The Most Overlooked Source of Back Pain: Fatty Infiltration of the Multifidus

Your back hurts, and no one can figure out why. It can be incredibly frustrating when you've had x-rays, MRI's and more doctors visits than you care to remember.

Well, there is a very common source of back pain that is often overlooked. It's impossible to see on X-rays and often overlooked on MRI.

What is the most overlooked source of back pain?

Fatty infiltration of the multifidus. If you have a patient that has an MRI, first of all, take a look at those pictures. Don't just look at the report. Furthermore, take a good look at those axial slices when you go down to L4-L5-S1. You will see the multifidus in what I call it the channels or gutters directly posterior to the lamina. The multifidus there should look like a beautiful marble sized steak and then on the outside should be superficial fat, which is white. If you cannot tell the difference between what is the fat and what is the muscle tissue- then you have fatty infiltration of the multifidus.

This is very important because very few docs are talking to their patients about that right now. But if there is deconditioning and fatty infiltration of the musculature, it is going to result in needed more than one or two adjustments to get where they want to be. They are genuinely deconditioned, so it helps you set better expectations for your patients.

The pain occurs in this area because essentially they are unstable. Normal movement patterns will place a tremendous amount of stress and strain on the facets, discs, and all other supporting structures when the muscles are deconditioned. Those other structures aren't designed to handle the extra load and will often fail- thus resulting in pain.

This is also relevant information to know if that patient is exploring a surgical intervention such as a laminectomy or decompression. How well do you think that's going to hold together? Probably not very well.

One more questions, do you think spinal injections are miraculously going to take care of 50 years of degenerative change? I don't think so!

So, I would encourage you to be different, be better. A lot of physicians are not looking at those axial pictures, and if you are, you probably haven't checked out the integrity of the multifidus lately. I would encourage you to do so for next patient that comes in that has an MRI. Look at those actual pictures. Take a look at multifidus and see what you think about the integrity of the muscle and set a better expectation for the recovery of your patient. Your practice is where they should be if they have this challenge. Establishing proper motion with adjustments, gapping the facets, getting movement into the disc and improving the multifidus through exercise and rehab is typically a great start to a successful plan of care.