Frequently Asked Questions on Chronic Back and Spine Pain

The most important thing for me as a physician to help you figure out what your underlying problem is that’s causing your symptoms is to get a good history. Do a good physical exam and then put that together with imaging so the imaging for the spine would consist of X-rays and an MRI. The X-rays we get are called flexion and extension X-rays. Nine times out of ten times your primary care doctor or the emergency room does a frontal view and a side view, but the X-rays that we need are a little more advanced than that.

We have you flex forward and then shoot an X-ray. And the reason for that is that if you’re just standing upright oftentimes your vertebrae in your spine are perfectly aligned. But then what happens in some patients is when they bend forward those bones shift off of each other. And the only way for me to pick up that problem is by you bending forward and taking an X-ray and that’s why oftentimes when people come in with their X-rays we have to still sign them for the flexion and the extension and X-rays because if I don’t see that flexion and extension X-ray we can miss the diagnosis.

The other component of imaging that we need to make an accurate and proper diagnosis is an MRI. Some people say well I had an MRI, so I don’t really need X-rays. Unfortunately, that’s not true. MRIs are done with you lying flat when you’re lying flat your vertebrae are also lined up perfectly. When you stand up and bend forward, they shift off. So, I still need those flexion and extension X-rays in addition to the MRI. Otherwise, I could look at an MRI and say well there’s nothing wrong here but then you get an X-ray bending forward and there’s a big shift. And that was the diagnosis. With MRIs, we need them typically done within six months to a year. If an MRI is two years old, we’re talking today about a picture taken two years ago and a lot can change in your back in those two years.

So, the best way to approach the diagnosis and treatment of a back problem or somebody that has an acute problem or pain in their back would be to first figure out is this a new problem. If it’s a new problem typically 90% of people it’s going to get better within the first four weeks just with a little bit of rest maybe some anti-inflammatories you know don’t overdo it don’t try to work through the pain because that’s probably just going to aggravate it because most likely it’s a muscle strain or ligament or tendon tear. A little bit of time and anti-inflammatories will help that settle down and go away.

For patients that have severe leg pain or weakness in their legs or it’s a chronic problem or it’s lasted for more than three or four weeks or it’s so severe you can you know you can’t even get up or go to work that’s kind of you’re in a different category. With those problems, we address more quickly and more thoroughly and the first thing we would do is get X-rays and probably an MRI to really figure out what the underlying problem is. Then after that, once we figure out what the diagnosis is whether that’s a bad or torn disc or a pinched nerve or a herniated disc, we can treat it appropriately with the anti-inflammatories or with some physical therapy or a steroid injection like an epidural thing like that. Chiropractic care can also be very helpful in those situations oftentimes.

Anytime somebody has a back or a neck problem, we always make sure that we try to get them better without surgery, which means number one giving people time. The human body is very powerful, and I believe that it has the ability to heal itself in many cases. So simply giving the body time to just do that is the most reasonable course of action to take first. So, giving the patient time and maybe a few anti-inflammatories to decrease the inflammation.

After that, if it doesn’t get better, we can try physical therapy to strengthen the core and make sure that the muscles in the abdomen and the extensor muscles in your back are balanced.

If that doesn’t help, then oftentimes we go on to injections like epidural steroid injections or facet injections. The little bit of steroid that’s in those injections will decrease the inflammation because steroids are the strongest anti-inflammatory and inflammation is what causes pain. If we get rid of the inflammation people will feel less pain.

We really want to take things in a stepwise fashion from most conservative to non-interventional to more interventional as the symptoms progress or persist.

The best candidates for minimally invasive spinal surgery would be those with problems like foraminal stenosis, herniated discs, or compressed nerves causing sciatica. In those patients, we could do procedures that often take less than an hour. Patients go home about an hour after the procedure. The incisions are less than an inch long.

The way that we do that is we just spread the muscle fibers and place a small tube through the muscle fibers without actually cutting the muscle or cutting the ligament or tendons. When you do the procedure that way there’s much less blood loss, there’s much less anesthesia time, and there’s much less tissue disruption so people have much less post-operative pain and get back to work a lot sooner.

The surgical option is really best for people who fit into probably two different categories. The first category would be somebody who has failed all the other conservative measures. You gave in your body adequate time to try to heal it on its own, which usually means months even years just trying to make the symptoms get better, which can often happen. You tried anti-inflammatories or maybe light pain medications, physical therapy, epidural steroid injections, or maybe even chiropractic care and it’s no longer helping. Or sometimes in the case of physical therapy people even tell me it makes them worse.

