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 highlighting common injections for back and joint pain. Joining me is Dr. Lisa Witkin. She's the site director of pain medicine at NewYork-Presbyterian Lower Manhattan Hospital and an associate professor of clinical anesthesiology at Weill Cornell Medical College, Cornell University.

Dr. Witkin, thank you so much for joining us today. I'd like you to start by telling us a little bit about joint pain, back pain. I mean, I always say, if you have never experienced back pain, you can't really appreciate the really debilitating quality of it. Tell us a little bit about the scope of what we're discussing here today.

Lisa R. Witkin, MD, MS: Yeah. So back pain and joint pain represent an enormous global health burden. collectively, they affect approximately 1.7 billion people worldwide, and it's the leading cause of disability globally. And then here in the United States, back and joint pain affect over one-third of the population, and it's also the number one driver of healthcare spending across all medical conditions, with estimated direct annual costs of over $380 billion.

Specifically low back pain, it's something that almost everyone will experience over the course of their lifetime at some point, with approximately 84% of people experiencing at least one episode of low back pain. And joint pain is also extremely common, particularly osteoarthritis, and it's a significant reason for, activity limitation across adults in the United States.

Melanie Cole, MS (Host): Those are pretty sobering statistics

I'd like you to tell us a little bit about your field, the pain management. That's a pretty new field. It's a burgeoning field. And since pain is somewhat subjective, how do you measure it when somebody comes to you?

Lisa R. Witkin, MD, MS: Pain management is really an exciting field. It's a multidisciplinary medical field. And so we have specialists kind of across the spectrum from neurology, physiatry, anesthesia, who do specialty training in pain management. and it has undergone a dramatic transformation over the past few decades, really shifting from this opioid-centric treatment model to a biopsychosocial multimodal treatment approach to patients, where we're really now prioritizing function and quality of life and trying to minimize opioid pain medications.

So now the emphasis is really on non-opioid pain medications and non-pharmacologic alternatives, things like physical therapy, acupuncture, cognitive therapy, and then my specialty in particularly is emphasizing targeted interventions or injections that can be really helpful in managing chronic pain. And then as you mentioned, pain, as you know, is subjective. Everybody experiences pain differently, but we try to use objective, standardized, validated instruments to try to understand and quantify, the pain intensity that a patient is experiencing. And also, as I mentioned before, trying to understand the impact of the patient's pain on their overall quality of life.

so one instrument we use is called a numerical rating scale. And this is the most common scale that's used, and we ask patients to rate their pain on a scale of zero to 10, zero being no pain at all and 10 being the worst pain imaginable. then some of the quality of life indicators, that we use commonly in our practice are PROMIS scales, which were developed by the NIH, but help us understand really what is the impact of the patient's pain.

How does it affect their daily activities, their sleep, their mood, their ability to, you know, enjoy themselves and participate in, you know, social roles and functions, et cetera?

Melanie Cole, MS (Host): So if someone has tried physical therapy, they've come to you, they've tried the conservative measures, physical therapy, all of the different modalities, what about injections? How can that help them? Tell us what they are.

Lisa R. Witkin, MD, MS: We can offer really a wide range of procedures to target the underlying pain generator. So, it depends on exactly what's going on with the patient. So, when we meet with a patient, we take a detailed history, do a physical exam, review prior treatments and imaging studies, and part of this is really to understand what are the generators, what are the mechanisms that are causing pain in the patient.

And then depending on the source of the pain, we can offer targeted interventions, and they can serve both diagnostic and therapeutic purposes. So, in other words, it can help us confirm the source of the pain and then treat the underlying pain symptoms. And as I mentioned, it's really most effective when used as part of a multimodal treatment plan in addition to things like medications and physical therapy and alternative therapies. Some of the common procedures that we do include things like trigger point injections, which can help with soft tissue or muscular pain. and then there are a variety of spinal injections that we offer. Epidural steroid injections are the most commonly performed procedure in the United States, and this is an injection of steroid medication directly around the exiting nerve root to help reduce inflammation around a compressed or irritated nerve.

So, this is really helpful for someone, for example, that comes in with sciatica-like symptoms or radicular pain coming from the neck or the low back. another really common injection or intervention we offer is for facet-mediated pain or for the arthritis in the spine. That's also a really common debilitating condition.

We can do targeted injections into those joints themselves, or we can do something called a medial branch block, where we can block the branch of the nerve that provides sensation to these joints. And if patients get good relief, we can do long-lasting procedures, something called a radiofrequency ablation, where we can go in and we can burn and destroy those nerve branches.

They'll grow back, but it can take six months to a year for that to happen and can provide long-lasting pain relief, sometimes more than twenty-four months or two years. And if the pain returns, it is something we can consider repeating. And then another common spine injection is a sacroiliac joint injection.

