Please note that Dr Stuttaford isn't familiar with all the circumstances in individual cases and can only deal with the points raised in general terms. Patients should always discuss any specific problems they have with their own doctors.



Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.

I have been suffering from backache for several years now. I have had osteopath treatments, x-rays, etcetera. The latest theory is that because I have a hip problem, this had distorted my spine and is causing the pain. My hip is not bad enough to be replaced and I am inclined to think this is not the problem. The pain is at the base of my spine and occurs when I have been sitting, standing, lying in the same place for even a short time. I am 72 yrs old and when I stand up I look about 90! Have you any advice? Patricia New, Upchurch.

This is a very common story. If a hip, knee joint or a joint in the foot is faulty the effect it has on the patient's walk and stance will cause other abnormal strains in several joints including the spinal joints. These may then wear out more quickly than would have otherwise been the case. Likewise a spine that is not straight will result in abnormal wear on other spinal joints. I of course haven't examined you and so can't comment on your own particular circumstances but in general the sooner any joint giving trouble is corrected the less the damage from wear and tear in other parts of the body. I notice that you haven't had an MRI or CT scan. If there is ever any question of a spinal problem I have always found that a scan gives the better picture and the doctor more information than an x-ray

I know the root-cause of my back problem. I used a pick-axe to break up some rock-hard soil in my garden. What puzzles me is that the focus has moved around the small of my back - originally in the middle, then on the left, and now the right. Also, after a couple of weeks I virtually recovered, but then it returned with a vengeance for no reason that I can think of.

Given that the pain has never radiated into the buttocks or lower limbs, and the excruiating spasms have only occurred when in bed (I have now taken to sleeping at night on a recliner chair after a good dose of pain killers) presumably all I can do is tread carefully and wait for the muscle strain to heal itself? Phillip Perris, Bookham

Gardeners have back problems, it is as much associated with this hobby as green fingers. If after three to six weeks, depending on the local NHS rules, the back is still giving rise to crippling pain an MRI scan is indicated. If the back pain is causing any other symptoms such as difficulty in passing urine, opening the bowels or impotence the scan should be done at once, as it should if there is obvious evidence of muscle-wasting such as a foot drop. A foot drop is the condition in which someone's foot doesn't automatically lift up when they are walking so that their toe caps drag along the road.

It is not at all uncommon for a prolapsed disc to give rise to slightly different pains of varying intensity depending on what nerve or nerves are being touched by the protruding disc. Every now and again the pain may disappear suddenly. If the disc that has prolapsed is above the lumbar vertebrae the pain doesn't always go down the leg. Muscle "strain", in reality muscle spasm, of this type is nearly always the result of a nerve being stimulated by a disc causing nerve root pressure.

I have been off work for more than two months with a bad back. It has been diagnosed as sciatica. An MRI scan has shown a prolapsed bottom disc, having extruded to fill 50 percent of the nerve space. Just over a week ago I undertook an epidural steroid injection, in the spine. This appears to have improved mobility but not removed a debilitating pain, which comes along particularly after sitting. So I am having to continue with the pain killers, by mouth.

The treatment route prescribed has been suggested as firstly try the steroid injection. If after time that fails, undertake an operation to remove the damaged part of the prolapsed disc that is impinging on my nerve roots. This can be, but not neccesarily, accompanied by fusing of the bottom spinal bones.

My questions are as follows: I do not fancy surgery, for a number of reaons, is this the only way forward, or are there other treatments with a potentially high success rate and low risk? Secondly, the use of oral pain killers seems a very blunt weapon to deal with a very localised pain source. I realise the injection is a treatment to help with that. The side effects of the pain killers are a limiter to normal life, nearly as much as the pain itself. i.e drowsiness, constipation, etcetera. Is there any other tried and tested pain relief? Stephen Medlock, Brompton on Swale

Although I can't discuss your case directly as I haven't seen you it would seem from what you have said that the advice you have had has been absolutely first class. Surgery for a disc lesion especially one that is localised and identified on a scan is nothing like as dramatic or as major as it was ten years ago. It is a comparatively minor operation although it requires a skilled operator and, as in any operation, success can't be guaranteed.

There are various modifications of TENS machines, transcutaneous electrical nerve stimulation machines, that treat persistent pain by passing electric currents into the spinal cord or sensory nerves by applying two electrodes to the skin. TENS is becoming more efficient but the effect is too often short term.

The most tiresome side effect of effective pain killers is that they produce constipation, but doctors usually prescribe suitable laxative to be taken with the pain killers.

