Joey Wahler (Host): It's very common and can adversely impact our quality of life, so we're discussing back pain. Our guest is Dr. Rebecca Kuo, an orthopedic spine surgeon for Silver Cross Hospital. This is Silver Cross Hospital's IMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Kuo. Welcome.

Rebecca C. Kuo, MD: Thank you. Nice to be here.

Host: Great to have you aboard. So, first, give us an idea, please, just how prevalent is back pain these days here in the United States?

Rebecca C. Kuo, MD: Back pain is extremely prevalent. About 40% of all adults in this country will have back pain at some point. It is one of the most prevalent reasons for visits to your doctor. It costs this country about $86 billion a year or more in lost productivity, time off from work, care costs. It is one of the most common causes for disability filings in this country as well. It is a number two reason for doctor's visits. So unfortunately, it's a very common thing that most of us will see at some point in our lives.

Host: So, you're saying it's not just painful, but very, very costly as well.

Rebecca C. Kuo, MD: Yes, it costs the country a lot of money just in time off of work, lost productivity, et cetera. That's how they measure those numbers.

Host: Gotcha. And so, you alluded to that lost productivity at work. Naturally, people are affected adversely by it impacting their activity. Otherwise, when it comes to getting out and about, recreation, how would you illustrate some of the ways in which people are most commonly hurt by back pain? Where does it really hurt most?

Rebecca C. Kuo, MD: The most common injury that we see in back pain are lifting type injuries. We see people have a fall-- it depends on the demographic too. But in the working demographic, we see lifting injuries, we see occasional falls. In non-work related, we see lots of car crashes that cause back pain or neck pain. In the elderly population, we see lots of falls and more chronic causes of back pain such as stenosis or just arthritic changes. In the younger adult, it's often an exertion, an exertional type thing, maybe they were lifting something, maybe they engaged in a sports activity and they did something that's pulled their back.

So, there are a variety of ways for people to injure their back. But the most common thing we hear is, "I was lifting something. I felt a pop. I had back pain and/or leg pain." That's a very common story we hear. Not required to have back pain, but it's a very common thing we hear.

Host: And when you talk about that being the cause in many cases, lifting injuries, right? Something acute like that. I guess it's mainly from either lifting too much, overdoing it, or not lifting properly, right? Like not protecting yourself in terms of posture, bending the knees, lifting with your legs, and so on, right?

Rebecca C. Kuo, MD: That's correct. Many people don't lift properly. I would say this happens more in my male population. You guys have lots of good upper body strength, and you think you can just bend over and lift that really heavy box, and then you feel something. I see back pain in my athletes too. And most of the time, it's from improper technique. When they're doing improper squat or improper deadlift, they feel a pull in their back. That's one of the most common reasons why I see people who seem to be in great shape walking to my office. They're often because a lifting injury of some sort, whether it's at the gym or at work or whatnot, lifting improperly, not using your legs and your hips, not squatting properly, keeping your spine neutral is it disposes you to a greater risk of injuring your back when you're lifting something.

Host: And then, let me ask you further about that, because you mentioned there athletes lifting weights and so on. Sometimes back pain can be caused as well, can it, by an imbalance in your workout routine. If guys do too much arms and chest, but not enough or maybe no back and neglect the back, that can cause problems because you're lifting a lot with certain parts and not enough with others, right?

Rebecca C. Kuo, MD: Yes. We actually call it more core strengthening. Because what stabilizes your spine isn't really your back muscles, your back muscles are actually secondary. Your primary stabilizers are your core, that's really most of your abdominals, and not that six pack you can see on the surface. We're talking about the deep abdominal, the transversalis, all those other deep muscles. And obviously, your gluteus, your butt muscles, your quad, your hamstring, these are all important. And obviously, your back muscles as well. These are all important parts to stabilize your spine.

And yes, it's actually rather amusing when you see this really big muscly, really cut guy come in your office complain about back pain. MRI looks normal, they just really strained their back because they did an improper deadlift or something, or even they may have herniated their back. You stick them in an exercise ball, they'll work on their core, and they're sitting there shaking. It's not funny, but it's interesting to watch because you're thinking this guy has worked out a lot, but they've obviously not worked on their core as much. Because that's very important, particularly as people start to do more and they want to engage in more significant activity, whether it's lifting, whether it's quick motions, whether it's jumping back and forth, whatever that might be, the core is always important.

Host: Hence, the name core, right?

Rebecca C. Kuo, MD: Yes.

