 Greetings from Manipal Spine Care Center at Manipal Hospitals, Bangalore. I am Dr. Vidyadharayesh, Head of the Department and Consultant Spine Surgeon. Today I am going to talk about low back pain, what I have learnt in the last 20 to 25 years, trying to be a better and better spine specialist. Back pain is a major health problem. It constitutes to 8 out of 10 of us suffering from back pain at some point of time in life. It is a major epidemic in a metropolitan city like Bangalore where most of us are having a sitting job. It is a big business as well because anything you want to sell you can say it works for back pain and it sells better, whether it is anointment, bed or surgeries as well. There are a lot of myths revolving around the issue of low back pain like people saying lifting heavy weights causing back pain which is not true, bed rest is the main way of treating a low back pain, not true again, x-ray city scans and MRIs giving us the exact diagnosis which is not true again and that once you had back pain that you will always need a surgery in the end which is not true again. But the truth remains that many people suffer from back pain, there is no standard of cure. Two doctors, you will get two opinions, you go to 20, you will get 20. No two doctors can talk the same language. Briefly to know about what is normal in spine, there is functional spinal unit which is constituted by two vertebrae separated by one cushion or the intervertebral disc and two facet joints, the joints which move or back, front and back, sideways as well as the twisting moments. But that is not all friends, there are ligaments holding the two bones together, there are muscles which contract and give the necessary movement to the low back, there is a delicate spinal cord which runs from the brain to the tail tip giving rise to branches in the neck going down the upper limb, in the low back going down the lower limb. Coming to what can go wrong in the back to cause back pain, most of the time it is the disc which is the king pin maker in low back pain, it is either the starting point of all the problems in the back or commonest end point in almost all low back pain patients. To know more about this disc, this disc when we are born is liquid inconsistency, it becomes gel, it becomes solid merely because we all grow in age and we lose water and protein from our tissues, like how we lose water and protein from our skin and the skin gets wrinkled, how we lose water and protein from the joints and we become arthritic. So, similarly the disc loses water and protein and becomes degenerated, this is normal degeneration of the disc which causes back pain in 90 percent of people with the normal or abnormal. This is a schematic diagram of a child with functional spinal unit, two vertebral bones and the disc spinal cord and nerve root going down the leg. Now, this disc in a child can be equated to a balloon filled with water, mouth tied kept between two hard surfaces, just to act like a shock absorber. Now, as the child grows adult, the balloon becomes thicker, the water becomes lesser, making it more and more stiffer compared to a child who has got a very flexible and very elastic shock absorber. This is a stiff and rigid shock absorber with less water, more thicker balloon. This can only tear and the liquid from inside the disc can come out, it can either mechanically compress the nerve root going down the leg or it can chemically irritate the nerve root going down the leg. So, this causes a slip disc or a disc prolapse which in addition to back and neck pain causes arm and leg pain. Friends, this is the MRI of a 10 year old child, done for academic interest, child has no back pain and you can see these balloony watery discs. In contrast, this is a 80 year old man, no back pain and the MRI done for academic interest. You can see these thick balloons with hardly any water. Friends, after 70 years, even this child's MRI would look like this 80 year old man's and every single of our 33 discs will have to go through these phases of degenerative disc disease. From above down, the normal disc loses water and proteins becomes degenerated. It bulges backwards, the disc balloon tears, the inner nucleus comes out. Once that comes out, the disc space becomes less, thins out. Once the disc space is thinned out, you remember from my previous slide, there are muscles and ligaments, they become loose. So, the bones start wobbling, one on top of the other and body senses it to be abnormal and then body starts forming bridging osteophytes, trying to bridge the two bones, holding them together. Now, these are called as stages of degenerative disc disease and every single disc has to go through this before we die and depending on when you take an MRI, you will see the discs in different phases of degeneration. Now, all this is boring, we will go to how patients present to you in the outpatient. Before we go into the depth, we need to know two concepts, one is pain. Friends, pain is a protective reflex, it is a response of the body towards an underlying injury or damage. There is a physical injury, like you get cut, you feel pain because that is the way body tries to make you remove your hand from the area of injury. It is a psychological component