Evo Terra (Host): This is The Healing Podcast, brought to you by Marin Health. I'm Evo Terra. And today, I'm joined by Dr. Harjot Bhandal, an Anesthesiology and interventional Pain Management Physician at Marin Health Spine Institute. We're talking about lower back pain. Dr. Bhandal, thanks for being with me.

Harjot Bhandal, MD: Absolutely. Thank you for having me.

Host: So, let's start from the beginning where I like to start these conversations. What are the most common causes of lower back pain that you see in your practice?

Harjot Bhandal, MD: Low back pain is unfortunately very common, not only in the United States, but also all across the world. Data suggests that, as an American adult, there's about an 84% chance that at some point we will all experience low back pain. And as a country, we spend about $800 billion per year managing low back pain. There's a variety of reasons that people come to the practice with low back pain.

Some of the most common things that we see are muscular in nature, so either a muscle strain or a muscle sprain. We also see a lot of disc herniations that can cause low back pain. Besides those things, there's a lot of degenerative processes that also happen to our spine as we age, which can cause pain. So, we see a lot of things such as arthritis in the spine and also degenerative discs that can lead to low back pain.

Besides all of these mechanical causes of low back pain, we also have some other culprits such as spinal stenosis, which is where the spinal canal actually narrows and puts pressure onto the nerves in the spine, and this can lead to low back pain. And additionally, we also have some areas where we actually have back pain that's being started at other joints but gets referred to the back. And one of the things that commonly gets missed is pain coming from the sacroiliac or the SI joint that gets referred to lower back area. The good thing is that although we have a lot of causes of low back pain, most of them are actually not dangerous. And we have really good ways of treating most of these causes of back pain.

Host: Yeah. There's a lot going on there. And as someone who has had his own bout with back pain, I can definitely understand. Now, let's talk about the difference between acute and chronic lower back pain and why that matters.

Harjot Bhandal, MD: Acute low back pain is essentially short term pain, so this is pain that usually lasts about four to six weeks. With acute low back pain, there's usually a cause or a specific injury. So someone might be at their job or they might be working in the garden and they do some type of a pushing or a pulling motion, or they have a fall, or they step out of their car the wrong way, then all of a sudden, bam! They usually feel some type of pain. A lot of times, patients will also say that, "I heard a snap," or "I heard a pop" that caused the acute low back pain to start. It's important to differentiate this be because we treat acute and chronic low back pain differently.

So, an opposite to that, chronic low back pain is usually pain that lasts more than 12 weeks or more than three months. And a lot of times, this pain may not have a clear cause. A lot of the times, the acute low back pain can turn into chronic low back pain if it doesn't get treated properly or if it lingers on. But usually, chronic low back pain starts as a dull process. Someone may wake up one day and all of a sudden they have back pain. They're not essentially sure what happened. Maybe they slept the wrong way. Maybe they did something different the day before. And treatment varies a lot between the two.

So for acute pain, we're more focused on relieving and allowing the body to heal itself so that the patient can get back to their normal living, their normal activities. For chronic pain, where pain has been there for at least three months. At that point, we're thinking more about restoring function, improving the quality of life, and preventing future flareups, so we're in more of a management strategy at that point.

And at that point, the pain may not completely go away, but our goal is to basically reduce the severity of the pain and reduce the amount of times it flares up and really takes over someone's life.

Host: One of the things about back pain, and I know you know this because you see it all day, is people are worried, " What's really happening with me?" And the best way, obviously, is to get checked out by a physician like yourself. So, what does a typical evaluation or a diagnostic process look like for you?

Harjot Bhandal, MD: We usually start with a very thorough history, because a lot of the times we can figure out what's causing the back pain based on how it started. So, we'll usually ask about when did this pain start as we talked previously. Is it acute? Is it chronic? That's an important distinction in the beginning.

We also go into the nitty-gritty of the pain. So, what makes it better or what makes it worse? Is it better with sitting? Is it better with standing? Does walking make it worse? Does walking actually make it better? That can also clue us into exactly what might be causing the back pain. And we're of course asking all these questions because we're trying to figure out the cause of the back pain. Like we talked previously, there's just so many different pathologies, so many different things that can lead to back pain. So, we're really trying to kind of dig into it and figure out what might be causing it.

