Why a Rheumatologist, Not a Spine Surgeon, Should Treat Your Back Pain


By David Borenstein MD, Executive Editor, theSpineCommunity.com

Back pain is a symptom or complaint associated with over 60 different illnesses. Most of these illnesses are treated with nonsurgical therapy. Rheumatologists are experts in nonsurgical therapy for the spine. They are the ideal place to start when you have back pain and a great source for a second opinion for individuals already evaluated by a spine surgeon.

The vast majority of back pain is caused by mechanical problems resulting from growing older and over-stressing parts of the back like muscles, discs, and joints. Following are the 4 most common mechanical problems that cause approximately 95% of all back pain:

Muscle strain. This is most common form of mechanical back pain and usually affects people between 20 to 40 years of age. Muscle strains occur in the back as they do in a calf or a hamstring. The forces placed on the muscle are too great for the muscle to withstand and an injury occurs in the muscle fibers. Although this is a very painful event, most of these muscle injuries will heal up in a week or two. Movement is the best medicine for healing. Gradually increasing activity improves blood flow to muscles and that is what heals them quickly. Surgery is not required.

Herniated disc. Again, people who are 20 to 40 years of age are mostly affected. Contrary to a popular description of this condition, discs actually herniate, they do not “slip.” Discs are like a jelly doughnut cushion—they work well as long as the jelly stays in the doughnut. If the jelly leaks out, it can touch the nerves that supply signals for sensation and muscle strength in the legs, creating a very painful event called sciatica. The body has a way to get rid of the jelly. Surgery is not needed to resolve this problem. The vast majority of people with a disc herniation can gradually improve as the body removes the disc and the function of the nerve is restored. A minority of people require surgery or a discectomy to remove the disc. Surgery is needed when the pain is too intense or the muscles do not function well. People who undergo surgery get better faster. However, people with or without surgery evaluated at 1 or 2 years later have done equally well.

Osteoarthritis. This disorder occurs when the joints of the low back wear out, and individuals 50 to 70 years old are most commonly affected. Pain is greatest when weight is placed on these joints that are about the size of a dime. Exercises are prescribed to strengthen the abdomen, resulting in core strength that will use the muscles in place of the joints to support the back. Drug therapy to decrease pain helps individuals participate with their exercises. Back surgery to fuse joints usually results in more back pain over time.

Spinal stenosis. This affects individuals who are 60 to 80 years old. Stenosis means narrowing. Narrowing occurs inside the spinal column. The spinal cord and nerves that exit the spine can get pinched by bone and soft tissues that grow as we age. When we stand, the room in the spine is narrowed. Patients with spinal stenosis have pain with standing that can cause aching in the legs. Sitting increases the volume in the spine so the pain is relieved. Medicines, injections, and exercises have been used to relieve the pain of spinal stenosis. If the pain cannot be controlled, that is when spinal surgery to free up the nerves can relieve the pain and have patients return to being able to walk again without leg pain.

When choosing a physician to take care of your back pain, why not go to the doctor who can help you 19 out of 20 times. Medical, non-surgical therapy is the form of treatment that is appropriate for the vast majority of low back pain problems. Your local rheumatologist is a good place to start to get your back pain better.


Understanding Back Pain