Transcription:

Scott Webb (Host): Back and neck pain are common for many of us and understanding the origins of our pain and what we can do to help ourselves can often leave us with more questions than answers. And I'm joined today by Dr. Phillip Kocoloski. He's a Genesis Interventional Pain Management Specialist. And he's going to help us to understand how back and neck pain are diagnosed and treated, including how the Genesis Back Pain Treatment Center may be able to help us with both.

This is Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. I'm Scott Webb. So Doctor, thanks so much for your time today. We're talking about back and neck pain and at 53 years old, I definitely have a bit of both. So some free medical advice for me today. And for listeners, I want to ask you what's the first step a

Host: person should take if they have back pain, but they haven't seen a doctor yet.

Philip Kocoloski, M.D. (Guest): Well, the first thing that I would recommend would be that the patient try to identify the things that are causing that pain. Now, if it's pain that they have morning, noon, and night, then that's something that needs to be seen and evaluated perhaps through an urgent care setting, even before they can get to their own primary care physician or a new physician.

But on the other hand, if there are certain activities that bring it on, but then at other times, not so much; the thing to do would obviously be to stop the things that aggravate the pain. And then we oftentimes will recommend oral over the counter analgesics, like Tylenol or, you know, generic forms of that.

We also recommend the non-steroidal anti-inflammatories like ibuprofen and different categories like that. There's many of them in the drug stores available over the counter. Certain patients though have medical reasons not to be taking some of those, but basically it would be to stop what you're doing that's aggravating it, try to take oral medications, so over the counter and give it some time.

Host: Yeah, that sounds right. For me, it's usually, when I attempt to, you know, cut the grass and whack the weeds and those types of things about halfway through, I think, you know what I'm going to run inside and take a couple of Tylenol and then come back out here and try to finish this. And I think we all deal with on some level chronic pain. Like we all know what acute is. You injure yourself. That's the time to go to urgent care, perhaps the ER, emergency department, but that chronic pain that a lot of us deal with, me included. I guess the question is, you know, when should a person consider seeking medical help, if that pain or chronic pain is persistent.

Dr. Kocoloski: Um I would say that if you do the things we have talked about and maybe consider using ice to the area, although certain medical conditions shouldn't use ice, like folks with poor circulation to the extremities. Maybe if you roll an ankle, you wouldn't want to put ice on that because that could further decrease perfusion or circulation to the area.

But I would say in general speaking, I mean, five to seven days, something ought to be at least improving some, especially if it's muscular, because muscles have very good blood flow. Unfortunately, ligaments, tendons, which are often the structures that are injured or gradually wear over the years, those do not have good blood flow.

And so it can take a long time for some of those structures to improve. But basically I would say on the order of five to seven days, no more than a week.

Host: Yeah, that sounds good. I think that's right. If you have the same pain after five to seven days, probably time to seek some medical advice for sure. And want to get your opinion about massages. What are your thoughts about massaging for a sore or stiff neck?

Dr. Kocoloski: I think if you're not acutely injured, in other words, if this hasn't just occurred over the past few hours to maybe few days, I don't see any problem with it. Most of the pressures that are exerted through massage therapy tend to be towards muscle and fascia, the connective tissue that wraps around the muscle. It's not really something that I see done a lot for joint issues, more range of motion. So, as long as there's not an acute injury to the process, I don't see a problem with people doing that. It's just sometimes will be of limited benefit.

Host: What are some of the common causes of back pain?

Dr. Kocoloski: Typically we see muscle strain, myofascial pain, again, that connective tissue that wraps around the muscle. Many times it's an underlying arthritis that is developing. Things occur within our joints as we age that are a set up for arthritis, like a reduction in the fluid that lubricates the joints inside the joint space; that diminishes over time, the discs in the lumbar spine that keep the vertebrae bones separated properly; those discs decrease in height, the spine takes on more wear and tear. So basically, from a tissue from an anatomic standpoint, the majority of it is going to be soft tissue, muscle and again, that fascia that wraps around the muscle gives us our definition. The thing that creeps in as we get older, and for the sake of this discussion, generally 35 to 40 is when the body starts to change in terms of how supple, how strong, how much elasticity there is in the tissues, such as muscle. And so most of the time it's an aging process that also incorporates the changes in the tissue structure themselves, but mostly it's muscle and connective tissue.

