Oh, My Aching Back. Part 2: Chronic back pain

About 20% of adults 20-59 and even more people 60 and over suffer from chronic back pain, pain that lasts 3 months or more and bothers you most days. Chronic low back pain can interfere with your enjoyment of life and is the leading cause of disability world-wide.

Unfortunately for sufferers and their doctors, most of this pain has no clear cause and no great remedy available.

There are two specific causes of chronic back pain that have a defined cause and a potential surgical treatment: spinal stenosis and ruptured disk.

Lumbar spinal stenosis is rare in young people but gets more common with age. The symptoms are classically pain in the legs when standing or walking with almost immediate relief upon sitting down. If it is truly disabling, surgery is an option to consider.

A ruptured disk can put pressure on the nerve root coming out of the spine; the pain will run down the back of one leg, usually as far as the ankle. On examination, lifting the leg when you are lying on your back is very painful. Most acute disk ruptures will improve with time. Unless you have obvious leg weakness, you should NOT rush to surgery. In a minority of people, however, the pain persists.

What about the majority of sufferers, whose back pain has no clear cause?

There are numerous treatments available, their number and variety testify to the fact that most do not work well for most people.

Anti-inflammatories such as ibuprofen and naproxen have the best success rate. There is no good evidence supporting nerve ablation, epidural injections or intramuscular injections, and all of these have potentially serious side effects.

Unless there is strong clinical evidence for spinal stenosis or a nerve root compression, do not get imaging of your back. If you are over 50, there is a 60% likelihood imaging will show one or more abnormalities, and if you are over 70 this rises to almost 100%. This is true even if you have never had a backache in your life! Never allow anyone to operate on you based on imaging; imaging should confirm a clinical diagnosis, not substitute for one.

Finding arthritis in the spine will not change treatment.

What can you do?

Exercise helps, particularly exercises that strengthen the core. Heat and massage often help. Spinal manipulation by a physical therapist or a chiropractor may help.

Avoid narcotics. They may help initially but often must be taken in increasing doses and carry the risks of addiction and side-effects.

Proper use of pillows or other forms of back support are key when sitting or driving.

If surgery is recommended, ALWAYS get a second opinion.

Try to stay as active as possible. Exercise within your limits.


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Oh, my aching back. Part 1 - acute back pain

Most of us have (or will have) experienced an acute lower back pain. Sometimes the cause is obvious – you unloaded six bags of loam from the trunk of your car – while other times “I just bent over to pick up a pencil.” Our back muscles extend over a long distance and stretching them just the wrong way may be all it takes.

Whatever the cause, it can make for a very uncomfortable time. What should you do?

First, what you should not do is go to the emergency room. Unless you have one of the “red flags” I list below, you do not need X-rays or CT scans. What you need is pain relief and a short period of rest.

Pain relief for acute onset back pain takes many forms, no one of which works for everybody. Getting flat with your knees bent and some pillows under your knees may be all you need. Both heat and cold can be very helpful. For acute pain, I tend to start with ice rather than heat, but if you have found a heating pad works, stick with it.

Note that you should only spend an hour or two lying down. After that, gentle movement such as walking is fine.

Get some over-the-counter pain relievers: acetaminophen, ibuprofen or naproxen are equally likely to help but each of us has a favorite. If one anti-inflammatory does not work, try a different one.

When might you need an imaging test? If the pain extends down the back of one leg towards the ankle you might have a ruptured disk, a condition that can be suspected based on clinical exam and confirmed with a CT scan. If you have known osteoporosis or cancer, or have been on long-term cortisone-type medication or the pain comes after a serious fall, you may be dealing with a fracture of one or more vertebra. This can be proven with a plain X-ray.

Cancer, an unexplained fever, IV drug use or a depressed immune system raise worry about an infection near the spine and suggest you seek early medical attention.

Assuming none of these uncommon situations fits, your pain should subside within a day or two with rest, pain relievers and ice or heat. Don’t try to ignore it and push through or the pain will last longer.

Next week: what about back pain that does not go away?


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What price for "miracles," and who pays for them?

There are now five drugs on the market to treat genetic disorders that are each priced at over $2 million.

They have been approved by the FDA to treat illnesses that had no curative therapy. Some, such as spinal muscular atrophy, were fatal while others such as hemophilia and sickle cell anemia led to repeated crises and frequent hospitalizations.

Are these astronomical prices justified? The pharmaceutical companies justify the prices by citing two factors: the high cost of drug development and the long-term financial benefits.

The problem with using research costs as a justification for the prices is that much of the basic research is funded by NIH grants or academia rather than by industry.

In the case of Zolgensma, Novartis’ $2.1 million drug for spinal muscular atrophy, the bulk of the early funding came from a private charity founded by parents whose child had the disease. ProPublica documented how their efforts, both financial and emotional, were ignored when the commercial potential of the drug began to become apparent. They hoped for a cure for their daughter and others similarly afflicted, not a windfall for the executives of the start-up they helped fund. See: https://www.propublica.org/article/zolgensma-sma-novartis-drug-prices-gene-therapy-avexis

Research published in JAMA provided details of the sponsorship and funding of 341 trials of gene therapy. Fewer than half were industry-funded. Academic hospitals, universities and the NIH were more often the funders, and yet the financial rewards almost all go to the pharmaceutical industry.

One could make a case that the sky-high one-time cost of gene therapy pays for itself by preventing the numerous emergency room visits and hospitalizations that it will eliminate. The estimated lifetime cost of hemophilia is $20 million! This makes the one-time $3.5 million cost of Hemgenix seem a bargain.