So along with those questions, we also want to know what the pain feels like, and that can sometimes be hard for patients to describe the pain. A lot of times, they'll say, "Well, it hurts." But then, we kind of have to tease that a little bit more. Is it a sharp pain? Is it dull? Is it aching? Is there burning with it? Is there numbness with it? Is there electrical shocks? Are there spasms? Are there pins and needles? So, all these things will help us figure out exactly what's causing the pain.

So next, we move on to a thorough physical exam. Once we have the history, then we move on to a lot of different maneuvers that we have to try and figure out what the pain is. Then, we move on to try and figure out where the pain is coming from. So, this usually involves first kind of palpating or pushing on the area where the pain is located. Does that hurt? Does pushing on it hurt? Does it make it better? We also do a lot of maneuver where we can overload some of the joints in the back to see if the pain is coming from the joints. We can have people bend forward, bend backwards to try and reproduce the pain.

So once we have the history, once we have a good physical exam, then if needed, we can move on to diagnostic studies such as imaging, like x-rays, CT scans, or MRIs. And this again lets us figure out a little bit more about where the pain may be coming from, and it's important to have all three of these things together because just looking at an MRI of a back may not really give us a lot of the information. And if you've ever had an MRI or an X-ray before and you've looked at the report, you'll see there's all these words, all these things that are listed. And as we know, a lot of those degenerative discs, a lot of those arthritic changes, we all develop those naturally as we age. But it's really important to tie those in with the history, with the physical exam findings to really figure out where this particular back pain might be coming from.

Host: We've gone a long way from, "Doc, it hurts when I do this." And the doctor says, "Don't do this." Clearly, obviously, we're well past that one. Okay. Let's talk about non-surgical treatments for a second. Other than me just continuing to chew ibuprofen, aspirin, whatever I can get my hands on, what are some of the effective treatments for managing pain without having serious intervention?

Harjot Bhandal, MD: Absolutely. So, you mentioned the ibuprofen and the Tylenol. Those are good therapies. It's always good to start with over-the-counter medications if needed. The other cornerstone is always physical therapy. So if you haven't gotten into physical therapy, hopefully, you're already doing some type of an exercise program where you're strengthening the core muscles, strengthening the back muscles, because that's really important in the long run. But getting someone into physical therapy is important. But again, it really depends on the type of pain. If somebody has pain that gets worse with movement, then physical therapy might not be the right choice right off the beginning because it might be too painful to go into physical therapy.

Other things that can help are, of course, heat, especially in that first week. Heat therapy can be really helpful. Things like massage therapy. Acupuncture can also be useful for a lot of people. And also, lifestyle changes can be important as well. So if somebody has a desk job, they're sitting at a desk, they have poor posture, correcting that. Correcting some lifestyle changes. So, making sure if you're lifting, bending, twisting, changing those things. So, that's not making the pain worse. And also, things like more long-term things such as weight management can be important as well. So, keeping a good healthy diet, making sure that your spine is not carrying too much weight can also be important for long-term success.

But when all of these things don't work or people have already tried them, but they still have the low back pain, then we have some minimally invasive things that we can do. So, these things include Injections. We can do different types of steroid injections depending on where the pain is coming from. We have nerve blocks, we have nerve ablations. So, a lot of things that still we can do to try and help with the pain if some of those other things haven't worked.

Host: Well, let's talk about injections because, as you mentioned, and I know there's a lot of them from simple injections to more of spinal injections. But let's start with that one, these epidural injections with steroids. How do they work and when would you recommend one?

Harjot Bhandal, MD: So, there's a lot of misinformation out there on these epidural injections. A lot of people will come in saying, "I want a cortisone injection. Is the cortisone injection same as an epidural injection? I've heard of cortisone injections, but I've never heard of epidural injections." So essentially, the cortisone injection is a steroid injection. Cortisone is a medication, but it can vary where we put the medication. So, you can put the cortisone into the knee, into the shoulder, into the hip. But when we put the cortisone medication into the back, into the epidural space, that's called an epidural steroid or an epidural cortisone injection.

So, what we're doing there is we're putting strong anti-inflammatory medication into the back where those nerves are being pinched. So, the injection delivers this strong, powerful medication. It helps with the irritation. It helps to reduce the inflammation around the nerves, so that people can move more comfortably, so that people can go back to their normal life and also reduce the pain.