Once you’ve failed all those conservative measures and if you have a problem in your back like degenerative disc disease, spinal stenosis, or scoliosis then you may be a surgical candidate. Those patients often will benefit from a minimally invasive procedure that takes less than an hour. They can leave an hour after the procedure and be back to work in a few days. Those patients really fit nicely into the minimally invasive category.

The other group of patients that I referenced that have more severe problems such as weakness in their leg, maybe your foot won’t lift up, or bowel or bladder dysfunction. When you have symptoms like that you really don’t want to wait because those things can become permanent. Also, there are other symptoms that a lot of times people don’t associate with spine problems, for example, balance. If people have difficulty with balance or difficulty with fine motor movements of their hands those two things are often early indicators that there’s actually spinal cord damage occurring from the compression of the spinal cord. In those situations, it’s often important to get the pressure off the spinal cord sooner rather than later and the only way to do that is surgical.

Things that people often do that predisposed themselves to back injuries and recurrence and chronic back pain would be repetitive lifting, twisting, heavy lifting, and also lifting overhead.

Lifting overhead, if you have weight in your hands and you’re just holding it there or you don’t even have to be pushing up really that weight is transferred all the way down through your spine. So if you’re holding 20 pounds here that’s 20 extra pounds on each disk through your back. So heavy lifting overhead is always going to put more pressure on your joints of your back and your discs and lead to them wearing out quicker.

What’s even worse than lifting overhead is actually lifting while you’re bending forward. When you bend forward you put pressure on the discs so bending forward and then lifting is really the ultimate sin for your back. You really want to avoid heavy lifting you definitely want to avoid bending and lifting and extend repetitive twisting as well.

A lot of driving is really a bad for your back and neck too I would see a lot of truck drivers in my practice because they drive for hours and days and years on end and it’s really that subtle up and down vibration that’s just over time just slowly wears out those joints and dips.

Facet injections are typically for patients that have back pain or neck pain and under X-ray, we put a very small needle into the area of the spine that’s called the facet joint so it’s the joint in the back that usually it gets arthritic with age and time and so if we put a little bit of steroid right by that joint it can often decrease the inflammation in the joint and therefore people feel less pain. This is a procedure that takes 2, 3, 4 minutes under X-ray. You go home just minutes afterward.

An anterior lumbar interbody fusion or “ALIF” is a procedure where I and a vascular surgeon make an incision below the belly button, move the blood vessels to the side, and I take the disc out and then put in a spacer block. The reason why we would do that approach through the front that typically we need more stability of the back.

Your underlying problem would typically be degenerative discs, so the disc is wearing out and causing the pain. It’s usually for either that reason or because there’s the instability of the back. There’s an abnormal shifting of the bones or scoliosis. In those scenarios, the name of the game is to get stability, to stabilize the spine. If you don’t get a good fusion with good stability the surgery won’t help you.

The reason why we want to do it through the front as opposed to doing it through the back, which we can do and I do four different scenarios, is because when you go through the front you can get all of the discs out is as compared to some or most of the disc out when you go through the back, and you can put a spacer block in through the front that’s about seven times as big as the one that we put in through the back. So, when you have a graph that seven times is big your chance for fusion is much better in the fusion that you get is much more solid much more rigid giving you that stability that you need. That’s the reason why you’d want an anterior approach as opposed to an all posterior approach.

Micro endoscopic discectomy is for patients that have nerve compression typically from herniated discs or from spinal stenosis. Stenosis just means narrowing, literally, so the spinal canal is narrow where the nerves are running through it and that narrowing is compressing the nerve.

Typically what we do is make less than a one-inch skin incision and I make a little window in the bone, take away a little bit of bone, a little bit of the ligaments, so I can get to the area where the nerves are being compressed and then make more space for the nerves and take the pressure off the nerves. We do that procedure we do through a tube less than an inch in diameter and the tube just spreads the muscle fibers apart so there’s no cutting or stripping of the muscles or the ligaments or the tendon. We’re really preserving the muscular, normal human anatomy and that leads to less blood loss, less post-operative pain, and quicker recovery.

That procedure takes usually about 45 minutes to an hour. Patients usually go home about an hour after the procedure and most people are going back to work in just a couple of days. After about four to six weeks of just taking it easy, there’s no restriction at all. You can go back to playing tennis, golf, playing with the kids or grandkids, whatever you want to do.

Some of the most common causes of low back pain and resultant leg pain are degenerative disc disease of the low back, herniated discs, nerve compression, spinal stenosis, and then there are more complex problems like scoliosis. Any of those things can cause back pain and leg symptoms.

