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Melanie Cole (Host):  It's important to recognize and understand the potential symptoms of spinal stenosis because having this knowledge can help you obtain an early diagnosis and treatment. My guest is Dr. Leif-Erik Bohman. He's a specialist in neurologic surgery and spine surgery with the Christiana Care Health System. Dr. Bowman, welcome to the show. Tell us about the current state of back pain today. What are you seeing as far as prevalence and the economic impact of back issues in this country?

Dr. Leif-Erik Bohman, MD (Guest): Thank you so much for having me. Back pain is the second most common cause of disability in adults in America, and is a cause of an estimated almost 150 million lost work days a year, and it's very, very common. About 80% of people have an episode in their life, and of these, most of them will have another episode. That's one of the most common reasons people go to their primary care doctors and it also has been linked to and probably played a very significant role in the current opioid crisis.

Host:  So today we're focusing a little bit on spinal stenosis. Tell us what that is, what it means, and where on the spine does it affect someone?

Dr. Bohman:  So stenosis is just the medical word for narrowing of usually a tubular structure. So you know, people with heart disease will have narrowing of their blood vessels in their heart, and that's coronary stenosis. This is- the tube we're talking about here is the spinal canal which transmits the spinal cord in the cervical spine in your neck, the thoracic spine past your ribs, and then in the lumbar spine transitions into something called the cauda equina which is just a series of nerve roots. And so the spinal canal transmits all of those things, and so stenosis is narrowing of the spinal canal, which can then apply pressure either to the spinal cord or to nerve roots depending on where it is. That can be caused by a variety of things. I mean, the most common things are disc herniations or bone spurs or overgrowth of ligaments or joints from arthritis, although people can also have mal-alignment of the spine where the bones don't line up right, kind of closing the tube, or more rarely it could be from a tumor or fat or some other substance narrowing the tube.

Host:  Why does it happen, Dr. Bohman? Why does that tube narrow? Why does this stenosis happen?

Dr. Bohman:  So there are a variety of ways it can happen depending on what is actually doing the narrowing. But by far the most common is just wear and tear over time from arthritic changes in the spine. The most common way it would happen suddenly is through a disc herniation, and the disc being the padding between two vertebrae, but one of the weakest points in the disc is at the back of the disc, and so some of that soft padding material can squeeze back into the spinal canal, and then take away some of the room that would otherwise be occupied by nerve roots.

Host:  Can someone have spinal stenosis without back and neck pain? Can they not even realize that they have it?

Dr. Bohman:  Yes, I think in fact that's very, very common, and it's one of the things that makes figuring out what the right treatment is challenging sometimes, is that we know that people can have stenosis that doesn't cause people pain, and we know that people's symptoms from it can come and go.

Host:  Then let's talk about the symptoms, and do these symptoms happen quickly, or do they develop slowly over time? Give us some of the specific symptoms that we might notice for lumbar, thoracic, cervical spine stenosis.

Dr. Bohman:  Sure. So yeah, the symptoms as you point out would be very different based on where the level of the stenosis is. For cervical stenosis, we worry about clumsiness with the hands, numbness in the hands, and trouble walking. And these are symptoms that are often overlooked because they frequently do come on slowly and they don't necessarily seem attributable to the spine. You know, people just have- they notice that they're walking like they're drunk they'll tell you, or they feel like they're on a ship, or they're dropping things all the time and they don't know why. And while some people have neck pain with that, not everybody does, and so sometimes these symptoms can become quite advanced before anyone puts it together that it's coming from the neck. In the thoracic spine, the symptoms are generally pretty similar to the cervical spine, although without the hand symptom. So it's more focused on balance. Occasionally people can have incontinence, but usually balance trouble is predominant, sometimes real weakness in the legs. In the lumbar spine it's a little bit different. It tends to be more pain. People have pain, heaviness, the pain can be in their low back, it can be down both legs, it can be down one leg more than the other, and frequently heaviness when they walk. And in the lumbar spine, we have something called neurogenic claudication, which is a symptom where people really feel okay when they're sitting down, and then when they get up, they start to have the back pain, potentially leg pain or heaviness of the legs, and it just gets worse the longer they're standing or walking. The classic thing those people will say is that if they lean over a shopping cart they feel much better, or they'll go for a walk but they find they then have to sit down several times along the walk and take a break, and then once they get up, they feel okay again for a few minutes, and then sit down again.

