Investigating Pain

My CT scan report, dated three days ago, concluded the following:
“At L4-L5 there is a broad-based posterior disc protrusion centered in the right paracentral region resulting in mild spinal canal stenosis and effacement of the right subarticular recess with probable compression of the descending right L5 nerve root. There is mild right-sided neural foraminal narrowing and minimal right facet arthropathy.”

This sounds pretty ominous. But strangely, these are common findings on spinal investigations for a guy in his early 50’s. Some people even have these findings without any pain or disability. If we summarize this paragraph, it simply states, “it looks to be a disc bulging out against a nerve”.

Generally, this is good news. Really! We know how to treat the pain from an irritated nerve, we know what the medical community can do to help in this situation, and we know what the patient should do to promote recovery. Most importantly, though, we know that a disc pushing against a nerve is not sufficient for the experience of pain. In other words, even if it hurts like stink now, it doesn’t mean it will always hurt.

For me, this news was a huge relief. The findings matched with those of my physical examination on the day of the CT scan. Additionally, at that point I had a ‘diagnosis’ on which to blame the last five months of pain, combined with my ongoing intolerance for sitting, lifting and bending over. It would seem (my dear friends) that I am not faking it or am just a wimp (the stigma of chronic low back pain is powerful and cruel). It would also seem that the strategies of stretching, gently challenging my pain and dysfunction, meditating, and working on motor control exercises were a good plan – even though the pain and limited function had not resolved.

The odd thing about this experience can be summed up in this timeline:

• The week or so before the CT scan, I was experiencing constant, moderate-to-severe low back and right buttock pain. (I had been sitting much more than usual.)
• The day of the CT scan, I had constant, severe, leg-dominant pain, worst in the side of my calf and the top of my foot and ankle. Any weight bearing produced even more pain, sweating, and almost twice my normal resting heart rate. (The inciting incident for the increased pain was a dreadfully tiny side bend to pick up a pen.)
• The day after the CT scan, I awoke with the same intense pain. Any attempt to be upright, either sitting or standing, made the pain scream. (My big toe was numb, and both my big toe and outer calf muscles were weak.)
• Two days after the CT scan, I could stand again and sit again. The leg pain was mild, as was the low back pain. (The numbness and weakness remained the same.)

My contention would be that my L4-L5 disc didn’t change much over these few days, even though my pain did. Discs are made of strong fibrous tissue. They are difficult to injure, but slow to heal. The probability is low that the side bend in question applied sufficient force to injure even an already damaged disc, and certainly the disc wall could not have healed sufficiently in less than 48 hours to fully explain the amazing change in my pain.

Science suggests that some people have loads of pain when a disc leans against a nerve. Nerves tend to act really angry when they are annoyed. Science also shows that some people have no pain from the very same thing. Apparently, it can take a lot to annoy a nerve. But how would a scientist explain my recent experience? Other than the possibility that I had both a wildly fragile disc AND some sort of accelerated healing capacity, it appears that a disc bulge can produce drastically different pain experiences even within the same person. Such experiences have got to make us wonder about what we think about pain and tissue health. Can we really still hold on to the idea that tissue damage is the sole determinant of pain? Can we really still believe that the only way I will have less pain is to have the disc retracted from the nerve and the disc to heal?

As with any theory, I could be wrong about this. My pain changed an extraordinary amount in a matter of a few days. Yet I do not believe that my disc is that fragile, or that it could heal so quickly.

Pain is complex. Everything influences pain. I am exceedingly happy about this. It means I don’t have to worry so much about why the pain changed, or about whether the disc problem will heal up. I can focus on the idea that there are infinite ways to change how my nervous systems interpret what is happening in my back, and stay with the optimistic view that, given time and the right inputs, my systems will decide that what’s happening in the disc is old news, and not worthy of my constant attention.