Scott Webb (Host): There are lots of causes of acute and chronic back pain. And determining the best course of action, surgical or not, often requires the expertise of an expert like my guest today. And I'm joined today by Dr. Kelly Gassie. She's a neurosurgeon with Health First.

 This is Putting Your Health First, the podcast from Health First. I'm Scott Webb. So doctor, thanks so much for your time today. We've had a chance to speak and get to know each other a little bit. We have some common interests like basketball and sports in general. And that's kind of what we're going to talk about today. We're going to talk about back pain and spine care. And as we get rolling here, let's just talk about some of the causes. Is it family history, genetics, sports injuries? Maybe you can just share with the audience the greatest hits, if you will, of folks that you see and the causes of their back pain.

Dr. Kelly Gassie: Yeah. Well, it's a favorite topic of mine. I feel like, you know, outside of sports, as we've connected on, I see a lot of people. And my specific history is in spine surgery, so I see a lot of people with back pain. But it's sort of a leading contributor of disability today for people, so it's a pretty common thing. In fact, I believe there's a lifetime prevalence of about 40%.

I think that general understanding is when somebody says, "I have back pain," most people are talking about their lower back or their lumbar spine. But actually, if you didn't know this, there's a specific definition of low back pain. And the North American Spine Society puts this out and they describe back pain, specifically low back pain, is pain of musculoskeletal origin that extends from our lowest rib to the gluteal folds and may intermittently extend into the thighs. So, that's the true definition of low back pain. So when I see somebody with back pain, that's kind of what I assume, unless they say "My neck hurts," which is your back. So, what are some causes of back pain, I think, was the original question.

There can be a lot of causes of back pain. Most of the time it's sort of an age-related process such as arthritis or osteoarthritis. So, I see a lot of back pain just because unfortunately as we get older, the joints in our body get older too, the bones in our body get older. So, there are a lot of things that happen in your spine. Degenerative disc disease, the joints in our spine are overused, so a lot of arthritic issues can cause back pain. So, that's a common thing that I see and you can see that on imaging.

Other things can be muscle or ligament strains. Some patients have osteoporosis, which can cause back pain. And then, you have those sort of things like sports injuries or car accidents or trauma that can involve the spine. And that can actually lead to acute or more dangerous types of things that cause back pain or chronic back pain.

Things that other people might come in and see me for is, "Well, I've had previous back surgery," and there's a term, we call it failed back surgery syndrome, and that can lead to chronic back pain. And then, the sort of things that you don't see very often, they're like inflammatory arthropathies like ankylosing spondylitis, and these are based on genetics and environmental factors. And interestingly so, there have been some studies that have sort of unfortunately shown that there's a genetic predisposition to back pain.

Host: Yeah, it's what I figured. I figured it was going to be some family history, genetics, behavior, lifestyle. There would be acute and chronic pain, I'm more of the chronic sufferer. And of course, I blame my mom. As you say, there can be a genetic component, so I blame her for all of my osteoarthritis and everything else. But let's talk about the acute pain, acute injuries. And really, I'm wondering when someone should go to see their provider or be referred to someone like yourself. Like, you know, when is back pain so serious, maybe especially acute, but also chronic and they really need to reach out?

Dr. Kelly Gassie: Yeah, that's a really good question and people ask that. As you said, there are different types acute and chronic. And acute pain is usually within those first six weeks. That's what we define as sort of acute back pain. New pain within six weeks is acute, whereas chronic is actually defined as something that lasts beyond 12 weeks. And of course, in between would be a subacute if we're looking for actual definitions. But when you're asking me that, I'm thinking, "How do you know if it's serious?"

Host: Yeah. How do we know? So, you know, as I was telling you, I said, I have trouble even bending over some days and putting my cat bowls down on the floor for the cat. So, Should that be a sign to me? Should that be a sign to folks when there's just simply things that they can no longer do without pain? Is that one of the signs we should reach out?

Dr. Kelly Gassie: Yeah, definitely reaching out if it's new or it's not going away or you're like, "This isn't normal for me." Most low back pain and back pain in general could be kind of nonspecific and sometimes even self-limiting, so it can be really tricky to sort of determine, but there are a couple things that I sort of term red flag symptoms that definitely warrants a visit with your provider. They're going to be more on the really acute side.

So what about, let's say, back pain that's associated with recent trauma? I mentioned, you know, trauma, sports-related injuries, things after a car accident, the patients I see falling off a ladder or trying to trim their tree or something, if you have back pain associated with those types of things, definitely needs to be evaluated. I think patients who have history of cancer and they have sort of new-onset back pain, things that are waking them up at night, a nagging pain that they've never had before, that should definitely be something that should raise their eyebrows, and "I should probably go in and be seen by my primary care physician," or even your neurosurgeon or spine surgeon.

