Depression and Low Back Pain

I just did one of those continuing medical education courses — in psychiatry, my very own field no less. It says that people who get a bout of depression are twice as likely to get a bout of back pain. What I read is a meta-analysis.  That means some clever person who probably needed the publication on his (or her) resume did a statistical (and critical) analysis of research other people did. This a noble attempt to asymptotically approach “the Truth and the Light” on a subject. It is also a delightfully erudite way to do research and get a publication without using a lot of time and money that the author had to scrape up.

Look, the relationship between depression and low back pain is something I have seen from every imaginable angle. As a neurosurgeon, it did not take me terribly long to figure out that surgery was not a very good solution for back pain. Of course, we rigorously restricted ourselves to operating focalized sciatica.  Cases where we could reasonably infer that an intervertebral disc seemed to be compressing a distinct (lumbar) nerve root that formed part of the sciatic nerve (plexus) that descended from the spinal cord to the leg and foot. There was the physical examination.  If someone were lying flat on his (more rarely, her) back and their straight leg was raised toward the ceiling, pain would appear on a trajectory anatomically consistent with one of those nerves. This was the sign of Laseque.  And we took it to be as solid as money in the bank.

There was myelographic evidence.  An X-ray study where the only way to see things like discs between the vertebrae (which, except in cases that included the worst calcifications imaginable, were never bad enough to show up on a regular type X-ray) was with a myelography, using either injected gas or injected contrast material to get the X-ray. Getting such X-rays often involved whipping people around in various postures using specialized chairs. This was a matter for specialized neuroradiologists, who somehow always seemed to bar me from observing such procedures. I remember the joy of being able to abandon such rooms when scanning technology improved.

In the final analysis, nobody could be quite certain of what they were doing until we got to the operating room.  Non-correlation of clinical and (allegedly) anatomical data with what we saw there was more the rule than the exception. My chief would seem able to pick out who would do poorly before the operation. All he had to do was say “C’est un psi,”  meaning “they’re psychiatric,” and we all knew we were headed for (what the patient would doubtless consider) rotten surgical results. All of this has to do with sciatic pain.  The kind of pain that starts in the back and descends to the foot or leg.

There are overwhelming numbers of folks who have back pain that starts in their back and goes no place in particular.  They sometimes make it to doctors and never make it to surgeons. Mostly, I think, they just stay home and complain. My mother of blessed memory took advantage of every birthday of my lifetime to remind me that I had ruined her back for life because of my kicking and fussing when I was delivered. The fact I was in no way sentient and not in control of my actions at the time was (of course) in no way to be considered an acceptable excuse. I had my first bout of back pain when I was in prep school.  Nothing too serious, but I was not going to take any pills for it, as I found that sort of behavior escalated rapidly, seemingly more so among women. My family physician applauded my aversion to pain medicine. He told me lots of women wore “a good, firm girdle” for that sort of thing, and I could seek consultation from my mother. Since she generally complained her girdle caused more pain, it was not hard to determine this would be a losing proposition.

I decided, as I so often have in life, to simply grin and bear it. I was already immersed in what I perceived as preparation to become a neurological surgeon when I decided to attack the problem of back pain (my own, as well as that of a seeming infinity of other parties) the same way I attacked everything else. That was, of course, by reading like crazy and learning all I could. I became rapidly convinced that nobody really knew very much about back pain. I remain convinced to this day, that nobody — but nobody — has a clue what structure causes the pain. There was as serious patriarchal eccentric (and of course, Jewish) surgeon at the Jewish Hospital in Cincinnati, Ohio, who was dead set convinced he alone knew what caused back pain. He said it was the “cuneal nerve.”  He had his taken out and had no back pain whatsoever since, and was trying to convince his friends to get their cuneal nerves cut out.  He said it was a simple procedure and free of complication. I guess I wasn’t one of his friends. It did not take much research to figure out that this procedure would not be a good idea. He said “taken out,” with the gay abandon of a general surgeon who must have cherished the belief that the way to make things better was to cut them out. You don’t cut nerves that creates pain, at the very least. You can take anti-inflammatories (ibuprofen-type), which are the customary back pain treatments.

These irritate the stomach and kill about ten thousand people annually from causing bleeding ulcers. I tell my patients about Methyl Sulfonyl Methane or MSM, cheap, unpatentable over-the-counter anti-inflammatory. Even if the pain was caused by entrapment of the cuneal nerve — and this could indeed happen with twisting, flexing kind of back movements, like the kind of movements that cause back pain — then some (neuro?) surgeon would have to free it from entrapment in the fascia (membranes) of the back which would be a long and complex dissection that could cause more pain post-operatively. I was just starting to jump into residency and plow through all the technical literature I could find when I realized the enigma of back pain had followed me. Back pain was more correlated with depression than anything else.

This revelation made sense. I was then and am now a “grin and bear it” sort of person. I remember realizing that my back hurt a bit from bending over the operating table while I was preparing to leave neuro surgery. I think I was indeed a bit depressed when I realized that my career would require a course correction. I was early in my psychotherapy training when I winced with back pain when getting up from a chair in the office of my supervising psychiatrist. I had been asking him for help with a particularly difficult patient. Dr. C. asked me if my head started to hurt when I took on this particular patient. It had. He told me I work through both my back pain and this patient’s course of therapy at the same time.  I did.

He said back pain and depression were “just different words for the same thing.”  There was no literature to clearly validate him, but he was right. So many patients — I have simply told that antidepressant drugs will help their back pain, and they have. Me, one of the advantages of growing older is that I have managed to have many ailments (mostly quite minor, thank God) that my patients have had, so I have a special confidence in being able to get them through. My latest newsletter just came out yesterday — only my opt-in subscribers receive this.  If you want to get on the list, just sign up at the top of this page.  If you want the most current issue, send me an email at docteurg@docteurg.com.