Amanda Wilde (Host): Seems like we all experience back pain at one time or another. In fact, back pain is so common that we're often inclined to dismiss symptoms that might actually be quite serious. So today we'll talk about when to be concerned about back pain with orthopedic spine surgeon Dr. Gary Alegre. Dr. Alegre is a Fellowship Trained Spine Surgeon and Assistant Clinical Professor at UC Davis Department of Orthopedic Surgery.

 This is Hello Healthy, a Dignity Health Podcast. I'm Amanda Wilde. And Dr. Alegre, thank you for stopping by to talk about back pain. Is this just about the most common ailment there is?

Gary Alegre, MD: Pretty much, other than a common cold, it's, probably the most common thing somebody will seek treatment for. So it's, it's very, very common. In fact, roughly, uh, 80% of the population in their lifetime will have disabling back pain, at some point.

Host: You're a spine surgeon, so you probably see the most severe cases, but what causes most back pain?

Gary Alegre, MD: Typically, what causes most back pain is as we age, once we get past our thirties and into our early forties, the discs become a little bit more dehydrated, or they're not as mushy or flexible as they were when we were younger. So the discs tend to get a little bit dehydrated and they can rupture or they can cause pain in the back. The disc issue would be probably the most common. Also as we age, the little joints that we have in our, in our back tend to get a little bit rougher so they can also cause pain. When we're younger, we tend to have more muscle type pain or muscle sprain, strains, or if, if somebody were in a minor injury, they can have like muscle sprain and strains. But as we age, typically the more common causes of back pain are the disc or the facets or the little joints that we have in our back.

Host: And sometimes those injuries we have when we are younger come back to haunt us, don't they?

Gary Alegre, MD: They can. Yeah, I mean, when we're younger, we tend to be more active. We engage in sports and a little bit more higher risk type activities. So something that may have seemed kind of minor as a younger adult or younger person, it comes down the road to have more degenerative changes in the area where it may have been seemingly a minor injury at that time.

Host: So you're talking about causes that have to do with wear and tear and dehydration, is there anything we can do to prevent back pain? Those sound like things we can't help, but are there things we can do?

Gary Alegre, MD: There's modifiable things certainly avoiding nicotine products. We do know that nicotine is associated with pain because it tends to dehydrate the disc earlier. It tends to block off the circulation to the disc. Also, activities that require frequent bending, stooping, lifting, so things of that nature that require repetitive use of your back.

Also, good posture, avoiding high risk type activities, cause as we said earlier, you know, things in the earlier age are going to come back to haunt you when you're older. But, some of it's also just genetics. I mean, some people are just born with genetically predisposed to poor connective tissue, higher risk for tears in the discs, and the injuries to the joints.

Some of those things are just unavoidable, but the modifiable things are the avoiding the nicotine. Avoiding high impact type activities. Avoid frequent bending, twisting, lifting. When you're lifting, making sure you use proper lifting mechanics.

Host: And at what point should we be concerned with back pain? At what point should we maybe pay a little more attention?

Gary Alegre, MD: I mean, back pain is pretty common. I mean, the things that we would be concerned about back pain that doesn't get better over the course of, say a few days. Also back pain that's associated with any radiation of pain or weakness at the leg or legs. The most serious thing would be if somebody loses control of their urine or their bowel function or has numbness in their private areas, cause that could be a surgical emergency. That's pretty rare, but does occasionally occur. Also back pain that's associated with any kind of fevers, disabling back pain that prevents sleeping at night, for many consecutive nights would be also concerning. And also any back pain that's associated with unexplained weight loss.

Host: Interesting. So if it's interfering with your daily functioning, what should you do about it?

Gary Alegre, MD: Typically, disabling back pain will last a couple days, so you tend to try to take it easy as far as avoiding any activities such as requiring frequent bending, stooping, lifting. Also, back pain can be triggered by prolonged sitting, so maybe standing or changing, sitting to standing positions.

Typically if somebody has acute back pain or re back pain, they can take over the counter anti-inflammatory medications. Also Tylenol, is also effective for back pain, but if it becomes persistant, persistent also it's associated with any referred pain or any numbness into the leg or legs, that would be something of cause of concern.

Even if it does then, oftentimes those can get better. But, because that may indicate a pinched nerve, that's something you'd probably want to seek treatment for is seek evaluation. Because if you start having radiating symptoms, it means that it's probably causing some pressure on one of the nerves or the multiple nerves.

Host: So if the pain becomes persistent, goes on for more than a few days, you probably should see your primary care physician.

Gary Alegre, MD: If it's present for more than a few days, I mean, most acute back pain resolves after the course of a few days. If it doesn't resolve after the course of a few days, probably want to seek advice, get it checked out. It may be something you just need some reassurance on. Maybe some different medications, some physical therapy, would probably be the typical approach. But if it's something that lasts more than a few days, despite the fact that you're taking it easy and avoiding activities that are going to bother you, then I'd probably at that point seek treatment or seek advice.