or psychological expression to pain, you get a pinch and you get angry, you shout, you slap, you get tears in your eyes, that is the psychological expression. So, pain is a protective reflex, it is not only physical, not only psychological, it is a combination of two. Next important point is stress, under stress, how our body perceives pain. Stress by my definition is extreme of any emotion is a stress on the body, be it anxiety, apprehension, tension, happiness, unhappiness, fear. Anything in extreme is a stress on the body and that itself can cause the pain to amplify and you will not realize that it is because of the stress that you are feeling the pain much, much more. And this is a very important thing because in today's world, most people are stressed out and unless we give importance to stress as an element in perception of pain, we may easily get carried away by the severity of pain that the person explains. Now, lot of people have their own explanations of pain, it is throbbing, it is pinching, it is a catch, it is a pull, it is a burning pain, it is you know, you can write a book on how to express pain and still the patient will tell you that no doctor, you did not get me right. That is not the way, I feel it is something different which I cannot put it in words. But we as doctors will have to listen to you because it is you who has paid money and come to the doctor, so I cannot say no, no, no, you tell me next. So we tend to pretend that we are listening, but we in fact are trying to pick up if there are any red flags. Now, to give you a brief idea as to what are the red flags, a child complaining of back pain is a red flag for us, child does not know existence of neck and back and if a child complains of back and neck pain, it is a red flag for us. A elderly person may be 50, 60s, usually does not go to a doctor unless it is bothering him or her for long enough time, maybe 2, 3 months it is bothering and he starts getting a doubt whether something is really going wrong in his body. So they come to you when they would have waited it out for sufficient length of time and then they come to you, so you consider them as red flags. Not to say that people in between 20 and 50 years are mad, but most of us have lot of other stresses which may bring us to the doctor early or which may make us feel the pain much, much more than what it would have hurt a child or a elderly. Trauma, a simple slip in the bathroom if the patient is an elderly, fever with constitutional symptoms like loss of weight, loss of appetite, not to forget today tuberculosis has come back with a vengeance, there are at least 2 to 3 patients with tuberculosis pain coming to me in a week's time. Patients with neurological symptoms or neurological weaknesses like somebody having tingling, numbness in the legs, in the arms, somebody is unsteady when he walks, he is lurching, he is his knee is buckling, he is not able to walk straight, he has to hold people and walk, definitely it is a red flag for us. However, 90% of people with back pain become better on lying down at night or become better on taking painkiller medications. Now if somebody comes to you and says that the pain is worse at night, it is not improved with painkillers, definitely you will have to think of infection in the spine or malignancy or cancer in the spine. Now as a doctor we see so many patients and we need to quickly examine and find out as to what is it that we are looking for in this patient. Basically we are checking the integrity of the nerves which is reflected by the power of the muscle. So we ask the patient, we look at the patient walking into your cabin, if he is walking normal he is okay, if he is not walking well, he is lurching, he is taking the support then it is abnormal. But somebody may look to be normal but if you ask him to heal walk or if you ask him to tow walk it is not possible then you know that there is a neurological deficit in this patient and that again becomes a red flag for us. Having said all these red flags are seen in less than 1% of patients who are presenting with back and neck pain. So the remaining 99% have lot of yellow flags otherwise the stress related stuff but they do not have a red flag but they all need a diagnosis, they need to be treated because everybody is paying the doctor to get cured. Now that is a big diagnostic puzzle and we in addition to having so many doubts in our mind we are added with the doubt of which investigation to choose from because there are enough and lots in the market that can empty anybody's bank balance. Friends to add to our confusion, some of the patients come and tell you that doctor so and so has diagnosed me with spondylosis in 1996 and ever since I have had on and off back pain. People come and tell you that I have a slip disc which was diagnosed in 2013 in this hospital and I have an extra bone, I have a crack in the back, friends it is not because of the patient, it is because of doctors like me who have driven it deep into their head that they have these problems. And it is not uncommon to see that there is a extra piece of calcification in the x-ray or a defect in the bone or there may be a small piece of extra bone or a small snow or irregular bone but these need not cause