I am 75, fit and active with no joint pains or swelling associated with arthritus. However, it is becoming increasingly painful to hold my head up when walking or eating at table. Effort to raise my head causes acute neck and back pain and tense, painful muscles. The condition recedes temporarily with paracetomol. No help from the GP who dismisses the problem as ageing. Osteopath treatment diagnoses tense knotted muscles. Manipulation and massage has not helped. I would welcome any advice or help. Mary Parsons, Poole

I suspect that the tense knotted muscles are a result of your troubles and not the cause of them. It is not uncommon for older people to have quite severe pain from problems with their cervical vertebral joints. No doubt your doctor would be happy for you to see a rheumatologist with whom you could discuss osteoarthritis of the cervical vertebrae. Various treatments are available for this, varying from the wearing of a collar - possibly nights only - to more drastic intervention.

This letter comes from desperation. My partner has been in real pain for 18 months. What started with lower back pain and cervical disc trouble has become severe chest pain (stabbing pains causing panic), tingling and loss of control in limbs and shooting muscular spasms causing the strong, sparky man I fell in love with to be a depressive terified man, afraid to leave the house in case he passes out. It's taken over his life - he cannot go to work, he cannot drive, he is in almost constant pain and has spiralled into a depression that terrifies me. In a recent crisis point I found he had been planning suicide as the only option to release him from the pain.

He has seen private specialists who have said there is nothing they can recommend other than sympton relief (drugs and physio). The relief at hearing there is nothing wrong becomes farcical when faced with a once strong man who can no longer get up the stairs. He is 43. He has had tests on his lungs and heart (because his pain is chest-centered) and all is fine. And yet he is in agony and cannot function.

I know his symptons exist and are real. I know that they are exacerbated by stress (his brother died this week of cancer) but, for all my reassurance that this is not a heart attack, I cannot dismiss his terror. His pain is real. I privately believe he has had some form of nervous breakdown - I have no qualification other than knowing him - yet his physical pain is undoubtedly real.

My question is two-fold: is it possible that someone can have a psychosomatic illness that creates physical symptons as real as this? And how do we make it manageable? Sarah Law, Milton Keynes

It is possible for people to have disabling psychosomatic pain but this is a diagnosis that can only be made by exclusion. You haven't told me whether your friend has had his spine examined with an MRI scan as well as by x-rays, or if all his doctors have been preoccupied with making certain that there is nothing wrong with his heart or lungs.

Some years ago a large diagnostic centre seeing 150,000 patients a year studied the causes of unexplained chest pain and found that the most common cause was neuro/muscular skeletal. That is to say the pain stemmed from some skeletal problem that was causing pressure on a nerve. Any spinal pain is always made worse by nervous tension as the back is held rigid and joints are ground together.

I suffered the symptoms which you describe in your article of November 3 and after MRI scans etcetera, which revealed impinged spinal nerves, went through a procedure called the X Stop (at two levels). No doubt you are aware of this non-invasive surgery but I wonder how many long-suffering patients have knowledge of its existence and, more importantly, its benefits. Perhaps you could be persuaded to include its benefits on your health pages. Margaret Grainger, Bradford

I am not familiar with the X Stop but wonder if it is a variation of the TENS principle (see the answer to the third question above) as these use electrodes at two different levels. With most of these machines, and there are now several variations of them on the market, the pain is relieved but tends to recur. One very expensive variation of this principle that requires intricate surgery is to use an electrical implant.

I'm an active 27 year old female and in August this year my whole back went into spasm. It took three days until the lower back spasms stopped. Thereafter I suffered with a lower back dull ache for three weeks or so. I now occasionally still get the lower backache but with what also feels like a bruised coccyx. I have also suffered from more headaches and neck pain since this happened. Massage doesn't seem to help. Is this something that will work itself out or should I seek a further medical examination?

Yes. This is a common sequel to an acute prolapsed disc. It is because there is a residual pain after the acute pain has ceased to be crippling. It is because disc pain rarely disappears entirely or quickly that doctors always talk in terms of the acute phase of the problem when discussing a suitable time for intervention.

Very often the chronic stage is manifest as a lower dull ache in the back and a pain that feels like a bruised coccyx. If a person has a disc lesion they hold their spine in such a way, and the muscles along its whole length are tense so that is not unusual to get neck ache. Headaches that stem from the neck are frequently frontal and felt over the forehead. The residual pain after the acute phase of disc pain has passed will usually slowly improve, but if it doesn't and it is restricting either your work or domestic life you should go back to consult whoever was treating you.

I have been diagnosed as suffering from facer joint disfunction/sacro iliac joint strain. I have had sessions of physiotherapy and acupuncture which have not cured the problem. I would appreciate your opinion on the advisability of injections of cortizone or similar substance. Name and address withheld

I wrote about sacro iliac joint strain fairly recently in my column in The Times. Sacro iliac strain was a diagnosis that was frequently made in the past but modern methods of investigation usually show that the pain that is diagnosed as sacro iliac strain is in fact often coming from a disc lesion in the lower back. Some patients do have a true sacro iliitis but there is then usually an obvious cause for this such as ankylosing spondylitis or Reiter's syndrome. There are specific treatments for these conditions. Once again it is the MRI scan which gives us true cause of the trouble.

