The Hot Pursuit of a Diagnosis: A Case Study in Neck Pain

We seem to see ourselves as machines: If a part is broken, we fix it or get a new one. If a fuel pump breaks and we replace it, our car should run like new. Find the problem, treat it, and move on. Sadly, chronic pain problems don’t follow this recipe, nor do human beings come with an easy-to-read owner’s manual. Setting ourselves up to fail by taking this approach to chronic pain can lead to tragic consequences like broken marriages and chemical dependency. The financial effects of lost wages can be devastating to families. The emotional wear and tear on the person at the center of it all can’t be measured or put into words.

Where I often see problems first arise for patients is in their preoccupation with finding a diagnosis. But isn’t finding the diagnosis what doctors are supposed to do? Surely there must be some value to all those diplomas you see on the wall. Why spend all of that time in the waiting room if you aren’t going to get answers? Believe me, doctors feel your frustration and the pressure to give you the information you so desperately crave. In fact doctors may feel so obligated to give you a diagnosis that they lose sight of the big picture. Yes, they can find medical nomenclature that appropriately pairs with your symptoms, but if what they come up with doesn’t take into consideration the full breadth of your own particular circumstances, the treatments they prescribe have little chance for success, and you may add weeks, months, or even years to your pain instead of eliminating it.

Problem solving a patient’s signs and symptoms to reach a diagnosis is, indeed, one of the fundamental arts of medicine and what most doctors believe is an integral part of what they do every day. Doctors also know that patients expect them to give answers and solve problems. Let me explain how we all get our wires crossed and, as a result, how doctors fail to truly help their patients.

There is a big difference between getting a diagnosis and learning the cause of a problem. A diagnosis is a conclusion based on analysis of the problem. This implies that the diagnosis also explains what is actually causing the problem. Unfortunately my experience has taught me to not automatically make that assumption. Having a diagnosis doesn’t necessarily mean you know what is wrong with the patient or how he or she got to this point. The central problem is the pain, yes, but the patient may also be experiencing physical, emotional, psychological, lifestyle, and prescription drug–related problems. Just settling for a diagnosis may tell you relatively little about what you need to know to help your patient to get better.

For example, degenerative disk disease is a diagnosis. It means that the cartilage and fluid between certain vertebrae in the spine have deteriorated. A common treatment for this painful disease when it occurs in the neck is a surgery called cervical fusion. In a typical cervical fusion surgery, a surgeon fuses vertebra together with bone grafts or metal hardware to prevent motion and stabilize the area. The surgeon picks the spot or spots to fuse based on his or her assessment of where he or she thinks the trouble is coming from.

The problem is that the degenerated disk may only be a small component of the neck pain, or possibly not a factor at all. Certainly degenerated cartilage can be found with simple imaging tests, and doctors can quickly find out where the anatomical change has taken place. Therefore the diagnosis would not be, by any means, a misnomer or an inaccurate pickup by the health care team. However, the discovery may not adequately explain why the pain is present. Focusing all treatments and energies toward a problem that isn’t really the problem can’t be expected to yield fulfilling results—such as alleviating the neck pain.

Visualize a patient who has just been diagnosed with degenerative disk disease in the neck, also known as the cervical part of the spine. She is about forty-five and works as an administrative assistant. She spends hours keyboarding at a computer, and her boss can often come across as rude and ungrateful. If we watch our friend at work, we see that her keyboard is too high and she scrunches her shoulders when working. We also notice that every time her boss walks by, she tenses her shoulders even more. On stressful days she might have four or five cups of coffee to help her get her work done.

Her commute home includes thirty minutes of driving in thick freeway traffic. Her neck seems to hurt more by the end of the day, and it feels like it is getting progressively worse. Eventually it gets so stiff that she isn’t comfortable turning her head to change lanes.

Once she gets home, she has to hurry to find something to throw together for dinner for her husband and teenage son. After dinner she tries to unwind a little by reading her friends’ e-mails, browsing the internet, and watching a little late-night television, especially since she doesn’t sleep too well. Her husband has become increasingly frustrated and disheartened by his wife’s neck pain. She doesn’t seem like herself anymore, so he pressures her to see a doctor and get something done to take care of the problem.

She visits her family doctor; her husband goes too, because he is concerned and wants to make sure the doctor understands how bad things have become. Her doctor checks her out and runs some tests. The X-rays and MRI both show degenerating disks in her neck. Once she gets the reports, she and her husband agree that something needs to be done to fix the problem, because she can’t go on like this.

Once our friend has locked into the notion that her pain is due to degenerative disk disease, it may be difficult for her to agree to try any treatments or advice that don’t directly address that problem. At this point, making needed lifestyle changes may seem too late to her. Let’s say her workstation gets an ergonomic makeover, and she tries a little physical therapy. Her therapist tells her that there seems to be a lot of tension in the muscles around her neck and shoulders. “Well, of course there is,” she thinks. “I have degenerative disk disease!”

She goes back to her doctor with the bad news: “My neck still hurts.” In our world there is pressure on the doctor to do something more immediate. At this point he prescribes pain medications and refers her to an orthopedic spine specialist who treats degenerative disk disease of the neck.

The orthopedic surgeon’s office looks impressive. He shows her, in detail, the films of her degenerative disk disease and where the problems lie. They discuss what surgery would look like for her, and, as he seems like a smart doctor who knows what he is doing, they set a date.

Now, let’s fast-forward a year or so, when we see that our friend is now coming to see me for the first time for “pain management.” She has had a two-level cervical fusion surgery. She is still in a lot of pain and has been taking strong painkillers around-the-clock since the surgery. She never made it back to work after the surgery, and she still can’t sleep well. Now she is also feeling depressed, so her primary care doctor has prescribed an antidepressant. She spends a lot of time at home watching television, avoids her friends, and struggles just to get basic chores done each day. Her relationship with her husband has become strained. She finds herself short tempered with him, and he feels uptight about their finances, especially since his wife is not working.

Her doctors have sent her to me to do something. Is there is an injection I can give her that will help? Can I prescribe stronger medications to dull the pain? Her surgeon is looking at doing more tests to look for the problem and is considering more surgery if necessary.

Time-out! What went wrong here? Why would a nice, hard-working woman end up like this after getting state-of-the-art tests to figure out what was wrong and treatments from highly trained and fully competent doctors and physical therapists? How many other lives start down a similar road?

Let us assume that in the hypothetical case discussed above, the X-rays of the patient’s neck backed up the diagnosis of cervical degenerative disk disease. Sadly this particular diagnosis, though not inaccurate, did not help our friend get the help she needed to address her neck pain. Her preoccupation with her diagnosis may have blinded her and her providers to other important factors. For example, how bad was her workstation and how long had it been that way? Did this cause muscular imbalances in her upper body that could have been treated? What about the effects poorly managed stress from work, home, and commuting had on her pain? How about the lack of balance among work, family, and self in her life? She really wasn’t spending any time on herself to manage her health. How long had it been since she had exercised or gotten any fresh air? When was the last time she did a hobby or read a great novel? When did she last held hands with her husband? When we look at the big picture, we can see the problem with putting too much emphasis on a simple, quick diagnosis. It can lead us to ignore possible solutions to the real cause of the pain.

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