back pain. How do you know that the patient's grandfather or grandmother did not have these changes on the x-ray? They did not have any major problems in life and they all lived till 80 to 90 years because they never had time, they did not have money, they did not have doctors like with the other, they did not have hospitals like Manipal. So they lived happily and today we have time, money, doctors and technology we go chasing problems the more closer we look the more scarier it is to see. So friends this brings us to an important document which is a study done by the insurance companies in US about healthcare expenditure on treatment of patients with back pain. You know they did analyze how much of money was spent on treating patients with back pain over a period of 1994 to 2004. They found that the number of MRAs was increased by 2 times or 5 times, number of opioid analgesics that is pain killers was increased by 2 times, the number of injections was increased by 4 times and of course the surgeries were increased by nearly 5 times. But the bottom line remained that these increased expenditures were not accompanied by increased or improved patient outcome or patient disability. So this made them wonder if patient disability in 1994 and 2004 is the same why we need to spend extra money on healthcare of these patients with back pain. So they gave the project work to different people to find out what was it that was going wrong, why people are not ok despite spending more money. And they concluded that more than two thirds of this final MRAs were inappropriately being asked that means they should not have been asked and they have been asked and that is why there is a increased expenditure. And once they did the spinal MRI patients were undergoing more and more spinal surgeries. So they found that centers where spinal MRIs were done highest were doing the spinal surgeries highest. So friends no matter who is sleeping next to you you need to safeguard your blanket not everybody needs a diagnosis. Think of it today morning when you get up you have a severe back pain catch in your back. Do you think you need an x-ray? Of course the answer is there no. When do you need an x-ray? In children of course no matter how many days of duration of back pain needs an x-ray. If somebody is involved in a road traffic accident definitely needs an x-ray. Somebody coming in a stretcher not able to just get up from the bed needs an x-ray and severe back pain in an elderly needs an x-ray. We are not talking about MRI friends it is just x-ray we do not need it for everybody. But rest all people can wait for at least 3 weeks and if it is not resistant I think it is better that you get a x-ray. And if somebody is coming like this crooked definitely you need to get an x-ray. X-ray gives us mainly a bony pathology in and around the spine. But it is not the best of investigations. The best of investigations are the diagnostic gold standard friends is the MRI. MRI magnetic resonance imaging is the gold standard because it can detect dehydration or degeneration of the disc, loss of water and protein or a large slip disc like this pressing on the nerves or a large bone slip which is totally malaligning the spinal column or even it can diagnose the infection and malignancies at the earliest. There is no other investigation which can pick up spinal infection and spinal cancers earlier than MRI. But there is a very important landmark article published by Eugene Keraghi from Stanford University US which is published in New England Journal of Medicine which is one of the highest impact factor clinical journal with impact factor of 55 which is why it definitely gives me a pleasure to share this article with you in detail. What he did was he put up a small paper advertisement saying if you are between 20 and 40 years of age and you have never had back pain you come to me I will do a free MRI. I am sure in Stanford most of the Indian IT scholars would have gone thinking that why not do it? Why not see what is going on inside our back? And to his surprise he basically this Keraghi was a smart person. He wanted to see what is normal finding in an MRI of a normal volunteer without back pain ever in his back. He found these pictures on the MRI and this is the schematic diagram that he has given in his article. He found that there were patients with volunteers with slip disc, there were small snorts, irregular inflates, there was dehydration of the disc and there was annular tear with high intensity zone the balloon rupture and the liquid coming out. And he shocked the world with this table. He found that 60 percent of normal human volunteers had disc degeneration, 55 percent of population normal population without back pain had a slip disc or disc prolapse or disc protrusion, 30 percent annular fissures and 25 percent high intensity zone. In other words he concluded that just because you do an MRI on people you will your likelihood of seeing an abnormality is more than 80 percent of the population and most of them have more than one problems on MRI although they do not have any problem. Now he put a very important question to the scientific world should you treat the patient or should you treat the MRI? If you treat the MRI you are like