A lot of the times, these injections will work for just back pain. We can also do these injections when people have back and leg pain. So, we always hear of this sciatic pain that can sometimes come along with low back pain. So, these injections can be really effective for any type of a pinched nerve in the back. It can also be effective for a herniated disc or for spinal stenosis as we talked about, where those central nerves of the spine are being pinched.

Host: Anytime a needle is getting close to the spinal nerves, I'm sure some people get a little anxious about that. I certainly know that I would. So, what's the safety level of these?

Harjot Bhandal, MD: So, the good thing is that these are actually very, very safe, but I certainly do understand that patients getting a little scared or hesitant about having these injections. But as we talked about, it is a medication that we're using a steroid usually either dexamethasone or betamethasone, which is a strong anti-inflammatory medication.

But just like any other medication, as long as you use it appropriately, it's very, very safe. Just like if you take too much Tylenol or too much ibuprofen, you can damage your liver, you can damage your kidneys. That's true for the steroid injections. So, we usually follow very strict guidelines. We limit the number of injections and the frequency of these injections. So, the current recommendations say that you can get four of these injections per year. So, that comes out to basically one every three months. So, a lot of my patients that I've been seeing for years, the injections give them really good benefit, really good relief. So, I'll see them every three to six months. They'll get an injection, it helps them with their pain. They go back to their normal life. And a lot of these patients, they either are not candidates for surgery, they can't have surgery, they don't want surgery, or maybe they've already had surgery, but they still have this low back pain that's ongoing.

The actual risks from the injection is also very low. Of course, anytime you poke someone with a needle, even if you're getting an IV, if you're getting a vaccination, there's all this risk of bleeding, risk of infection, risk of nerve injury, but that's extremely uncommon. And we actually do these injections under a live x-ray guidance. So even though the needle is underneath the skin and I can't see it visually, I always have an x-ray machine there where I can see exactly where the needle is going, exactly what it's doing. So, that also helps with the safety profile for the injection.

And then, for a lot of patients, I'll tell them, statistically speaking, there's a much higher chance of you getting into a big major car accident on your way to the injection versus anything that's going to happen while you're actually there and getting the injections. So for most patients, the benefits of these things really far outweigh any of the risks.

Host: How quickly does the relief come after getting a steroid injection?

Harjot Bhandal, MD: So, it really varies, because we use these injections for a lot of different pain conditions. So usually, I'll tell people that the relief may take a few days, but sometimes up to a week for it to kind of fully, fully kick in. So, people do have to be a little bit patient with it. A lot of times, we will put a little bit of numbing medication in there as well. So, sometimes people will notice that the relief kicks right away, but it only lasts about a day. So, that's just the numbing medicine that's kicking in and then going away. But I'll usually tell people to give it about a week or so to really know if the injection's working or not.

Host: And when these injections work, what's working? Is it palliative care just simply removed the pain, or is it actually somewhat curative and actually fixing the problem?

Harjot Bhandal, MD: Yeah. So, that's a very common question that we get where patients are like, "Well, I don't want to just get an injection to mask the pain, because that may actually end up hurting me more in the long run because I'll do more, I'll be more active and I'll end up causing more pain." So, the injection doesn't mask the pain because as we talked about, it's actually an anti-inflammatory medication that goes in and actually helps with the inflammation, helps with the irritation, and helps with the swelling around the nerves and around the spine.

But of course, the injection is not going to go in and fix the arthritis. I wish we had something that did that, but you would probably need a time machine to reverse the arthritis. And unfortunately, we haven't invented that yet. So, it's not a direct cure to the problem, but it helps with the inflammation, the irritation that actually allows the body's own healing processes to kick in. So, it can lead to recovery, reduction of the pain, and cutting down on that pain cycle so that people can get back to their normal activity.

Host: Just a few more questions for you, aside from injections and that time machine, are there other interventional procedures that you're offering for lower back pain that maybe we're not familiar with?

Harjot Bhandal, MD: Absolutely. It's actually a really exciting time to be a pain management physician. Because in the last five to 10 years, we've had so much research, so much money poured into the field that we have a lot of treatments today that we didn't even have five years ago.

