Ongoing Back Problems Should Be Re-Evaluated

Two years ago, I had lower back surgery for a pinched sciatic nerve. I still have pain in my right thigh that goes down to my calf. It hurts to put weight on it, especially to stand or walk; I get relief by sitting down.

I did sit more than I was told to after the surgery because it hurt to stand then also. Could I have added to my problems because of that?

Is it true that back surgery is usually more successful on the second go? Is there a method or test to pinpoint exactly what my problem is? Since I have a metal plate, I cannot get an MRI.

Unfortunately, back problems are very common in adults. The back is susceptible to pain because its mechanics include many pieces imprecisely put together, and it's loaded with nerves.

The players in back pain can include the vertebral bones, the connective tissues (such as ligaments and tendons), the muscles, and of course the nerves which must navigate through these muscles and connective tissue. The vertebral bones are essentially round with a hole in the middle for the spinal cord to go through, but also flare out in many places to form joints with other vertebrae and to connect to ligaments and muscles.

Because of this complexity in the back, only about one-fifth of all cases of back pain have the pinpoint diagnosis you are looking for. The generalist physician (such as myself) often suffices with making sure there are no alarming signs suggesting an inflammatory arthritis, infection, fracture, cancer, or significant interference with the spinal cord. And, usually, this strategy works: most people's back pain goes away with simple treatments like pain medicines and exercises.

With more than two years of back pain and a failed surgery, you need a different approach, and possibly a fresh start. Back surgeries are not always successful (possibly because, though no fault of the surgeon, the diagnosis was not pinpointed correctly in advance of the surgery), but repeat surgeries are not, as a rule, likely to be any more successful! Scar tissue develops in the healing process, and I'm sure you have scar tissue, but not at all sure if that has any role in your continued pain.

I think you're right to ask about further tests (and there are plenty to be tried), but they should be ordered only after careful consideration of the complete story of your back and a thorough exam. And even if a specialist evaluation does not give an exact diagnosis, there are many ways to treat back pain - even though you may have to undergo several different trials to find your best treatment.

If you have had ongoing pain despite previous treatments, ask your doctor to take a new look at your back.

Julie L. Mitchell, MD, MS, is an Assistant Professor of Medicine at the Medical College of Wisconsin. She practices at the Froedtert & The Medical College of Wisconsin General Internal Medicine Clinic - East. Her column appears in the Milwaukee Journal-Sentinel.