So again, it's a very common source of pain, low back pain, and we can inject steroid medication under X-ray guidance into this joint In addition to the spinal injections that we reviewed, we can offer a lot of different targeted joint injections as well. And so it's really common to do, intra-articular steroid injections for patients that have osteoarthritis, for example, in the hip, in the knee, and in the shoulder. And this can provide significant pain relief, usually for up to a couple of months.

If they get good relief, we can repeat it, and sometimes we can get a cumulative benefit from that. We can also offer viscosupplementation or hyaluronic acid or gel injections, and this is kind of a steroid-sparing intervention that's FDA-approved for knee osteoarthritis but can be really helpful in lubricating the knee and helping to provide kind of a cushion or shock absorber in the knee for patients who have lost a lot of the cartilage in their knee. this can be really helpful for usually around six months or so, and again, can be repeated if people find that this is helpful. And then in addition, we can also offer targeted nerve blocks. For example, for chronic knee pain, we can do something called genicular nerve blocks. If patients get good relief from this, we can do a radiofrequency ablation, similar to what we can offer for spine-related arthritis, where we can burn and destroy these nerves.

They're peripheral nerves, so they will regenerate, but it can provide long-lasting pain relief for patients of, with chronic knee pain. And again, it can be useful for patients who have arthritis and either are not interested in surgery or not surgical candidates or even in patients who've already had a total knee replacement but continue ha-to have chronic pain.

And similar types of procedures can also be offered for patients with chronic hip pain or chronic shoulder pain, where we can do different nerve blocks, and then offer ablations that can be really helpful as well. So, I think we have a lot of different options that we can offer for joint pain as well as spine-related pain.

Melanie Cole, MS (Host): That's quite a list. I mean, it really is amazing the technology that you have today, and it's a pretty exciting time in your field. There's so many tools that you have in your toolbox to help people with pain. Explain h- a little bit about how you use X-ray and ultrasound technology when you're targeting that source of pain.

Lisa R. Witkin, MD, MS: X-ray and ultrasound are really good techniques where we can use live imaging guidance to ensure both the safety and effectiveness of the injection. They've done, you know, large studies, for example, looking at joint injections to show that a lot of times when people do these blind injections, it's not really going into the space where someone thinks it may be.

But now we can confirm with live imaging exactly where the needle is. so for spine injections, for example, we typically use fluoroscopy or X-ray guidance. That allows us to see exactly where the, the needle is going and targeting the correct structures. Once we get to the appropriate spot, we often use contrast dye to help outline the area of spread of the medication and ensure it's in a correct location.

It's not inside or i-close to a blood vessel or in a different tissue plane. And once we confirm everything looks good, then we deliver the medication, the steroid medication, exactly where we want it to go. Similarly, ultrasound is a technique that uses sound waves instead of radiation to create a live image.

And this is really helpful to visualize soft tissue structure, so blood vessels and particularly nerves. So, a lot of peripheral joint injections, hips, knees, shoulders, and a lot of different nerve blocks we do, we use ultrasound, so we can actually see those nerves and ensure that the medication is spreading safely around those nerves or whatever we're t- you know, targeting with our injection. So, I think it's extremely valuable, and it's made the field much more accurate, much safer, and more effective in terms of the injections and interventions we can offer

Melanie Cole, MS (Host): So what, Dr. Witkin, are some of the biggest myths that you've heard from patients about getting injections?

Lisa R. Witkin, MD, MS: So one common myth is that these injections are dangerous, and the truth is these injections are really very, very safe. Serious complications from any of these spine and joint injections are exceedingly rare, especially when done with a provider that is board-certified, fellowship-trained, and does these all the time and uses imaging guidance, during the injection. Another common myth is that if the injection doesn't work, then there's nothing else that will work, and that's really not true either. As kind of we alluded to earlier, there are a lot of different potential pain generators, a lot of different potential interventions we can offer. Sometimes it takes more than one procedure to see the best relief or the more, most long-lasting and sometimes patients have multiple pain generators that are causing their pain.

It's very common that people coexisting or overlapping conditions, so patients that have arthritis but also have a disc herniation with a pinched nerve causing their symptoms.

Melanie Cole, MS (Host): Well, what about patient selection then? How do you know? I mean, obviously you say if one thing doesn't work, there are other things that you can try. But how do you pick and choose which injection for which patient? Because I imagine you have patients that are athletes all the way up to the way elderly that have arthritic stenosis and all kinds of degenerative disc conditions.

How do you decide, doctor?

Lisa R. Witkin, MD, MS: Yeah. So I think part of it is this shared decision-making model. So again, it's a collaborative process with, the physician and the patient trying to understand what's been going on, how the patient is feeling, what are the sources of the pain, what have they tried before, and what are their values and preferences and goals?

