Spine care has become complicated. We have MRI scans, CT scans, injections, ablations, stimulators, biologic treatments and advanced surgery. With all of that technology, it is easy to lose sight of the most basic question:
Why do I hurt?
A simple way to think about spine problems is to ask four questions:
Why do I hurt? → What structure might be causing it? → What is the proposed treatment actually targeting? → Does that match my symptoms?
- Why Do I Hurt?
The best place to start is by simplifying the anatomy.
Your spine is made up of vertebral bodies stacked on top of one another. Between them are discs, which act as cushions and allow motion.
Behind the vertebral bodies is the lamina, which you can think of as the roof. The facet joints are located on each side of the lamina.
Under that roof is the spinal canal, almost like an attic, where the spinal cord and nerve roots are located. The nerves leave the canal through openings called the foramen, or windows, located in front of the facet joints.
At each level, think of the spine as having:
- 1 disc
- 2 facet joints
- 2 nerves
- The overall structure and alignment
Any of these can contribute to pain.
- What Structure Might Be Causing It?
The Disc
Discs naturally lose water and wear with age. This is called degenerative disc disease, but it sounds worse than it often is.
Many people have worn or bulging discs on MRI and little or no pain.
A disc can hurt by itself, or it can bulge or herniate and irritate a nearby nerve, causing pain, numbness, tingling or weakness into an arm or leg.
An abnormal-looking disc does not always mean it is causing your pain.
The Facet Joints
Facet joints are small joints in the back of the spine. Like a knee or hip, they can develop arthritis and become painful.
Facet pain usually stays in the neck or back, although it can sometimes spread into the shoulder, buttock or upper leg.
Stenosis and Nerve Compression
Stenosis simply means narrowing.
The spinal canal or the foramen—the windows where nerves exit—can become tight from disc bulging, arthritis, enlarged facet joints or thickened ligaments.
If a nerve becomes compressed, symptoms may travel into an arm or leg and can include pain, numbness, tingling or weakness.
In the lower back, stenosis can also cause leg pain or heaviness with standing or walking that improves with sitting or bending forward.
Muscles, Ligaments and Structure
Not all spine pain comes from discs, joints or nerves. Muscles and ligaments can become strained, inflamed or overworked.
The overall structure of the spine can also be part of the problem. A vertebral body can weaken and collapse, causing a compression fracture. One vertebra may slip forward, called spondylolisthesis, or backward, called retrolisthesis. The normal curves of the spine can also change.
The spine often tries to compensate for these changes. Posture changes, muscles tighten and nearby levels may move differently in an effort to keep the body balanced.
Sometimes the pain is not coming from the spine at all. The SI joint, hip, shoulder, peripheral nerves or circulation can create symptoms that resemble a spine problem.
- What Is the Proposed Treatment Actually Targeting?
This is where the basic anatomy becomes important.
At each level there is one disc, two facet joints, two nerves and the overall structure. You can treat one of these without treating the others.
For example, a treatment may involve injecting material into the center of a degenerative disc. That treatment is directed at the disc.
But it does not treat the facet joints.
If the disc is significantly degenerated, the facet joints at that level may also be arthritic or carrying abnormal stress. Treating the disc does not automatically treat the facets, nerve compression, stenosis or alignment.
The same principle applies to other treatments.
An epidural injection may help an irritated nerve, but it does not repair a degenerative disc.
A facet treatment may help facet pain, but it does not correct spinal stenosis.
A procedure can make perfect sense for one structure and still fail if that structure is not the main source of the patient’s pain.
- Does That Match My Symptoms?
Once you understand what is actually being treated, you can decide whether that treatment makes sense for the pain and symptoms you are experiencing.
Ask yourself:
Where does my pain start? Where does it travel? Do I have numbness, tingling or weakness? What makes it better or worse?
Then ask:
What exactly is this treatment treating?
An MRI may show several abnormalities at the same time, but that does not mean every abnormality is causing pain.
The goal is to determine which structure best explains what you are experiencing—and whether the treatment being recommended actually addresses that structure.
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