Could severe back pain drive someone to commit a terrible crime? Some thoughts from someone who sees chronic back pain patients regularly.
This is the lumbar spinal xray posted on Luigi Mangione's Twitter profile. It shows he had a spinal fusion surgery (the screws at the bottom), along with some degenerative changes that you'd normally see in a later middle-aged person, but could also be present in a younger person who's had a serious injury.
Along with my ER work, I also work part-time in a pain management clinic. I find it a good change-of-pace from the absolute chaos of the hospital. Chronic back pain is an extremely difficult condition to treat, and our tools are very crude and imperfect. Very often there are potent psychosocial issues that set people back as well, and we try to direct these patients to resources that would better suit them.
Most of our patients have suffered car accidents, sports accidents, work-related injuries, or are laborers and tradespeople nearing the end of their working career (40s to 50s) along with elderly with significant age-related degenerative changes.
Our treatment programs progress something like this:
1) Physio referral and a daily home-based core exercises regimen (based on fellow Canadian Stuart McGill's Big 3 exercises). I track reps and frequency and suggest modifications if they find these difficult. For elderly patients, we'll recommend something gentler like aquafit classes at the local pool, and the Otago balance exercises. The AAOS's Spine Conditioning Program (Google it) is also excellent.
2) Medications: Tricyclic antidepressents like Amitriptyline, old seizure medicines like Gabapentin and Pregabalin provide relief for some people, but I find they work on, at best, 20-30% of people. Low-dose Naltrexone (LDN) can help with people who suffer from Fibromyalgia (a condition that deserves its own thread!). Anti-depressents like Duloxetine can help, especially if there's a depressed mood component. Synthetic cannabis (in the form of Nabilone) is a good option for short-term pain relief. Last-resort are opioids, and in very limited amounts, rotated and discontinued quickly if there's any sign of tolerance developing. Ketamine-containing compounded topical creams are useful in postsurgical limb pain (very often from chronic regional pain syndromes). Oral Ketamine is useful as an absolute last resort, but has to be used extremely cautiously (it is extremely addictive and psychoactive) and only after you take a bunch of courses on how to safely prescribe it. There's rumours that Elon Musk uses it for neck pain...
3) Trigger point and nerve block injections: a unique practice that's evolved over the last few decades in Ontario and BC is GPs with extra training (like me) injecting lidocaine (local anesthetic) into trigger points and near cutaneous nerves and fascial planes, which often will provide days to 1-2 weeks of pain relief. It's a great bridge to allow patients the mobility to do the strengthening exercises in point (1) above. Your goal is to transition people off of these shots as they get stronger and recover.
4) Epidural steroids, Radiofrequency Ablation, Selective nerve root blocks. These I refer out to more advanced clinics that do these procedures under fluoroscopy. These can help some patients with their symptoms for a few months at a time.
5) Ketamine and Lidocaine infusions - like with everything here, great for some people (especially in people with overlapping depression), limited benefit for most.
6) Spinal stimulator - this is much harder to get (only two centres in Ontario do it), and often not covered by government health plans, but does work for some of the more intractable back pain. I've had a few patients do extremely well with these.
7) Surgical referral - this can be a bit of crapshoot. If you have 'red flag' symptoms such as limb weakness, paralysis, stool incontinence, etc then you don't have much to lose in getting surgery, you are going to be paralyzed if you don't do it. For less critical cases, very often surgery will offer only a temporary reprieve, if any at all. Scar tissue can ensnare more nerves, other spinal segments can start causing more issues, and very soon, you're stuck with needing more interventions.
Surgeons in Ontario are very conservative, and will usually redirect milder cases to physio or to our clinics to manage. They have long waiting lists and don't need to drum up the business like their more entrepreneurial colleagues elsewhere.
Obviously I don't know what happened with this young man, but I'm guessing a few things:
- He may have sustained an injury, possibly surfing (which some have reported here). I see many young men with back injuries from powerlifting and squats. Jump squat exercises should be banned as far as I'm concerned!
- He may have tried conservative measures like core exercises and medications, with poor results
- He may have had uneven results from other interventions, or these could have been inaccessible or denied by his insurer
- As I've seen with many high-agency type A people, he might have pushed for surgery, having a faith in a treatment (surgery as a cure-all) informed more from popular culture, and not fully knowing (or not wanting to know) the risks of a poor surgical outcome. Or he could have been oversold on a treatment by an aggressive surgeon.
- he could have dabbled in oral Ketamine, and progressed to mushrooms, and on to psychedelics, looking at his reading list on Goodreads. I've had patients travel to Mexico and elsewhere for courses of treatments costing thousands of dollars, with mixed results. Unfortunately, there are people out there who will sell you anything for a price.
Last year I suffered a back injury while moving boxes, and I was fairly disabled for about 6 weeks. I was only able to walk 10 feet before I had to rest, I had to sit frequently at work, and use a rolling computer cart almost as a walker to get by. Luckily I did not have radiating pain or other signs that I had slipped a disc, thank goodness. Gradually, after much core exercising and stretching, things got better, though it does flare-up from time to time. It gave me a good insight into the life of my patients, many who live this reality constantly. I would have given anything, paid anything to be better again, and often even that is just not possible.
I can imagine the thought process of someone who isn't getting better, who doesn't have a medical provider giving good advice, who mourns an active life that is now impossible, and who thinks he found a solution elsewhere. I guess we'll find out soon enough.
Overall my advice is to all young people is to really safeguard your back. Once your back is injured, it is never quite the same again. If I had my way, I would run a mandatory back safety course in high schools so those going into labour jobs don't end up in my clinic too prematurely. Same goes for anyone in high level sports as well.