Host: I had a great aunt who had spinal stenosis and she would tell me things like, well you know it just runs in the family. Everybody just had spinal stenosis. So I've always wanted to ask an expert. Is that a thing? Is it possible for things like that to just sort of run in a family?

Dr. Kocoloski: Absolutely, that's something that has not always been perhaps given its props. God, we talk about people with diabetes. We talk about people with cancer and onco genes and things of this nature, but, the number one condition that tends to cause back problems other than mechanical issues like muscle and fascia is the aging process where in the disks begin to degenerate, get smaller, they get harder and more force is transmitted to the joints instead of the disks, protecting the joints from it. The other thing that happens, so with age is this spinal stenosis that you alluded to, which is a condition where in the space inside the spinal column called the spinal canal begins to narrow because ligaments thicken that hold the bones together and joints begin to become arthritic.

And we've all seen people who have had the need for a new knee, or maybe arthritic hands from injuries over the years or perhaps athletics or other things. The joints become deformed and they start to crowd into that space. So not only is spinal stenosis, a real thing, but congenitally that happens as well. In fact, that's of the different diagnoses that we can choose from when we treat a patient, one of the forms of spinal stenosis, that's recognized is a congenitally acquired spinal stenosis, not something that you got because you live to 95.

Host: Well, it's so great to have the expertise of an expert here, because I always thought I was just sort of humoring her. It turns out she was right. So good to know. And I know for me, a lot of times neck pain is just what we'll call it sleeping funny, sleeping awkwardly, having the pillow in an unusual position for some reason. But generally for everybody, what are the common causes of neck pain?

Dr. Kocoloski: Generally with neck pain, we find that it's ligamentous. It's the structures that hold the bones together. And it's also the muscles that support the head and neck, that are along the side of the neck. And then the muscles that go up the back of the head, that attach to the skull, and provide with for flexion, which is looking down, extension, looking up and of course, rotation, turning your head from left to right.

Those are the common causes. The soft tissue causes the things that we look for a little bit .More so in certain patients that are referred to us are what is happening with respect to the cervical spine itself? How do the discs look? How do the joints examine? We do certain amounts of imaging, but basically when it comes down to the neck and you can say this even for the back, it's basically the supporting structures, the soft tissues that are involved in it.

Host: Yeah. And how do you diagnose when people come in, be it acute or chronic? How do you diagnose the causes of back or neck pain? Because it seems like there could be such a range. And so in the process of diagnosing and then thinking about a treatment plan for a respective patient, how is that done?

Dr. Kocoloski: Well, most of the time when you get back to how we're trained, not only in physical medicine, not only in pain clinics, but as physicians in general, it's the history and the physical examination. And the history is really where it starts. If you, cause when we have a person that's referred to our practice, they get a call from our nurse that does an intake as we call it. And she puts together all the information, according to a template of questions that I and my colleagues had put together for her; that tells me probably at least half of what I need to know in order to formulate some thoughts. Then when you elaborate on that with the patient in the room, when they come in on the day of their visit, that further helps to support or not, your considerations early on, and then the physical exam. But most of the time, the physical exam in these sorts of situations is driven by the patient's history. So far and away one of the most important things for knowing where to go and where the likely problems are coming from is the history that the patient gives you about what they can or cannot do or where they started to notice pain.

And they'll talk about an area of pain in one spot. And then, well, then I got this down here, you know point to somewhere else, and they're thinking they're half crazy. And really I'll pull out a chart that shows where pain from the arthritic joints in the neck can be felt. And in certain instances it can be felt halfway down the back, which is a, you know, a foot and a half from the neck.

So, there's a lot of nuances in examining patients. So, I'd have to say it would be the history and a good exam is how we do most of it. Imaging helps, the imaging is generally driven by something you've seen or heard or evaluated in the office.

