Transcription:
Managing Your Back Pain

Melanie Cole (Host): Welcome to Say Yes to Good Health with Memorial Hospital. I'm Melanie Cole. I'm so glad you could join us today because we're talking about back pain and spine health. Joining me is Dr. Rahul Basho. He's a spine specialist and orthopedic surgeon at Midwest orthopedics in Hannibal, Missouri.

And he now also sees patients at Memorial medical clinic in Carthaginian. Dr. Basho, I'm so glad to join you. You and I were speaking a little bit off air, back pain, huge problem in this country. I mean, it's like, it affects people's work, their quality of life, you know, their anxiety, everything. Tell us a little bit about how common it is and some of the most common reasons that you see that people have back pain.

Rahul Basho, MD (Guest): Well, Melanie, I had a professor that once told me that there are three types of people in the world. People that have back pain, people that are going to have back pain and people that have had back pain. And I think it comes down to the fact that we pay a heavy price for walking upright, fighting gravity our whole lives, lifting, pushing, pulling, all of that over time, takes a toll on the spine. And what we're noticing is that the breakdown and the wear and tear that occurs doesn't necessarily cause pain, but that accumulation over decades and decades of life can have a toll. And that's the predominating thing that I see as a Spine Specialist.

Host: So there's acute and there's chronic. And as you're mentioning things like standing upright, and I agree with you and I realized the first time, my back "went out" in quotes that and I'm, I mean, I'm a personal trainer for God's sakes and it happened to me after my first baby, I think. And you cannot appreciate someone's back pain until you have experienced it yourself. I swear to God. Acute and chronic, two different things. Can you tell us a little bit about why something might be chronic, arthritis or whatever, versus something that we actually hear about like bulging discs, people hear that? Can you tell us a little bit about what those are?

Dr. Basho: Yeah. So, these are all great questions. And when you break down acute versus chronic back pain, there are a myriad of different definitions. Some people and some insurance companies will quantify chronic back pain is back pain that has been present for greater than six months. Some will say, you know, eight months or a year.

And so, you know, really what it comes down to is that if the back pain is something that has occurred for a number of months, that people have adjusted to and begun to live with, I consider that chronic back pain. Now, if we have someone who was previously asymptomatic and all of a sudden they have severe and sharp back pain, or they have pain that's radiating from their back down their leg, that's more of an acute problem that requires a little bit more urgency in terms of looking into. Not all back pain as is created equal, as you said you know, we can have back pain with different activities throughout our lives. I see actually quite a few gals that are pregnant and develop back pain just based on the baby weight.

I see a lot of athletes, people that you know, young, healthy, 20 year old guys that are lifting a lot of weights and that puts some stress on their lower back. Then I see, you know, retirees and senior citizens in their 60s, 70s and 80s that are maintaining an active lifestyle, trying to walk. And they have pain that limits their ability to do these. So, back pain can affect, you know, a myriad of populations. And going back to your question, when we talk about acute versus chronic. So, you know, chronic back pain as you alluded to is due to arthritic change and that gradual wearing down of the joints and the cartilage in the back.

Acute back pain we see when there is an acute injury to some of the stabilizing structures of the spine, such as the intervertebral disc, if you get a little tear in the disc, just like you have cartilage in your knee, the disc is the cartilage in your back is how I like to explain it. And when you get a tear in that disc, it can cause tremendous pain, cause difficulty standing upright, getting comfortable.

If the disc itself tears and pieces of cartilage come out, then you can have what we call sciatica or radiculopathy, pain radiating down the leg. And we usually see that with more acute type injuries, a heavy lifting episode, an episode where, you know, someone has done an excessive amount of work in awkward positions. Some people are more prone to these things. Some people develop them due to overuse.

Host: Well, I'm one of those, cause I'm shrinking and I'm only 4' 10" to begin with. So, you know, I get that lower back pain and I need a booster seat to drive, but since pain and I think this is such an important question for you docs, since it's somewhat subjective, how do you measure it? How do you figure out what's wrong with someone? Does that really matter when you're starting with first-line conservative management, whatever's wrong or, I mean, do we start right away with NSAIDS. Speak about how you figure out what's wrong with the person and what that first line of defense is.

Dr. Basho: Well, in terms of figuring out what's wrong with the patient, the first step is always to get a good and detailed, thorough history. Okay. To really understand what happened. What was this patient going through? What changed for them? A lot of people live with a certain degree of pain. A lot of people have an idea of what they can do and can't do and can live within those limitations. So, what has changed is one of the, one of the key questions that I like to ask. If you've been having these symptoms, let's say for a decade or five years, what's changed now that you're in to see me on a sunny afternoon? Is it, is it that you're not sleeping at night because of the pain or the pain is waking you up?

