HHC: Easing Back Pain
Hi, good afternoon, I’m Dr. Gerald Girasole. I’m the director at the St. Vincent’s Medical Center of Orthopedics and the Chief of Spinal Surgery. Today I’d like to take you through a very common problem that we have in our society, is low back pain. I’d like to try to help you understand what causes low back pain and how to either treat it or prevent it from happening.
I’m a board-certified orthopaedic surgeon, but my entire practice is 100% spine. I did a spine fellowship at the New York University Hospital for Joint Disease in New York City. As I mentioned, I’m the Chief of Ortho Spine at the St. Vincent’s and I’m a clinical faculty professor at Quinnipiac Medical School.
My practice consists of both adult and pediatric spinal problems. I do minimally-invasive spinal surgery. I also do deformity and scoliosis disc replacement and now doing robotic spine surgery. Today I’d like to try to take you through the anatomy and physiology, the biomechanics and how we affect, in our bodies, how we affect our back, how we can strengthen our back, and how we do run into problems where we get back pain and give you the common causes of that.
Today I’d like to talk about the psychological, the physical, the pharmacological, procedural, and rehabilitation for treating low back pain. Low back pain is a very common problem in our society. 8 out of 10 patients have back pain. 85% suffer recurrences. Back pain is the 2nd leading cause of why people see their doctor.
Low back pain is the most common cause of missed work. It’s the most common cause of disability in our society. As you can see on this slide, it’s very costly to our society the amount of functional work loss people have because of low back pain. Studies show that bed rest for 2 to 7 days is the worst than ordinary activity. The problem is that most people intuitively think that when they hurt their back, they should cut it down, shut everything down, and sit on the coach and rest it. That is the worst thing you can do because realistically when you hurt your back, the best thing you can do it try to get back to functionality by stretching, moving, and you know, taking anti-inflammatories. So the adage of when you hurt your back to doing nothing is really counter intuitive to how we treat our backs.
Prevention is based on multifactorial. You want to change your environment. You may want to change your work place, your ergonomics and how you deal with your day to day activities. Your morphologies, your size, people that are overweight, people that have weak cores. We need to change our body habits. Changing our attitude, which means education, which we are showing you today to try to understand the nuances of back pain. As you see from this slide, we do a lot of things everyday that is focused completely on our low back. Our low back is how we get through life and there are proper ways of doing things such as lifting, bending, and doing our daily chores. Are you at risk? Are you overweight? Do you not exercise? Do you not engage in recreational activities? Are you a smoker? All of these things come to play when we deal with low back pain.
The functions of the spine, as you can see, there’s many different motions that we do through our ordinary daily life like getting out of bed, walking, bending over to put our shoes on. This is the main function of the spine, is to orchestrate this for the rest of our body. As you can see on this slide, this is the outline of the vertebral body which shows, if you look there, it says Zygopophyseal Joint, that’s the facet joint. What these joints are in your back is analogous to your knee, your shoulder. These are actually what we call synovial joints. They have fluid in it, they allow the back to move in unison. So, at every level of the spine, there are these joints, so when you bend and flex, the joints bend and flex. Most of the problems that deal with the back and, so called, “I pulled my back out” has to do with an injury to these joints.
The next part you want to know, for anatomical reasons, is the disc. The disc sits, if you look here, it would sit right on top of here. These yellow structures discs and the discs are avascular structures and that not only give a cushion or support to the spine, but as you can see, the nerves exits at each level. It allows room for the nerve to exit so when we injure our discs, it’s not only a herniation, where there’s a pressure on the nerve, but also that this can degenerate and causing the bones to get closer together. Analogous to this is the oreo cookie, so think of the cream being the disc and the cookies being the bone. If I take the cream out of it the cookies come close together and that’s what sometimes what happens when people get pinched nerves in their back. The intervertebral discs run throughout the entire spine and as mentioned here I mentioned before, it allows compressive tensile and rotational motion. It is the largest avascular structure in our body. Avascular means there is no blood supply to the disc. Similar to the cartilage in your knee that when you tear these or you damaged the disc, it is very difficult you cannot repair it because there’s no blood supply. Blood supply would bring nutrients and the ability of the body to repair it but because there is no blood supply you can’t repair it. So, most times when you damage the disc, it’s a final product. So how does the disc get nutrients if it doesn’t get a blood supply? So that’s the importance of standing and sleeping. When you stand, the pressure comes in and it’s like in your spine is like an accordion and it pushes the disc down and that allows all the waste and it clears out the disc. Then at night when you’re lying supine or lying in a position the accordion opens and then it allows everything to flow in. This is an osmotic gradient and that’s how the disc nourishes itself.
This is showing you a rendition of what happens in the degeneration on the right side of the slide you see the top you see that nice. Now I’m going to use another food analogy, a sunny-side up egg. So think of the egg yolk part being the disc itself at the center of the disk and then the white part being the periphery which holds it together, so if you look at that slide the top, what you’re seeing on one side is what we call the sagittal view which is looking at the disc, it’s nice and plump and on the other side you’re seeing the cross-sectional view and that shows how this affects the nerves. If you follow it down and in progression you can see the bottom that that is a very degenerative disc with a disc is completely collapsed and it’s starting to get pressure and it puts pressure on the nerves and if you look at the cross-sectional view, which is the bottom left, you can see that there’s not a nice circle there anymore. Things have grown in there and cause compression and this is what one of the main causes of how we get back pain and nerve pain.