Host: Yeah, and it is interesting. You're so right. Everything in the body is connected in some way or another, right? So, the origins of your pain may be your neck, but you might feel it all the way down your back, you know as you say, when you talk about patient history, you start talking to people, you're going to get a quite a laundry list from many, but maybe the origins really, you know, it helps you target.

Okay. Well, yeah, you're feeling it here and you're feeling it there, but it really originates here. This I believe is the beginning of your pain, right?

Dr. Kocoloski: Yeah, that's what you try and do with them. And, you sometimes have to reign some of that in, because it's an opportunity for them to speak with someone who does this all the time. And that's, you know, if there's one thing that's a challenge or certain practitioners, physicians, nurse practitioners, depending upon where they would be working, it's this laundry list of complaints about pain.

That's sometimes insufferable for some of my colleagues, but again, that's what we do, but we still have to, you know, rank like, okay, give me the top two or three, we'll come back to the other ones.

Host: Well, you mentioned this earlier that maybe ice is appropriate in some cases, but not appropriate for people with circulation issues, but let's just talk about that ice, heat, sore neck, sore back when to use one or both, or which order, you know, there's a lot of doctors around, I'm putting that in air quotes, you know.

So when it comes to sports with my kids, everybody has opinions. Oh, use ice first, no use heat first. From an expert here, ice, heat, neck, back. When should we use either or both? And in what order.

Dr. Kocoloski: If you're acutely injured, if something has just happened, the best thing for it, is ice because with an injury, the body is going to send blood flow for a variety of reasons. For example, if there's an injection that we do have some sort or any kind of trauma to an area, the body sends blood flow and ice can help decrease that blood flow to a certain area. Now, long-term of course that's not a good idea, but in the short term, after any kind of an injury, ice is a good idea to help prevent swelling. One of the things though that you have to make certain of, especially in extremities, arms, legs, and especially in situations where there's been some trauma and not wear and tear, maybe a, an acute injury athletically, make sure that there's good pulses beyond where the injury is. Like, if it's a shoulder or an arm, make sure you've got a good pulse in the wrist, make sure that the fingers are perfusing well, have good color, things of that sort, because once you apply ice to help reduce the swelling of the effected area; it can decrease the blood flow distal to that, as we say, beyond that, by constricting blood vessels at that site.

And that's not a good thing, obviously. So, ice is better than heat for acute issues because it helps to decrease the swelling. But no more than 20 minutes at a time and allow the area to reperfuse is the best way to go. Ice should not be on under virtually any circumstance I can think of for any more than a half an hour at a time.

Host: That's perfect. Let's say somebody has been treated for back pain. They've tried, you know, muscle relaxers, pain medications, things that we discussed earlier. They've done everything they can, including physical therapy and it hasn't helped. What's next?

Dr. Kocoloski: Well, if they've been through a lot of those things, typically, what we would do is evaluate them from a standpoint of where the pain is and how well localized it is. So, if we were seeing them, we would try to get a sense for, is this related to something say like the spine that might be causing pain to radiate down the arm or leg or up into the neck, or is this of an arthritic nature?

And so we look to see whether the shoulder is involved or the hip is involved as opposed to it being the back. I see a number of patients routinely from our orthopedists who were referred to them by their primary care providers who, when the patient arrives, their problem in their shoulder is not anything with the shoulder. They got x-rays. They have maybe a slight reduction in range of motion kind of consistent with their age, but the problem seems to be coming from their neck and sure enough, when I evaluate them, they have arthritic pain from documented arthritic joints in the neck that radiate out to the shoulder part way down in the arm. And that's where the pain is coming from now.

Now there's no sign that hangs in our lobby that says you only get one pain generator. I mean, you can have it to neck. You can have it in the to shoulder that's where we got to sort out the pile and see who's got what. But oftentimes things hurt in areas may be more do in referred areas than in the primary area where it's being generated. And once you see enough of that, you start to look at it, you look at problems a little differently. When somebody comes in with problem X you're thinking of like X, Y, and Z as possible options for where it's coming from.

Host: Yeah. Like we were saying earlier, it's all kind of connected and that's why we seek the medical advice of experts. Right. You start with your primary and then you see an expert like yourself and we try to figure out, okay. You know, you're feeling it here, but let's work backwards here and figure out where it's really coming from.

