Michael Anderson, MD (Host): Hello, everyone, and welcome to this episode of the FortCast, the official podcast of Fort HealthCare. I am your host, Dr. Michael Anderson, ENT doc and President and CEO of Fort HealthCare. Thank you for joining us today. And we have a very special guest today, Dr. Doug Keehn, who's our pain specialist here at Fort HealthCare. Dr. Keehn, thank you so much for being a part of this episode of the FortCast.

Douglas Keehn, MD: Dr. Anderson, thank you so much for having me today. I really appreciate it.

Host: Well, the pleasure is all ours. Trust me. So, most of our listeners know that I've been part of Fort HealthCare for a little over 20 years. And Dr. Keehn, if you could just let our listeners know, how long have you been practicing pain management and how long have you been-- I know you've been part of the Fort Atkinson community for quite some time. Just please educate our patients on that.

Douglas Keehn, MD: Yeah. Absolutely, Dr. Anderson. You and I are really pretty much peers. I started practicing in the Fort Atkinson area in about 2005, when I first started practice. And I was focused in another market, but recognized the need in this market. And so, kind of dabbled here now and again, I was here probably once every other week for about half a day. And fast forward over 10 years and ended up building a surgery center that was essentially dedicated just to myself with that group, and was down here three days a week and pretty busy. So, we really built a nice practice over that time and have been able to care for the patients in the community for quite a while.

Host: Yeah. Absolutely. I mean, you're tickling 20 years now. And it's just been wonderful to have you as part of our medical staff and the services that you provide to our patients in our community just really are wonderful to have. And today, I'd like to focus on lower back pain. So, obviously, lower back pain is very, very common. So, in your practice, Dr. Keehn, a lot of people go to their primary care physician or provider with lower back pain. Some people go to the emergency room for lower back pain. In your practice, at what point do you typically get involved with patients when they have low back pain?

Douglas Keehn, MD: Dr. Anderson, that's a great question. I just like to go back and point out some really specific statistics of what you were talking about. Lower back pain is one of the most common complaints that people see a doctor for. In fact, behind only upper respiratory infections patients present to their primary care providers, their second most common reason to seek medical attention is pain. It's an incredibly common problem. Seventy percent of Americans at some point in their lives are going to have back pain. Now, that doesn't necessarily mean that it's going to be a forever problem, but it is a significant issue for a huge number of patients. Thirty percent of that 70% of patients or 70% of the U.S. population will have some management issues that we'll just need to kind of manage their pain over time. So, we're not necessarily a pain care clinic, we're a pain management clinic, but we can certainly help whole lot of folks.

So, going back to your question, when do we see those patients? We really see patients kind of along their whole continuum of when they experience pain. Anywhere from, you know, "Hey, a week ago, I was out doing some yard work. And man, I pulled something in my back and it's just killing me." So, we see those patients. Luckily, we can see those patients, because we are able to really accommodate new patients quite readily in our clinic. So, it's pretty easy to get an appointment, thankfully, for the folks in the surrounding area. So, we see those folks quite frequently, but we also see patients on the other end of the spectrum patients who have had five back surgeries and have struggled with pain for a number of years. And we really see patients all across that spectrum.

Host: And you know what? I just want to highlight something in there. First of all, those statistics are very telling as to how common lower back pain is. And you and your team do a phenomenal job of getting patients in to be seen in a very timely fashion. And I think some people, myself included, thought that a pain management practice was often a referral practice or something you sought out after numerous treatments have failed, but that is not the case. A patient can call and schedule an appointment with either yourself or your nurse practitioner if they experience pain in an acute fashion. It doesn't have to be a chronic condition. Is that right, Dr. Keehn?

Douglas Keehn, MD: That is true. We're more than happy to see those patients. That said, I would say the bulk of our patients do come from our primary care providers. And some primary care providers are very comfortable with kind of getting the ball rolling on treatment of back pain and some are not. And we're, again, happy to see all of those patients really anywhere across that continuum. So, just to kind of set the table, you know, if we see you and do an exam, we may get some basic x-rays just to make sure that there's not some sort of, you know, acute fracture or something like that, some sort of acute bony abnormality. But then, a lot of times, we'll just institute some basic therapy. So, physical therapy is common. We recommend chiropractic care for certain patients or manipulative management, anti-inflammatory medications. Those things are all part of the cookbook first steps of taking care of just your average garden-variety axial back pain.

Host: Yeah, absolutely. You got to try those a little bit more conservative measures. In your experience, Dr. Keehn, when you try medicines or you do physical therapy or the chiropractor, do you have a sense of how many patients get better with those measures?

