Back Pain – What are your options?

Intro: This is Weekly Dose of Wellness brought to you by MemorialCare Health System. Here's Deborah Howell.

Bill Klaproth (Host): Hi, this is Bill Klaproth in for Deborah Howell. According to studies, 10% of the US population suffers from some form of lower back pain. Ask anyone who suffers from chronic back pain and they will tell you how debilitating it is and how it can make daily life a painful struggle. So when it comes to treating back pain, what are the options? Here to talk with us today is Dr. Azi Farin, a fellowship-trained and board-certified neurosurgeon with experience in a wide range of neurosurgical procedures. Dr. Farin has published several dozen manuscripts, articles, and book chapters and is on staff at Long Beach Memorial Medical Center. Dr. Farin, thanks so much for being on with us today. So let's start at the beginning. What are the main causes of back pain?

Azadeh Farin, MD: Well, thank you for having me. So, there are many causes of back pain. By far, the most common cause is what we call degenerative or arthritic changes. So what that means is anything that's age-related. Just as you get gray hair and wrinkles as you get older, just as your windshield wipers wear out on your car as they're used over and over again, the same happens with our spine. Uh, with 100,000 bends, uh, all the things we do, picking items up, putting on extra weight during the course of our lives, bending over, twisting, turning, all these motions end up causing degenerative or arthritic changes to our spine, and that is the number one cause of back pain. The other causes of back pain would be things like, God forbid, tumors, uh, these are tumors involving the spine itself or metastatic tumors, deformities of the spine, including scoliosis, and vascular lesions of the spine. Those are some of the more rare causes of back pain.

Bill Klaproth (Host): So we've got normal wear and tear, which is probably most likely, and then tumors, deformities, and other things like that, correct?

Azadeh Farin, MD: Sure, absolutely.

Bill Klaproth (Host): So what are some of the risk factors then for somebody that's experiencing the normal wear and tear type of pains? Is there a way to combat against that?

Azadeh Farin, MD: There are some risk factors that are fightable and some that you just can't do anything about. Let's talk about the ones that we can do nothing about first, and then we'll get into more detail about how we can modify our lifestyles. So, genetics probably plays a role. That's not been well studied, but that's a strong suspicion that we have as clinicians. Uh, secondly, what you do for a living may play a role. For example, if you're a manual laborer, if you're doing listing, you know, 30 to 50 pounds a day multiple times a day, if your work involves a lot of bending and twisting, uh, that will most likely wear your back out uh to a greater extent than somebody who has more of an office-type job. Now, the factors that you can modify would be things like avoiding being overweight. Think of your spine as, as a chair, if you will, and it's meant to carry the weight of a normal person. Now, if you take an ordinary chair and you load three, four times the weight of a normal person on that chair, eventually, over a period of years, that chair will start to break down, the fabric of the upholstery will tear, the chair legs may get weak, and the same with your spine. When you put on excessive weight, when you're beyond your ideal body weight, that's one of the main risk factors for accelerating the degenerative process. Smoking is another bad habit. What smoking does is it causes compression of the blood vessels, the blood vessels become narrowed, and so nutrients are not delivered to in the same way to normal structures around the spine. And so those structures go through the degenerative process at a much faster rate.

Bill Klaproth (Host): And when should someone go see a doctor about their back pain?

Azadeh Farin, MD: Well, let's start with the more serious reasons why you'd see a doctor. Anybody with acute or progressive, meaning weakness that has started immediately or is slowly ongoing and getting worse and worse, any type of weakness involving the legs, any type of numbness involving the legs, and frankly, any problems with bowel, bladder function, or sexual dysfunction needs to be addressed immediately by a qualified spine professional. So, if you have weakness in your legs, numbness in your legs, problems with bowel, bladder, sexual function, you need to see your doctor right away. Now, if you don't have any of those problems, but you just have severe unrelenting pain that's resistant to basic, non-aggressive measures. For example, Tylenol's not helping. Advil's not helping. Physical therapy is not helping. Massage is not helping. Six weeks have passed and you're still miserable. That's the time to see the doctor as well.

Bill Klaproth (Host): And what type of tests are done to diagnose back pain?

Azadeh Farin, MD: Well, the most common test that we do as surgeons would be an MRI. Not everybody needs one, but if you meet certain criteria, for example, the criteria that I described, which is weakness or numbness in your legs, bowel, bladder dysfunction, or severe unrelenting pain that's not effectively treated with over-the-counter medications, those patients generally get an MRI. Other tests that we use on an adjunct basis would be a CT scan, a CT myelogram, or X-rays.

Bill Klaproth (Host): Dr. Farin, when you talk about weakness in the legs and problems with bowel and bladder function, would that occur with back pain? So, when you have back pain and you have weakness in the legs or bowel and bladder dysfunction, that's all tied together, right?