So this has been really educational today. When is surgery indicated? We've tried everything, you've done all of your work. You've gone through the whole laundry list. When do you get to a point where surgery is the only option?

Dr. Kocoloski: It's a great question. So, many patients would like to see a surgeon, although they really hope there's nothing there that can be done or needs to be done. But a lot of times they get referred there initially by the primary care provider. And that's where our Back Pain Treatment Center has kind of developed in terms of trying to get with these folks before they are scheduled with any particular provider or any particular discipline and find out what you've done, what's going on with this and get you in the right hands. Cause the last thing you want to do is wait six weeks or four weeks or two weeks even to see a surgeon and then have them say, now, listen, you need an MRI and I don't think you need back surgery anymore than I do. When would it be the answer? I would think the answer would be, it kind of lies in loss of function. Typically we think about it with pain, but surgeons, let's say back surgeons, for example, they're very reluctant, almost loathe operating for pain alone because pain can be caused by so many things that can't be fixed with a graft or, you know, a scalpel or a drill, or what have you.

So loss of function is what they're really after. But if all other modalities have failed, then typically we will consider getting the higher end diagnostic imaging, like a CAT scan, or most of the time an MRI, if patients can have them because of certain devices that might be implanted or such would contraindicate that.

But we get that type of imaging and just ask for a surgeon's opinion and surgeons will operate. Hate to say if all else fails, certainly they'll go in right away if there's a clear indication for it. But if there's not, they will do a number of things to try to, I don't want to say hold off, but try to make it more optimal when they go in timing wise, and it's not uncommon for us to get referrals from our orthopedists, for what we call an epidural steroid injection. Steroids placed into like in that spinal stenosis example, space, placed into the epidural space to help decrease swelling in that area.

And if the MRI doesn't show anything significant, like a hugely herniated disc or something that is just literally going to take a surgeon to get fixed, they will see what we can do. They'll see them back and they will operate if the patient's pain is what we call intractable or just unremitting and things up to that point haven't helped. On the other hand, if there is loss of function, like you're losing the ability to, with your arm, or you pick up a coffee cup in the morning and you can't hang on to it, those are the kinds of things that are nerve related and those can't wait. So, I guess the answer is to when a surgeon jumps in depends upon how much damage is hanging in the balance if you will.

Host: Yeah, definitely. And when we think about all the different therapies and options for patients, where do the injections come in? What are the injections that can be used for back and neck pain? When do you use them? When is it appropriate? When are they indicated? That tell us about the injections.

Dr. Kocoloski: Probably the most basic one is something called a trigger point injection. Trigger points are tight bands of muscle and the connective tissue around the muscle that gives them their definition, as we mentioned earlier, the fascia. And those are most commonly in the low back and in the neck. And you can feel them as almost like nodules underneath the skin and by pushing on them, you definitely reproduce that pain that chronically has been afflicting someone. Those sorts of things, we can inject with a small amount of local anesthesia and sometimes a small amount of steroid mixed in with that. And that's typically done right in the office. It doesn't require imaging. It's very safeprocedure. And those trigger point injections help to break up that tight band of muscle and relax it and can oftentimes provide patients significant relief.

Now those trigger points can be coming on because the joints not far from them are very arthritic and there's a lot of pain in that area which causes muscles to tense up. It can also just be the process of aging, in so far as those trigger points developing a little bit more so in older patients. From there, we think of joint injections you think about, is there something going on within a shoulder, within a hip, within a knee.

And oftentimes those injections are based on diagnostic imaging and it doesn't need to be an MRI. It can be an x-ray. Where you're looking for narrowing of the joint space, arthritis, things of this sort. So, joint injections are also typically done in the office and can be done in a pretty straightforward manner.

A couple of them are best done under some type of imaging, like a hip injection, et cetera, but joint injections would probably be next. The thing that we see a good bit of here in our practice are what are called epidural steroid injections, as we talked about earlier, where the steroid medication, which has a duration of about three months, maybe four is placed into the epidural space, generally under some type of guidance. Mostly x-ray, sometimes with CT, but a lot of times under regular x-ray. And those are placed into an area where the nerves are inflamed and irritated and therefore causing pain into the arm or the leg. And it's placed there under x-ray guidance. And that steroid medicine is kind of like the same thing as a joint injection in terms of how long it'll last.