Douglas Keehn, MD: That's a really great question. Because there are some folks who come in and see us and they're frustrated that they have to go to physical therapy. And the whole reason that we send them is that most people, most patients, get better with conservative management in really six to eight weeks, really without any further intervention. And so, that's why we employ those conservative management techniques first. And some of it is also frankly driven by third party payers as well, because they understand those statistics as well. And they will say, "Hey, before you consider anything like injections or anything like that., Let's do some conservative management first. And, it really does make a whole lot of sense." Because a lot of patients will respond to that conservative management with a little bit of time.

Host: Yeah. That's definitely well said. So now, for that subset of patients that don't get better in their lower back pain with the conservative measures, at that point, Dr. Keehn, what other potential treatments do you discuss with them?

Douglas Keehn, MD: So, how we kind of go through that process and what we do is we create what's called a differential diagnosis. So it's really trying to figure out, "Well, what is the most likely cause of the patient's pain and then treat it there," because not everything responds to one thing. If all you have in your toolbox is a hammer, everything looks like a nail, right? And so, what we do is we really kind of break up back pain into kind of two functional subsets because that differential diagnosis is very different for each one of those and the management is very different for each one.

So, there's one that we refer to as kind of like mechanical back pain or axial back pain. And that would be back pain that is really focused really mostly in the back. And it can refer kind of into the buttock, posterior thigh, typically doesn't go past the knee. The other subset of back pain that we see would be what we call a radiculopathy. Colloquially, people call it a sciatica. So, you have that hot disc that is pushing on that nerve that is sending nerve pain and shooters all the way down your leg and into your foot, that sort of thing. So, we really try to get a sense from a patient where most of their discomfort is located. And do a good neurologic exam as well, because that will certainly help to direct your next steps.

With axial back pain, if they have done conservative management, so anti-inflammatory medications, muscle relaxers, rarely we'll use some stronger pain pills, you know, Vicodin, Percocet. But really, It's not common. Most patients do not require those. Or if they do, it'll be just a couple of pills kind of to help them sleep at night or get over acute pain flares. But typically, they're not required for most patients.

But then, usually, a lot of times, facet arthritis is a common cause for what we call axial back pain. So, people with facet joint pain or arthritis pain, they're typically focally tender, like you can almost put your finger on it. And it's like, "Yeah, that's the spot that bothers me." A lot of time that can refer to the buttock and posterior thigh, typically doesn't go past the knee. Usually, by history, those patients, they can't sit too long, they can't stand too long, they can't walk too long. Usually, they're stiff when they get out of bed in the morning, feel a little bit better when they change positions, but then they fatigue with activity.

So, the reason that we don't jump out of the blocks and just get an MRI if they don't have pain going all the way down their leg is because data has shown that neither imaging nor exam are necessary nor sufficient to diagnose axial back pain or a facet-mediated component to axial back pain. What that means is that the amount of arthritis that you see on an x-ray or an MRI doesn't always correlate with the amount of pain that it causes, meaning that you can have lots and lots of arthritis in a joint and have absolutely no pain from it at all. And you can also have almost no arthritis in a joint, and it's definitely the cause of your pain. So, how we do figure that out is if we're suspicious of that, we do some nerve blocks. There's a tiny nerve that sits next to each joint that feeds it anywhere along the spine from your occiput or the back of your head all the way down to your tailbone. And so, we know where those nerves live under x-ray, because they live at predictable bony landmarks.

So, we take a very tiny needle under x-ray and we place it next to that joint. We put in a tiny, tiny amount of local anesthetic. So, it's about a 20th of a teaspoon. It's a really small amount of medication. And the reason that we use such a small amount is that it's very, very specific then for just that nerve. So, we're just freezing that little nerve that goes to the joint. And then, we'll typically go see the patient afterwards and see how they feel, because you should be numb within about 10 minutes. It's kind of like going to the dentist. So, it's just meant to temporarily freeze that nerve. It's not meant to fix you. It's meant to help us figure out what the problem is. So, we do the injection, see the patient afterwards. And if they're feeling better, then we give them a pain diary and have them do the things that typically bother them. So, if they tell me it hurts to stand, or to walk, or to sit, or to lie down, we tell them, "Well, go do those things and try that out and see how you feel for the next couple hours that it's numb." So, it's meant to wear off a couple hours later, kind of like going back to the dentist. They inject your mouth and your face is fat and warm and numb and funny and you're drooling your soup, but then it wears off by dinnertime.

But if it feels better during that time, we always do what's called a comparative block, meaning that we freeze it again on a different occasion with different medication. The reason that we do that, and that is kind of the protocol for diagnosing facet-mediated pain, is that it helps to improve what's called the validity of the test. So, validity just means that it's the truth of the test. Is that really what's bothering you? Because if you just do a single block, just freeze it once, almost 30% of patients can respond with what's called a false positive, meaning kind of like a placebo response. It's like, "Oh, well, the doctor is doing something, so this is just going to plain make me feel better," and you can kind of talk yourself into it.

