It wasn't your spine that was hurting. It was something else pressing on it.

You thought your spine was damaged, but the doctor says, "Your spine is fine; the surrounding area is the problem." Many patients are surprised by this. So, what exactly is the problem? The answer is closer than you think.

There is something I hear very often in my clinic: "Doctor, but isn't my spine the part that hurts?" Patients naturally assume that because their back hurts, the spine must be the problem. However, in the medical field, the first question we ask is: "The spine itself is healthy, but could the tissues surrounding and pressing on the spine be the issue?"

Why do we think it's the spine?

It's a natural question. It's perfectly normal to think that back pain equals spine pain. But anatomically, it's a bit different.

When we feel back pain, we assume the painful spot is the "spine." But if you look around the spine, there are muscles, ligaments, and a membrane covering the nerves called the nerve sheath. If these tissues become inflamed or stiff, you will feel pain in the exact same location.

Source: Korean Spinal Neurosurgery Society, The Role of Tissues Surrounding the Spine and the Principle of Pain Generation

The problem is that it's difficult for patients to distinguish this. Since the pain occurs right where the spine is located, it's only natural to think the spine is the issue.

How do medical professionals distinguish this?

The first thing we do in a clinical setting is a neurological examination. We test your reflexes, check your muscle strength, or test your sensation. Doing this helps us figure out to some extent: "Is a nerve really pinched?", "Is the spine itself the problem?", or "Is it a problem with the surrounding tissues?"

Source: American Academy of Orthopaedic Surgeons (AAOS), The Importance of Neurological Examinations in Spinal Diagnosis

Next, we take an MRI. An MRI shows whether a spinal bone is protruding or if a nerve is pinched. However, problems with muscles or ligaments often do not show up on an MRI. Conditions like myofascial pain syndrome or inflammation of the nerve sheath do not clearly appear on MRI scans.

Therefore, medical professionals synthesize multiple pieces of information. We look at the neurological exam results, MRI findings, the patient's symptoms, and the pain patterns all together. By doing this, we can conclude, "Ah, this isn't a problem with the spine itself, but a problem with the surrounding muscles."

What are some real-life examples?

One patient came to me and asked, "Doctor, the MRI showed I have a herniated disc, but it keeps hurting. Why isn't it getting better?" After conducting a neurological exam, we found the nerve wasn't severely pinched. The disc was present, but it was only pressing on the nerve slightly.

Upon closer examination, the muscles around the spine were extremely stiff. The tense muscles were irritating the nerves. Once we focused the treatment on muscle relaxation rather than nerve injections, the patient improved significantly within a month.

Another patient was in constant pain even though nothing showed up on their MRI. A neurological exam confirmed the nerves were healthy. However, there was inflammation in the nerve sheath wrapping the nerve. This doesn't show up on a standard MRI. After diagnosing the nerve sheath inflammation and applying specialized treatment, the patient drastically improved in just two weeks.

Another patient had visited multiple hospitals and received different opinions from each. One place said, "You need surgery," while another said, "You're fine." When I re-did the neurological exam in my clinic, the main cause was actually the stiffness of the muscles next to the spine, rather than the spine itself. Through conservative treatment and lifestyle improvements instead of surgery, they completely recovered in three months.

Is your pain really caused by your spine?

Now it's your turn. Is your back pain really due to your spine? Or is it an issue with the surrounding tissues pressing against it?

Check for yourself. Does it only hurt in a specific posture? But does it get better as you move around? Does it hurt less when you lie down at night? These symptoms highly suggest that the muscles around your spine have become stiff.

Conversely, does it hurt constantly regardless of your posture? Do your legs lose strength, or do you have abnormal sensations? If so, it's more likely that a nerve is pinched.

Source: Clinical Textbook of Neurosurgery, Differentiating Symptoms Between Spinal Problems and Surrounding Tissue Problems

An accurate diagnosis comes from consulting with a medical professional. You receive a neurological exam, get an MRI if necessary, and a diagnosis is made by synthesizing those results. And when the diagnosis changes, the treatment changes drastically. If the spine itself is the issue, we might consider nerve injections or surgery; if the surrounding muscles are the problem, we focus on muscle relaxation or physical therapy.

Q&A

• Q. If my spine is in bad condition, will it get better with treatment?

  • A. Yes, even if the spine itself is the problem, over 90% of cases can be treated without surgery.

• Q. It's scary that some things don't show up on an MRI. What should I trust then?

  • A. We make a judgment by synthesizing MRI results, neurological exams, and symptoms. Please trust your medical team and undergo a thorough examination.

• Q. If it's a muscle problem, should I exercise?

  • A. It depends on the situation. It's generally recommended to control your movements at first and start exercising later.

• Q. Spine vs. Muscle: Can I distinguish this on my own?

  • A. It's difficult. Examination and testing by a medical professional are essential.

• Q. If I have pain even though my spine is healthy, should I get treated quickly?

  • A. Yes, conditions like nerve sheath inflammation are better treated as quickly as possible.

Wrapping Up

The pain you feel is absolutely real. However, determining whether that pain is due to the spine or the tissues surrounding it requires an accurate diagnosis. Only with an accurate diagnosis can you receive the correct treatment.

Which case are you?

• Does it hurt only in a specific posture? Does it get a bit better when you move? Does it hurt more when you rest? If so, it's highly likely to be a problem with the surrounding muscles.

• Does it hurt continuously in any posture? Do you have any symptoms in your legs? Any abnormal sensations? If so, you should suspect a nerve problem.

• Are you in pain even though the MRI showed nothing? Have you had a neurological exam? It could be a muscle or nerve sheath problem.

Sources:

• Korean Spinal Neurosurgery Society, The Role of Tissues Surrounding the Spine and the Principle of Pain Generation

• American Academy of Orthopaedic Surgeons (AAOS), The Importance of Neurological Examinations in Spinal Diagnosis

• Clinical Textbook of Neurosurgery, Differentiating Symptoms Between Spinal Problems and Surrounding Tissue Problems