Pathophysiology and treatment of intervertebral disk disease

Back pain is like quality--you know it when you see it--but it is hard to precisely identify and quantify all the factors that are responsible for it. Quality of care in back pain compounds this dilemma. Because we cannot often precisely identify specific causes of back pain (we are usually overwhelmed by an excess of putative factors) and we cannot often assess therapeutic results with precision (double-blind randomized studies of multivaried pathologic and psychologic factors and multiple coexistent therapies and compliance variables), assessment of treatment modes is extremely difficult. Nonetheless, we ultimately must treat the patient. Nihilism is unrealistic. The art and science of medicine must be integrated. Pseudoscience based on high-tech dazzle must be viewed with appropriate skepticism. Treatments must enlist patients' understanding of their options with carefully directed self-care and home therapies augmented when needed by proven safe treatments as well as reasonable, inexpensive, safe remedies still lacking proof of efficacy to help comfort and support the patient during the healing process. Surgical interventions, with a few exceptions, are a last resort and should be employed judiciously and skillfully by experienced surgeons. The surgeon also must be both knowledgeable and experienced in the conservative treatment of low back pain to know when conservative treatment has truly failed. Failure to profit from an investment in a poorly managed business does not mean that the business per se has no value but rather that the business can only prosper with committed qualified management. No less can be asked of conservative rehabilitative therapies before they have been judged a bankrupt failure. Conservative treatment of low back pain is not complicated, but it does require knowledge, skill, and persistence and the ability to recognize when its failure is the result of a lack of response to optimal therapy and when further therapy is procrastination, redundant, and wasteful of time, suffering, and resources.