Host:  We've heard about sciatica. Does radiating pain especially down the legs always mean that you have stenosis?

Dr. Bohman:  It doesn't always mean that, and the term sciatica is confusing because the sciatic nerve is actually not in your back, it's in your leg, and that's not generally where the problem is. You know, most people who have what we describe as sciatica have a herniated disc or a narrowed neural foramen, which is the little windows that the nerves exit the spine through. And so you know, the colloquial we call the pinched nerve and that generally is in the spine, not in the leg where the sciatic nerve is. But because it goes down the same distribution as the sciatic nerve, we all call it sciatica, which is a little bit confusing. It doesn't have to have to be from lumbar stenosis, but certainly lumbar stenosis is one of the most common causes of that kind of sharp radiating pain down the leg.

Host:  Then how is it diagnosed when someone comes to you? What questions, what history do you take, and then what imaging do you use to confirm your diagnosis?

Dr. Bohman:  Sure. So I think it depends a little bit on how rapidly the symptoms have come on and what brought them on. So we always ask about how long people have been having the symptoms, how are they progressing, are they getting better or worse or staying the same? We always ask about what makes things better or worse. Imaging is usually a first line move if somebody is having symptoms that are concerning for the sort of cervical or thoracic stenosis with dysfunction of walking or some sort of neurological problem. Whereas in the lumbar spine, somebody with leg pain or just some difficulty with back pain, particularly if it's relatively acute, frequently the first things to do are physical therapy, some stretching, some back exercises, some non-steroidal anti-inflammatory medications, because many times these symptoms are relatively brief flares that will get worse and then will get better without surgical intervention or without injections. And so we don't necessarily jump right to MRI for people with those sorts of problems unless we're worried about a neurological dysfunction like a foot drop or real weakness.

Host:  Then before we talk about some patient stories or first line of defense treatments, can anything be done to prevent spinal stenosis from happening?

Dr. Bohman:  Unfortunately I think that what any person can do is somewhat limited. I think that there are a lot of common sense things like worrying about our posture, trying to sit and stand straight, avoiding excess weight gain, but a lot of these things do build up as sort of a response to wear and tear over time, and so it's not necessarily one thing that somebody could avoid, and they're not always avoidable. And I think there is also probably a genetic component. Certainly you hear a lot of stories about people who say, "Oh, everybody in my family has a terrible back," although that's not well-described in the literature.

Host:  Give us some patients stories on people for whom this really started to affect the quality of their lives or trouble walking that occurred from spinal stenosis.

Dr. Bohman:  Sure. I just saw a patient back today who had had progressive back pain, bilateral leg pain that had really gotten worse over a period of six or eight months from being a mild nagging issue to just worse and worse. And this is a very active 75-year-old man. He's lifting weights, he's hiking, going out dancing with his wife until this really starts to slow him down and he found it got to the point where he could barely walk to the mailbox without having really debilitating pain, although he was pretty comfortable once he sat down. He had an MRI and he had both quite severe lumbar stenosis at multiple levels, and he also had a slippage of the spine or a malalignment of the spine at the bottom level at L4 L5. And so we started with physical therapy and he felt like he got only a little bit of relief with that. We tried injections, which again provided him some temporary relief, but not a durable benefit. And so ultimately for him, we ended up proceeding to surgery, and he's now a month out of surgery and feeling great.

Host:  If somebody comes do you and you've determined they have spinal stenosis, what can be done? Speak about the most conservative management treatments that you might try right off the bat, and when we get into medications. You mentioned opioids, so speak about NSAIDs, and opioids, and stewardship now. So what's different about first line treatments?

