Lost in the System: A Case for Coordinated MSK and Spine Care

Even in an optimized healthcare system, patients can still slip through the cracks. I was reminded of this with my mother’s neighbor, Mike, a 70-year-old man who had been suffering from back pain and sciatica for 3 months after lifting heavy items at home. His journey to recovery was a reminder of how fragmented care can lead to unnecessary suffering.

Mike’s initial treatment involved medications and an MRI, which revealed severe lumbar stenosis at L3-4. His PM+R physician ordered an epidural injection, which led to some improvement. That’s when I became aware of his condition and went over to help with a set of centralization exercises. He responded well to extension exercises, and his pain became much more tolerable.

However, when physical therapy was introduced, Mike was given a regimen involving lumbar flexion exercises. Flexion exercises, in light of symptoms that are pointing to disc injury, should’ve raised a red flag. Flexion likely worsened his disc injury, and within days, he was in excruciating pain with severe leg symptoms, leading to an urgent care visit. Worse, urinary retention set in (likely due to cauda equina syndrome, a syndrome that results from severe compression of the lumbar nerves).? He was diagnosed with a presumptive UTI — though tests were negative. This treatment path, focused solely on the urinary symptoms, missed the bigger picture: Mike's worsening spinal condition was the likely cause of the leg pain and the urinary symptoms.

Despite being an active and independent individual, Mike found himself wheelchair-bound, unable to walk more than a few steps. His psychological state deteriorated as well — he was crying frequently, feeling trapped by his pain, and becoming severely depressed.

Fortunately, I reached out to a spine surgeon in his health system. A repeat MRI revealed the severity of his condition, and Mike was operated on a few days later. Within days, his symptoms improved dramatically.

This case raises several questions: Could Mike's symptoms have improved if flexion exercises hadn’t exacerbated his disc injury? Would his urinary retention have become permanent without surgical decompression? How much more psychologically damaging would his condition have become without intervention and proper reassurance?

This experience underscores the importance of integrated care in the treatment of MSK and spinal conditions. Coordinating care between the surgeon, physical therapist, and behavioral health providers — and taking a holistic view of the patient — and being able to navigate them to diagnostic studies or intervention as needed can prevent needless suffering, speed up recovery, and improve overall outcomes.

I have seen hundreds of cases like this throughout my surgical career and have spent almost two decades attempting to integrate spine and MSK care to provide the most optimized, holistic, nonoperative care, but also to navigate patients in a timely manner to appropriate intervention when needed. I’m fortunate to continue tackling this issue with Livara.

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