Approximately three years ago I was experiencing extreme pain in my feet, knees, hands and lower back. My GP referred me to a rheumatologist at my local hospital. Following an MRI of my lower back it was discovered that the S1-L5 disk had prolapsed. This was referred to an orthopaedic surgeon who removed the disc approximately 18 months ago.

Immediately following the surgery I had new pain in my left lower calf and left ankle and left toes. Initially I thought that I had been dropped or bumped into a wall, this was not the case. Lower back pain was very much reduced, walking and standing was much easier. However, other original symptoms were the same. Over the past 18 months I have received a course of injections into my lower back, a course of medication from the pain management clinic at my hospital and three months of psychological pain management. None of this has really helped. Nerve conduction studies have shown that within the left leg nerves are "hyper sensitised".

My original pain in feet, knees and hands is still present but is now duplicated on to the right side. A recent return to my original rheumatology consultant suggested that all of my pain is neurological. My current medication consists of BuTrans patches, Co-Dydramol, Dromadol and Amitriptyline but I always experience pain, on bad days walking can be difficult. I am now awaiting an appointment to see my surgeon. I have the impression that no one is really sure what to do next. All of the professionals that I have seen in the past three years seem to be suggesting that I am somehow unique, this cannot be the case. As you would imagine, these issues are having a profound effect upon my quality of life. I would appreciate your advice as to how I can move my pain management forward. Name and address withheld

Patients who have spinal surgery are usually warned that although the majority can expect to be better there is an appreciable but small minority who are made worse. Nerve conduction studies have illustrated that you are still getting irritation to the nerves leading down your left leg.

You don't tell me whether you have had an MRI scan after your surgery so that your doctors can find out what is causing this irritation. It may be something that a neurosurgeon could put right for you, but obviously this often requires considerable skill on the part of the neurosurgeon, who should have a special interest in spinal problems, but also be someone who can make a reasonable assessment of the likely benefits and possible risks, and weigh the one against the other.

I have had lower back pain since November 2005 which has got progressively worse. The pain is in the L5 region and radiating down into my pelvis, hips, sacrum, and sometimes down the front of my legs into my feet. The pain seems to be in the bones as well as the joints and has a burning sensation. I am advised by an orthopaedic specialist that I do not need an operation for a hip replacement and that the pain is caused mainly by arthritus and wear and tear. My GP agrees with this.

I have been described most anti inflammatory and analgesic drugs, including a combination of both, but have little for the pain. My doctor says the next step is morphine. I have had x-rays but not a scan. I have also had physiotherapy, exercises and have attended back exercise classes - all to no avail. I also have a TENS machine which does not help much.

My doctor has referred me to the back specialist service at my local hospital and I am waiting for an appointment. I am 56 years old and male, and am really struggling at present. Name and address withheld

I am glad to hear that you are going to see a back specialist. It could be that a patient's hip joints, although not at first sight severe enough to warrant surgery, are causing the back to the held in such a way that nerve root pain is stemming from spinal joints. It is very interesting that you are having the pain down the front of your legs as well as your lower back. The area supplied by L5 tends to be the front of the lower leg and half the foot. L4 supplies the inside of the lower leg and the other half of the foot. L3 deals with the inside of the leg including the inside of the thigh and across the bottom and the rest of this area is supplied by L2. S2 goes down the back of the leg. There are variations from person to person and often more than one vertebral joint is involved. Usually someone expects the sacral area to be supplied by L1, L2 or L3. Once again it is easier to make the diagnosis if there is an MRI scan. Then instead of making a probable diagnosis the actual spot or spots - for more than one disc space is often involved - where there is pressure on a nerve root can be seen.

I've recently lost two friends to pancreatic cancer. Both suffered horribly. Both had complained of back pain, which was dismissed as insignificant by their doctors, long before being diagnosed. Is there a connection? Caitlin Hammil, Durban, South Africa

Unfortunately the initial symptoms of pancreatic cancer are insidious and non specific. When upper abdominal pain radiates to the back there is one characteristic of the pain that strongly suggests cancer of the pancreas. This is that the pain is relieved when the patient bends forward or assumes the so called foetal position with knees up and with chest and abdomen hunched forwards. The other symptoms that are characteristic of pancreatic cancer are weight loss, a very marked and sudden but rapidly increasing loss of appetite and jaundice.

Unfortunately by the time the back ache occurs the tumour is already advanced, is likely to have spread and to be pressing on the back of the peritoneum and the structures behind it. I am sorry to read about your two friends. It is a very unpleasant cancer that unfortunately is usually diagnosed far too late for effective treatment. The only consolation is that the backache, although it was the first symptom your friend suffered, frequently only occurs after there has already been spread into the retro peritoneal tissues, and by then there is never any other outcome than a fatal one.