The big if is that the only data we have is that the benefits last 3 years – hopeful, but only a short span in a life-long disease. If the benefits fade after 4-5 years will CSL Behring refund the cost?

Will health insurance companies be willing to pay for a drug that may benefit the patient for 50 years or more when they know that their average subscriber is probably going to change insurers in a few years?

We need a different way to pay for these “miracle” drugs. One option is to have them paid for on an annual basis, spreading the cost over the patient’s estimated lifespan, with payment to stop if the drug stops working. A plan must be devised soon, or scientific advances plus pharmaceutical greed will exceed society’s ability to pay.





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Osteoporosis: could I have it?

Osteoporosis, thin weak bones, is common in post-menopausal women and older men. While not fatal, it is a major risk for fractures and can severely impact your quality of life.

Estrogen in women and testosterone in men are needed to maintain healthy bones and the biggest risk factor for developing osteoporosis is aging. The precipitous drop in estrogen levels in women who go through “the change” accelerates bone loss, and some 80% of those with osteoporosis are female.

Other factors increasing your risk are smoking, alcohol consumption, poor intake of calcium and vitamin D, lack of weight-bearing exercise, taking cortisone-type drugs and being thin. (One of the few health benefits of obesity is that you are less likely to get osteoporosis.)

How do you know if you have it? Osteoporosis is a “silent disease,” with no symptoms until it is advanced, and may first be discovered when you suffer a fracture.

The best way to find it before a fracture is to have a modified X-ray called a DEXA scan, which measures the density of your bones at the hip, spine and/or wrist. This gives you two numbers, a T-score, which compares your bones to those of a young healthy adult, and a Z-score, which compares you to an average person of your age.

If your T-score is: (note that these numbers are a consensus, not “truth.”)

• –1 or higher, your bone is healthy.

• –1 to –2.5, you have osteopenia, a less severe form of low bone mineral density than osteoporosis.

• –2.5 or lower, you might have osteoporosis.

The risk of broken bones increases by 1.5 to 2 times with each 1-point drop in the T-score.

A DEXA should be done when a woman is 65, a man 75, unless they have many risk factors for osteoporosis. While there is no hard rule, it should be repeated in about 2 years. If the results are stable, you can probably wait 5 years before a third.

If you want a precise estimate of your risk of fractures, google “FRAX Score.” The first link that shows up (https://frax.shef.ac.uk/FRAX/tool.aspx?country=9) will take you to the validated tool developed at the University of Sheffield in England. In addition to your T score, it asks for information such as age, height and weight and will then tell you your risk of a major fracture in the coming decade.

How can you prevent osteoporosis? Don’t smoke; don’t drink much alcohol; do resistance exercise (weights); get adequate calcium in your diet (dairy, leafy greens, almonds) and get adequate Vitamin D. Note that dietary calcium is better than pills. We get D from sun exposure and fortified milk.

Since few adults are big milk drinkers, and most of us do not spend all day outdoors soaking up sun, a vitamin D supplement is a good idea, and the amount in a multivitamin is probably adequate for most.

If you are at high fracture risk, many different medicines are available that have been shown to reduce the likelihood of fractures – but are not a guarantee. The best-studied are the “bisphosphonates,” taken as a weekly or monthly pill, but there are many other classes of drugs highly marketed. All these remedies have the potential for serious side-effects, so the decision to start requires a careful dialog with your doctor.

There is also good evidence that taking a bisphosphonate for a couple of years and then stopping is a better idea than taking it forever.

Remember: prevention is better than treatment, so start early. The bones you preserve will be the ones to keep you upright and moving.



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Measles: do I need a booster?

It may be hard for younger people to accept this, but when I was in medical school, we talked casually of patients having had “the usual childhood diseases,” referring to measles, mumps, chicken pox and rubella (German measles).

Measles is a highly contagious disease that spreads easily to others with near 100% transmission. While generally a flu-like illness with a rash from which children recover, about 5% of measles patients develop pneumonia, 1 in 1000 develop brain swelling with deafness and/or intellectual disability resulting and 3 per 1000 die.

A vaccine to prevent measles was introduced in 1963 with dramatic results. Prior to 1963, nearly every child got measles by age 15. There were 3-4 million cases a year, with 48,000 hospitalizations and 500 deaths annually. This fell dramatically after the vaccine was available. Reported cases fell 97% between 1965 and 1968 and measles was declared “eliminated” in the U.S. in 2000.

Unfortunately, this very success has led to complacency, and the disinformation by “anti-vaxxers” has contributed to a falling off of vaccination rates.

Not surprisingly, measles has recurred. In 2024, the U.S. saw 16 outbreaks (3 or more cases) involving a total of 285 cases. As of the end of February, 2025 has seen 9 outbreaks, with a total of 164 cases. The best known is the Texas outbreak, but there have been others around the country. 95% of the cases involve people who were unvaccinated.

Do you need to worry?

If you were born before 1957, you almost certainly had measles, whether you remember this or not, and if you were born before 1963, you probably did. Natural infection gives virtually 100% life-long immunity, so there is no need to get a booster.

If you were vaccinated between 1963 and 1968, you may have received a less-effective vaccine and may want to have your antibody levels checked with a blood test.

If you received two doses of the standard MMR (measles/mumps/rubella), you are 97%+ protected unless you have an immune deficiency.

So, for most of us, protected by childhood infection or vaccination, no worries. For our children and grandchildren: GET VACCINATED. The MMR does NOT cause autism, and there have been no deaths from the vaccine in healthy people. Children with immune deficiency, a very rare condition, cannot get the vaccine, and depend on the other 99% of us preventing outbreaks by getting vaccinated.



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