Back Pain and Asking the Wrong Question

For nearly 100 years, modern medicine has studied low back pain. Since the 1932 discovery linking disc herniation to sciatica (a term that became synonymous with leg pain from the spine), we've been on a quest to define and diagnose pain. But we’ve also been asking the wrong question—and this misunderstanding has led to decades of unnecessary suffering.

A major shift happened in 2022 with the adoption of the ICD-11 (International Classification of Diseases, 11th edition), which redefined chronic pain. Historically, pain was seen as a symptom—a sign of an underlying problem, like a fever signaling an infection. This view, rooted in Descartes’ 17th-century model, suggested pain was simply a signal from the nervous system reacting to injury or disease.

But what if that’s not true?

Pain Is Not Just a Symptom—It’s a Diagnosis

Think about how often things in life aren’t what they seem.

• Atoms are 99.9% empty space, yet everything appears solid.
• Marriage, some joke, is the antidote to love, with 50% of them ending in divorce.
• Pain—which we assumed to be a signal of an underlying problem—might not be a symptom at all.

If pain is not simply the result of an underlying injury or disease, then constantly searching for a root cause is not just futile—it makes the pain worse.

Imagine you believe pain must come from a structural issue in your spine. You undergo test after test, searching for an answer. But what if there’s nothing to find?

What if pain itself is the condition?

As of January 1, 2022, the global medical community officially recognized chronic primary pain—a condition where pain lasts over three months, causes emotional and functional distress, and cannot be explained by another medical diagnosis.

This is a game changer. It means:

• If no fracture, infection, tumor, or nerve compression is found, low back pain is its own diagnosis.
• There is no longer a need to search endlessly for a cause when the pain itself is the condition.

For decades, patients have asked:

 Why am I in pain?

 What is causing it?

 Please, just give me a diagnosis.

These questions only make sense if pain is a symptom of something else. But if pain is the condition itself, these become meaningless questions.

It’s like asking:

• Why are you gay?
• Why are you male or female?

We now understand that people are born gay, just as they are born male or female. Some questions aren’t just unanswerable—they distort reality and lead to harmful biases.

Similarly, continuing to search for a structural cause of chronic pain is a dangerous and futile pursuit. It leads to unnecessary treatments, harmful interventions, and most of all, prolonged suffering.

Patients often ask: How do you know there’s no underlying cause of my pain?

• Have we searched every inch of the spine?
• What if we missed something?

This is the classic problem of proving a negative. You cannot prove that something does not exist—no matter how long you search.

Imagine Columbus setting sail in search of new land. But instead of discovering America, he finds nothing but endless ocean. How long would he need to sail before he could prove there was nothing there?

Forever.

The same applies to pain. We could spend an eternity searching for a cause, and still, we wouldn’t prove it doesn’t exist. But our brain won’t accept that—it keeps demanding answers. Something must be wrong. Keep searching.

This endless search fuels suffering.

The challenge is acceptance. Telling a patient, "There is no more testing to be done. This is the diagnosis. We stop here." is one of the hardest conversations in medicine.

Because pain fluctuates, doubts creep in:

• What if my pain gets worse?
• What if I feel something new?
• What if something really is wrong?

These thoughts haunt patients, keeping them trapped in a search for answers that do not exist.

But science requires a leap of faith. We must accept what the evidence tells us and stop asking the wrong question.

Instead of asking:

 What is causing my pain?

We should ask:

 If pain itself is the diagnosis, what does that mean?

 What actually happens in the body when we feel pain?

Every diagnosis is linked to an underlying pathology.

• Heart attacks = Death of heart cells from lack of oxygen.
• Diabetes = A metabolic disorder of insulin regulation.
• Pain = ?

What is pain’s underlying mechanism?

According to 2018 Nature Reviews: Disease Primer, in 95% of chronic back pain cases, there is NO identifiable pathology.

Let that sink in. 95%.

So why are we still searching? Why are we still blaming the spine?

We need to stop.

Once we accept that pain itself is the condition—not a symptom—we can finally start moving in the right direction. The journey toward recovery begins when we stop asking the wrong question.