This is the lumbar spinal xray posted on Luigi Mangione's Twitter profile. It shows he had a spinal fusion surgery (the screws at the bottom), along with some degenerative changes that you'd normally see in a later middle-aged person, but could also be present in a younger person who's had a serious injury.
Along with my ER work, I also work part-time in a pain management clinic. I find it a good change-of-pace from the absolute chaos of the hospital. Chronic back pain is an extremely difficult condition to treat, and our tools are very crude and imperfect. Very often there are potent psychosocial issues that set people back as well, and we try to direct these patients to resources that would better suit them.
Most of our patients have suffered car accidents, sports accidents, work-related injuries, or are laborers and tradespeople nearing the end of their working career (40s to 50s) along with elderly with significant age-related degenerative changes.
Our treatment programs progress something like this:
1) Physio referral and a daily home-based core exercises regimen (based on fellow Canadian Stuart McGill's Big 3 exercises). I track reps and frequency and suggest modifications if they find these difficult. For elderly patients, we'll recommend something gentler like aquafit classes at the local pool, and the Otago balance exercises. The AAOS's Spine Conditioning Program (Google it) is also excellent.
2) Medications: Tricyclic antidepressents like Amitriptyline, old seizure medicines like Gabapentin and Pregabalin provide relief for some people, but I find they work on, at best, 20-30% of people. Low-dose Naltrexone (LDN) can help with people who suffer from Fibromyalgia (a condition that deserves its own thread!). Anti-depressents like Duloxetine can help, especially if there's a depressed mood component. Synthetic cannabis (in the form of Nabilone) is a good option for short-term pain relief. Last-resort are opioids, and in very limited amounts, rotated and discontinued quickly if there's any sign of tolerance developing. Ketamine-containing compounded topical creams are useful in postsurgical limb pain (very often from chronic regional pain syndromes). Oral Ketamine is useful as an absolute last resort, but has to be used extremely cautiously (it is extremely addictive and psychoactive) and only after you take a bunch of courses on how to safely prescribe it. There's rumours that Elon Musk uses it for neck pain...
3) Trigger point and nerve block injections: a unique practice that's evolved over the last few decades in Ontario and BC is GPs with extra training (like me) injecting lidocaine (local anesthetic) into trigger points and near cutaneous nerves and fascial planes, which often will provide days to 1-2 weeks of pain relief. It's a great bridge to allow patients the mobility to do the strengthening exercises in point (1) above. Your goal is to transition people off of these shots as they get stronger and recover.
4) Epidural steroids, Radiofrequency Ablation, Selective nerve root blocks. These I refer out to more advanced clinics that do these procedures under fluoroscopy. These can help some patients with their symptoms for a few months at a time.
5) Ketamine and Lidocaine infusions - like with everything here, great for some people (especially in people with overlapping depression), limited benefit for most.
6) Spinal stimulator - this is much harder to get (only two centres in Ontario do it), and often not covered by government health plans, but does work for some of the more intractable back pain. I've had a few patients do extremely well with these.
7) Surgical referral - this can be a bit of crapshoot. If you have 'red flag' symptoms such as limb weakness, paralysis, stool incontinence, etc then you don't have much to lose in getting surgery, you are going to be paralyzed if you don't do it. For less critical cases, very often surgery will offer only a temporary reprieve, if any at all. Scar tissue can ensnare more nerves, other spinal segments can start causing more issues, and very soon, you're stuck with needing more interventions.
Surgeons in Ontario are very conservative, and will usually redirect milder cases to physio or to our clinics to manage. They have long waiting lists and don't need to drum up the business like their more entrepreneurial colleagues elsewhere.
Obviously I don't know what happened with this young man, but I'm guessing a few things:
- He may have sustained an injury, possibly surfing (which some have reported here). I see many young men with back injuries from powerlifting and squats. Jump squat exercises should be banned as far as I'm concerned!
- He may have tried conservative measures like core exercises and medications, with poor results
- He may have had uneven results from other interventions, or these could have been inaccessible or denied by his insurer
- As I've seen with many high-agency type A people, he might have pushed for surgery, having a faith in a treatment (surgery as a cure-all) informed more from popular culture, and not fully knowing (or not wanting to know) the risks of a poor surgical outcome. Or he could have been oversold on a treatment by an aggressive surgeon.
- he could have dabbled in oral Ketamine, and progressed to mushrooms, and on to psychedelics, looking at his reading list on Goodreads. I've had patients travel to Mexico and elsewhere for courses of treatments costing thousands of dollars, with mixed results. Unfortunately, there are people out there who will sell you anything for a price.
Last year I suffered a back injury while moving boxes, and I was fairly disabled for about 6 weeks. I was only able to walk 10 feet before I had to rest, I had to sit frequently at work, and use a rolling computer cart almost as a walker to get by. Luckily I did not have radiating pain or other signs that I had slipped a disc, thank goodness. Gradually, after much core exercising and stretching, things got better, though it does flare-up from time to time. It gave me a good insight into the life of my patients, many who live this reality constantly. I would have given anything, paid anything to be better again, and often even that is just not possible.
I can imagine the thought process of someone who isn't getting better, who doesn't have a medical provider giving good advice, who mourns an active life that is now impossible, and who thinks he found a solution elsewhere. I guess we'll find out soon enough.
Overall my advice is to all young people is to really safeguard your back. Once your back is injured, it is never quite the same again. If I had my way, I would run a mandatory back safety course in high schools so those going into labour jobs don't end up in my clinic too prematurely. Same goes for anyone in high level sports as well.
This article from Vox is a great resource on the less savory parts of the back pain 'industry'
vox.com/science-and-he…
vox.com/science-and-he…
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