this hunter who is hunting for his prey which he does not know where it is hiding. Friends today if a doctor thinks that he can treat the patient based on the MRI finding he is like this lineman who does not know which wire is faulty and all levels need not be treated. Today we are in a world where the patient goes to the first general practitioner because of couple of days of back pain the practitioner writes some medicines and he says come back after 5 days. The patient goes back to him and sees that the pain is not better and the doctor says no no in addition to this I will add one more drug and take this for 10 more days. And after 10 more days patient is not ok and he loses faith in this old man he is a general practitioner he has been in the same place for last 25 years he thinks maybe he does not updated his knowledge and he goes to the orthopedic surgeon who would as soon as he says it is already 3 weeks I think you need a diagnosis I think you go and do a MRI. So the patient goes to the MRI center and he sees that all of a sudden the MRI bill is 7500 rupees and he gets a shock of his life my god 3 weeks of back pain and I have to shell out 7500 bucks. But what to do world is like that you will have to pay to get services. So he does the MRI he goes back to the orthopedic surgeon who sees the report and says in addition to these changes in the medications you also do physiotherapy for 2 to 3 weeks and come back to me. Now religiously this patient goes and does physiotherapy in addition to the medications and he does not find any relief even after 3 weeks. Now he is starting to get frustrated. He looks at internet today that is the media where lot of knowledge is freely available. So he looks forward saying that orthopedic should not treat and there are specific surgeons called spine surgeons to deal with these problems and he looks for the highest rated spine surgeons in the city and he goes to the surgeon. Surgeons do not look like this they will all come in cap mask and OT dress and apron on top that is their brand today. And he comes he puts the MRI on the lobby and patient thinks yeah yeah now the previous orthopedic surgeon did not even look at the MRI he just looked at the report and wrote the medicines and this doctor is so nice he is knowing how to read an MRI. The doctor sees the MRI he sees that there is a disc prolapse and it is pressing on the spinal cord and he shows it to the patient. Patient is thoroughly impressed and the surgeon says we will have to do a small surgery just to make a small opening to remove that disc pressing on the nerves. And patient is shocked for such a 6 weeks of pain I need to go for a surgery actually he starts then thinking that from day 1 to now actually 75% of the pain is already gone and this doctor is telling me that I need surgery. Now he gets totally lost he goes mad because somebody has told surgery it is like poisoning your mind. You go running you go to 10 doctors trying to hear that you know opinion poll trying to hear that you do not need surgery but at least in a place like Bangalore you will get to hear that 8 out of 10 of the surgeons would tell you small smaller and smaller surgery anyway that is how we sell surgery friends and 2 of the doctors would have told him that one more hump one more jerk one more pothole and the whole disc may come and your leg may get paralyzed. This hits him hard especially if he has gone with his wife the wife would cry every night saying that you will have something what will happen to me. So this man although the pain is gone he would have to definitely go for a surgery because he needs to get a peaceful sleep. And he thinks he is helping himself by jumping and doing something to get rid of the problem he does not know what is waiting for him. This is the exact picture that I feel the patient is in. Now quick slides on treatment treatment I divide it into 2 parts one is treatment when there is pain which all of us do because pain chases you from behind so you want to get treated. The problem is with prevention which starts only after the pain goes after 3 months you forget that you had pain after 6 months even wife will stop nagging you that you have to exercise. Friends these are the evidence based guidelines of treating back pain after all the advances in science today we believe that it is the nature which heals not the doctor not the physio not the bed rest not the painkillers. It is the nature which heals given time in 3 months 90% of the people become alright on their own. Now how many of us have the patients or ability to hold on to not going to doctors for 3 months. We have 2 major problems in waiting for nature to heal one impatience because we have lot of other things which are more important than our health like friends wedding somebody is grave privation and so many things. And to suit our needs we have every street having a clinic every main road having a hospital so we keep changing hospitals and doctors still finally nature heals and the last doctor gets the credit that is why I pray God every night every day morning make me the last doctor let them finish 3 months and then come to me. Friends bed rest bed rest in back pain and neck pain has been like a 5th religion in India after Hindu