What are they looking to achieve? and as I mentioned before, it's really a combination of the physical therapy, the medications, alternative therapies that work best with the intervention. So I think if patients have already tried over-the-counter pain medications, they've already tried physical therapy, or if they're really suffering and they're in quite severe pain and they can't make it to physical therapy or can't get into some of these other, you know, options because they're in so much pain, then an intervention can really be very helpful and enable them to then participate in the physical therapy that we know is really important. So we work with the patient to try to understand what they're looking for, what they've tried, and what we can offer to help with their symptoms kind of in this multimodal treatment approach

Melanie Cole, MS (Host): Well, I imagine that one of the most frequent questions that you get is how long does it take until they feel some pain relief?

Lisa R. Witkin, MD, MS: So that's a good question. I think it depends a little bit on what we're doing. For a steroid injection, a typical steroid injection for an epidural or for a joint injection, usually within a week or so, it's a gradual kind of onset, but usually within a week up to two weeks, they start to feel significant relief.

With some of the other procedures, particularly the radiofrequency ablation, it can take a couple weeks, two to three weeks to see the full effect. and so there may be kind of a lag, you know, where they have some soreness from the procedure, where they feel some relief immediately after from the procedure from the numbing medication, but the actual therapeutic benefit from the ablation can take a few weeks to really fully kick in.

Melanie Cole, MS (Host): You touched on it a little bit before about how long they typically last and that, you know, depending on the nerve block or what you do. But when people think of how long they last and maybe repeating the procedure, and we've heard over the years that like cortisone shots, for an example, there is, there's a limitation to how many you could have in a year or in a couple of years.

Tell us a little bit about why that is. How long, you know, do they last, and how many are people allowed to get of these?

Lisa R. Witkin, MD, MS: So the duration of relief from these injections is quite variable. and I always tell patients I can never promise exactly how much pain relief you're gonna get and how long it lasts, because again, there is a lot of variability. They tend to be short-term, so weeks to months, for the epidural steroid injections or the, the joint steroid injections.

Although we have some patients that get one injection, and they really need an- don't need anything further. so it really kind of crosses the whole spectrum. In general, though, we do have to be cautious of the cumulative amount of steroid that patients get really over the course of the year. and the current recommendation is really not to do more than four injections at a given site, like at a epidural steroid injection, for example, over the course of a year.

And that's because we know too much steroid is not good for you. It can be associated with a lot of side effects or issues. Some of those things include transient hyperglycemia, so increase in your blood glucose. It can weaken the bones or, you know, cause bone mineral density loss, and it can cause adrenal suppression.

so kind of decrease your body's natural production of cortisol. So it's a safe and effective treatment, but we do have to be cautious of how much steroid patients can get over the course of a year and, and their lifetime

Melanie Cole, MS (Host): Thank you for clearing that up, 'cause I know that that's a common question. Now, after a procedure like this, any of these, how soon can we get back to our daily activities or even an increase in activity like exercise or weights or driving, that sort of thing?

Lisa R. Witkin, MD, MS: Yeah. So usually patients leave and can resume normal activities that day. but we tell them nothing too strenuous or exercise or physical therapy, usually for 48 hours or so, just to prevent any issues. but some people feel pretty good right away

Melanie Cole, MS (Host): You've given us so much great information, Dr. Witkin. So I'd like you to end with not only your best advice about back and joint pain, which, like you said, so many of us will experience, if we haven't already, at some point in our lives. But what are some of the most exciting things that you're seeing on the horizon in this exciting field that you're in?

Lisa R. Witkin, MD, MS: The really great thing about the field of pain management is there are so many innovations in the field and it's constantly changing and there's new technology, new medications. What I'm excited about is the opportunity for neuromodulation, things like spinal cord stimulation and peripheral nerve stimulation, which can be really helpful for specific types of pain.

Spinal cord stimulation is a procedure where we use a tiny device in like a pacemaker and we insert, tiny leads into the epidural space and it essentially can interrupt the transmission of pain signals before they reach, the spinal cord and the brain. And so it can be really helpful for chronic low back pain or chronic radicular pain or sciatica-like pain as well as kind of diabetic nerve pain and other types of chronic pain like CRPS.

And then peripheral nerve stimulation is a similar type of procedure, except this may... There are different companies that make these devices, but some of them are temporary procedures. So it's not a surgical implant, it's not a permanent device, but we can place these tiny wires, these leads around peripheral nerves to help with certain types of chronic pain that maybe is refractory to other types of treatment.

And that can be really helpful peripheral pain or joint pain, you know, hip, shoulder, knee pain, either in patients who are not candidates for surgery or not interested in surgery or maybe they've already had surgery but they still have chronic pain. And so we have really good options, that can provide long-term relief that are non-medication options. So be sure to come see us for an evaluation if you're experiencing chronic pain because we do have a lot of options in our toolbox, and you don't have to suffer. We are here to help you, get your life back

Melanie Cole, MS (Host): Thank you so much, Dr. Witkin, for such great advice and for sharing your incredible expertise on all the different options for injections for joint and back pain. Thank you again 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, iHeart, and Pandora. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast.

I'm Melanie Cole.