Has the pain changed in caliber? Is it radiating into a different location? And so the first thing that I want to figure out is what has made this patient take time out of their day to come to the doctor's office? And once you get that thorough history, then you start to put other pieces of the puzzle together. Then we're looking at, you know, what does the imaging show? The first thing that we start with is x-rays, we look at the overall alignment of the bones. X-rays are nice. A lot of people come to my office and say, well, I had a CT scan in the ER, or I had, you know, an MRI in the past. Why do you need x-rays? And x-rays are nice because not only do they give us bony anatomy and bony detail, but they're dynamic studies, so I can get an x-ray with you bending forward.

I can get an x-ray with you bending back. And that allows me to see what's happening dynamically. As you move in certain positions, which you can't do with a CT scan or an MRI. And then when you have the imaging and the history, then we want to get into the physical exam and see, are we picking, how is the patient walking?

How is the patient standing? Do they use a cane? Do they need a walker? Can they make it from here to the parking lot without any assistive devices or without stopping? Can they go to the grocery store and get their groceries and do their grocery shopping? Or do they have to get onto that cart and lean forward? All of these are pieces of information that help formulate a diagnosis. And then based on that diagnosis, that's when we get into the treatment options.

Host: So, tell us what you might try once you've figured out what's going on and you've assessed the situation. And as you say, the good history. Then what do we look to generally first as conservative management? Because everybody thinks, because you're a surgeon, you're going to jump right into surgery, but that's not the case, is it?

Rahul Basho, MD (Guest): Yeah. That's, you know, as a good surgeon will try to avoid surgery. And so our goal as Spine Specialists is to get people through their pain, without surgery, with the least invasive methods possible. The first thing that we will look at is what medications have you tried? So, most patients before they have come to see me have been on Tylenol, they've tried the ibuprofen, the over-the-counter stuff.

And you know, if it's, if they come and see me and say, hey, I just want some answers. I'm on some anti-inflammatories. We will continue those. If anti-inflammatories haven't worked, then we look at, and if there's an acute, you know, compression going on of the nerves, sometimes we will send people for MRIs and based on the MRIs, we can do injections.

Dr. Basho: I love physical therapy. I think that a good therapist will listen to what causes pain, what caused the pain, what the patient's expectations are. And then formulate a, a therapy protocol that emphasizes stronger legs, a stronger core, shows patients how to lift, how not to lift. And then as patients go to that therapist over a number of sessions and develop their own home program, that's where the real benefits are.

But if I had to summarize, you're looking at, you know, non-narcotic medical management, which typically falls into either Tylenol or ibuprofen. You're looking at steroid injections, which are meant to not only make patients feel better, but make them able to participate in therapy and get more out of therapy. The third part of that is, is the therapy itself where we're trying to build on gains that we've made, prevent these episodes from occurring again. And if they do occur, making them less severe.

Host: Well, we only have about a minute left, but I find it so interesting that back in the day, everybody was separate. You orthopods and us trainers, chiropractors were over here. Acupuncture was over there, but now we're kind of all coming together. Right. Especially when it comes to back pain. Just kind of wrap up this portion of the show today for us with, when you talk about physical therapy and some of the options that someone might try, other, you know, non-surgical approaches, whether it's chiropractic, when would you recommend those things, if medication doesn't work or in conjunction with them?

Dr. Basho: You know, I think that a multi-pronged approach is always best for the spine. And the fact that, you know, we have come together with chiropractors, with acupuncturists, with you know, yoga, physical therapists. It just underscores the complexity of the spine and how no one specialty has all the answers. And so I think that a multi-pronged approach is always the best approach. I think that, you know, chiropractic care has a role and there's evidence that it can be of benefit. And I encourage my patients always to try everything under the sun before you try any type of surgical intervention. So, you know, if you're having, you know, back pain, I think the medications, the therapy, that chiropractic care are all good things.

I have patients that try acupuncture and these are things that have been around for thousands of years. And there's some patients that come back to me and swear by them. And for some people they don't work, but there's no harm or real side effects to trying these things. And so my message to patients is always surgery should be a last resort. There's a lot of different conservative options that you should try prior to undergoing surgery.

Host: What great information we are giving. You're a great guest, Dr. Basho. So, you mentioned all the nonsurgical, not all of them, but a lot of non-surgical approaches, exercise, yoga, acupuncture, chiropractic, medications, all of the, physical therapy, all of these things, and certainly exercise, keeping a strong core. Right. And we'll talk a little more about that, but when does the subject of injections, I'd like to start with those before we hit the surgical options and injections, people say, oh, cortisone shot whatever. But in the back, it's a little bit different than say one in your knee. Can you explain a little bit about injection therapy and really what that is?

