A spinal MRI is usually a pre-surgical investigation. Occasionally it is necessary to confirm an unusual non-mechanical diagnosis. It should never be used as a screening investigation. To justify an MRI, the primary care evaluation must raise the strong suspicion that the patient has a pathology requiring an operation. This is rarely back dominant pain and typically includes radicular symptoms. Even then, most radicular back or neck pain does not necessitate surgery. MRI is greatly over used and should be ordered only when a diagnosis is already contemplated and findings on the image will alter management.

First, the state of bowel and bladder function; Cauda Equina Syndrome is the only surgical emergency in low back. Location of the dominant pain. Constant or intermittent. Duration of symptoms. Level of disability. Positive neurological findings. Progression of symptoms. Significant co-morbidities. Presumptive diagnosis.

Between 60 and 80% of Canadians will have a significant episode of back pain in their lifetime. Less than 5% will be come chronic. Over 95% of back and neck pain is the result of altered biomechanics. Less then 3% is the result of other pathologies, of which the most common is inflammatory spine disease. About ½ of 1% is due to malignancy.

Surgery is required in between 5 and 10% of patients. The overwhelming majority for arm or leg dominant pain. The most common pathologies are unresolving radicular pain (sciatica, “pinched nerve”) where 85% will recover fully without an operation: disabling neurogenic claudication: degenerative cervical myelopathy impacting normal function.

Back patients require education and reassurance that regardless of the pain (which can be intense) their problem is not life threatening, will not lead to paralysis or permanent disability and, in almost every case, will fully recover. The problem is a minor mechanical malfunction where hurt does not equal harm. Stay as active as possible, avoid bed rest, use a minimal amount of analgesic medication, NO OPIOIDS, find movements or positions based on the presenting pattern of the pain that reduce the symptoms, establish methods of mechanical pain control before attempting more aggressive exercise, accept some discomfort if it allows a return to desired activity, experimentation is never dangerous, expensive devices and treatments are rarely needed. Consumer beware!

Patients are frightened by back pain and unsure of the reason for their symptoms. Because the pain can be intense they are naturally afraid the cause is sinister and can only be eliminated by a dramatic intervention like surgery. People are also frequently reluctant to accept an option that requires personal effort and accepting responsibility. They would rather shift the burden to someone else.

There are no widely available options. The ISAEC program in Ontario covers the spinal assessment but not the cost of ongoing physiotherapy. Several other provinces are experimenting with this approach but none offer paid mechanical therapy. Management is pushed back to the family physician who may be unable to offer the necessary support and supervision. Many private health insurance plans will cover some physiotherapy, chiropractic or physical training but the duration is limited and often inadequate. The current pandemic has dramatically increased the use of virtual care and many physiotherapy clinics are now offering on-line assessments with directed care. This lower cost alternative may become more accepted. So much of successful care depends on patient education, reassurance and common sense.

Success depends on the degree of scoliosis. Managing back pain in these patients is no different from managing back pain without scoliosis (See the answer to Question 5). But as the degree of curvature increases there will come a point when non-operative measures will not be sufficient to control the pain. The question becomes how much is the patient willing or able to endure and what are the risks of surgery?

It is too early to tell if virtual treatment will be effective. Physiotherapy clinics are experimenting with on-line assessment and the preliminary results are very promising. Both physiotherapists and surgeons are recognizing that many pre and post operative visits do not require an in-person consultation. There is growing consensus that once the pandemic ends things will not return to the way they were and the emphasis on telemedicine will remain. Improving patient compliance is a challenge that long preceded the current situation and will remain long after the lockdown is over. Getting patients to accept responsibility for their own recovery will require changing societal expectations and that is not likely to happen any time soon.