Dr. Bohman:  Sure. So certainly the first line treatments are to be as conservative as possible. I think stretching exercises for low back. There are a number of books you can get at the library or on Amazon, or you can Google exercises on YouTube for some McKenzie back exercises. Physical therapy is really an important first line or very close to the first line for any pain flare that lasts longer than a couple of weeks. And frequently some combination of physical therapy and medications is all that is required. In terms of medications, it's a combination of things. It's anti-inflammatory medications, so the most commonly used would be a non-steroidal anti-inflammatory like Ibuprofen or Aleve. But then we sometimes will also do, for people with shooting pain down the legs, real nerve root irritation, sometimes steroids can be very helpful. Generally a short tapering dose over a few days. Tylenol can be helpful and muscle relaxants can be helpful if people are having really seizing back pain that when they first stand up their back seems to lock up, or sometimes people will be woken from sleep at night, or can't get comfortable at night due to spasms in their muscles, and muscle relaxants can be helpful. And while those of everything we've mentioned are probably the most dangerous because they can be a little bit habit forming and sedating, they are non-opioid and not nearly as dangerous as opioid. Opioids on the other hand really do not have much of a role in the management of acute back pain. You know, the evidence generally suggests that they're not that effective for it, and moreover with all of the concern about overuse and over-prescription of opioids, I think particularly for a problem that though frequently self-limited, doesn't always have a clear end in sight. Most providers these days are being very, very careful with how they hand out opioids for things like that because it's really the indefinite use of opioids for chronic pain is a big contributor to the opioid crisis, and moreover has been shown by large studies to not be very effective in actually doing what it's supposed to do, which is relieve people's pain.

Host: So you mentioned some non-surgical, non-interventional approaches such as exercise, physical therapy, McKenzie back programs; where do things like acupuncture or chiropractic care to manipulate the spine, where do they fit into that stenosis picture, and how might anti-depressants even be used sometimes to treat back pain?

Dr. Bohman:  Sure. So in terms of chiropractic care and acupuncture, I think that they absolutely can have a role. They're not for every patient. I think generally for low back pain, chiropractic care can be very helpful either as an adjunct to physical therapy or instead of physical therapy, just providing different manipulations and stretches, and is generally safe done by an experienced chiropractor. Acupuncture is a treatment that there is not great evidence for in the medical literature, but certainly has been around for several thousand years, and anecdotally I've had patients have wonderful response to it. I don't necessarily understand exactly how it works, but I think it is very low risk, and so as an intervention it's reasonable to try. I generally am of the opinion to try everything you can prior to considering certainly surgery, and that's on the list of things that are worth trying for patients who are open-minded about it. In terms of anti-depressants, certainly there is some evidence for that, more for chronic pain, I think. We do use Gabapentin, which is actually an anti-epileptic by design. It is not a very effective anti-epileptic but it has some role in neuropathic pain or nerve-generated pain and has some evidence for it in lumbar stenosis and reticular pain or pinched nerve leg pain. But there are some side effects of those medications that do have to be watched a little bit, but certainly not as habit-forming and not dangerous in the same way as opioids.

Host:  So now onto the subject of injection therapy. What would you like people to know about the different types of injections that are available, and what that discussion looks like?

Dr. Bohman:  Sure. So I don't perform injections, so I generally defer to interventional pain specialists such as anesthesiologists or physical medicine and rehab doctors who've done fellowship training in that to talk about really the nitty gritty of the injections. But certainly I send people to get injections all the time. And my feeling about injection therapies, and there are a number of different kinds of injections that can be done in the spine, is that they can have both diagnostic value and therapeutic value. I would say the most common question I get about injections is somebody comes in with a herniated disc, and it's pushing on a nerve and causing leg pain, and they're miserable and they say, "Well isn't an injection just a Band-Aid? It doesn't make the disc herniation go away." And to some extent that is true, but ultimately we also see patients who have asymptomatic disc herniation. And my point is generally that people with asymptomatic disc herniations are not talking about having surgery for them. And so the problem is really the pain. You know? Lots of people have disc herniation. If you do an MRI on everybody walking down the street, you're going to find stenosis or disc herniation in many of them, and yet if it's asymptomatic, to some extent, who cares? And so injections have a big role in breaking what I think is a cycle of inflammation causing pain and can be really effective. A good number of patients get one or two or three injections and avoid surgery by doing that. And I think that's tremendously helpful for an intervention that really has very, very low risk, and certainly much lower risk than surgery.

