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A FEW WORDS ABOUT PAIN (Or, Why the Surgeon Might Not Want to Operate on You!)


What is pain anyway?

It would seem at first that is such a dumb question...everybody knows what pain is, right? It’s whatever hurts!

My tax return hurts. A professional criticism from a colleague hurts. But they’re not painful .

See what I mean? There are actually several different types of pain and many different technical definitions of it, but what is the essence of pain? I’m no philosopher. At a basic biological level, pain like every other thing we’re aware of boils down to a few brain cells receiving one of those electrochemical messages they get from other cells.

Really, think about it. Stub your toe. Ouch! A microscopic sensor in your skin called a "neural end-organ" (there are a bunch of different types) reacts to the injury and generates a nerve signal that runs through the nerves in your leg to the spinal cord where it "excites" another nerve cell in the spinal cord that it’s connected to. That nerve cell sends its signal up the spinal cord to your brain, where it connects to some specific brain cells (let’s call them cells XYZ) and excites them in turn. Your body is programmed to know that cells XYZ getting fired up means you’ve stubbed your toe. Got it?

Your body doesn’t really "know" that you’ve stubbed your toe. All you know is that brain cells XYZ have been excited. This is kind of like you hearing the doorbell ring at home. You don’t "know" there’s someone on the doorstep, but you expect that there will be because the doorbell just rang. Understand?

The behavior we call pain

Pain will obviously affect the way we behave, but the way we behave will also affect our pain experience. What I mean is that everyone responds differently to pain. Let's go back to my sprained ankle comparison.

Once a year or so I used to see (I stopped taking general orthopedic call a few years ago) a patient my fracture clinic who has turned their ankle and sprained it. This patient will come in hobbling on crutches, often sobbing with pain and needing help from a friend or relative to move around at all. We'd examine the ankle and not find any bruise or swelling, yet any attempt to touch that ankle is met with a yowl! This is obviously a hysterical person, no?

Similarly, once every other year I'd have someone limp into the ER when their ankle turns purple a week or so after what they thought was a trivial stumble, and X-rays will show the patient's been walking around on a broken ankle!

Why one patient will be so “wimpy” and the other so tough is a difficult question. People don't consciously decide to go either way. The way we react to pain is a complex issue and seems to relate as much to our genetic makeup as to how we've been taught to behave by our family, friends, culture and perhaps the media.

Some of it may relate to neurological "programming" and the issue of just how sensitive brain cells XYZ really are. Think about radios. A cheapo may be fairly insensitive and pick up only the one or two local stations that have the strongest broadcasting systems, while an expensive set may catch lots of faint signals and give you dozens of stations. Perhaps in the "tough" person those brain cells are fairly insensitive and need a great deal of neurological signal input to fire up, and in the "wimp" the sensitivity is so high that the barest hint of a nerve signal lights 'em up like a firecracker!

So what determines that sensitivity? Lots of things. Stay with me, and keep reading.

The difference between pain, dysfunction, and disability

The concepts of dysfunction and disability are very important in discussing pain issues.

The word "dysfunction" means "dis-function" or "this doesn't work". It makes sense that pain would cause dysfunction. You can't walk on a broken leg, can you?

The word "disability" means "dis-abled" or "not working". There's a subtle difference here. If my car runs out of gas it's disabled but it's not dysfunctional, it just needs a fill up.

The sensitive wimp with the sprained ankle is disabled but probably not dysfunctional. That not-swollen and unbruised ankle would probably work just fine if that person found themselves being chased by a mugger. The tougher person is dysfunctional because that broken ankle wiggles when it's stepped on to cause a limp, but he's not disabled because he's still limping around at work.

A given amount of pain can cause more or less dysfunction and more or less disability in a given case. The "why" of this issue is a minefield of controversy. It's what I, like most physicians and therapists, would really prefer to be able to avoid but I really should explore it a bit for us in this section.

