Lower Back Pain: When to Worry

Low back pain is the 5^th most common reason for visits to the doctor in the United States. Most individuals with low back pain have a simple disc herniation or muscle sprain and will experience significant or complete improvement within one month.

However, there are some causes of lower back pain that are serious, debilitating and potentially deadly. These causes include cancer, vertebral fractures, ankylosing spondylitis, cauda equina syndrome, severe spinal stenosis, and spinal infection. Fortunately, there are red flags (specific warning signs and symptoms) that allow physicians to distinguish between a worrisome cause of lower back pain and a self-resolving cause of back pain.

Worrisome Signs and Symptoms of Low Back Pain which should be evaluated appropriately by a qualified physician:

General, Non-Specific Red Flags:

-Severe pain during the night

-Pain worse at rest

-Pain worse in the supine position

-Weight loss, fever, chills

-Failure of conservative treatment

Red Flags for Cauda Equina Syndrome:

-Saddle anesthesia (numbness in the inner thighs and groin)

-New onset urinary retention or incontinence

-New onset fecal incontinence (leaking stool)

-Motor deficits (muscle weakness) at multiple levels

-Loss of sensation around anus and perineum

-Loss of rectal tone (anal sphincter laxity)

Red Flags for Spinal Tumor or Spinal Infection:

-Age less than 20 years or more than 50 years

-History of cancer (not including non-melanoma skin cancer)

-History of chronic infection or recent infection

-Immunosuppression (steroids, HIV positive)

-History of IV drug use

-Weight loss, fevers, chills, night sweats

Red Flags for Vertebral Compression Fracture:

-Major trauma (serious fall, car accident)

-Minor trauma with elderly, people with osteoporosis or history of steroid use

Red Flags for Ankylosing Spondylitis

-Alternating buttock pain

-Severe morning stiffness

-Improvement with exercise

-Younger age (usually teens to 20’s)

-Awakening due to low back pain during the second part of the night only

-Positive Shober’s test

Red Flags for Severe Spinal Stenosis:

-Radiating leg pain with nonspecific low back pain

-Older age

-Pseudoclaudication (burning in the buttock and thighs with walking or standing that improves with sitting or lying down)

-Association with Paget’s disease, acromegaly, hyperparathyroidism or Cushing’s syndrome)

Any individual with lower back pain who is experiencing one or more of the red flag signs and symptoms above should see his or her physician. If your physician suspects cauda equina syndrome you can expect to immediately be transported to the hospital for MRI and possible surgery. Cauda equina syndrome can cause paralysis of the lower half of the body if left untreated.

If your physician notes red flags associated with any of the other worrisome causes of lower back pain then you can expect to get imaging (ranging from x-ray to MRI) and blood drawn for labs. Never hesitate to see your doctor if you experience any of the red flags of lower back pain, it could save your life.

Cryosurgery: Using liquid nitrogen for warts and more

Warts, actinic keratoses, molluscum contagiosum, small basal cell carcinomas, condyloma acuminata and more, the list of skin conditions that can be easily and successfully treated with cryotherapy is quite extensive. Cryosurgery is a surgical technique that uses controlled freezing to deliberately destroy diseased tissue.

Cryosurgery most often uses liquid nitrogen as the freezing medium, though nitrous oxide may be used as well. The cryotherapy surgical method is a much preferred alternative to surgical excision of skin lesions for many skin conditions for the following reasons:

Benefits of cryosurgery of skin lesions:

-Freezing produces minimal pain

-Results in little to no scar formation

-Takes less time than conventional surgery

-Often allows patients to avoid injections of local anesthetics, so needles can be avoided

-Preoperative skin preparation (sterile technique) isn’t required

-No significant post-procedure care is required

-Postoperative infection is rare

-No significant change in activity is required after freezing, patients may bathe, swim, etc.

-Cryosurgery is cost effective

-Multiple lesions can be done in one office visit

However, there are a few disadvantages to cryosurgery of skin conditions. These disadvantages may limit the use of cryosurgery in some individuals, particularly darker skinned individuals as described below.

Additionally, there are certain skin lesions which should not be treated with liquid nitrogen or other freezing techniques. Cryosurgery does not allow for the gathering of tissue samples to send for pathological examination. Therefore, there is no way to know whether the entire squamous cell carcinoma or melanoma has been destroyed when treated with cryosurgery. These lesions are best removed with surgical excision or MOHs procedure.

Disadvantages of cryosurgery of skin lesions:

Freezing the skin, even with brief partial-thickness freeze technique, will destroy some pigmented melanocytes. Therefore, when the lesion heals, it will be a bit lighter in color than the surrounding skin.

The lack of pigment producing melanocytes within healed cryosurgical lesions may also make the lesion more susceptible to sunburn. Healed cryolesions that are exposed to the sun may require extra sunscreen protection.

Cryosurgery is also not recommended for use in areas of hair growth. These areas include around eyebrows and eyelashes, as well as the scalp. Even very brief freezing treatments can destroy hair follicles.

Overview of the cryosurgical procdure:

Cryosurgery is a wonderfully simple procedure. For most lesions, there is no required skin preparation. However, lesions that have a thick keratotic layer may respond to cryosurgery better if the keratotic layer is removed. For thick warts, patients may need to apply salicylic acid for a couple weeks to peel off the top layer prior to cryosurgery. An alternative to this is to let the healthcare practitioner scrape off the top.