Host:  So you're a spine surgeon, Dr. Bohman, so now we're going to talk a little bit about surgery, and we understand it is basically the last line after you've tried all of the other conservative managements for pain and stenosis. So what does the discussion look like when you say, "I think we should really consider surgery," and what would you like listeners to know about finding a spine surgeon? What should they be looking for?

Dr. Bohman:  So I think the important thing about- in any surgeon I think you certainly want to make sure that they are doing a reasonable volume of the sort of procedure you're talking about having. I think that there are a lot of studies that suggest that surgeons who are busy tend to have better outcomes, and similarly probably better to be done at a busier hospital. I think you want to make sure they have a good local reputation. You can certainly ask about board certification. One thing patients sometimes don't understand for spine surgeons in particular is that for orthopedic spine surgery, orthopedists have to do a special fellowship in spine surgery because their residency training does not include a full complement of spinal training. Neurosurgeons do not do additional fellowship necessarily in spine surgery because their residency includes that training upfront, and both are considered equally qualified for the vast majority of spinal indications. So it is totally reasonable to go to a neurosurgeon or an orthopedist for a spinal problem. If you have a problem that they don't feel comfortable with, I think they will send you to someone who is, but generally they're considered equally qualified. But I think in terms of finding a spine surgeon, it's important to recognize that spine surgery is sort of as much an art as a science. The spine is really incredibly complicated, and figuring out what is causing people's pain, and how to relieve it is often not completely straightforward. And so it's not just about understanding the imaging findings such as MRI or X-ray or CT, but it's really understanding the imaging findings in the context of symptoms, and then putting all that together with a patient's overall medical condition, their age, and really their values. You want to find a surgeon who's going to listen to you about all of that and can really talk to all of the particulars of your case, and be able to discuss their rationale for recommending one treatment or another, and even offering choices.

Host:  Is spinal surgery these days- how has it changed in the last say twenty years, Dr. Bohman? Is it being done minimally invasively? Are you able to use robots? Speak about what kinds of surgeries you might be able to offer, and what the benefits for the patient and for the surgeon of these types of surgeries today.

Dr. Bohman:  Sure. So there have certainly been some dramatic technological advances in spine surgery over the last twenty years or so. I think the overall trend is to make things less invasive. I think that it is important, however, to recognize that it's not always a binary choice between some sort of maximally invasive surgery and a minimally invasive surgery. You know, there are a lot of decisions in between, and that's particularly true in spine surgery, because so much of what causes pain, so much of what is truly 'invasive' is not about the size of the incision, but about the work that is done on the inside. That's in contrast to something like abdominal surgery where a minimally invasive laparoscopic surgery really cuts pain just tremendously mostly by limiting the size of incisions. In this case, it's less about limiting the size of incisions, although that can help, but about changing how we dissect the muscle, because so much of the pain in spine surgery comes from the muscle. I think the most exciting innovations in spine surgery in the last twenty years from my perspective are number one, disc replacement technologies. These are certainly not for everybody, but in certain cases to be able to do a procedure where we actually can replace a disc that is causing a problem with a new joint, that can be really exciting. But at the same time, it's not for everybody. At this point, there are three joints at every level in the spine. There's the disc in front, but then there are these two facet joints in the back of the spine, and so you really need to select patients who have isolated disc based disease and not disease of sort of every joint in the spine that might be better served by another therapy. I think that we use, at Christiana, neuronavigation with interoperative CT scans in order to place the vast majority of the hardware we put in, and that has really dramatically increased efficiency in the operating room, which is good for patients and for surgeons, and has really reduced the rate of pedicle screws particularly being placed in the wrong spot, and has let us do things that are safer, faster, and we get an interoperative CAT scan before patients leave the operating room so that we know all of the instrumentation is perfectly placed before the patient leaves or wakes up, whereas in previous days that would happen post-operatively only if they had a problem and would require returning to the operating room to fix the thing. Another exciting advance is the use of lateral surgery, lateral approaches to the lumbar spine, which uses special nerve monitoring to navigate safely and with a minimally invasive approach to do certain types of fusion procedures particularly, and allow really limiting muscle dissection on the posterior aspect, and really allow people to get up faster after surgery and feel better. In terms of robotics, robotics in the spine is still relatively young. It is essentially just an adjunct to neuronavigation or guidance to put screws in. At this point, my personal opinion is that the marginal utility of it is relatively low, but I think it's an exciting field and it's an exciting question of how that will develop in the future.

