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The Goals of the Evaluation

About 10% of all patients complaining of chronic spinal pain have an abnormity which can be seen on an imaging study or found by examination.  In 90% the typical examinations do not determine the cause of pain.  There is a great tendency among spinal surgeons to focus only upon those patients with obvious abnormalities to be repaired by surgery.  The 90% who do not have these abnormalities are typically sent away and told nothing can be done to help them.  Most are given nonspecific treatments such as physical or manipulation therapies without regard for what is actually wrong with the spine.  My evaluation begins when those fail.  The ultimate goal of my examination is to make the best diagnosis possible which identifies the cause of the pain and/or other complaints and allows treatment to be specifically matched to those physical abnormalities.  Some patients have problems that need urgent or immediate treatment.  These diagnoses can nearly always be made by imaging studies such as x-rays, CT, or MRI.  The majority of patients will not have these kinds of abnormalities.  The causes of pain in them can usually be determined by nerve blocks which anesthetize specific structures in the back.  There will still be some patients whose complaints cannot be defined by any techniques we have available currently.  However, making the best diagnosis possible will provide an answer as to the cause of pain in most patients.  The best diagnosis allows choice of the best treatments.

Most acute spine pain complaints will go away spontaneously.  The first goal of treatment is relief of symptoms while recovery occurs.  When improvement does not happen with time or treatment, then the comprehensive diagnostic program should proceed.  When the diagnosis is made the best available treatments can be prescribed.

Some patients will need no more than pain relieving medications, exercise, an active physical therapy or manipulation.  Many patients will be candidates for immediate treatment by nerve blocks.  Medications to improve the underlying disease can be injected around the structures causing the pain.  Sometimes the same pain nerves can be interrupted by needle techniques, which injure the pain carrying nerves, but do not damage any other structures.  Some patients require surgical repair if the simple measures are not adequate.  In some patients treatment of the underlying problem is not possible, so the only thing to be done is to relieve pain.  The goal of our program is to make the best diagnosis possible using the least number of examinations and procedures.  The philosophy of treatment begins with the application of the least invasive treatments which carry the least risk and progress to those that are more invasive and carry greater risks.  Thus, physical therapy and manipulation measures plus medications are usually the first choice; procedures done with needles come next; and finally, surgery as a last resort.

Of course there are diseases which require urgent treatment for which nothing but surgery will suffice.  It is important to identify them immediately, so that surgery can proceed without any unnecessary delays.

None of these procedures will cure everyone.  Our philosophy is to apply the least dangerous and most appropriate first.  We want to reduce the use of those things that will not be effective, focus on the ones most likely to help, and progress from least invasive to surgery as a last resort.