Dr. Basho: Yeah. And so when you talk about injections you really have to first talk nerves in our back. And so nerves are structures that send power to our muscles and sensation to our skin. And they don't like to be compressed. If something compresses a nerve, we can have numbness in a leg. We can have weakness in a muscle, or we can have radiating pain and sometimes a combination of all three of those. And so when you have that going on, how do you confirm where the patient's pain is coming from and make the patient feel better? And that's where the injections come in. And they're a very powerful tool. And what I explain to patients is that injections are not meant to fix you. They're meant to help you weather the storm.

And they're meant to help me figure out exactly what part of your spine is your pain coming from. You know, if your knee hurts and it's your right knee, it's pretty clear cut where your pain is coming from. But if you've got some vague back pain that radiates into, let's say your right buttock or down your right thigh, that could come from a number of different areas in your back.

And so what I do is I send people for targeted epidural steroid injections. And what that basically means is you go and you see a specialist who uses an x-ray machine and guides a needle in under direct visualization to a particular part of your spine, and then puts the medication right around the nerve there. And if we have, you know, localized what nerve is causing or responsible for those symptoms, you should have relief within, typically within a few days, sometimes, immediately. And when you come back and see me, we talk about, you know, did it help, how much did it help? How are you doing? Your body will try to heal disc bulges and disc herniations that are pushing on nerves.

So, these injections, they help the patient weather the storm. And so in some patients it's a couple of injections and we can kind of get them through the acute phase of pain. And then they go on to heal and in some patients, the injections help, but they don't last long. And that's when we talk about more permanent solutions.

Host: Just briefly, very briefly talk about some of those more permanent solutions, minimally invasive versus more traditional. Just kind of give us a quick overview.

Dr. Basho: Yeah, and this is a expansive topic. So, I will try to be as brief about it as possible, but, you know, surgical options have evolved tremendously over the last 10 years. We are now doing things through smaller incisions. We're getting patients up the day of surgery and getting them out of the hospital much quicker. Recoveries are much better, but typically if you have, let's say a disc herniation, that's pushing on a nerve, we use a microscope, make a small incision, expose the nerve, move the nerve out of the way and shave away any pieces of disc, which is cartilage in the back that's pushing on the nerve or a bone spur.

You know, oftentimes get patients out of the hospital the same day, whereas 10 years ago, you know, you'd have an incision about the length of an adult hand and you'd have to wait for that big incision to heal and there would be blood loss. It's really remarkable, what type of microsurgical techniques have really evolved over the last 10 years.

Host: Oh, I agree with you. It's really fascinating what you can do. But one of the main things that I wanted to get to today, is repetitive strain injuries, ergonomic risk factors, as people in rural communities, whether they're farm workers or factory, back issues are prevalent. Can you tell us some of the things that we are doing to our own backs, even if we're sitting behind a computer all day that are contributing to some of these back problems and what we're supposed to do, if we just start to feel them.

Dr. Basho: Yeah. So, you know, these are great questions that come up all the time. And I always reference back to a study that was done, looking at the pressure within our backs or the pressure within the intervertebral discs. They had someone who actually put small little needles that were pressure transducers into the different disks of a patient's spine. And they had that, you know, these patients stand up and sit down and hold something and lay down and they looked at when are we putting the most pressure on these disks? And what they found is that when you're in this seated position, holding something heavy, that's when the most pressure is there.

Being in the seated position puts more pressure on your back and the cartilage in your back then standing does. And when, obviously when you're laying down, that's why, that's when we have the least amount of pressure on our disks. And so in our society where we've evolved to being you know, desk warriors and typing and working all day in a seated position, we're actually putting more stress on the disc. So, that the seated position is something that we want to avoid for long periods of time.

Now, if you take a look at the biomechanics of the disc, you know, the discs, in my clinic, when I see patients that have had an acute injury to the disc, it's usually due to more of a torsional injury. What does that mean? That means a turning type injury. So, if we're going to be doing repetitive movements where we're lifting something heavy, and we're, we're twisting, that's where we're putting the most stress on the back and putting ourselves at risk for injury.

I always counsel my patients if you have to lift something heavy, you know, first of all, try to avoid it. But if you can't avoid it, if that's part of your day to day, hold it close to your body, don't hold it away from your body. And when you move, you gotta move kind of like a robot. You gotta turn your shoulders and your hips together. Don't twist. It's that repetitive twisting that puts that torsional stress on the disc and the outer portion of the disc that predisposes it to injury.

