Transcription:
Neck and Back Pain

Melanie Cole, MS (Host):   Neck or back pain can be debilitating and keep you from taking part in the activities that you enjoy, but when that pain begins to interfere with your daily life it really is time to see a physician to assess the situation. This is Doc Talk presented by Montefiore St. Luke’s Cornwall. I'm Melanie Cole and today we’re talking with Dr. Esteban Cuartas. He’s an orthopedic spine surgeon at Montefiore St. Luke’s Cornwall. Dr. Cuartas, I'm so glad to have you join us. What are some of the most common causes of back and neck pain that you see every day?

Esteban Cuartas, MD (Guest):   The most common situation that we see for these problems is osteoarthritis, which is plain run of the mill arthritis that everybody gets.

Host:   So tell us the difference between symptoms that are very acute, sharp, shooting that just sort of happen or these chronic things like you're talking about osteoarthritis that can develop over time and the pain is little and then it starts getting more severe or lasting every day. How do we know what’s which?

Dr. Cuartas: That’s an important distinction. Some patients have very acute pain. The symptoms just began a week or two before. That’s important to note. Then other patients have more of a chronic situation which by itself doesn’t mean that it’s any less important. The other major feature that we try to look at is it neck or back pain alone or is it associated with any shooting pains into the arms or legs—or what we call radiating or radicular symptoms. Those situations often times bigger problems when we start investigating.

Host:   Well then Dr. Cuartas, since pain is somewhat subjective, how do you measure it? How do you diagnose what the cause of it is based on a person’s pain level?

Dr. Cuartas:   We take into account the person’s pain level, but we also take other features into account like I just mentioned. Additionally we look into whether the pain is debilitating or effecting the person’s function, quality of life. If it’s interfering with their work or leisure activities, that’s another important point. We also take a complete history and verify that there’s nothing out of the ordinary in terms of any past medical history, problems that could effect or even sometimes cause back or neck pain.

Host:   So if someone comes to you and you’ve looked at what’s going on with them, what is your first line of defense? Tell us about chronic pain in the back or in the neck. How you approach it, this multifaceted approach tell us what you might start with.

Dr. Cuartas:   The algorithm usually is we try to divide it into acute or chronic and also whether or not it’s what we called axial or axial pain associated with radicular symptoms. If it’s purely axial pain or pain that’s centered around the middle of the neck or lower back and there are no other situations which we call red flags then we typically will focus on what we call activity modification, focus on wellness and possible exercise, sometimes job modifications. These are situations where the person really has what we would plainly call back or neck pain. Often times there's certain things they're doing. For example, they're looking at a monitor on a desk all day and they're not getting up. The monitor may be positioned too high and that exacerbates neck pain. So sometimes discussing what their daily routine is like and their activities, maybe their leisure activities. Maybe there are no leisure activities and that’s when I often times emphasize a strategy of wellness, of pursing wellness. So it would be really to try to think about enhancing their quality of life by exercising, maybe some stretching really on a daily basis as much as possible. Those are some of the main algorithms that we use to try to sort out through cases of back and neck pain.

Host:   So if someone tries some of those they try yoga and exercise, physical therapy, maybe some modalities—ice, heat—those kinds of things. When might someone like a chiropractor come in? Do you ever recommend someone like that? What about the subject of injections? If you would speak about those first before we would get into anything surgical.

Dr. Cuartas:   Yes, that’s a good question. Chiropractic is a separate and long tradition. In some areas, for example, I'm located in a semirural area. A lot of patients have close ties with their chiropractors. They have long histories of treating with their chiropractors. The chiropractors themselves sometimes use typical traditional chiropractic maneuvers, but sometimes they also incorporate other measures that are more akin to physical therapy. Some do even acupressure type of techniques modalities. So it’s a wide range of things. So I think it’s difficult to make a blanket recommendation. In general I try to not recommend the sort of rapid manipulation and sort of cracking of the joints for elderly or frail patients, but I think for the most part the chiropractors realize that that’s not the best way to treat these patients. Their spine get stiff and their fragile. Oftentimes patients will have a bad experience when they're manipulated, and their spines are not ready to sort of accept those types of treatment. The other point I make in general is that chiropractic treatments are in some ways sort of short lived. So I think the patients need to understand that if they're going to pursue chiropractic treatment it’s really a situation where they're going to have to go multiple times over a period of time. So it’s not a “fix”. The truth is that for a lot of these situations there is no quick fix. We try to use different means and methods and techniques to try to achieve a higher or better level of functioning and quality of life and a lower pain level. So I think it’s something that sometimes comes up. I think that as long as they're getting benefit out of going to the chiropractor, I see no problem with that.

As far as injections and epidural injections, we have very skilled practitioners these days. They typically will go under the title of pain management. They are very skilled at doing injections for different reasons. They tend to not be as effective for axial pain situations. For example, those caused by just plain osteoarthritis. They tend to be more useful for patients with radicular symptoms or pain shooting down their legs or situations like stenosis, which is narrowing of the spine. Nevertheless, when patients are really failing to find an adequate relief of their pain I do think these pain management colleagues can help these patients.

Host:   What does the discussion look like if you are recommending surgical? When does that happen doctor? If you would briefly just give us a little look at the types of surgery that you might be able to offer.

Dr. Cuartas:  Yeah so in certain situations after an initial treatment plan if there is failure of the patients to get better and/or if there are any red flags—for example pain that is excruciating or worsening or pain that has associated nerve symptoms. If the x-rays which are sort of a screening method are showing that there is some misalignment of the spine, then we proceed with advanced imaging, which for the spine would be MRI. Then we at some point start to analyze whether or not there is any benefit to considering surgeries. In some situations, there is usually very little benefit over traditional non-surgical methods. There are certain situations where surgery can offer improved outcomes and lower pain levels. The flipside of the coin at that point is also to see whether the risk benefit analysis favors surgery. Some patients have other medical problems, other things going on in their life. So surgery may not be in their best interest. So it’s really a discussion, as you mentioned. It’s something that we present to the patient and eventually we come to a decision as to whether surgery would be a good idea or not.   

Host:   Well thank you for that answer. Do you have any best advice as we finish and wrap up for listeners about hopefully preventing back and neck pain in the first place and when you feel it’s important that they see a physician.

Dr. Cuartas:   In general my best recommendation is to try to stay active, try to have a focus on wellness, which is your body needs some motion. It needs to move. It needs some exercise every day, and you deserve it. You need to take care of yourself, not just of all of the other folks around you. I think that keeping that in mind helps keep your pain at bay and also helps you deal with the pain that your joints will undoubtedly give you at some point.

Host:   That’s great information. Dr. Cuartas, thank you so much for joining us today. That wraps up this episode of Doc Talk presented by Montefiore St. Luke’s Cornwall. Please visit our website at montefioreslc.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke’s Cornwall podcasts. I'm Melanie Cole.