Host: So, there are two categories of back pain, right? Muscular and structural. Symptom-wise, what are the basic differences?

Rebecca C. Kuo, MD: Most of the muscular back pain seems to occur when I see them when they have an overuse type injury. They feel like they have an event or maybe an overuse situation, and they're feeling that I do certain motions. I feel a pulling in my back. Structural back pain is different. That's what we often call that mechanical or axial back pain. Those people typically have pain even when they're sitting. People with muscular back pain, they often feel better moving around. They get up and they move around. But when they do certain things, it hurts more. The sitting itself may or may not be uncomfortable. But when you have structural back pain such as disc pain, disc degenerative pain, or maybe even facet-mediated pain, there's often a different set of complaints, but one of them is they can have pain when they're sitting. It's the opposite of pain from stenosis, we have structural back pain. Often they come and tell me they have a hard time sitting unsupported. So if they're sitting in a chair, they're always slouching. If they're sitting on a stool, it causes them discomfort because they're putting lots of pressure on their spine.

Host: Understood. So, you've covered just how common back pain is in this country. How does someone know, Doctor, if their pain is serious enough to see a professional like yourself?

Rebecca C. Kuo, MD: Well, that's a really big question, because there's so many reasons why you should see a professional. From a short-term perspective, if you've pulled your back and all you have is some back pain, try icing it and you're still able to get around, you can certainly try stretching it, taking some Aleve. If it goes away, it doesn't come back, there's not much to do.

The reason why you may want to see a spinal surgeon is if the back pain is persistent. If you're having what we call leg pain, numbness or tingling or radicular symptoms. If you can't stand up straight and it's persistent, if you have a more chronic situation, and it's been persistent for a while, you've done the physical therapy and it's just not getting better, then maybe it's time, that maybe your medical doctor has exhausted what they can do with anti-inflammatories, reasonable medications and physical therapy. Then, it might be time to seek a second opinion spinal surgeon. It doesn't mean you need surgery, but at least you get a different set of eyes on it. And for older people who have stenosis, for example, we haven't even touched on that subject yet. But if you have chronic stenosis, you can't stand up straight, you have to lean on the grocery cart all the time to get around. You've had the therapy, you've had the injections, and you can't even walk a block before your back is killing you unless you sit down, or you lean on the grocery cart or lean on your walker, then you might want to see someone and say, "What are my options? Is there something that can fix this problem?" Is it surgical? Is it not surgical? And for that, you probably should see a spinal surgeon.

Host: Well, you mentioned spinal stenosis. Many of us have heard it, the term. Tell us what it is.

Rebecca C. Kuo, MD: Stenosis in broad terms is just a narrowing. We've all heard of aortic stenosis in the heart. It just means a narrowing. So if you ever stepped on a garden hose, you stuck your finger over a garden hose, you've caused stenosis of the garden hose. In this case, we're talking about spinal stenosis, we're talking about the spinal canal. So, stenosis means a narrowing of that canal. And in some cases, for some people, that can cause difficulty with either back pain. Or if it's in the lumbar spine, we're talking about the lumbar spine today, if it's in the lumbar spine, it can often cause back pain, it can cause leg pain, it can cause difficulty with standing and walking.

Now also, there various causes for stenosis. The stenosis I'm talking about right now is more the degenerative, what we call, just generalized stenosis because the disc is bulging backward, the ligaments are pushing forward, maybe the joints in the back of the spine have enlarged, all pushing on the nerves, so the nerves are caught between the proverbial rock and a hard place. Those people may have pain with walking, may have pain when they try to stand up straight. Because when you stand up straight, you have to arch your back, because if you don't, you're leaning forward. When you're sitting, your spine is more straight. So, those people, when they get up, they have difficulty standing up straight. I think we've all seen these people at the grocery store, wandering around with their elbows on the cart, just leaning on the cart. Because the minute they stand up, they can't take it. That's because they're treating themselves by stretching their spine out, making the canal bigger. But when they have to stand up straight, they make the canal smaller.

If you have stenosis due to a herniated disc though, you have a different situation, because then you have leg pain. When you bend forward, you're tenting the nerve over the herniated disc and causing leg pain. Once again, that's a different problem. It's a more of an acute problem, rather than a chronic issue. So, that's why I threw in the possibility if you have leg pain, which can go away, weakness, numbness, you probably should seek a specialist.

The things that you absolutely should seek ER care for, if you lose your bowel and bladder function and it doesn't come back, you have numbness in your butt, those are emergencies. But that's maybe a discussion for a different day.