I think other things are sort of back pain and fevers if you've had a recent infection. We do see some patients who have had drug use and back pain. That's usually an indication there might be something wrong, like an infection in the spine. And then, the other things that you hear about back pain that's associated with some sort of neurological symptom like new numbness, weakness in arms or legs, you have a radiating sort of electric pain down one or both legs, if you have difficulty walking, bowel and bladder incontinence, or just back pain that is truly intractable. Those are the things that I think would sort of spark somebody that they need to be evaluated. Definitely, those really scary sounding things like, "My legs, I'm having weakness," those usually prompt more of an a, "Well, I need to go to the emergency department." but if you're having intractable back pain, you're like, "Something's not right," definitely, I would reach out to your provider. And then, it's probably time to take a look and see what's going on.

More often than not, you know, in the clinic, especially for people like me, I'm seeing people with kind of chronic back pain. So, it's not always something that needs, you know, an emergency department visit or something that's truly urgent needs to be taken care of. And that can sort of be something that between you and your provider, you can work through. Sometimes you need to have an image. You need to have, if you've had previous surgery, or if you're having, you know, back pain and pain down a leg, maybe there's a disc that's herniated. That's sort of a variable thing that depends on coming in to see you.

Host: Sure. You know, as you say, like some of the red flags for acute back pain might prompt us to just go straight to the emergency department, whereas the chronic stuff, we might work with our primaries over time. And I want to get into how we treat back pain, how you treat back pain. And, you know, I think for most of us, I think the reason we don't speak to our provider, why we don't get referred to someone like yourself is the thought of surgery on our backs, right? But you, as you say, this is what you do. This is like your thing. But let's talk about that. The different treatment options, how do you, you know, differentiate who's a good candidate for surgery or the non-surgical treatments and so on.

Dr. Kelly Gassie: Surgery is a really serious thing. And I think for most people, it's a really serious thing. And so, surgery in my hands is really reserved for those really either acute, urgent, serious neurological issues or an infection in the spine or a fracture of the spine. Those are things that sort of require a surgical solution needs to be done for that.

And then the other things, failed back surgery or chronic pain due to degenerative disc disease, those things I reserve surgery for sort of your last end-all be-all. I truly think that Some people are going to get better with physical therapy. Our pain management physicians are usually really good with injections. So, the non-surgical things that you hear about, like NSAIDs, anti-inflammatory medicines, physical therapy, traction sometimes you'll hear, and other modalities like acupuncture, hey, if that's helping you, I'm a huge proponent of that. And then, you kind of move along that tier, sort of the next level, like those injections I mentioned, where you can inject sort of the joint. You can get epidural injections, you can get radiofrequency ablations, all these sort of, I know, terms I'm throwing out. I feel like the use of like opioid pain medicines, it should be sort of cautiously limited and we kind of restrict that to short durational use. And that long-term duration for those patients who do need that, they're typically under the guidance of expert like a pain medicine physician that does that. But I'm a huge believer in conservative treatment for back pain. We reserve surgery here for, you know, truly, if you're miserable, just absolutely miserable, we've tried everything. Then, we go forward with other surgical solutions. And so, that's kind of my philosophy of treatment. So, the non surgical treatment is our sort of first tier.

Host: It's ironic, doctor, that most of the surgeons I speak with, even though they love performing surgery, they trumpet the same message, which is, "Hey, listen, I'm a surgeon and I love doing surgery. However, we don't just jump right to that. We don't get patients in the office or in the clinic and then rush them right into the OR. We try other things, over-the-counter, physical therapy, injections. But if we get to that point where nothing is working and surgery is indicated, well, you know, "I'm your doc," right?

Dr. Kelly Gassie: Absolutely. I love surgery. So, it's not that we don't like operating. We take surgery as a big deal. You go under anesthesia sometimes. You have to have a wound, we want that to heal. And so, most people do really well with surgery for the right indications, but definitely is sort of a last resort for those sort of chronic issues.

Host: But let's talk about any lifestyle changes. You indicated, you know, how folks usually end up with the acute injury. So sure, try not to fall off ladders, things like that.

Dr. Kelly Gassie: Yeah. More easier said than done, I know.

Host: Absolutely. Right. Easier said than done. But in general, what are some of the lifestyle changes that we can make to avoid either the acute injuries or lessen the effects of the chronic injuries?

Dr. Kelly Gassie: Yeah. And I know I'll probably repeat a lot of things that people have heard, but it's true, I think those standard healthy lifestyle behaviors such as, you know, refraining from smoking, being physically active and having good weight control or sort of those modifiable influencers on back pain. And in fact, you know, weight control in particular, studies have shown that increasing BMI over time is associated with developing back pain, in particular in women. I mean, I'm a female, I'm aware of this. So, we know that those healthy lifestyle behaviors do impact the joints in our body. And that includes the spine.

The other things are those ergonomic factors that play a role in back pain. I mean, hey, even for me, I'm constantly looking down in the operating room. So, we wear headlights and loops on our eyes and we wear lead and we can get neck pain from that. And so, ergonomics, it's a real thing and this plays a role in back pain. So, I mean, the old adage that don't bend and twist is true. Always sort of squat down with your knees, don't twist, how we stand, our posture. Just being cognizant of ergonomics, I think, can really pay off over time, at least it's within the margins of what we can control. I mean, as you know, Some genetics and things we can't control with our back. But I think we can do some of those things as I've mentioned.

