SeetoMD
司徒醫生，俄勒岡/加州
《司徒醫生手記》：為什麽病人腰痛，醫生頭痛
在門診，經常有人問，醫生，我為什麽會腰痛。
我通常的回答是：我這個辦公室裏的人，幾乎都有腰痛。
是的，很常見。
大約60%到80%的人，都會經曆過腰痛。在任何一個時間點，10%到20%的人，正在腰痛。
為什麽人類特別容易腰痛。
簡單地說，我們是站著走路的動物，但脊柱其實還沒有完全適應這個負擔。
腰部每天要做三件事：支撐上半身重量，參與走路彎腰轉身，維持身體平衡。
所以隻要哪裏有一點點問題，身體很容易把壓力甩到腰上。
大多數腰痛，其實不是神經問題。大多數腰痛，痛源於肌肉和結構的不平衡。
久坐，姿勢不好，核心力量弱，腰部受力不均，就開始慢性疼痛。
腰不是孤立的，它是整個運動係統的一部分，從足到踝，到膝，到髖，再到腰。任何一個地方出問題，比如膝蓋痛，髖關節僵硬，步態改變，兩側受力不均，最後都可能表現成腰痛。
那真正的神經性腰痛是什麽。
神經內科最常見的是坐骨神經痛。
特點很典型，從腰開始，向臀部，大腿，小腿放射，多為一側，同時伴有麻木或者電擊樣的感覺。
常見原因是椎間盤突出，或者神經根受到刺激，不一定是完全壓迫。
一個讓人頭痛的事實：影像不等於症狀。
很多人做了MRI，就以為找到了答案。但現實是，影像看起來很嚴重的人不一定有痛，影像看起來沒什麽問題的人卻可以很痛。
影像隻是參考，不等於痛的病因，這也是腰痛最讓醫生頭疼的地方之一。
為什麽醫生常常建議先保守治療。
因為大多數腰痛，會在幾周之內自行改善。
治療的順序通常是這樣的。
第一步，物理治療，也就是理療，這是最重要的一步。核心肌群訓練，姿勢矯正，恢複活動，還有走路方式的調整。有些人配合針灸，也會有幫助。
如果效果不好，再考慮下一步。
第二步，局部注射，比如在影像引導下做類固醇注射或者神經阻滯。
第三步，射頻消融，對一些小關節引起的疼痛效果不錯。
什麽時候才考慮手術。
需要比較明確的幾個條件，有神經壓迫，有對應的肌肉無力或者功能下降，影像檢查結果支持，而且保守治療無效。
即便如此，大約還有40%到50%的病人，手術後仍然有疼痛。因為手術解決的是神經壓迫，但疼痛的來源往往不止一個。
那到底該看哪個科。
這在現實中非常常見。很多人到處打電話，從家庭醫生開始，再被建議去專科，結果越問越亂。
我的建議是這樣。
第一步，先看家庭醫生。這是正確的起點。因為很大一部分腰痛，會在一個月內自然改善，不需要一開始就進入專科係統。
如果持續不改善，再往下分。
如果有明顯的放射痛，麻木，或者無力，可以考慮神經內科/神經外科。神經外科的優勢是判斷手術的可行性，神經內科通常使用肌電圖和神經傳導來做準確神經定位。
如果更偏向骨和軟組織結構或者關節問題，可以看骨科或者疼痛科，比如小關節的問題，退變性改變，或者需要做注射治療的情況。
但很多時候，關鍵的還是理療。理療重點： 放鬆肌肉（熱敷、按摩）；改善姿勢；核心肌群平衡訓練。
In clinic, patients often ask me, “Doctor, why do I have back pain?”
My usual answer: almost everyone in my office has it too.
Yes，very common.
About 60–80% of people will experience low back pain at some point in their lives. At any given time, about 10–20% are having it.
Why are humans so prone to back pain?
Simple: we are upright walkers, but our spine is not perfectly adapted to this task.
The lower back has three main jobs:
support the upper body,
allow movement (walking, bending, turning), and maintain balance.
So when anything is slightly off, the body tends to “dump” stress onto the lower back.
Most back pain is not neurological. It usually comes from muscle and structural imbalance.
Prolonged sitting, poor posture, weak core muscles, and uneven load distribution lead to chronic pain. it’s part of a whole kinetic chain: foot → ankle, knee, hip → back. A problem anywhere (knee pain, stiff hips, abnormal gait, asymmetry) can cause back pain.
So what is nerve-related back pain?
The most common is sciatica.
Typical features: pain starts in the lower back and radiates to the buttock, thigh, and leg, usually on one side—often with numbness or an electric-like sensation.
Common causes include disc herniation or nerve root irritation (not always full compression).
Here is a frustrating fact: imaging does not equal symptoms.
Many people with severe MRI findings have no pain. Others with minimal findings can have significant pain.
Imaging is only a reference—not the cause. This is one reason back pain gives doctors headaches.
Why do doctors recommend conservative treatment first?
Because some back pain improves within a few weeks.
The usual approach:
1: Physical therapy
Core strengthening, posture correction, restoring movement, and gait training. Some patients also benefit from acupuncture.
If that fails:
2. Injections
Image-guided steroid injections or nerve blocks.
Step 3: Radiofrequency ablation
Helpful for certain facet joint pain.
When do we consider surgery?
clear nerve compression,
objective weakness or functional loss,
supporting imaging findings,
and failure of conservative treatment.
Even then, about 40–50% of patients may still have pain after surgery—because pain often has multiple sources.
So which specialty should you see?
Start with your primary care doctor. Many cases improve within a month and don’t need specialty care.
If symptoms persist:
? Radiating pain, numbness, or weakness, then Neurology or Neurosurgery
? Structural or joint-related pain. Orthopedics or Pain Management
But in many cases, Physical therapy is essential: Relax muscles (heat, massage), mprove posture, and restore core balance.