If you do comparative block, meaning that you freeze each joint twice on separate occasions with different medications, and it's not like, "Oh, it's a little bit better," we're talking like, "Wow, that's a major difference." So, we actually look for like 75-80% relief for their back pain for that expected duration of the local anesthetic. Then, that improves that false positive rate from 30% down to about 10%. So, it's not to zero, but it dramatically improves the validity of the test. So, if we freeze those joints and your back feels a lot better, then we can cauterize those nerves through a needle. And it sounds scary, but it's actually quite easy to do. And it's a very simple procedure. We just take another needle, we place it next to the joint, numb up the area. And then, we're able to heat up the very, very tip of that needle, and it cauterizes that nerve that feeds that joint, and typically stops it from working for about a year at a time.

Now, those nerves do grow back over time, but we can re-lesion them down the road. The lesioning process takes about 15 minutes, and most people can resume their normal activities the next day. Granted the definition of a minimally invasive procedure is anything that isn't done to you. But, nevertheless, it is a fairly minimally invasive procedure, and most people are pretty pleased with the result.

Host: Yeah. Dr. Keehn, I'd like to follow up on a couple of things you were saying because that was a lot of information.

Douglas Keehn, MD: Yeah, I know.

Host: No, it's wonderful information. I'm learning a great deal just listening to you. So, when you do these procedures, whether it's the block or the cauterization, could you please give our listeners-- you mentioned minimally invasive. I like your joke, you know, the definition is it's not being done to you, because a lot of times we miss that in healthcare, right? But how long does it typically take to perform these procedures? What's the infection rate like? Can just comment on that a little bit?

Douglas Keehn, MD: I think those are all really good questions. Infection rate really is minuscule. So, anytime you stick a needle in the body, there's a risk of bleeding, infection, or nerve damage. That's just a given. If you look at the literature, the risk of any of those catastrophic things happening with this injection in particular, it really is about 1 in 200,000.

Host: Yeah. So, it's minuscule.

Douglas Keehn, MD: Very, very low. I mean, quite frankly, you have a better chance of being hit by lightning than you do of getting some horrible thing. And really, what would happen is It would probably be like some sort of anaphylactic reaction, so some sort of allergic reaction to one of the compounds that we were injecting. I think I've had that happen a grand total of twice in almost 20-year career. So, it really is a very, very uncommon thing.

As far as how long does it take to do, I think that's a little operator-dependent. I've been doing this for a little while. So, what I tell patients before I see them is getting the skin numb feels like a bee sting. It goes away pretty quick. And then, it takes me probably 10 to 15 seconds to place each needle. It actually goes pretty quickly and the reason that it doesn't hurt after you get the skin numb is because, even though it seems like it may be a little bit of a ways to get through the skin and to that area of the spine, there frankly aren't any nerves in those muscle bellies. And that's really what you're going through. And so, it's not an uncomfortable process for most patients. And typically, I can talk most patients through it. And let's say we were going to do probably my most common procedure, would be both sides, so bilateral procedure and we would do the L4-L5 and L5-S1 joints, that would be three injections. The whole thing takes less than five minutes.

Host: So, it's a very, very safe and relatively quick procedure to go through that can be hugely beneficial to patients with this sort of back pain.

Douglas Keehn, MD: Absolutely.

Host: So now, you mentioned the classic word sciatica. So, when those patients are struggling with conservative measures, where does the conversation go when they come in to see you, Dr. Keehn?

Douglas Keehn, MD: A lot of it has to do with their acuity, meaning, are they saying, "Yeah, this has been bothering me for six months and the side of my leg is kind of numb and it bothers me at night. I mean, I can get up and I can walk a little bit and walk it off, and it doesn't really bother me as much there. But man, I try to lay down at night, and it wakes me up." I see those patients. But then, I also see the patients who I walk into the exam room, and they're flat on their back on the exam table, and they're like, "I can't get up. I can't sit. I can't lie down. I can't do anything." And they're just, you know, "This has been bothering me for a week. It's like, oh my gosh." So, that certainly does have some play.

Obviously, we do a good exam. A good neurologic exam is vital in those patients, especially if you have severe pain in your buttock and leg. We want to make sure that you don't have what's called a cauda equina syndrome. And that's where you would have a disc herniation that would be so big that it would be pinching off your pelvic nerve roots. So, if they have things like saddle anesthesia, meaning if you were sitting on a horse, that area would be completely numb, so their perineum or in their genitals. Or if they have any loss of bowel or bladder function, that would be a surgical emergency. And so, we would have them be seen by Neurosurgery urgently. That also is a very, very uncommon thing,. As a physician yourself, you understand that we always kind of rule out the things that could be most hazardous to the patient, though they're probably uncommon. Nevertheless, it's important to rule those things out to those patients. But we do a good neurologic exam. And a lot of times imaging is indicated, and that is when we would get an MRI.

