Spine Surgeon Richard Guyer Gives Straightforward Answers to Questions About Back Pain


"Before I do surgery, I tell my patients they have to be in tip-top shape."(RICHARD GUYER)

Richard Guyer, MD, a spine surgeon at the Texas Back Institute in Plano, Texas, answers important questions about back pain.

Q: When should I see a doctor about low back pain, and when can I treat it at home?

A: In most cases for an acute episode, resting a day or two, intermittent ice on the back, and ibuprofen—that is good first aid. If after a few days its not beginning to feel better or you have neurological symptoms—weakness, numbness, loss of bladder control—you need to see a physician. We know that 70% [of people] will get better in two to three weeks, 90% will get better within three months, and a small percentage will end up having some chronic back pain. Between 80% and 90% of people will have at least one episode of acute back pain in their lifetime; about one-third may experience intermittent pain throughout their life. Most first episodes will get better in a few days.

Q: What are things I can do every day to minimize low back pain or keep it at bay?

A: The first thing is to make sure that you're physically fit aerobically and that you have a strong core. This entails exercises on a regular basis. Second, make sure you have a good ergonomic workstation with a good chair and a good support in your car. Practice good body posture and body mechanics. If you drop a pen, dont bend at the waist; instead squat down, bend your knees, bring your center of gravity closer to your trunk. Lift that way, and utilize over-the-counter anti-inflammatories.

Q: Does exercise help?

A: Its always a good option. One of the first things that we try to do when patients have a problem is we send them to therapy, where they will do two sets of exercises—those that help alleviate pain and those that help strengthen the back to prevent problems in the future and allow faster recovery.

Q: How can back pain patients help you treat them?

A: They have to take an active role to try to get better. Its a multifactorial approach: make sure they are aerobically fit, do core stabilization exercises, have good body mechanics, dont smoke—we now know that contributes to degenerative disk disease—and, last thing, make sure they are close to their ideal weight.

Next Page: How has medical thinking about the back changed

[ pagebreak ] Q: How has medical thinking about the back changed over the past 10 or 20 years?

A: Weve learned a lot more about the biomechanics of the spine. Weve learned about the importance of strengthening the core, similar to what Pilates and yoga were teaching 25 years ago. Exercise, rest, and anti-inflammatories are really the mainstay of treating 95-plus percent of the back pain patients I have.

Q: Has back treatment improved?

A: It is an imperfect science, but we have a better understanding of where the pain comes from. It's not just muscles and ligaments but other structures. Weve also learned a tremendous amount about the interaction between the body and mind of the patient and pain perception. If they are depressed, it can make the pain much worse. We need to treat patients physically and psychologically. Before I do any surgery, I tell my patients they have to be in tip-top shape. They dont send a space shuttle up at NASA unless all the lights are green.

Q: How does the orthopedic profession view the field of chiropractic?

A: I can tell you my perspective. At this point there are more and more spine MD and DO practices that are incorporating chiropractic. Twenty years ago it wasnt like that. I think more patients go to chiropractors initially for low back pain than go to a medical physician. About 60% of patients have been to chiropractic before they see us. A lot of medical physicians see working in conjunction with a chiropractor as helpful, and more and more chiropractors are incorporating physical therapy in their offices. I work with a number of chiropractors, and they will do the postoperative rehab. They are aware of the proper physical therapy modalities in addition to chiropractic. Their training has been upgraded over the years.

Q: When are steroid shots helpful?

A: Steroid shots are helpful in helping to control the pain if a patient has a pinched nerve from a herniated or ruptured disk. They will not cure the pain, but my goal is to lessen pain so the patient can continue some regular activities. Typically a patient will get better over the course of eight to 12 weeks.

Next Page: Why is it so difficult to operate on the back?

[ pagebreak ] Q: Why is it so difficult to operate on the back?

A: The anatomy is very complex. There are many nerves that we have to be very careful with and preserve their function, and thats really it. Its not like operating on an extremity. The spine has nerves that control the bowel and bladder functions and the lower extremities, and that can be a disaster if something goes wrong.

Q: What questions should I ask before deciding to get back surgery?

A: Ask the following questions.

  • Do you think I can be treated conservatively?
  • If not, what are my surgical options? What are the risks and benefits?
  • What is your experience in the techniques? Are there newer techniques that you might not be acquainted with?
  • What are the short- and long-term expectations of the treatment?

Q: If I am considering surgery, should I hold out as long as possible for new techniques to come along or for older techniques to be refined?

A: Its almost like looking for a new computer: Do you go ahead and jump in now or wait till the next one comes out? There are always newer and better techniques. I tell my patients it's about quality of life. If they say, "I cannot go on this way, I cannot do my work or enjoy my family," thats when they should look into the options. If a patient can tolerate the pain, go to work, enjoy their family, then they are not ready for surgery. If they say, "I cant concentrate, work is too much. I'm crabby to my spouse. I cant take care of my kids the way I want to," then its time. The newer techniques are marvelous. We have the ability to do fusions now with new biologic materials such as bone morphogenic protein, and we can have the patient heal in two to four months. Twenty-five years ago it could take up to two years. We have artificial disks now. You can go back to work in a desk job in two weeks. This is so much more advanced than when I started my career.