Melanie Cole, MS (Host): Welcome to Back To Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole, and today we're talking about managing spine care before, during and after surgery with Dr. Alina Boltunova. She's an Assistant Professor of Clinical anesthesiology at Weill Cornell Medical College Cornell University.

Dr. Boltunova, thank you so much for being with us today. I'd like you to start. You are an anesthesiologist and you see this every single day. Tell us a little bit about the current state of back pain today, the prevalence, some of the most common causes and really the effect that you've seen on the quality of life of the people that suffer from chronic back pain.

Dr Alina Boltunova: Thank you so much for having me. So, I am a practicing anesthesiologist, and I also practice in the pain clinic as a pain medicine physician. So, I'm able to see back pain through the spectrum of the patients coming to the clinic with back pain, and then all the way to them having back surgery, and then recovering from back surgery.

Melanie Cole, MS: So, you really see the whole gamut of this, and it's such a huge problem in this country, really, I mean, just globally. And what do you see with these patients as far as quality of life when they first come to see you? Because pain management, what a burgeoning field that you're in. That's just huge and growing all the time. It's really amazing. What do you see as the difference from when you start working with these patients until when they are done and in their final physical therapy.

Dr Alina Boltunova: So, I see patients in all stages of their journey with back pain, so commonly a patient will come see me in clinic with sometimes weeks of back pain, sometimes years of back pain. So depending on their range of symptoms and the severity of their pain, there's different approaches that we try. In general, back pain is extremely common. Almost everyone, at least up to 90% of us will experience back pain in some point of our lives. And currently, about 8% up to over 20% of people experience chronic back pain or back pain that persists for over 12 weeks. And it can have a significant, negative impact on quality of life, including activities of daily living, being able to work. So, it's something that can be very debilitating.

Melanie Cole, MS: Well, I'm an exercise physiologist, doctor, and I have seen as you have the effect on the quality of life. And I always say nobody can really understand how really awful back pain is unless you've experienced it yourself. So, I know I have. I've crawled on the floor, you know, trying to get myself back up into a chair, but it's definitely something that affects your whole life.

Now, I'd like you to just touch on non-surgical conservative management that you want patients to hear that they generally try when they go first and you can also get into some of the interventions that you yourself practice, maybe Injections where they fit into this continuum of chronic pain before we get into the surgical realm.

Dr Alina Boltunova: Of course. So, most back pain is actually nonspecific. There's many, many different causes to back pain that can include pain from a pinched nerve or a radiculopathy, something that people often refer to as sciatica, which is a non-specific term to describe pain in the back or the leg. People can have musculoskeletal causes of back pain. They can have pain from arthritis in the back. People can also have pain from joint in the back called the sacroiliac joint. So depending on the specific cause of back pain, different therapies can be attempted. For many, many different causes of back pain, physical therapy is an appropriate place to start. The reason physical therapy can be so effective is that it can improve our posture, it can strengthen our muscles in the core and the back, and that can help take the pressure off the joints and the nerves in the back, and again, helps with posture, which can itself be, very, very helpful.

Other modalities to help with back pain include medication management. Usually, we use multi-modal approaches to medication management, meaning that we'll target pain from different angles, including targeting the inflammation component of pain with medicines such as anti-inflammatories or acetaminophen, also known as Tylenol. We'll sometimes use muscle relaxants to help with the muscle component of pain. And there's also many different types of nerve pain medications that can be helpful, especially if someone's having pain from a pinched nerve. Opioids are also sometimes used for the management of chronic back pain. However, studies show that they're not particularly effective for that treatment and also that often the risks of using opioids for back pain outweigh the benefits.

And as far as injections, there's a number of injections that we can try for the management of chronic back pain. These injections do not fix the structural problem, but they can be very helpful for symptom management. For example, an epidural steroid injection, which involves placing corticosteroid medication around a pinched nerve, can be helpful for symptoms of sciatica, for patients who have pain for herniated discs or spinal stenosis.