Host: What a great explanation that was. I remember doing that back in my health club days, lifting those 45 pound plates to put them away and I would turn and be like ah, I just did it there I knew better even, but I still did it. So, it's so important to be cognizant. Right. And tell us some things how we can lift safely because people have, there's a lot of different, you know, theories on lifting safely. Keep your knees straight, keep your legs straight. Don't straighten your legs. Then that's like a dead lift. How do we lift safely to help out our back and talk to us about good posture, workstations, all of that.

Dr. Basho: You know, the advice that I give is that I tell people to try to keep the top of their head pointed to the sky. So, that means using your knees more, that means bending down on one knee, holding something and trying not to bend forward, holding it close to your body. And then coming up. If you've got knee problems or knee arthritis or hip arthritis, some of these maneuvers can be harder and we tend to stress our backs more, but you know, doing it in a way where we're trying to keep our torso, our head as upright as possible stresses the back the least.

Host: One thing we haven't mentioned, doctor is what we're doing to ourselves as far as weight, because weight and obesity, which I'm sure since the pandemic has really gone up a lot, especially in kids, but our weight is directly relative, right to some of these kinds of pains, whether it's knee or back or whatever, but tell us about exercise and how important that is to keep that healthy weight so that it's not such pressure on our backs.

Dr. Basho: Yeah. You know, the way to think about it is if you take a look at a pyramid, the bottom of that pyramid has to hold everything that's above it. So that bottom layer of a pyramid has the most stress, you know, same thing with the skyscraper. So, think about your body like that and your spine like that. Those bottom disks and cushions are the ones that most commonly wear out in people's backs. Why don't we talk about mid back pain as much as we talk about lower back pain? Well, it's because the lower back is what's bearing the brunt of gravity and having do all the heavy loads, lift the heavy loads.

And so the more weight that you're carrying around, the more stress that's getting concentrated, you know, through this disc that's, you know, the size of gosh, just, maybe a hockey puck or a small hockey puck. And so everything from your head down to your torso is going through that surface area. So even reducing weight by 2, 3, 5 pounds, it's exponential how much you decrease the force going through that cartilage in your lower back. And so anything that patients can do to get that weight off is going to help their back pain. And a lot of patients have a hard time starting an exercise routine because they think you have to be on a treadmill for 45 minutes, or you have to, you know, go to the gym for an hour and lift weights and do all that.

I ask my patients to do, give me seven for seven, give me seven minutes of walking a day and do it for seven days in a row and just see how you feel. And that small change can have a tremendous impact on your health, on how your back feels, on your mood. And so these small changes that we ask patients to make can have a huge impact in the long run.

Host: What great information. Last 30 seconds, almost minute here. Best advice on keeping a healthy back, prevention of back issues so maybe Dr. Basho, we don't have to come see you.

Dr. Basho: You know, I always told my patients activities such as shoveling. It's something that requires you to, use a lot of twisting force and a lot of lifting force of something that's heavy away from your body is hard. So, if you're going to do shoveling of snow shoveling of, of dirt or gravel or anything like that, just make sure that you're warming up, make sure that you're keeping your core strong. I see a lot of parents that are having to lift little kids, put them in car seats, having to twist when they're holding car seats and things. So just, you know, keep your core tight, try to pull that belly button into your spine when you're doing these things and try to stabilize your spine.

For my senior citizens that are trying to be active, continue to walk, begin a walking program. There are reasons that I cannot explain where that cardiovascular exercise and that cardiovascular health actually makes your spine feel better. And so if listeners can, can try to implement some of those things into their day-to-day routines, they won't have to come and see me, or there'll be less likely to have to come and see me.

Host: 100%. That's really great information and it's totally true. And I'm 57 Dr. Basho, so I can attest to the fact that if my back's feeling tight and I feel like oh, oh, what's going to happen today, but I start walking around, moving around. It really does help. So, this is great information you're getting here today, listeners.

Melanie Cole (Host): To learn more about spine health, managing your back pain. You can always visit our website@mhtlc.org. Or you can call 5 7 3 2 4 8 1 0 1 oh. To make an appointment. And Dr. Bhatia is also now seeing patients at Memorial medical clinic in Carthaginian.

Host: And that wraps up this episode of Say Yes to Good Health with Memorial Hospital. We'd like to thank our audience and invite you to download, subscribe, rate, and review on Apple podcasts, Spotify, Google podcasts, anywhere podcasts are played. I'm Melanie Cole. Thanks so much for listening.