Please help me! I don’t know what you can say or do, but the pain I am in is driving me crazy.I have had pain in my lower back for a few years now As soon as I could I saw a doctor here…,he referred me to a specialist who? took an xray and also sent me to the local hospital for a MRI. I wish I had a scanner so you could look at them,but I don’t. The doctor said that I have Degenerative Disk Disease as well as an extra vertebra.He showed me where two disk have already deteriorated in my lower back.I think he said In the L5 and the one above it.At fist,he took my pain seriously.He had me on strong pain medication and I was in physical therapy.However,now he is saying that it shouldn’t hurt as bad as it does and has taken me off the medicine.I tried to explain to him that I am a full-time wife and mother.I do two or three loads of laundry,cook at least two meals,wash dishes,pick up toys and iron…..I clean the whole house and sweep and mop floors at least once a week.Sometimes, I am in so much pain I hardly move.It hurts when I sit,stand,or lay down for long periods.The pain is in about a three inch spread across my lower back.Sometimes,it doesn’t hurt,but most of the time it does.After I explained all of this to him, he said the only other thing he knows to do, is refer me to a surgeon.I saw another doctor… and he acted as if he didn’t believe me.When I told him I needed something for the pain,he said he didn’t want to give me anything addictive.He prescribed me Motrin and Amitriptyline to help me sleep.I don’t like taking what he gave me to help me sleep because it is hard for me to wake up.I feel like no one is taking me seriously.I feel like there has to be something that is causing all of this pain,but no one will help me.Is there anything you can do?Do you have any way of finding a doctor in this area that will believe me when I say I am in pain?Do you have any advice about my pain?Is there anything I can say to these doctors to make them believe me? I don’t know what to do.I feel like if I don’t get help soon I am going to have a nervous breakdown.

Dr. Joshua’s answer:

Obviously you are in real pain. I assume that in spite of the pain you manage to do all that work you described. This tells me the pain is not incapacitating, even though I can see that it’s bothering you a great deal - seems like you’re toughing it out. It does not seem to cause radiating pain or muscle weakness. The pain you describe is not typical - you characterize it as nearly continuous, and very localized, and you don’t mention it being provoked by changes in posture or movement. I wonder if it’s worse in the morning than during the rest of the day? If so, it may be more of a chronic inflammation problem. You do not mention any other symptoms, or anything else regarding your medical history.

This type of back pain can be caused by a number of things. The MRI and X-ray are very good examinations for back pain. Without seeing the pictures, or even the radiology report, I can’t say much. You mentioned “extra vertebra”. This probably means you have 6 lumbar-type vertebrae, which usually means your S1 (first sacral vertebra) is not fused to S2. This in itself is a normal variant and does not cause back pain. You don’t actually have an extra vertebra. You do however have degenerative disc disease, and this may be one of the causes of your pain. Since the pain is local, I assume there is no disc herniation or bulging, which means that surgery is not the treatment of choice. Also, you do not mention any sudden sharp pains related to movement (getting up, laying down, bending down etc), which suggests that you do not have an instability problem in your back. I’m sure the radiologist would have noted the typical signs if you had had them.

On the other hand, the degenerative disc disease may not be causing your pain. There are other possible causes as well, such as sacroilitis, or other inflammatory diseases. I would recommend you see your GP and get some basic labwork done to rule out inflammatory processes. Another course of action would be to take your X-ray and MRI pictures with you and go see a back specialist - neurosurgeon or orthopedic surgeon. A surgeon needs to see the pictures with his own eyes. Then, if the surgeon says surgery is not indicated, it’s time to see a physical/rehab specialist to get a good regimen of rest, exercise, and physical therapy.

Clinical examination is key to understanding the nature and source of your pain. Radiology and labwork are additions to clinical examination. I’m sure your doctors have done the clinical examination, and if not, someone needs to do it thoroughly. I tend to trust my colleagues, at least in the basic stuff, and I’m sure there have been solid reasons for their actions. Motrin (ibuprofen) is a good choice of medication in your case. You did not mention whether it helps at all, though, but if it does, it’s the right drug. Amitriptyline is also a good medication for pain, especially for chronic pain such as yours. However, the dose must be sufficient. I recommend 25 mg daily (taken in the evening) at first, then the dosage can be increased by 25 mg to 50mg in the evening. Later, even to 75 mg daily. At first you experience the side effects; dry mouth, drowsiness, etc., but bear with them for a few weeks and the therapeutic effect of amitriptyline will take over and the side effects will ease. I think it’s worth giving it a good month or two before you can actually say whether it helps or not. Perhaps a small dose of chlordiazepoxide (5 mg 2-3 times daily) would be beneficial in your case. It’s a muscle relaxant, and an anxiolytic. That would be for temporary use, for 1-3 weeks.

In summary, this type of pain should be approached by the following protocol: First, history and clinical examination is sufficient, and if nothing points to a serious underlying disease, rest, physical therapy, and medication may be tried for a few weeks. If the pain persists, some basic labwork and an X-ray should be done. If that doesn’t yield a diagnosis, MRI is a good next study, and then consultations with the appropriate specialists. If, despite these investigations, no specific cause can be determined, then the pain may be diagnosed as nonspecific musculoskeletal pain, and various treatment regimens may be tried, such as physical therapy, exercise, rest, NSAID drugs such as ibuprofen, along with drugs for chronic pain, such as amitriptylin, and chlordiazepoxide. Other, fancier drugs can be tried later on. If no specific cause can be determined, I am also of the opinion that addictive, opioid painkillers should not be used. These may end up being more of a problem than the pain itself.

There’s another mechanism by which your pain may also come about. That’s called psychosomatic. In my experience the psyche (brain) and the rest of the body are inseparable both physically and in context. You seem to be under a lot of stress, with all that housework, foreign country, and all that, and perhaps there’s some additional worries that you didn’t mention - marriage, uncertainty about the future, anything. If no clearly physical (somatic) causes are found, the psychosomatic mechanism should be accounted for. It’s an equally real and mainstream medical mechanism as the others I mentioned. I’m always a proponent of a psychiatric consult, and I’m throwing you the ball on that one. Wouldn’t hurt.

As for your question about the local medical facilities - I only know the country you are living in, and therefore I cannot recommend anything. However, I suggest you ask around for a good Schmerzklinik. This is the specialty that will take care of you once the other options have been exhausted. They are the pain specialists, anesthesiologists, neurosurgeons, neurologists.

This is what I could come up with, given the limited information I got from your e-mail. It’s not much, but I sincerely hope it helps.

Good luck,
Dr. Joshua

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