muslim christian sick is bed rest anything and everything it will work people believe and doctors also believe. So it is a belief that is why I say that it is a religion and to be honest in science it has been proven that more than 2 days of bed rest in fact delays recovery it causes you more and more psychological component to be increased. So it delays recovery corsets and collars and belts external supports to the spine wherein we have enough internal musculature which is giving us the support to our back and the neck if you tight tie the external supports the internal support dies off. So it is not recommended if you use it for more than 7 days the muscles will go for wasting. Physiotherapy symptomatically is useful but not as a curative measure. So if somebody is in acute pain he may get some relief of pain but not that it will fast forward natural healing. Friends what to do what not to do everybody has a rule book everybody tells you if you have had back pain whether you know the person or not he has an opinion to give you do not bend forward do not lift weights do not go on 2 wheelers do not do not only thing to do is bed rest which is again not right. So today what is believed or rather proven is resume normal daily activities within pain limits but do not do something that increases pain. The activities which increase pain indirectly mean that they increase the injury before it has healed. So who has to decide the patient has to decide it is not the doctor not the mother-in-law not the well-wisher who has to decide what a patient can do or what he cannot do. Today pain is there which is protective respect pain be within its limits I think that is the way to go forward and rest is equal to rest and today we believe in active rest being within pain limits and doing everything not bed rest. Pain killers or analgesics have to be taken on demand basis only if there is an important meeting please take a pain killer and go for the meeting do not have to suffer and show people to gain their sympathy. If you are going for a wedding reception please take a pain killer and go so that there is a good photo of you on the album which will last forever antidepressants which is very important. Now two bad things when do you need MRI when do you need surgery there are only 3 indications for surgery in 90 percent of clinical situations in spine mechanical back pain. Absolute indications are two weakness of limbs and trunk or urinary and motion incontinence or inability to pass. These are absolute indications because here some nerve or the spinal cord is pressed so hard that the muscles are not functioning and it is a cry of a dying nerve. So, the earlier you release the more is the chance that the nerve will become normal and the muscle will function normal. So, when we say absolute here I as a surgeon have a right to sell surgery because even if the patient goes to 20 other doctors they if they know about spine they should talk about spine surgery not medications not physiotherapy or anything else. In chronic pain is more difficult in fact the absolute indications are less than 1 percent in clinical practice 1 percent of back pain will have weakness and loss of control or urine and motion. However, in chronic pain where pain is subjective you know everybody's pain is different in some schools you would have seen some children when the teacher raises the hand children get pain and they cry in some cases teacher gives 4 on the students bum and teacher gets tears. So, patient's perception of pain is different and that is why it is a relative indication but the indication point is functionally disabling pain for more than 3 consecutive months 3 months because 3 months is the normal time for body to heal an injury if at all body has failed to heal it and pain is functionally disabling. Then it is the patient's call to buy surgery as a surgeon can offer that there is a option by intervening because the nature has failed to heal it, but this is a relative indication but it is very sad that we have to put it on patient's head, but we always give them the explanation that if you are not able to match your expectation and ability the gap between expectation and ability is your disability. There are two ways to treat if there is a disability for 3 consecutive months one is bringing down expectation living like 80 year old or take up the problem with the help of science and technology pinpoint it and kill it and get back your ability to match your expectation and that is where you have a relative indication. So, it is very highly individualized because everybody's pain is not the same. Friends spine surgery by no way is a cosmetic surgery it is not done to make this disc flush with the bones it is a cosmetic it is not a cosmetic surgery it is a functional restoration surgery somebody is not able to walk you make them walk somebody is not able to control urine and motion you make them control their urine and motion. So, it is functional restoration surgery and not a cosmetic surgery. Coming to the last part prevention to know how to prevent back pain you need to know two things one is natural history of neglected back pain if you do not do anything what will happen to back pain this is the natural history pain