So, sciatica is kind of bandied about as any back pain. Sometimes, it's really just pain in your back that goes into your buttock and maybe down your leg. So, the technical term for that would be a radiculopathy. And so, that's just basically a compression or irritation of a nerve root where it comes out of your spine and there are several of them that go into different areas of your leg. And differentiating which one through imaging can be very helpful, because it can help to direct therapies that you might perform for the patient.

Host: Gotcha. So, Dr. Keehn, when you do get that MRI and you are able to identify a potential cause in the lower back and in between those discs or involving those discs, what sort of treatment options do you run through the patient with?

Douglas Keehn, MD: Certainly. So, we still initiate physical therapy, because it's important to stay up and moving. It really is. While it's a lot of times uncomfortable, bed rest is one of the worst things that you can do for back pain. There was a really interesting study that was done that looked at bed rest for back pain. And they took NFL linemen, who are incredibly well conditioned athletes, and they stuck them at bed rest for 24 hours. And they noticed significant decreases in strength and endurance in their ability to perform activity. So, if it happens to an NFL lineman who is an exquisitely talented and conditioned athlete, to the average bear like myself, I can imagine that would be pretty debilitating. So, we do try to encourage patients to be up and around.

We also give medications. Sometimes, those pain medications that we talked about, strong pain medications, are indicated judiciously. There are some nerve pain medications that we prescribe that can be very helpful for some of those patients. Additionally, we do have some injection therapies that can be helpful. So, the most common one that we do is what's called an epidural steroid injection. So, everybody's heard of an epidural for like labor or pregnancy, what have you. So, epidural refers to a space. And it is actually the space that is within the spinal canal. It is outside of the sac that holds the spinal fluid and the spinal nerves. And that's where those spinal nerves sit. And so, we can access that space in a multitude of ways. And we can put steroids or cortisone around in that area where that nerve root is being pinched either by a disc or what have you. And a lot of times, that can help significantly the symptoms that patients are having.

Host: Gotcha. So, with the steroid injections, Dr. Keehn, because you hear a lot about those steroid injections, roughly how successful are they? And, if they're not successful, where does that take you in the patient care? Yeah

Douglas Keehn, MD: Another great question. So, if you look at the data, patients who have back and leg pain as a function of a disc problem, approximately 65-75% of those patients, depending on which paper you read, will get significant relief of their symptoms from a combination of physical therapy, medications, cortisone injections, and time. So, basically, about a quarter to a third of patients will not have relief from conservative management, but most, meaning about two-thirds to three quarters of patients, do get better with conservative management. Those folks who do fail conservative management or do not have relief of their symptoms with conservative management, we will send those folks to see our surgical colleagues to discuss surgical decompression to decompress that nerve root.

Host: Right. And then, that takes you down a totally different path.

Douglas Keehn, MD: It does. And, you know, your clinical judgment and exam and the patient's complaint all kind of plays into that as well. If patients have any neurologic findings, meaning that they're weak, if they are tripping over their foot, things like that, that raises the bar just a little bit. And so, typically, I'll initiate a surgical consult earlier in those folks than later, a lot of times because of just the way our healthcare system works. It can take a few weeks to get in to see a surgeon. So, if they're miserable and they're not getting better early on in their treatment, then a lot of times we'll initiate surgical consultation. And frankly, it's easier to cancel that appointment if you do get feeling better than it is to, "Okay, well, let's wait it for another month after our last injection, So now, it's going to be another month until I can see the surgeon" so, we really try to accommodate our patients rationally if that makes sense.

Host: Yeah. It makes complete sense because when you're in severe pain, time is of the essence.

Douglas Keehn, MD: It is. It seems like forever. It really does. It seems like forever. And it can feel like you're trapped. And I'm very sensitive to that.

Host: Well, I'm sure your patients really appreciate you, Dr. Keehn. I've learned a ton on this episode of the FortCast, talking about lower back pain with our pain specialist, Dr. Keehn here. Dr. Keehn, thank you for being part of this today.

Douglas Keehn, MD: Well, thank you so much for having me, Dr. Anderson. I really appreciate your time as well.

Host: And thank you to our listeners for tuning in. And if you enjoyed this episode of the FortCast, please see our full library on our Fort HealthCare website and also share it on your social channels. So, this is Michael Anderson. I'm going to sign off here today. Thank you for this episode with Dr. Keehn. Thank you for listening and have a great day. Bye-bye.