So, some of the things that we talked about besides the epidural injections, we have a lot of nerve blcoks. We also have a lot of nerve ablations that we can do. So with the ablation, essentially, we target certain nerves that sense pain from the arthritis in the back or from the arthritis that's coming from the discs. And we can go in same thing with a small little needle under x-ray guidance. We can apply a little bit of heat to those nerves and essentially deaden or kill those nerves so that people stop sensing the pain that's coming from that area. And depending on the nerve, depending on the area that we try get, a lot of these things are just one and done. So, the nerve is treated, the nerve doesn't grow back, and people can essentially be pain-free from that problem.

Besides the ablation procedures, we also have a lot of other minimally invasive procedures such as spinal cord stimulation. So, this is something that's really had a lot of data that's come out in the last few years. And this is something that's meant for people where they've tried a lot of things already. So, they've had a lot of injections, they've done the physical therapy, they may even have had back surgery, but they still continue to maybe even some leg pain with it. So, they can try out the spinal cord stimulation device. And you actually get to try it out. You try it out for about seven days, see if it's helping you with your pain or not. And then, if you decide that it does help with your pain, then you can definitely use it forever to try and kind of curtail that pain. So, these techniques, they're new. So if you haven't been checked out about your back pain, it's been a few years, I think it's definitely worth seeing someone, because a lot of these techniques are newer and they may help you kind of effectively treat the back pain.

Host: Yeah, it sounds like all sorts of new treatments I am unaware of. So, you know, the reality is all these treatments that are out there, all these new things that are developing. But look, most people, I shouldn't say most people, many people I know who have lower back pain have dealt with it for the longest time, and they're just going to ride it out-- I'm talking to you, dad-- who don't want to see anybody so when should someone do that? When should they go see a physician like yourself, as opposed to just waiting it out or, again, continuing to chew more and more Ibuprofen?

Harjot Bhandal, MD: Yeah, absolutely. People will have different pain tolerances, but I usually tell people that if the pain lasts for more than a few weeks or if it keeps coming back or it's severe, that it's actually limiting your activities, that's the time to go see someone, either your primary care doctor or come see us, as pain physicians.

But generally, we always say less is more. So, a lot of times when I see patients and they have back pain, but they're like, "Yeah, I get it here and there, but it doesn't bother me that much. I don't think I want to do anything about it." That's okay as well. We can talk about some more conservative therapies like the physical therapy, core strengthening, back strengthening, all those types of things. But definitely, if it gets to a point where it's affecting how much time you can play with your kids, affecting how much you can go out there and golf, affecting you being able to do your job, not being able to work properly, I think that's definitely time to go see someone.

And we also have these, we call them red flag symptoms. So anytime you have back pain, but then you also have some leg numbness with it and really bad numbness to the point where you're falling and you have a lot of weakness and you can't walk, or if you have any bowel or bladder control issues, or you have a lot of numbness around the groin area. Those are some of the kind of the red flag symptoms that people should pay attention to. If that happens, then definitely you need to get in right away and be evaluated.

Host: Excellent advice. Any parting thoughts perhaps on something about people you wish more people understood about or anything with lower back pains, treatments?

Harjot Bhandal, MD: Yeah, absolutely. I think the field of pain management, it's still small, but it's growing. So, I wish people knew that we had all of these treatments available. A lot of people think the only options they have is chewing the Tylenol, the ibuprofen, or getting back surgery. But there's so many things in between that we can offer patients.

A lot of times, people are surprised when they come in and they've had back pain for so many years and I'm like, "Oh yeah, we can do this nerve ablation." They're like, "Oh, how come, nobody ever told me about this? I haven't heard about this before." So it's unfortunate the field is so niche, but the good thing is it is growing. So, we're trying to get the word out there as much as we can. But yeah, if you haven't been evaluated and you have a lot of back pain, there's a lot of stuff that we can do that's not super invasive that doesn't mean surgery to try and help treat the back pain and get people back to doing what they love.

Host: Did you hear that, dad? Stop ignoring your back pain. Oh, Dr. Bhandal, thank you very much for all the information today.

Harjot Bhandal, MD: Absolutely. Thank you so much for having me.

Host: Once again, that was Dr. Harjot Bhandal. For more information, please visit mymarinhealth.org. If you enjoyed this episode, please share it on your social channels and explore our entire podcast library for more topics of interest to you. This has been The Healing Podcast, brought to you by Marin Health. I'm Evo Terra. Thanks for listening.