So when we think of all the common problems of why we get back pain, it’s really broken down into these two anatomic structures. The disc, which is here, and the Facet Joint, which is here. The disks allowed torsional stability and support 80% of the load on the spine and the joints also support 50% of torsion and resistance and support 60% of load. So if you damaged one of these, it affects the other. The natural history of the three joint complex being that the disc in the joints on one side you see as the disc degenerates, you get these tears in the disc. They physically tear where, think of that sunny side up egg that I talked to you about. When the yolk runs, the yellow runs through the white. That’s the tear. What happens on the other side is the joints are covered by what’s called a capsule. Think of it like a cap; a hat on it and the capsule keeps the joint in good form and keeps fluid around it. As the joint gets irritated from the disc, it causes this reaction is called a synovial reaction cause the fluid is called synovium and causes irritation and back pain. As this starts to progress, the tears become more prominent and the tears become bigger as you could see on this in the middle of picture and then what happens as the tears get bigger, it affects the joints in the back and the capsule becomes what’s called “lax”. Lax means it’s not as nice, tight fit and it allows the joints to move abnormally. And the end result, as you see here, is you get disk space narrowing so the cookies all out the disc is completely dried up, it collapses, and then what happens to the joints, the joints now that the capsules not holding it, the joint subluxed which means one bone goes in front of the other. If you look in the middle slide you see that the L4 bone is pushed ahead of the L5 bone. This is classically known as spondylolisthesis which is one of the most common causes of people having either back pain or nerve pain.
This slide I just showed you, the natural degenerative Cascade as we get older our body gets older and things start to generate however the misnomer is that the generation means like old age, it doesn’t. You can have degenerative disc disease at younger ages, but the natural progression and loss of function as you see from the slide deals with the damage to the discs and the joints.
Simple rule, almost all back pain is due to poor muscle tone, lack of exercise, poor posture, poor body mechanics, stressful living and stressful work habits, loss of strength and flexibility, and excessive weight all lead to back disorders.
The most common disorders that we have are acute strains and sprains. People don’t pull their back, that’s a real, very common saying. You really, if you injure your back, injuring the joints in the back which then lead to a reaction the body has a mechanism to try to protect things so what happens is the muscles in your back tighten up to protect it and that’s what causes really the spasm in the pain. It is not actually the pulling of any muscle or any structure. As you can see, most spinal conditions, the word idiopathic means, it just happens. So I mean everybody thinks of traumatic events and it doesn’t always have to be trauma I tell patients all the time you could have injured your back or herniated discs living in a glass jar it doesn’t have to be traumatic however, yes, when you do things like “oh I’m going to lift this heavy thing and throw it up into my closet”, yeah that can really lead to increased back pain, but most of this is idiopathic, which means it just occurs.
What happens with age? You see that nice, young guy here. He’s got a beautiful looking spine you can see that the disks are nice and plump you look at that, if you look at the MRI the the disks that you’re looking at which these are yellow, they’re white on the MRI, look nice and healthy and all nice normal height. And unfortunately the older gentleman you can see that his spine looks a little degenerative. You can see there’s collapse in his disc spaces, the alignment of his spine is not as normal and this does occur with age. Also, it can occur due to your genetics. Yes, your dad or mom could have gave this to you, however some environmental factors like this gentleman lifting these heavy loads can put trauma to his back so it doesn’t always have to be somebody of that is getting older, it just could be how we treat our backs or how we don’t treat our backs meaning that we don’t exercise and we don’t strengthen our core.
Degenerative conditions always involve the joints, the discs, and there was a degenerative conditions a very common word, most people know it called “Spinal Stenosis”. What spinal stenosis is, is narrowing of the natural cylinder where our nerves are kept. So, if you look at this model and this is a cross-sectional model of that model I had, there’s this yellow is your nerves and it goes through the spine and you can see there’s like a circle. Well, anything that impedes that circle to generation, collapse, anything can make that smaller that’s known as spinal stenosis. Spondylolisthesis is when I showed you how the bone, one bone slips in front of the other due to degeneration.
Sports can cause injuries. There’s a lot of different injuries that can occur, as you see that skier who missed the slope and looks like it’s in a lot of pain. The Weekend Warriors, the young kids being wrestling, tennis players. Look at the amount of torque that this tennis and golfer put on their back. If they have a weak core, they put so much strain on those joints causing them to have injury to the joints, so there’s the importance of we’ll get to the core exercises, on how you need to have a good strong core not only to prevent back pain, but to do the quality things you want to do in your life. In 2012 I published a book called 7-Minute Back Pain Solution. I did this with a patient of mine, actually, who I thought I had to operate on. She had severe degenerative disc disease. She was in great shape, but her discs were bone-on-bone. But she worked through it and I met her in a gym 5 years later and she was doing great and she has this wonderful exercises that we collaborated on and produce this book which will help you get through either to prevent back pain but to also try to help your back pain when it occurs.