intensity 0 to 10 age in years till around 30 years nobody has back pain first episode comes it will go in 3 days 3 weeks or 3 months 10 years the patient is ok 30 43 years he will get one more episode 50 years is one more episode 55 57 59 60 you know as the time goes if you do not take care the episodes will come more and more frequently and of initially it used to heal normal completely and in between episodes patient never had back pain and after sometime if you see although 80 90 percent of it has healed, but still you will not feel that same back that used to have in SSLC PUC days and this residual pain goes on increasing to a point at some point of time that you will end up needing a surgery for functionally disabling pain. So, if you are looking at stopping the or preventing you have to do something here so that this cascade does not flow the other thing that we need to emphasize is philosophy of back pain why some people get back pain have you seen a child with back pain of course not in a school of 2000 students you will not see even one child with back pain in a year. So, why because child does not even know that neck and back exists you ask any child parts of the body they will all tell eyes ears nose hands legs they do not know about neck and back exam time they look at in the mirror they say headache throat pain and stomach pain because they think they can see in the mirror and nobody else can see. Now, in another group this is true till 15 years of age till the person is in plus 2 take another group 25 to 30 years of age you do not have to talk to them or ask them if a group of people young adults are talking for more than half an hour to one hour invariably the discussion will end in who is the best spine surgeon which hospital is better whether acupuncture or Ayurvedic massage endoscopic or microscopic dyskectomy or you know lot of things that they talk about as though the next biggest threat to the world is not anymore nuclear weapons it is neck and back pain. So, friends what has changed a 15 year old child who did not know existence of neck and back by 25 30 years thinks that the whole lot of problems for the people today is neck and back pain it is only boiling down to this picture a child is like a tender plant you bend a tender plant belly in any direction it does not break a child can bend and touch the floor fully whereas, a after plus 2 by another 10 years the adult will become more stout more fitter, but more stiffer like teacher's chalk you bend a chalk it breaks you pick up a mug of water you get a catch you go on a 2 wheeler you get a catch you go on a hump you get a catch you go on auto you get a catch you write articles on times of India how Bangalore has 4564 potholes and so many humps humps nether whatever friends a coulee who is bending lifting weights who is going on a 2 wheeler bicycle on the same roads with same potholes and same humps has no back pain and we having a good car good 2 wheeler have back pain it only says that from a flexible child we have become stiff adults and we are prone to breaking whereas, a coulee or a manual laborer is still flexible that is why he does not break and we are masters of blaming somebody or something else other than ourselves. So, friends if at all you look why we have lost flexibility and become stiff it is not because our liquid disc has become solid it is nearly because of you remember the first slide that I had showed in anatomy ligaments and muscles if you do not move them and stretch them every day they are going to become stiff and once the body become stiff it can only break and give rise to slip disc or a disc prolapse and you will have in addition to back pain a leg pain and a need to see a surgeon. The best preventive measure is bringing back the flexibility into our spines and this can be the key for preventive measure. Friends our body is like this old car which if you do not start it every day in a weeks time you will have to push and start if you do not start it for a month you will have to get a mechanic change the battery and start. By virtue of us being able to stand direct against gravity fully humans were the most evolved animals on earth. But chimpanzees came very close but never fully straight and you see us today we are regressing the there is a regression of metamorphosis and I do not know where we are heading to preventive measures yoga is in the top of the list because yoga moves all the 33 bones and the discs in the back and there is no better way to exercise your back than yoga swimming is the next best smoking is the only thing which is proven to have accelerated disc degeneration and disc prolapse weight gain for obvious reasons is not good because it is going to be mechanical disadvantage for your spine it is going to pull your spine forwards and strain it much much more for all the software guys look straight six straight but more importantly take breaks you know nobody gets up they get glued to the chair and once after four hours they get up and they are like and all so get up take a walk and do some stretches and you are fine to sit again friends movement is life the more you move the more an individual moves the more the joints move the more is life and friends one of the very important