Host: Perhaps a discussion for a whole separate podcast, indeed. A few other things. So, let's talk about treatment, of course. What are the most common treatments? First, non surgically?

Rebecca C. Kuo, MD: Sure. The most common non-surgical treatments will be things such as anti-inflammatories, because inflammatories decrease the chemicals that cause pain when you're having compression or injury or whatnot. It sends of chemicals and inflammatories counter those. If you're having lots of muscle spasms, say you strained your back, you're having terrible spasms. You can't sleep at night, ice is not helping, then an anti-spasm medication could be useful.

If you're having leg pain or tingling or numbness, sometimes we use, they're called membrane stabilizing medications, the most commonly used one is gabapentin. That was originally created as a anti seizure medication, but it works so well for nerve pain, that we find that we use it for nerve pain as much or probably more than we do for seizures these days. And obviously, very judicious use of pain medications. I am not a big proponent of narcotic pain medication, except in the acute setting, very short term, or post-op if you need surgery.

Then beyond the medication treatment, you have the options of physical therapy. You'll have to seek a physical therapist who knows how to treat your particular problem. And then if there's stenosis, we can consider cortisone injections. And for that, we typically have a pain doctor or a spine surgeon who is comfortable doing them. And we brought up the term mechanical back pain earlier. If you're having pain because of the joints in the back, they may consider numbing up those joints to see if the joints are causing problems. And if they are, they may consider doing something called a radiofrequency ablation, which is more or less burning the nerve, and just try to buy you some six months or more relief from that. So, those are the non-operative options.

 For surgery, there's a variety of options. And which particular surgery would benefit the patient depends upon what the causing factors are. And when you're looking at their MRI and combining the MRI with their symptoms, then you need to determine which particular tool you need to bring out to fix their problem.

Host: So, what would, for instance, be the most common spine surgery, back surgery, these days?

Rebecca C. Kuo, MD: For lumbar spine surgery, the most common reason as we spoke for surgery would be If you have spinal stenosis, that's the most common reason. If you have nerve pain, it's something called neurogenic complication, that's what I describe when people can't stand up straight, and they have to lean on a cart, and they have chronic stenosis in their back. For that, the most important part is to remove the pressure off the sack of nerves and the lumbar spine, it's a sack of nerves. It's not the spinal cord there, it's just a bundle of nerves, and we need to take the pressure off of that. There are variety of ways we can do it. We can do traditional ways, the laminectomy. You go in there, the laminas, the arch of the back of the spine, ectomy means removal. We're literally removing the arch of the back of the spine. and allowing the nerves to have space. In that case, even if you have a bulging disc, even if you have enlarged joints, you can trim off some of the joints a certain amount before you become unstable. You typically leave the disc alone. This is the one people don't think, people don't understand. They're asking, "Aren't you going to fix the bulging discs?" No, we're going to free up the nerves by removing either the rock or the hard place, as it may be. You have to remove one of them and make sure the nerves has space to be, and then the patients typically can stand better and walk better. Fusions come into play when you have something unstable or you're going to cause instability with the surgery.

Host: And finally, in summary here, Doctor, what are one or two of the latest advancements in back surgery that help minimize recovery time and post-surgical pain, et cetera.?

Rebecca C. Kuo, MD: All surgery is invasive. Anytime you puncture the skin, you penetrate the body, there's going to be scar tissue of some sort, even if it's just radiation, for example. However, less invasive or minimally invasive surgeries are newer techniques we utilize to minimize tissue trauma, which in theory should help speed your recovery and maybe not improve outcomes necessarily, because the studies you show at one year, the outcomes for traditional open surgery and minimally invasive were very close, if not the same, as long as you've addressed the problem at hand. So, we do a lot of minimally invasive surgery where we're either doing surgery through smaller incisions, or even if we can't make a smaller incision, at least we're making a small, less tissue dissection. and improving the speed of surgery, which allows us to accomplish the same goals with less trauma to the body.

And then, obviously, we have other options such as what do you call it navigation, where we can do an intraoperative CAT scan and use little markers on the body to tell us where all our tools are going. So if we have to put screws and rods in, we can put them in with greater accuracy and, in some cases, greater speed as well.

Host: Wow. Well, certainly sounds like there are a number of different options. Folks, we trust you're now more familiar with back pain. Dr. Rebecca Kuo, appreciate it. Thanks so much again.

Rebecca C. Kuo, MD: Thank you for having me.

Host: Absolutely. Great to have you again. And for more information, please do visit silvercross.org/spine. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks again for being part of the IMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family.