Humans Versus Machines

It is an almost universally held concept among surgeons and patients that a specific structural lesion is usually the source of pain. If that lesion can be identified and repaired, the pain will resolve. This seems plausible. It seems likely in light of the intensity of back pain that a diagnostic test ought to be able to identify the source of intense pain and point to a solution.

During my first seven years of practice it was my assumption that if a patient had experienced low back pain for six months then it was my role to simply find the anatomic source of pain and surgically solve it. I was diligent in this regard. The test I relied on most heavily was a discogram. It is a test where dye is injected into several discs in your lower back. If the patient’s usual pain was produced at a low injection pressure it was considered a positive response. The only patients I did not fuse were those who did not have a positive response or had more than two levels that were positive. I performed dozens of low back fusions and felt frustrated when I could not find a way to surgically solve my patients’ low back pain.

I have a physiatrist friend, Jim Robinson, who is a strong supporter and contributor to the DOCC project. From 1986 to 1992 we both served on the Washington State Worker’s Compensation clinical advisory board in regards to setting standards for various orthopedic and neurosurgical procedures. Our discussions were based on this assumption that there always was an identifiable “pain generator.” It was just a matter of figuring out what test was the best one to delineate it. We did not think in terms of structural versus non-structural sources of pain. We knew about the role of psychosocial stress but did not fully appreciate how large a role it played.

You are not a machine. Machines cannot experience pain. They do not have pain fibers, a nervous system, emotions, hormones, or memory. There is nothing in the mechanical world that remotely resembles the pain experience. Unless there is a specific identifiable structural problem, you cannot take yourself to the “body shop” and have your pain removed.

physiatrist: a physician that is specially trained in the field of Physical Medicine and Rehabilitation (PM&R) – a branch of rehabilitative medicine that focuses on enhancing and restoring functional ability and quality of life for those with physical disabilities or impairments. Physiatrists focus intently on helping patients to regain optimal bodily function after suffering a muscle, bone, tissue, and / or nervous system injury (ex: patients who have suffered a stroke). Physiatrists are sometimes referred to as rehabilitative medicine specialists.

discogram: an invasive diagnostic evaluation procedure that is utilized in conjunction with intervertebral disc pathology. Usually reserved for persons with persistent, severe lower back pain who have abnormal spaces between their vertebra – usually determined by an MRI, if other diagnostic tests have failed to reveal clear confirmation as to the source of the lower back pain. At this point, surgical intervention may be necessary in order to relieve the pain.

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