We typically like to see that last for a few months anyway, to try to keep people functional. And as long as those steroid medications are not abused in terms of their frequency, people tolerate them pretty well. Steroids can have some significant side effects if, especially if they're overused, and they can be pretty serious, potentially serious for people.

So you don't want to get too many of those too often, but we do them regularly with patients, not the same patients. I don't have very few that come back every three months say, but that's a common thing that we would do. The other thing that we do is that procedure called an ablation where we use radio frequency waves, which are similar on a spectrum to like microwaves.

And we use a small wire under x-ray and we can ablate tiny little nerve branches that are mediating or carrying the pain from the joint to the spinal canal and then up to the brain. You see this sometimes with heart arrhythmias, cardiologists would do that. Interventional cardiologists will do these ablations for heart arrhythmias.

And so that is a very, very minimally invasive approach. And, that's something that we do rather regularly, one of our most common procedures actually.

Host: Yeah. And then we talk about the buzzwords in medicine for the patients, especially minimally invasive versus, you know, open big time back surgery. Yes, please. You know, I feel like I won the lottery today. I've gotten to spend so much time with you and ask you all the questions I've ever wanted to ask someone like yourself. As we get close to wrapping up here, I want you to tell listeners about the Genesis Back Pain Treatment Center.

Dr. Kocoloski: Sure. It's a concept really, that started a few years back when we were developing not only the Interventional Pain Clinic, but also enhancing some of the things that were done neurosurgically with the advancements in that field. And so, it's organized through the neurosciences, where the, the neurosurgeons are located.

And there's you typically, we typically do like to have a referral from a physician to this Back Pain Treatment Center. The Back Pain Treatment Center itself involves two nurses, two RNs, a Licensed Practical Nurse, and generally a department assistant who works with them. And these nurses evaluate things that come in to the Back Pain Treatment Center, and make the best disposition of them. Like, should we recommend, physical therapy or would we consider sending them over to the Pain Clinic or should this get directly to the neurosurgeon. ANd each of the areas that collaborate, like our Pain Clinic, like the neurosurgeons, like the neurologist, each of them have kind of given the Back Pain Treatment Center folks sort of a protocol or at least things that you should contact us for if you see this or that. So, it's basically a department the calls and patient referrals come into. And then the treatment plan is more or less organized in that way. It's in that same office where the neurosurgeons are. I don't think they participate in all of those, except for maybe like, is this something that we, the neurosurgeon should see right away versus going through physical therapy and such.

Now all those things, whether they be diagnostic imaging, whether they be physical therapy, whether they be a consult, those are generally generated by the medical staff, either a Nurse Practitioner, Physician Assistant or the Physician themselves. But the Back Pain Treatment Center is the spot where everything starts.

And then we try to get the patient treated in the most effective and time effective, especially manner by getting the conservative things such as therapy and things like this, perhaps ordered by their primary physician, et cetera, because we know that is a good first step for this particular patient.

And the payers also are looking more towards conservative care before getting into more comprehensive sorts of things. So, it's an effort on our part to organize the inflow of patients who come from all sorts of different areas and referred by all sorts of different folks for a variety of reasons. And so it's been an attempt to try to make their experience here, the patients, more efficient, because there's some value added and we're moving along each step of the way. We may not be able to fix your problem with the first person that sees you, but this is what we do. And this is why we do it.

Host: Well, I have really appreciated your time today. Thank you for your expertise and your compassion in explaining all this to us, breaking down what the Genesis Back Pain Treatment Center does, really appreciate it Doctor and you stay well.

Dr. Kocoloski: Thank you. Appreciate it.

Host: And for more information on the Genesis Back Pain Treatment Center, visit Genesishcs.org. And thanks for listening to Sounds of Good Health with Genesis brought to you by Genesis Healthcare System. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest.

I'm Scott Webb. Stay well.