Some of the more minor problems in the back would be like muscle strains or ligament strains and those usually will get better just in time. 90% of people that have back pain an acute onset of back pain their symptoms will improve within four weeks just with rest in the anti-inflammatories. Usually, when people just have an acute episode like that we just say just to take it easy don’t lift heavy things, don’t twist, don’t bend, take some anti-inflammatories with food because they can cause stomach irritation and if it persists beyond a couple of weeks that’s when we start to get into the more diagnostic realm. Let’s get some X-rays and MRI and figure out what the underlying cause is and then that’s when we figure out okay this isn’t a muscle strain this is degenerative disc disease or a herniated disc or spinal stenosis.

If the problem is degenerative disc disease, the disc which is a shock absorber in between the bones, if that’s the problem often times people experience pretty significant back pain and typically anti-inflammatories can help that or physical therapy and sometimes epidural steroid injections. That’s really the treatment algorithm for low back pain initially. When we get past the anti-inflammatories physical therapy and facet injections or back problems that’s when we have the discussion you either live with the symptoms or you have surgery if that’s one of your problems you know herniated this spinal stenosis you know or deformity in the back.

Oftentimes we can do a minimally invasive procedure that’s less than a one-inch skin incision, takes an hour, and you go home an hour afterward. It just depends on what the underlying problem is of course, but probably more than half of my patients are candidates for something like that.

The sciatic nerve is comprised of the nerves in the low back all coming together and traveling down your leg. It’s comprised of the l4 l5 and then s1 through three nerves. Any compression of the L4 through the S3 nerve and give symptoms down the sciatic nerve which people refer to as sciatica. That would be in leg pain or numbness or tingling in the leg.

So, what causes this compression of those nerves in the low back? That could be caused by herniated discs in the back, or from bone spurs, or from bulging discs that contribute to what we call stenosis. Stenosis just means narrowing. So, what are some of the treatments for sciatica for compression or inflammation of the nerves of the low back? Typically, we give them body time to try to heal on its own. It’s my philosophy that many problems in the back will get better just with time as the human body can mend itself. We can often help that along with things like anti-inflammatories or physical therapy to strengthen the core so that your abdominal muscles and your back muscles are nice and strong so that puts less pressure and less micromotion across the pinched nerve and therefore your symptoms slowly ease up and get better.

Another option we’d be an epidural steroid injection where we put a tiny bit of steroid around the nerve that’s being compressed and is inflamed and if we decrease the inflammation of that compression or people feel fewer symptoms.

The last option would be a minimally invasive surgery where we make less than a one-inch skin incision and we just make more space around the nerve, so we take the pressure off the nerve and therefore people feel less of the pain down the leg. That procedure takes about 45 minutes to an hour and you go home and half an hour afterward.

Some of the major causes of neck and upper back pain is a degenerative disease of the discs in your neck. There are seven bones in our neck. We number them from top to bottom: C1, C2, C3, C4, C5, C6, C7. The discs are like the shock absorbers in between the bones and oftentimes with age and time and wear and tear those discs will start to degenerate and wear out and they can get torn when they get worn out and that can be very painful.

Sometimes they’ll herniate back to a piece of the disc will move back into the nerves or the spinal cord and that can cause a lot of neck pain and upper back pain. Oftentimes people talk about their pain between the shoulder blades, what we call inner scapular pain. And nine times out of ten that’s actually from a problem in the neck. The problems in the neck just shoots down and people feel it in between their shoulder blades. So oftentimes degenerated this disease in the neck or herniated disc in the neck that’s actually causing those symptoms so when you have degenerative disc disease in the neck or spinal stenosis in the neck, we always start with the conservative treatments like resting.

Giving it time, anti-inflammatory medication, physical therapy can often help retraction of the compression is often very helpful to just kind of stretch and relax the muscles and the ligaments in your neck and that can often give people pretty significant relief as it takes the pressure off the nerve.

Myelopathy occurs when the spinal cord is damaged and chronic back pain symptoms develop. This condition can occur anywhere along the spinal cord. There are three types: Cervical Myelopathy, Thoracic Myelopathy, and Lumbar Myelopathy. Common symptoms include difficulty with: picking up fine objects like coins or pieces of paper, holding onto things or dropping things unexpectedly, unable to pull buttons through on clothing, and a worsening of handwriting.

In extreme cases, there may be a loss of the function of the bowel or bladder.  Patients may develop pain, weakness, clumsiness, spasticity, and hyperreflexia. Because myelopathy is potentially irreversible it is important to consult your spine specialist to evaluate whether or not you indeed have signs or symptoms of myelopathy.