Other types of injections known as medial branch blocks or a medial branch radiofrequency ablation can be done for patients having pain from arthritis in the back. Sacroiliac joint injections can be done for patients suffering from sacroiliac joint pain, which involves putting steroid medication in that joint. And trigger point injections can be done for muscle pain in the back, which involves basically breaking up the muscle knots with the needle and numbing medication.

Melanie Cole, MS: Well, that is certainly something we've been learning about more and more, is that really stewardship and the new guidelines on the use of opioids and the multi-modal approach that you were discussing. So now, tell us a little bit about the integrated approach to spine care as we're talking about before, during and after surgery. Is ERAS involved? Tell the listeners a little bit about what that multi-modal pain management really is. And if they are someone that is looking to go into surgery, the tools that you have to reduce that opioid use and how this all ties together.

Dr Alina Boltunova: Sure. So, ERAS basically refers to Enhanced Recovery After Surgery protocols that are designed to speed up recovery and improve recovery during and after surgery. So, it's a specific protocol that's used for specific surgeries, where we use multimodal pain medications, again aimed at overall minimizing the use of opioid medications, which tend to be the highest risk, but also geared towards early immobilization and early physical therapy after surgery, and sometimes even certain interventions before surgery in order to optimize care, such as reducing alcohol intake, reducing smoking, improving overall nutritional status and optimizing any other medical conditions the patient may have to improve recovery after surgery.

Melanie Cole, MS: It's really proven to work well. And when patients do this prehab and they work on any comorbid conditions that they may have before they enter into the surgical suite, it really has shown to have better outcomes. Now, what about in the surgical suite itself? What are you doing in the operating room to manage that experience for patients that are suffering from chronic back pain and to make it just a little bit less scary for them?

Dr Alina Boltunova: So, there's a few different approaches that we use in order to help with pain control during and after surgery. There's many different types of pain medications other than opioid medications that can be used in the operating room. So, for instance, Tylenol is a very common, very safe medication that we use, as well as medications such as ketamine. So, ketamine is an anesthetic that's been shown to reduce our tolerance to opioids and also help with pain control. So, it's something that can be helpful during and after surgery for patients. Sometimes for spine surgery, we'll use different types of opioid medications that people may not necessarily be taking in the outpatient settings, such as methadone, which also can provide longer lasting pain relief during and after surgery.

Melanie Cole, MS: Wow. It's really a comprehensive approach. So doctor, before we wrap up, what is your best advice for keeping a healthy back? Let the listeners know what you tell your patients every single day. Whether it's before surgery or when they're done and as they're going on about their life, really without that chronic back pain that is so, so debilitating, what do you tell them every day? And what would you like the key takeaways from this podcast episode on spine care to be?

Dr Alina Boltunova: Back pain is complicated. It has many different elements involved. But the flip side is there's many things that we can do to help prevent back pain or at least prevent it from progressing, getting worse over time. The most important of which is likely staying active. So, physical therapy is extremely important as previously discussed in order to improve our posture, strengthen our muscles in the core and the back. Staying active tends to be very important for pain control in general. It's usually inactivity that makes pain worse. Other things that can be very helpful is maintaining a healthy weight because extra weight can put extra pressure on our joints and nerves in the back.

Additionally, taking care of our mental health is extremely important. There's a strong connection between chronic pain and various mental health conditions. So, getting a handle on anxiety, depression, stress levels can be extremely important and very much have a positive effect on our pain levels when those are under control.

Melanie Cole, MS: Great advice from a true expert. And Dr. Boltunova, this is really important because so many people do suffer from back pain, and you've given us a lot of great information today. Thank you so much for joining us. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back To Health. We'd like to invite our audience to download, subscribe, rate and review Back To Health on Apple Podcasts, Spotify and Google Podcasts. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. We have so much great information there as well. I'm Melanie Cole. Thanks so much for tuning in today.

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