Azadeh Farin, MD: Well, it gets a little bit complicated, and that's an excellent question. You must have had some medical training at some point. Usually, yes, usually patients come in experiencing both the back pain and the lower extremity symptoms. But not always. Sometimes they have virtually no back pain or minimal back pain, and all they can tell you is that they're losing balance, they can't walk straight. That's a larger symptom of they have numbness in their legs, their proprioception is off, and that's because the nerves in their spine are being compressed. So not everybody presents with back pain. You may have some of the other symptoms and signs in isolation, typically they're presenting together, but not always.

Bill Klaproth (Host): And when we talk about diagnosis, sometimes you hear, 'forget about surgery, it doesn't help, you can take care of it all with physical therapy.' So, when is surgery indicated for back pain?

Azadeh Farin, MD: Anybody who has a what we call a neurologic deficit, meaning a change in the way their body is supposed to function, such as weakness or numbness or bowel, bladder dysfunction, we typically offer surgery to. I mean, neurosurgery is pretty complicated, if we go all go through years and years of school, so it's hard to make a blanket statement, but as a general rule of thumb, anyone who's got weakness in their legs, numbness, or bowel, bladder dysfunction is offered surgery, sometimes immediately. Now, if you don't have any of those, but you just have severe unrelenting back pain, the best thing to do is to treat you for several weeks conservatively, meaning non-surgically, with pills, with physical therapy, with aqua therapy, with massage, with a chiropractor, with acupuncture treatments, sometimes with steroid injections to the spine. If none of this works after about 6 months, 6 weeks to 3 months, then it's reasonable to consider surgery.

Bill Klaproth (Host): So that's a very important distinction. So thank you for explaining that, because I think that kind of wraps it up and makes it easy to understand when surgery is needed and when it's not. And if surgery is not indicated then, so what are some of the treatments for back pain at that point?

Azadeh Farin, MD: Well, we're always happy, by the way, when we don't have to do surgery because surgery is always a last resort. So to the extent that we can avoid surgery, if it's not needed, we take that path with patients and we only go to surgery when it's absolutely needed in the cases of weakness or numbness or bowel, bladder dysfunction. So those who don't need surgery, we put them in a friendly but aggressive program of physical therapy, aqua therapy, exercise, massage, chiropractor, acupuncture, muscle relaxants, oral steroids, oral analgesics, steroid injections to the spine. Any, not, no one gets all of these measures, but a subset of what I just described is what we prescribe for these people in the hopes of making them better without surgery.

Bill Klaproth (Host): So, for somebody that has the normal wear and tear back problems like you described earlier, is there a way to cure that, or somebody just has to manage that throughout their whole life?

Azadeh Farin, MD: Well, there are things we can do. There's no way to cure it. I'll be honest with you. It's just like you can never totally cure gray hair or wrinkles, there are things you can do to make them less apparent or to hide them, if you will, and there are things we do to the spine that can make you less aware of the symptoms. For example, we can enroll you in something called physical therapy traction. That would typically make the symptoms of the arthritis better. Doesn't cure it or make it disappear, but it makes it more livable because we are modifying your anatomy in some ways non-surgically so that you're less sensitive to the pain. So, we never quite cure things, but we do try and modify your body's response to the pain. Uh, so now, search, if you allow us to do surgery on you, if you meet the indications for surgery, there are newer implants that, I wouldn't say cure the problem, but get around the problem quite cleverly. And these are things like artificial discs or, uh, posterior instrumentation, there's anterior instrumentation. So there are a number of complex implants that have been developed in the last, say, 5 to 25 years that give us a few tools, help us get around the pain generator. We can sometimes cut out the pain generator, put in a replacement. Sometimes we can just stabilize the pain generator so it's no longer able to act as a pain generator. So in the realm of surgery, we have a few more options around that don't quite cure the problem, but help us get around what the pain generator is.

Bill Klaproth (Host): So those are the new options and new things that you're learning now. I was just going to ask you, what does the future hold and what is the outlook for people with back pain? Are you discovering new ways to treat this? And it sounds like you are.

Azadeh Farin, MD: Absolutely. I would say, as with any other disorder, the number one thing is prevention. Uh, you, you don't want to be in a surgeon's office if you could have done something to avoid it. You want to maintain your ideal body weight. Maintain a regular routine of exercise that keeps you fit and healthy. You want to avoid smoking. You want to avoid manual labor if possible. And excessive, uh, excessive dangerous activities with your spine. Number two, if you have the bad genetics or the job that does force you into a degenerative process at a much faster rate, and you end up at a spine surgeon's office, we do have newer implants that help us make your life much better. Now, not everybody needs an implant. I want to make clear that, to the extent possible, we try not to use any foreign bodies. But some of the newer implants do give people a level of functionality that they would not have been able to experience otherwise.

Bill Klaproth (Host): Dr. Farin, that's great advice. Thank you so much for your time today. We really appreciate it. For more information about lower back pain, please visit memorialcare.org. That's memorialcare.org. This is your MemorialCare Weekly Dose of Wellness. I'm Bill in for Deborah. Thanks so much for listening.