Host: Now as an orthopedic spine surgeon, Dr. Alegre, what kind of cases do you see?

Gary Alegre, MD: Pretty much in my practice, I see anybody that has pain from a couple days after it occurred to people that have had chronic pain for years to people that have very serious conditions. So I, I see the whole gamut of pain. So I see it from, from when it's first starts to when it's, it's lasted for a long time. So, in my practice it's, I see all comers as far as different type of issues with back pain.

Host: And then what do you offer? Is there a range of surgeries that you do to relieve that pain, and how does that work?

Gary Alegre, MD: Typically we start with some conservative treatment, unless it's something that's urgent or at risk for paralysis or long-term damage. We generally start with the basics of physical therapy. Maybe some anti-inflammatory medications, sometimes muscle relaxers.

Occasionally if that doesn't work, and patients still in pain and having problems, we offer injections or interventional type of things. And then if the pain becomes persistent or they're having some neurologic dysfunction, then we can offer them surgery. It's something that, like I said, we had to operate on you urgently.

But, surgery's typically the last resort as far as the treatment that we offer because oftentimes conservative care can offer some benefit.

Host: Yeah, surgery does sound like it's the last resort, but what is the success rate with surgery that you do?

Gary Alegre, MD: It depends on what a surgery you do. If surgery is well indicated, which means that you have pathology or problems that are amenable to surgery, such as somebody has a ruptured disc or they have some instability in their back, which means the bones are shifting on each other, causing pressure on the nerves.

If you operate on good indications, the results of surgery about 85%. If you operate on somebody that just has non-specific back pain, if you have just kind of deteriorated discs, not having a lot of radiating symptoms. You offer people surgery for that. You're looking at about 50/50. So it just depends on what you're operating on. If it's under good indications, like I said, you can have 85, 90%, bad indications, 50/50.

Host: And you said you offer such a range of treatments, so do you see that expanding in the future?

Gary Alegre, MD: There's new talk about basically injecting stem cells. It's really, something that's well established at this point. Some of the newer treatments that we have are basically more in the diagnostic realm as far as trying to figure out who's the best candidate for surgery.

You know, if you present with these certain symptoms, certain findings, you have these imaging studies that show this, what's the best route for surgery? Because you could see a surgeon, two different, maybe three different surgeons, and they may offer you different opinions as far as the different approaches to take.

And there's kind of the gray area of what's the best approach when you're offering somebody surgery. Do you, from a surgeon standpoint, we can attack the problem from various different ways. Having an algorithm that's the best approach, I think is something that's probably in the future as far as determining who's the best candidate for surgery, what's the best surgery that we can offer them, and what's the most predictable results that we can, we can obtain.

As far as the technology goes, newer there's newer technology as far as robotics, basically placing instrumentation in, in more precise locations. But I think the more exciting is going to be more of the establishment of who's the best person to operate on, what's the best way to operate on them as far as what technique and how's that outcome going to be optimized?

Host: So more tools for the best and most effective treatments.

Gary Alegre, MD: Exactly, it's somewhat controversial as far as what's the best way to approach somebody's problem because back pain is so common, and not everybody, if they're offered surgery, has an 85% chance of success. It just depends on what's the pathology or what's the problem you're operating on.

That's where the gray area is like I said, if you offer somebody surgery that has clear cut problems, you have nerve impingement, you have some instability perhaps, you can offer them surgery and say there's about an 85% chance you're going to get better. But other people, you know, it may be that the spine is too deteriorated. They don't have great nerve pinching. It's really just more back pain, if you offer them surgery, the results probably won't be that 85%, we're looking maybe 50%, or maybe you just don't offer them surgery at all.

Host: Yeah. As with all ailments, it's really individual assessment.

Gary Alegre, MD: Exactly. And that's, that's the art of medicine that we are, we're in now as far as trying to figure out who's the best, best candidate to operate on. As far as the tools that we have, that's also expanding. But in my opinion, I think the greatest gain we're going to see in the near future is probably somewhere along the algorithms to use. And I think AI will also help that, help us out as well, once we have more outcomes as far as we know the patients who will do well with this surgery, they won't do well with this surgery. And we can gauge that and give a, a more predictor of how well a patient would do with surgery or without surgery.

Host: Fantastic. Dr. Alegre, thank you for this information on the causes and treatments for back pain.

Gary Alegre, MD: Oh, thank you. It was, it was great talking to you.

Host: You too. That was Dr. Gary Alegre, Fellowship Trained Spine Surgeon and Assistant Clinical Professor at UC Davis Department of Orthopedic Surgery. For more information, visit Dignityhealth.org. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics of interest to you.

Thanks for listening to Hello Healthy, a Dignity Health podcast. I'm Amanda Wilde. Be well.