Severity and recovery

Doctors and the medical literature (The more serious medical literature is called "peer-reviewed". That means an editorial group of doctors reads over the article to decide if it’s worth anything before it gets published, as opposed to some guy just blowing his horn!) tend to report the results of "the operation". That’s silly. The results and outcome of a surgical operation are obviously going to be big-time affected by the condition of the patient having it.

Don’t believe me? Have an appendectomy. If your problem is a sore tummy you’ll have this surgery done as a day-case and be back at work in a few days. If your appendix has festered and burst to fill your abdomen with pus, you’ll need to be slit open from stem to gizzard and have drains put in and you may be in ICU for weeks! Same operation here, an appendectomy.

Many things will affect how quickly you "bounce" back to your life after a spine operation. Of course, how it’s done (the "surgical technique") has an effect. Who you are (wimpy or tough) affects it. But perhaps most importantly, how sore you are coming in to it affects it.

A while back I talked about pinched nerves behaving like your fingertip with a thumbnail pressed up against it. I think that’s a good comparison. If you hold your thumbnail gently against your fingertip, a small pain will slowly come on after a while and if this was sciatica you’d probably cope with it easily for a long time before coming to see me. I’d slick your disc out through a one-inch incision as a day case and you might be back at the office in a week.

However, dig your thumbnail into a fingertip really hard and hold it there. Pretty soon you’re screaming. Crawl into my office with that kind of squished nerve root (that really happens, folks hobble in and lie on the floor in the waiting room every so often, poor souls) and we’ll probably admit you to hospital as an emergency and try to do the surgery the same day, again with that neat tiny cut. You’ll wake up in the recovery room and feel much better than you did going to sleep, but all that inflammation is going to take weeks if not months to heal and you probably won’t be mobile enough to leave hospital for several days. Same problem, same operation, but very different circumstances make for a very different experience.

What you expect from the surgery affects how you’ll react too. If you’ve heard all kinds of horror stories from your friends and expect to be in agony after the operation, you’re probably going to be. If your surgeon has explained things well and you know what to expect, you’ll appreciate the very real fact that these are pain-relieving operations and probably feel much better as soon as you’re awake enough after the surgery to think about it.

I want you to feel that way. That’s why I’m writing, and you’re reading, this book.

Chronic pain

We commonly think of chronic pain patients as people who are sore all the time.

Western medicine generally labels you "chronic" if you're sore for six months.

I think a better definition of "chronic" pain is a pain that's not going to go away. Sometimes you can see that coming within days of a patient starting to hurt, a subtle thing in how the patient complains and reacts to the pain and their circumstances.

Pain sometimes becomes permanent because those nerve cells XYZ up in your brain effectively set up an electrochemical "short circuit" that feeds back on itself and keeps them excited even without any new pain messages coming in. Remember, you don't "know" that your back hurts, you only know that brain cells XYZ lighting up means "back pain".

Why do these feedback loops start up? We don't always know, but we think it may relate to central (read, "within the central nervous system, or the brain") programming or the sensitivity of those brain cells XYZ that I talked about before.

How can our brain cells be programmed? A bunch of different ways, but basically they're set up for programming by the connections they have (how our brains are "wired", basically our individual genetics) and actually programmed by the electrochemical signals they receive (not just the "pain" signals, but all the other ones too).

Some of those programming signals relate to our life experience and how we are taught to behave by those around us, part of the normal flow of "brain waves" that neurologists might measure with an EEG test.

A lot of programming may boil down to how long pain signals have been received before things go bad. If you've had a life of heavy labor with an aching back at the end of your work day for your whole life, brain cells XYZ have been lighting up daily for years and you may be more prone to pain becoming chronic than most people would be. The brain cell connections may be like any other piece of equipment that works better or becomes more sensitive when it's used regularly.

Some programming may relate to the circumstances of your life other than your pain that might be affected by the pain. Western science calls that "secondary gain".

