Michael Anderson (Host): Hello, everyone. And welcome to this episode of The FortCast, the official vodcast of Fort HealtCare. I'm your host, Dr. Michael Anderson, ear, nose and throat physician, and President and CEO of Fort HealtCare. With me today is a very special guest I have with us, Brad Wagner, one of our pain specialists. Brad, welcome to the program.

Bradley Wagner, CRNA: Hi, Dr. Anderson. Thanks for having me.

Host: And today's topic is going to be something that is near and dear to a lot of people's heart. We are going to focus on back pain. And Brad, as a pain specialist, you must see a lot of people with back pain.

Bradley Wagner, CRNA: Absolutely. Nearly 40-50% of people will have an episode of back pain that changes their life in some way almost yearly. So, I do see a lot of people that come in with all different types of back pain.

Host: I believe it. I've had back pain myself. And just a little bit for our listeners, Brad, how long have you been with Fort HealtCare?

Bradley Wagner, CRNA: I've been with Fort Healthcare about six years. I've worked in a couple of different capacities. I am a certified registered nurse anesthetist, so I do anesthesia. And then, I completed a fellowship in non-surgical pain management a couple of years ago. And I've been practicing in that capacity ever since.

Host: Well, I'll tell you, you're being very humble because you are an amazing CRNA and an amazing pain specialist, and I know you've been able to help so many people in our community. So, thank you for that. And getting back to back pain, I imagine most people seek out their primary care provider physician when they first experienced back pain. Brad, what typically drives that referral to see you? Is it when medicines aren't necessarily working? Or tell us a little bit about that.

Bradley Wagner, CRNA: Well, low back pain can be difficult to diagnose. There are several different pain generators that can be the culprit of your back pain. And they can present in similar ways. So, primary care physicians are great. And they can, you know, treat back pain with medications. But if it doesn't get better on its own, that's when I see patients referred to me.

 Those patients may have something like a bulging disc that they've tried, you know, pain medications or muscle relaxers or even oral steroids, which maybe helped some but didn't take care of it to the point where the patient is satisfied. That's where I see people coming to see me. Then, we can kind of take a little bit more targeted approach to diagnosing and treating the low back pain.

Host: So if we just focus on the bulging disc, what exactly does it mean when somebody has a bulging disc? Because I know it's very, very common. And what kind of symptoms will that patient have with a bulging disc?

Bradley Wagner, CRNA: That's a great question, because we've all heard of a bulging disc before. We've all heard of terms like sciatica, and that's kind of an all encompassing term for pain that may be going down your legs or radiating through your lower extremities. In our spine, we have discs that kind of cushion each vertebrae. And as we get older and collect birthdays, gravity takes its effect and can decrease the height of those discs and sometimes even cause them to bulge out backwards. And that bulge can put compression or pressure on nerve roots that exit out of your spine, that can cause you to feel that pain or numbness or tingling that goes down your lower extremities and can be very uncomfortable for people.

Host: Most definitely. So when you see a patient that's referred to you, Brad, and you're suspicious of this, what kind of diagnostic workup do you pursue?

Bradley Wagner, CRNA: Well, first of all, I like to listen to what the patient tells me. If a patient provides good information in terms of where they're feeling this pain, like what part of their legs, many times I can tell which disc is bulging. We would then order an MRI to kind of corroborate that and just make sure that we're going to have a nice targeted approach for treatment.

When we get those two things to line up, then we can really focus on where we need to do a spinal injection, like an epidural steroid injection so that we can decrease the inflammation of that disc with the intention of helping it shrink back a little bit and decreasing the inflammation of that nerve root, which is causing that pain and numbness and tingling in the lower extremity.

Host: I've had this issue. And the pain when that bulging disc compresses that nerve root, it's pretty painful. And I know a good history probably targets it pretty closely. But the MRI, Brad, does that tell you specifically which disc is bulging and which nerve is being affected? And so, does that allow you to target a potential steroid injection?

Bradley Wagner, CRNA: Yeah, absolutely. I mean, 20 years ago when people did epidural steroid injections, you know, the technology was not as good and they may have done a more broad intervention, hoping that the steroid would make it to the disc—the offending disc, as I like to call it. With a good MRI scan, with a good physical examination, and with good information provided by the patient, we can provide a very specific targeted approach and get that steroid right near that disc that's causing the compression.

Host: When you pursue this sort of treatment, Brad, after medications maybe aren't getting us to where they need to get us to, how effective is a steroid injection in helping this?

Bradley Wagner, CRNA: So, that varies patient to patient. I have some patients that come in for an epidural steroid injection and it takes care of it. I never see them again. I have some people that may need a couple of these before they get relief. And then, the challenging part about low back pain is, like I mentioned before, there can be several different pain generators that cause similar type symptoms.

So, the long answer is everyone's a little bit different in how well they respond to these types of injections. But overwhelmingly, the majority of patients get some relief from an epidural steroid injection and have some increase in their quality of life or improvement in their quality of life post-injection.

Host: That's very encouraging and the actual process of getting the steroid injection, take us through that. My impression is it's pretty straightforward and doesn't take very long to do, but please take us through it.

