specialists (anesthesiologists). These physicians are focused on treating pain as quickly as possible using pain blocks and narcotics. The emphasis on quick pain relief amounts to a sophisticated and temporary Band- Aid to the underlying problem. Note that the question of why the back or neck hurts is never answered. Pain, once a symptom, is now treated as a diagnosis that is passed along the assembly line. A series of practitioners are attempting to treat a problem without really knowing what they are treating. As a result, the source of pain remains unknown, an effective treatment plan is continually postponed, and restoration of spine function is elusive. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 15

16 The Alternative Scenario: Coordinated, Team-Based Care With medical spine specialists, there is an alternative path for patients suffering from back or neck pain. Not only do these physicians possess the necessary knowledge base to start with, but they tend to develop a focused team around them to address and consolidate the various aspects of spine care within one clinical practice. No longer are practitioners operating in independent silos without communicating directly with each other and the patient. Instead, care is planned, coordinated, and progresses toward clearly defined goals. Most importantly, spine specialists understand that pain is merely a symptom of a larger problem rather than a diagnosis on its own. Spine specialists consistently participate in the initial patient visit, which is critical for gathering comprehensive information about patients medical histories and the pain they experience, and for conducting physical exams and thorough musculoskeletal and neurological evaluations. Without this information, spine specialists cannot perform their core function: diagnosing spine problems and devising treatment plans. If no neurologic deficit is observed, physical therapy and manipulative treatment may be the best course. If a neurological deficit is detected, the spine specialist orders an MRI scan and then reviews the findings with the patient. Each MRI finding must be correlated with clinical findings from the initial patient visit and further confirmed or ruled out by specific maneuvers performed on the patient during the MRI review. The ultimate goal is to narrow down and eventually pinpoint the specific tissue or spine structure responsible for back or neck pain. Unlike generalists, spine specialists are equipped to interpret MRIs and correlate findings. If the spine specialist suspects a mechanical cause of pain, a selective diagnostic block is recommended to prove the culprit of pain beyond a reasonable doubt. This involves the application of a local anesthetic to a small area on or around the specific spine structure in question to determine whether the pain temporarily stops. This procedure is not intended to be a short-term treatment; rather, it is critical for refining the diagnosis. In most cases, the diagnostic phase should conclude within two to three office visits, and then the welldefined treatment plan whether surgical or non-surgical begins. This approach leads to an identification of the source of pain in the majority of cases and a timely resolution of patients problems. A regional center of excellence dedicated exclusively to restorative spine care, Advanced Spine Institute (ASI) is a perfect example of a team-based, coordinated, and comprehensive care approach. ASI is especially unique in that its founder, Dr. Robert Talac, is both a spine specialist and surgeon. With his team of highly trained professionals, ASI functions as a onestop shop for all spine-care needs. For more information, please visit asispine.com. 16 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

17 Conclusion A t this point, it should be clear that there is no better source of help for back or neck pain than physicians who focus solely on the part of the body where your pain is located: the spine. Medical spine specialists have the experience and expertise to identify and fix the source of your pain conclusively. And from a convenience and relief-of-suffering perspective, seeing one practitioner who can manage each aspect of your care is simply more efficient. When you re in pain, you don t want to make multiple trips to various practitioners offices if unnecessary. For the diagnosis and treatment of the underlying cause of back or neck pain, every other healthcarepractitioner option has at least one major drawback compared to the benefits offered by a spine specialist. When it comes to a potentially serious spine problem and the quality of your life, is it worth the risk of an inaccurate or overlooked diagnosis, delayed treatment, and irreversible spine damage? Isn t it in your best interest to go directly to a physician who specializes in your problem area? Choosing the right care provider can make a dramatic difference in your outcome you owe it to yourself to find a spine expert. Doing so will save you years of unnecessary pain and frustration, as well as time and money. Care Providers At a Glance PRIMARY CARE PHSICIANS MEDICAL SPINE SPECIALIST SPINE SURGEON PHYSICAL THERAPIST CHIROPRACTORS EDUCATION AND TRAINING Undergraduate degree Medical degree (4 years) Residency (3 years) Optional fellowship (1-3 years) Undergraduate degree Medical degree (4 years) Residency (3-4 years) Optional fellowship (1-3 years) Undergraduate degree Medical degree (4 years) Residency (5-7 years) Optional fellowship (1-3 years) Undergraduate degree Doctor of Physical Theraphy Degree (3 years) Undergraduate degree Medical degree (4 years) Residency (3-4 years) Optional fellowship (1-3 years) STATE LICENSURE PRIMARY ROLE Diagnose and treat a wide range of everyday health issues, and refer patients to specialists as needed Diagnose and treat the entire spectrum of spine problems Perform spine surgery on patients as part of a surgical treatment program for mechanical spine problems Guide patients through a prescribed regimen of non-surgical treatment for muscle-related back and neck pain Act as a complementary care provider for patients with non-acute, musclerelated back and neck pain, using natural, non-surgical means DOCTOR REFERRAL REQUIRED No No No No ABILITY TO DIAGNOSE SPINE CONDITIONS (Limited) (Limited) ABILITY TO PRESCRIBE MEDICINE No No ABILITY TO PERFORM SURGERY No Some* No No *Typically, medical spine specialists do not perform surgery. However, a small number of spine specialists have completed the required training to perform some invasive diagnostic or surgical procedures. ADVANCED SPINE INSTITUTE Robert Talac, M.D., Ph.D. 17

18 About the Author A renowned spine specialist and orthopedic spine surgeon, Dr. Robert Talac is the founder of the Advanced Spine Institute in Houston, Texas. His clinical practice is 100% focused on the treatment of spine-related problems. Most patients come to see him with back or neck problems that significantly affect their quality of life. He not only alleviates pain but also emphasizes the restoration of spine function and performance. Having earned his M.D. and Ph.D. in Biophysics from Masaryk University in Brno, Czech Republic, Dr. Talac completed his general surgery training and a fellowship in surgical oncology in Europe. He also holds a diploma in minimally invasive surgery from the University of Louis Pasteur in Strasbourg, France. In 1999, he relocated to the United States for a clinician/ scientist position at the Mayo Clinic in Rochester, Minnesota. In this role, he learned and perfected cutting-edge strategies for promoting spine healing and recovery. He then completed his residency in orthopedic surgery at the University of California San Diego, and fellowship training in spine surgery at the Center for Spine Health at the Cleveland Clinic in Cleveland, Ohio. In addition to his practice, Dr. Talac is dedicated to advancing patient care through clinical research. He has served as the lead author of more than 50 research publications and has contributed to several textbooks about spine surgery. Known for being personable and for spending a considerable amount of time getting to know his patients, Dr. Talac is a multipleyear winner of the Patient Choice Award and Most Compassionate Doctor Award. This honor is bestowed upon physicians who receive near-perfect scores in patient surveys. Only 5% of the nation s 830,000 active physicians are accorded this honor by their patients. 18 WHO SHOULD I SEE WHEN MY NECK OR BACK HURTS?

19 Phone: (832) Fax: (877) asispine.com