Host:  So then speak about what that's like for a patient. Everybody gets scared. They hear 'back surgery,' and oh my gosh. So what do you want them to know that if they have to undergo a surgical procedure for spinal stenosis? You told us a patient's story; what is that recovery like, and what's their life like afterwards?

Dr. Bohman:  I think it certainly varies by the particulars of the surgery. Even with less invasive approaches, some surgeries are still quite unpleasant to recover from. But I would say the vast majority of patients these days are in the hospital for a night or two, maybe three with a bigger procedure, and most people are getting home, getting to their lives, and not expecting to be completely immobilized by pain for weeks and weeks. Most people are up and about moving around. When I see most of my patients back at about a month after surgery, the vast majority are off of their pain medications.

Host:  Wow. Isn't that amazing? Your field is advancing so rapidly. So before we wrap up, we'd like your best advice, Dr. Bohman, for keeping a healthy back, and what you would like people to know about just general back health.

Dr. Bohman:  I really think the most important things for back health have to do with just ergonomics and safe lifting practices. I think that we put a lot of stress on our back in lifting things particularly, and lifting, bending, and twisting activities. There are things that you get away with doing the wrong way 99 times, and then the hundredth time, you get a disc herniation that puts you in the hospital. And so I think to be very cognizant of posture and particularly lifting practices is really important, and I think this is particularly true these days where we see a lot of younger patients who injure their backs doing things like lifting heavy weights, doing dead lifting and things like that. We have a culture that is very interested in fitness, which I think overall is incredibly positive for people's health, but I also think that people do things that perhaps would be fine if they were working with a physical therapist or a personal trainer or having somebody really work with them on their form, but it's the sort of thing that when you go to the gym by yourself, it's easy to hurt yourself. And so I think being very careful about how you lift things and good practices in that way, and just maintaining a healthy weight are probably the best things you can do for your spine.

Host:  Tell us what you love about working at Christiana Care, and tell us about your team there and your multidisciplinary approach.

Dr. Bohman:  Sure. So Christiana is a wonderful place to work caring for patients because there's really a very strong spirit of teamwork and shared commitment to providing care which is both technically excellent but also really compassionate. When I came to Christiana, I was really struck by how it combines very, very high quality sub-specialized care, cutting edge technology, and yet really the friendly warm feel of a community place. This is does not feel like a big anonymous hospital. People know each other. The specialists and nurses and various team members tend to work there for a long time and forge real relationships, and I think that those close bonds really do result in having better patient care. I think all of the parts of the team - the physicians, the nurses, the radiation technologists, and the surgical technologists in the operating room, the office staff outside of the operating room - everybody values and respects each other, and I think that really translates into providing the sort of care for patients that we would want for ourselves or our family members.

Host:  It's great information. Thank you so much. What a great educator you are, and thank you for really sharing your expertise so very well, and explaining spinal stenosis to us, the treatment options available, and why people should come to Christiana Care for their care. Thank you again, Dr. Bohman, for joining us today. To learn more about spine services at Christiana Care, please visit www.ChristianaCare.org/imback. That's www.ChristianaCare.org/imback. This is Melanie Cole, thanks so much for tuning in.