Secondary gains and pain behavior

The term "secondary gain" is a big deal around back pain issues. Secondary gain is something you get from a deal or situation that’s not the main point of things. There’s a military term "collateral damage" that means everything else that gets wiped out when you get the bad guys. Secondary gain is like a "collateral benefit". Like a child getting to stay home from school on the day of a test they’re afraid of but could probably score well on (that’s the primary gain) by complaining that he or she has a sore tummy (the secondary primary gain will be Mommy’s care and attention).

Secondary gain in back pain cases can be many things. The most obvious and problematic is money, such as the disabled pain patient might get from Workmen’s Compensation or other disability-insurance plans. Your back hurts when you work and if you can’t, your job-related pain is relieved and you feel better about life. This situation may feed unconsciously up into your brain and lower the sensitivity threshold for backache brain cells XYZ to light up. You get free money, you can’t help but feel better again, etcetera. This is a large part of why dealing with compensated or litigant (folks who are suing for damages relating to their back injury) back pain patients is such a problem for pain physicians like me, and in fact for society. Their odds of doing well with just about any injury or pain problem are just about cut in half by that fact of being rewarded for being sore.

I’m not for a second saying that all people in these circumstances are misrepresenting themselves, they’re usually not, but it seems they can’t help but be sore in these situations. We just don’t understand all of the reasons for this yet.

There are other kinds of secondary gain, too. The husband worried about loosing his wife may get to keep her around if his bad back needs to be looked after, kids may get away from the bully at school because their backache won’t let them sit to study in those hard wooden chairs. I recall a young lady, just graduated from college and with a good job lined up, with one of those not-swollen-but-crippled-with-pain ankles in the clinic who had her Mom with her all the time, attending the daughter’s every need. This was an obvious case of "my pain keeps Mom from kicking me out of the house" or something like that.

Sometimes this can be very sad, like the lady who came into hospital after "her back went out" when she spent two hours doing her dying mother’s hair. This lady’s X-rays, CT scan, myelogram and MRI were all as normal as you might ask them to be. She, it seems, just couldn’t handle being with her Mom at the end and obviously felt terrible to be that way. Back pain was her excuse to get away.

Psychology and pain

The medical literature is full of research about personality, psychology and the way different people will react to pain. There are many different behavioral testing scales (questionnaires that are used to define your personality) that have been applied to back pain and surgical outcomes research in spinal surgery. The point is to try to identify people who are having a reasonable response to their pain (and who would probably respond well to surgery too) as well as those who aren’t, and wouldn’t.

All this stuff seems to keep the shrinks and psychologists happy but it’s not doing a lot for you the patient or me the surgeon yet. We still don’t have a reliable way to "pick 'em right" 100% of the time in the context of a normal office practice.

This work has led to the evolution of a concept that says any patient with a history of depression or other psychiatric problems will do badly after spinal surgery. This is supported by a lot of clinical research. Sure, people who are "out of control" are not going to do their exercises and follow all the other instructions that are so important to how you’ll do after a spinal operation. However, experience suggests that many people with a psychiatric history can and will do well after appropriate spinal surgery – though looking after these patients can be very difficult for all of us involved in their care!

The key seems to be the "in control" question. Surgery of any sort is very stressful, particularly when the convalescence is prolonged like it is after spinal fusion surgery. It is very important that these patients be well in control of themselves during the preoperative discussions with their surgeon so that they might have a realistic expectation of what to expect, and that they maintain that control throughout the convalescence. That is not an easy thing to either assess or accomplish. It seems often just about impossible to be sure about the status of a patient’s psychiatric condition in these circumstances, and I think that’s probably why the surgical literature so consistently tells me not to operate on these people.

These principles in dealing with the full-blown psychiatric patient also seem to apply to people with neurosis and most mood and anxiety disorders. If you’re a terrified nervous wreck, chances are pretty good that you won’t communicate well with your surgeon nor have a realistic expectation of what’s to come from the operation. Don’t do it. Delay the surgery, suffer if you must, but get control of yourself before going ahead.
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