preventive measure is do not do an MRI unless indicated this is all about yoga there is a randomized study done by 10 Americans no Indian in it it won the best paper award in SRS yoga improves functional disability pain intensity and depression in adults with chronic low back pain so it not only tackles the physical component of pain but also the psychological component of pain so that is the important the breathing pattern of yoga also takes care of psychological component of pain and it is very important that you do it yoga friends is like a recurring deposit you invest one hour of your day in yoga I am sure that you will see the returns in after 30 years from the day you start it is a way of life it is not an exercise to sum it up it is not because you have a small disc ball that you can go on suffering if it is a small narrow canal by birth even a smallest of disc prolapse can cause such significant pain or neurological deficit that you may need to get surgery done it is not to say that the disc prolapse is very big and that is why you need to get surgery done sometimes the canal diameter may be by birth very large and this disc although is a large disc prolapse it may be floating freely it may not be pressing so why need a surgery so it is not based on MRI that you decide whether somebody needs surgery or not and no matter who claims what there is no center in the world which can give you hundred percent success in spine surgery or any surgery for that matter and friends conservative treatment is always reversible surgery no matter how small it will always leave behind a scar and I don't mind you doing thorough work up even doing an MRI knowing well that it is not to look at the degenerative normal aging process it is only if you are looking at to a point to prove whether there is underlying infection or cancer you may do an MRI but think conservative and stay conservative indications for surgery are only three as I mentioned weakness urine motion incontinence or inability to pass or intractable pain functionally disabling pain for three consecutive months friends rest all can be managed non-surgically to sum it up in one slide the whole thing that I talked pain is protective friends respected be within its limits when you have pain flexibility is the key when you don't have pain maintain it with yoga both MRI and surgery are having same three common indications weakness bowel bladder involvement and functionally disabling pain for more than three consecutive months and it is not to say that you should never do a surgery please don't let the pain become chronic that is more than three months because then it becomes chronic pain syndrome wherein it goes deep in the brain and even if you treat the primary cause it will never go out of your brain then it becomes chronic pain syndrome it can then be only treated not cured it becomes like asthma and diabetes friends there is no way that we are able to reverse this degenerative cascade and we are yet to find a way to get back these baluni watery discs of children on a philosophical note I would end this topic what God wanted us to do was be farmers sweat it out in the hot sun morning to evening end of the day any food would taste nice it would get digested and no matter which pillow which matters the farmer gets such a sound sleep that next day morning when he gets his fresh energetic and happy today what we are doing exactly opposite sitting in air conditioned rooms body is cold brain is heated up anything and everything we have extremes of emotions too happy too unhappy too anxious too apprehensive too tense too fearful everything is too much that strains the brain and once brain gets heated up it is the controller of all the organs in the body and all the organs becomes autonomous they lose control because boss is heated up so they start misbehaving and you will start getting giddiness dizziness headache just pain palpitation breathlessness neck pain back pain acidity constipation menstrual irregularities you name it you will have it and trust me friends every single symptom that you have we at Manipal Hospital have a super duper specialist if you do not find a suitable specialist for your problem or disease or a symptom you please write to the customer care they will get new new fellows from UK and US everybody now wants to come back to India so end of it each person each doctor at least for namesake he has to give one or two medicines and you have 10 doctors 10 prescriptions you will end up taking 10 medicines in the morning 15 in the afternoon 20 in the night so we invariably end up creating patients out of you so you have three choices to avoid all this one leave all this go back to your grandfather's farm and do agriculture work I think it is safest you do not have any health hazards you will get good food good nutrition happy life or you want to be in Bangalore doing the work that you are doing please do one hour of yoga daily or stop cribbing start enjoying pain or at least do a favor to the doctors keep changing doctors for entertainment do not irritate the same doctor by going every three months thank you friends I honestly feel that we are over treating back pain and it's time that high time that we have to back off thank you one and all