I do think that sort of psychosocial factors can matter in persistent or chronic back pain. We're still trying to understand and learn how those psychosocial factors relates to our spine health, such as kind of stress and support at home and workplace factors. But we're learning more and more about that. And a lot of times, at least in my clinic, I like to understand, you know, what's going on in people's lives and, you know, how that might relate to their chronic back pain. So, I think we're just sort of getting interested in how that might relate to the whole person. So, I think that plays a part in your spine health as well.

Host: Yeah, that is interesting. Of course, none of us set out to fall off ladders, so we do our best to be as safe as possible, but it does happen. And as you say, it's really interesting. You and I were talking about how just everything has evolved and changed and is moving so fast. But really, as you say, looking at the psychosocial aspects of this. And not that back pain, chronic pain is necessarily a figment of somebody's imagination, but could be the result. As you say, the back starts in the neck, the neck's connected to the head and the brain. And as those things work their way down, it could be more a sign or a symptom of something that there is no specific physical cause for, right?

Dr. Kelly Gassie: Oh, yeah. I mean, even if I'm stressed, I'm holding my shoulders up closer to my ears and so the back of my neck can hurt. I just think pain is real. If you're having pain, that is truly real for you. So, that is not to say that we're thinking, "Oh, this is something you're making up." But there is some evidence that, you know, what's going on in our lives can exacerbate maybe an underlying chronic back pain, it can make it worse. But I think providers are trying to look at the whole person, and I do think there is some component in just being cognizant of that in your life. And maybe even just your posture at work and things like that can affect your back and the pain you may or may not have.

Host: Yeah, I'm checking my posture right now and I know that I'm not--

Dr. Kelly Gassie: I know. We're sitting up straight now, both of us.

Host: Yes, absolutely. I would never lean forward because I'm 55 and I can't see the screen. I would never do that, doctor. I would always be sitting straight up.

Dr. Kelly Gassie: As I look down at my phone, shooting a text message, you know...

Host: This has been really educational and fun today, both to get to know you, learn more about back pain and spine care. I just want to ask as we wrap up here, especially when it comes to the chronic pain, besides it affecting our quality of life and our daily lives and our families and all of those things, we don't want to scare anybody of course, but what can happen if chronic back pain, I guess maybe even acute, but really chronic back pain, what can happen if it goes untreated for long periods? Can it spread? Are there other concerns that that pain or the cause of that pain might end up affecting and then really, you know, kind of interfering with our lives?

Dr. Kelly Gassie: Yes, you're right. For those scarier trauma situations or falls, those acute things are a different set of back pain. But for chronic back pain, you know, as I said, most back pain is self-limiting, but if the pain is persistent, if you have worsening or any of those sort of red flag symptoms that I mentioned, we may be missing something here, we need to take a look. And in rare occurrences, you could have permanent neurological damage. Very rare occurrences that you're just, you know, "I don't want to go see anybody even though my foot's not working well..."

Host: "My foot's numb, but you know, whatever."

Dr. Kelly Gassie: Yeah. But I do think that with this chronic pain, of course, that's going to affect your day to day and quality of life, that's, you know, just as important. So, I think for those, you know, neurological deficits or things like that, yes, you can have permanent damage if you do not seek treatment. Yes, you can have permanent damage if you've got some new pain and you might have history of a cancer or you might have history of a recent infection. You need to be seen by somebody.

But for the most part, people with chronic back pain, and there are again, some surgical and non-surgical solutions to help with that. Unless you have a neurological deficit, anything that's truly, truly new or concerning, most of the time, we're not going to miss something too serious. But again, it's your life. It affects your quality of life. That's pretty serious for you. So not to scare anybody, and I don't want people running in, but I think if you just stick to those principles of what's new for you and do I have any of these previous histories, I do think it's important to be seen for that. Because, yeah, we might, see something and hopefully we have a solution for that.

Host: Well, that's perfect. I mentioned to you earlier that, you know, one of the goals we have for these podcasts is to encourage folks to not suffer, whether it's in silence or not, but not suffer, to speak with their providers, to be referred to specialists. And maybe surgery will be indicated, maybe it won't, but you won't know until you go and you get the imaging and you share your history with your docs. So, really good stuff today, really educational and fun for listeners. They didn't get to hear we did an entirely separate podcast about women's basketball, but maybe we'll share that at a later date, but for today, doctor, thanks so much. You stay well.

Dr. Kelly Gassie: Thanks for having me. Really appreciate it.

Host: And thank you for listening to Putting Your Health First. Get back to what you love and find a spine care specialist at hf.org/spine. And if you enjoyed this episode, please be sure to tell a friend and share on social media and check out our entire podcast library. I'm Scott Webb. We look forward to you joining us again.