Bradley Wagner, CRNA: Sure. Yeah, it's done as an outpatient procedure. So, you know, you don't need a driver or anything like that. We do this in a procedure room, where we have an x-ray machine called a C-arm, or a fluoroscopic x-ray machine that helps us find our trajectory for our needle path. And we can be very precise in placing that needle right next to the offending nerve compression. And you'll be placed on your stomach so that we can access your back. And most people can do this awake. We use a lot of local anesthetic or numbing medicine on your skin and soft tissues. The initial discomfort, most patients describe as a bee sting or some burning with that local anesthetic. After that, typically patients describe it as some pressure deeper down and a little bit of burning when we put medication in.

Host: So, how soon do people—if they're going to get better, how soon do they notice the improvement?

Bradley Wagner, CRNA: So typically, after an epidural steroid injection, the patient may feel really good that day, because of some of the local anesthetic that we put in with the steroid. So, they may have great relief that first day, and that's a good sign. That means we've gotten the medicine where it needs to be. After that local anesthetic sort of wears off, they can have a return of their pain for a few days, up to a week, before that steroid has a chance to exert its anti-inflammatory effects to its fullest capability.

Host: Gotcha. So, let's say for a moment that the steroid injection isn't as helpful as we'd like it to be. What other options, Brad, can you offer those patients?

Bradley Wagner, CRNA: Oh, that's a great question. And going back to the statement I made earlier about there being several different causes of low back pain, sometimes we have to kind of go back and reassess to see if something else may be causing this pain. Is it your SI joint? Is it maybe some facet joints that are arthritic in the low back?

Typically, if someone doesn't receive the level of pain relief that they're hoping for after the first epidural steroid injection. If they did get some relief, that's promising. And like I mentioned before, also, it may take two or three injections before that disc starts to kind of recede and shrink back a little bit before some of that nerve root irritation goes away. So, there are several patients who need several injections before they get the, you know, anticipated relief.

Host: Gotcha. Gotcha. So with the steroid injection, one thing I've heard a lot about in the pain world is radiofrequency ablation, and I want to touch base on that. I know that's a very important tool in your world. Tell me a little bit about that. And does that have an application in back pain when you see patients?

Bradley Wagner, CRNA: Absolutely. I have patients that benefit greatly from radiofrequency ablation. Now, radiofrequency ablation is a treatment for a certain type of back pain. Before when we talked about epidural steroid injections, that is most effective in treating disc-related pain, something that's compressing a nerve root, okay?

In our spine, we have these little joints called facet joints. As we get older, they can become arthritic. And that osteoarthritis in those joints can give you the sensation of just that diffuse low back pain that kind of stays in your lower back, maybe goes down the back of your leg a little bit, but doesn't shoot all the way down to your feet. Now, for arthritis in those facet joints or that just kind of localized low back pain, radiofrequency ablation is a great option. There are nerves that feed those little facet joints. And their sole purpose is to transmit pain information from those joints to our brain and tell us, "Ouch, that hurts."

So, there's a procedure that we can do called radiofrequency ablation, in which we can essentially put a little burn on those nerves and cut off that pain transmission line. Now, the osteoarthritis in the facet joint is still there. We haven't fixed that. But we have interrupted that pain signal's ability to go from the facet joint to the brain. And that's how we experience pain when we get that transmission of the pain signal. And if we can interrupt that, then patients are much more comfortable. And that's an intervention that can last six to 12 months many times.

Host: That seems like a pretty good option. The process of using radiofrequency ablation, is that pretty straightforward? Tell us a little bit about that. How is that done?

Bradley Wagner, CRNA: You know, it's a three-step process typically. Radiofrequency ablation is, for lack of a better word, putting a little burner, a little blister on that nerve. Now, before we move forward with something like that, that has, you know, six to 12 months of repercussions, we want to make sure that those nerves are the ones that are transmitting that pain information, okay? So, it's a three-step process. We have to do two diagnostic blocks or two test blocks. That's where we place the needle next to each one of those nerves, and we inject just a very small amount of local anesthetic or numbing medicine, kind of like the dentist would use. Then, we send a patient home for the day with a pain diary and they keep track of how they feel. If they get adequate pain relief from that test block, we will repeat it one more time about two weeks later. If we get two positive test blocks or they get adequate pain relief from those, then we know that if we target those nerves, we should be able to reproduce that, that pain relief for a longer period of time. Like I said, about six to 12 months typically.

Host: So, it sounds like you get to test drive the nerves before buying the car in this case.

Bradley Wagner, CRNA: Exactly. And like I said, we want to make double sure that those are the nerves that are the culprits before we move forward with something that's going to last six to 12 months

Host: And my guess is that's what leads to the radiofrequency ablation success, is just knowing exactly which nerves are causing the pain.

Bradley Wagner, CRNA: Exactly.

Host: Yeah. Well, Brad, I tell you, I've learned a lot about back pain today and your treatment options for these patients that are suffering from back pain. I want to thank you for being on this episode of the FortCast.

Bradley Wagner, CRNA: I appreciate you having me and helping me get the word out to our patients here in Jefferson County, because I know that a lot of people experience this. And people should not have to go through life in pain. So in our clinic, we try to do all that we can to help them get back to a functional baseline with less pain.

Host: And you do a wonderful job, Brad. So, thanks again. And thank you for tuning into this episode of the FortCast. Please share us on your social media channels and please check out our complete library of vodcasts on our website. For now, this is Dr. Michael Anderson saying thank you again and have a great rest of your day. So long.