Questions & Answers with staff members of the Spine Center and the Health and Rehabilitation Pavilion. In this issue, we interview David A. Tillema, M.D., an orthopedic surgeon with the Kansas City Spine Center.

When a patient seeks consultation at the Spine Center, what tests do you request?
We begin with a thorough history and physical. We also require back X-rays if recent ones aren't available. We don't normally order CT Scans or MRIs on the initial evaluation of the patient with acute back pain. However, if symptoms do persist and offer signs of a herniated disc, then we'll go ahead and order these tests for confirmation of our clinical diagnosis.

Why would you order one test over another?
No one test tells everything. We usually start with a CT Scan or MRI. If the findings aren't clear, we go from there. The MR is best for soft tissue and herniated discs. The gadolinum-Enhanced MRI is particularly useful for differentiated between scar tissue and ruptured disc on a previously operated back. The CT Scan is much better for bone detail. We may do a myelogram in conjunction with a CT Scan if we're treating a previously operated back and there is a lot of scar tissue.

What treatment do you generally recommend for back pain?
When a patient comes to us with acute back pain, we like to start with a couple of days to a week or two of rest to give that injury time to heal. Then we'll begin a mild exercise program, such as walking, to help strengthen the surrounding muscles. For the patient with chronic back problems, we frequently recommend an intensive work hardening program.

Does your treatment include pain medication?
Personally, I have no hesitation about prescribing strong medication, including narcotics, for patients with acute back pain injuries. But I do feel very strongly that there is no place whatsoever for the use of narcotics in treating chronic back pain. Instead I will recommend a non-steroidal anti-inflammatory medicine.

What factors determine whether you'll do surgery?
This is a team decision by our Spine Center staff. We consider test results, X-rays, the patients symptoms, psychological makeup, job, age-all of these things are important. People who have definite clinical findings usually do well with back surgery.

Then how do you treat the patient who still reports back pain when you can find no organic reason for it?
We try to be a bit more positive and say, "Yes, we know you hurt, but you're not a candidate for surgery." People who are motivated, who have a reason for getting back to work, get back even if they're in pain. They don't fixate on it. But people who have problems in their lives, who are getting paid whether or not they're working, will let their psychological problems intensify their pain.

How do you help these people?
If we've done everything we can, we consider referral to a psychologist or a behaviorally based pain management program to help them gain insight into why they hurt. This also prepares them psychologically to accept and live with this pain. If every other type of treatment has failed, this is all that's left. There's a definite psychological component to pain, and we always try to be sensitive to this. It's a very important component in every patient's treatment.