Stem Cells are very powerful cells in our body that can differentiate into ligaments, muscle, bone, nerves, and oftentimes we use stem cells to help augment healing of the body. The way that I use stem cells is to try to promote bone growth to get bones to solidly grow together and enhance what we’re already trying to do, and this can be very efficacious and beneficial for the patient.

Foraminal Stenosis can be caused by a number of different things. Quite often it’s caused by a herniated or bulging disc that’s compressing a nerve or it could be caused by a bone spur that’s growing off the joint in the back that can also be compressing the nerve. The foramen itself the term just means opening. So, it’s the opening where the nerve comes out of the spine so the herniated disc or the bone spur protrudes into the opening where the nerve is exiting the spine it pinches it. When the nerve gets pinched you can get symptoms of leg pain or numbness or tingling or weakness in the leg and even reflex changes that we pick up on the exam.

So, what are some of the treatments for foraminal stenosis? Typically, we try to give your body time with maybe some help from some anti-inflammatories to decrease the inflammation of that nerve and hopefully you get some relief of your symptoms. Physical therapy can help stabilize the back so there are less micromotion and irritation in the foramen and therefore less irritation of the nerve and hopefully your symptoms subside. Injections like epidural steroid injections can also help to decrease the inflammation of either the herniated disc or the inflammation from the pinched nerve that can also give you some symptomatic relief or pain relief from your leg pain.

The last option would be a minimally invasive procedure to help take the pressure off that nerve directly. The way we do that is we make less than a one-inch skin incision in the back. We make a little window in the bone and ligament to free up the nerve basically taking the pressure off the nerve. That means we could shave down the disc or the bone spur and when we get the pressure off the nerve you get relief of the symptoms in your leg. That procedure takes about 45 minutes to an hour and you leave about an hour afterward.

So how do patients know when it’s time to go see a spine specialist. I would say when their symptoms are such that it’s affecting their activities of daily living or their quality of life. When that is happening, I think it’s time where the person or the patient they owe it to themselves to have an explanation at a minimum. So if you’re having pain to the point of weakness or to the point where you’re missing days of work, you can’t even walk around the mall or the grocery store you can’t play with your kids or go play tennis or golf that’s when I think it’s probably time to get an X-ray or an MRI and see a spine specialist and just try to try to find out what’s going on.

Scoliosis surgery is a lot different than it used to be. Scoliosis is a deformity of the spine where the spine abnormally curves in a direction it’s not supposed to be curving in. Not everybody who has scoliosis needs surgery, not everybody who has scoliosis needs anything. If they don’t feel pain from it and don’t have any weakness of the legs, we just watch it you know periodically maybe once a year we get an X-ray. When it gets to the point that the deformity or the scoliosis is the curve is so large that it’s causing them disability, severe pain, that’s when we consider surgical procedures for scoliosis. There are new techniques that have been developed over the last 10 years surgically that can help address the curve or stabilize the curve so at least it doesn’t get worse that is much more minimally invasive than the past. Some of those procedures mean going in the side through one-and-a-half-inch skin incisions as opposed to the traditional scoliosis surgery where you know maybe a neighbor or friend you know might have had it where their incision is up and down their back. Now we can avoid that in a lot of cases.

The most common questions I get from patients in-office whenever we discuss a fusion procedure would be relative to the loss of motion is number one and number two would be that people are concerned that if they have a fusion that one day they will need another fusion maybe at the next level.

So, the first question, which is actually the most common question, is will I lose motion if I have a fusion. Technically speaking, yes you would lose some motion because we fuse one disk. But most patients, in my experience, when they come back after a successful fusion surgery report back that they either don’t notice any loss of motion and in fact many patients even say that they feel like they have more motion than they did before surgery. This is obviously very counterintuitive but the reason for that is when you’re in pain because you have a bad disc or arthritis in the back or a pinched nerve you’re an under a lot of pain and stress you don’t move as well so you’re not utilizing the goodness that you have. Once we get rid of the bad disc you’re now out of pain and so you’re able to at least utilize the other 25 good discs you have and your hips and knees.

The second issue that people often hear about reading about or ask me about is if I have a fusion at one level is that going to put more stress at the next disc and that’s going to wear out I’m going to require another surgery down the road. I think that’s a great question the statistic is that about 20% of patients who have a fusion will need a next-level fusion within ten years. So, the other way to look at that is about 80% of patients will not.

The other issue we come across when we contemplate this problem is that we don’t really know how many of those people would need a procedure at that next level even if they didn’t have a fusion because maybe that disc was going to wear out regardless.