Treating back pain all breaks down to training the core. People have a misnomer about what the core muscles are. They think it’s their abdomen and say “yeah, I do sit-ups”. Well, sit ups, the abdomen is a fifth of the core. If you think about it, your belt in your pants and how it goes circumferential around your body, all of the muscles around your body equal the core. It is your back extensor muscles, your abdominal muscles, your gluteus muscles. All of these muscles work together and if you train them and strengthen them, you will be better off in your life and it’s also helpful to prevent back pain. As you see, with core stability, it stabilizes you in every facet of your life whether you are a laborer or even working on a computer at home, you need to stabilize your core. Just by sitting at your desk and pulling your belly button in and sucking it in and holding it and repeating that is part of core training and strengthening.
This slide shows the actual musculature. This is only in the front of your spine, the local muscles and then you have your your, what we call the six pack the transverse abdominis and your global muscles with your external obliques, your erectus spinae, and your rectus abdominis. There’s many different layers to that six-pack that we need to work on.
The benefits of strengthening the core are not only to transfer energy to correct posture imbalances, prevent injuries, and develop functional fitness. People say “well I’m not an athlete, why do I care?” Well, you have to care. When you have a good core and you work out and you train these muscles, you help your cardiac and you pulmonary health, you reduce your fat and weight loss, you strengthen your trunk, and you put pressure away from your lower back. Right now people that don’t do anything and really do not exercise they put all the forces to them put to their lower spine and into where their spine meets the pelvis and the amount of force that’s put there, if we have weak core, that’s where the most common causes of back pain in the most common areas that’s why everybody says low back pain because all the forces go there. When you have a strong core, it disperses the weight and the ability for your body to do things to all the other muscles.
Basic exercises, it increases blood flow, calories are burned, fat content is decreased, and core training is very important in pregnant women because obviously they’re carrying a load in the front of their spine which puts pressure on their back. We have total programs for pregnant women to work out their core.
This is an excellent exercise, it’s called a Russian Twist where you work out your obliques and if you look here he’s not working out of central abdomen, he’s working out the the muscles on the obliques are on the side of your body. Getting a simple ball like this, there are numerous, you can go on YouTube and you can find numerous exercises to strengthen your core and it can handle strengthening your upper abdomen, your lower abdomen, your gluteus, your back extensors all with this is very simple very inexpensive tool.
In this slide, you see this gentleman doing what’s called a plank. Planks can be done in various positions. He’s doing it on his elbows, which makes it slightly harder, increases your core strength, you can do it on your hands and you can do it on your side. He’s obviously advanced. I don’t recommend for the first time goers to use the weight, but obviously you can progress and increase your core strength.
We’ve gone through how we prevent back pain and when we’re in back pain how we can get out of it by doing core exercises. Obviously, not everyone who hurts their back can get out of it through an exercise and there are other treatment modalities that we need to do that I’d like to briefly touch up on.
There’s always three tiers of treatment. There’s the non-operative treatment, which I explain, which is exercise and strengthening. Sometimes that’s not enough and the other option, we would move up, which is slightly invasive but it’s very common practice, are steroid injections. We can inject medicine, a steroid, which is like a very super anti-inflammatory into the facet joints or into the area where the the discs are, to try to decrease inflammation and help people with back pain. And of course the third tier is when they fail all this and the quality of your life is such that they require surgery. Surgery is the next form of treatment.
This slide shows you injections. The patient is awake, lying on the table in what we call the “prone position”, on their stomach, and the doctor who delivers the injection, uses a special image called a fluoroscopy and therefore the doctors able to see the actual level where he’s putting it in the spine. And as you see the needle, the needle in there is put into the joint itself. This is due to try to reduce the spasm in the joint and thereby decreasing pain. When the injection is put into the disc space, it’s not like a draino, it doesn’t really diminish the size of the disc. What it does do is to fold other theorie. One, it decreases the inflammation around the nerve which helps the pain and two, it decreases this acidic environment that herniations do when the nerve to live in and thereby neutralizing the pain.
If it comes to surgery, knowing the rules is very important. You need to know the risks of surgery. All surgical procedures have risks. Albeit, they’re very uncommon, but they have risks and you should understand that. You should understand the quality of life. How will this surgery help me? Feel good about the decision? A confident patient that goes into surgery is the one that does the best. Maintain a positive attitude. Sure you’re going to be nervous, but know that you’re doing the right thing for yourself. Follow what the surgeon instructs you and focus on the improvement of the quality of your life. One of the biggest warning signs I tell patients is we don’t operate on MRI’s. Make sure that your doctor is not just relying on the radiographic tests. He or she needs to correlate that with you. You need to examine somebody. We match people’s problems with your MRIs. If they don’t match, then that’s where failed surgery comes into play.
We’ve come a long way in spinal surgery and we do what’s called minimally invasive spinal surgery. There are many different types of minimally invasive spinal surgery. It’s a very vast term. The object behind minimally invasive spinal surgery is to do the surgery with less incision, quicker recovery, and less morbidity after the surgery. There are many minimal invasive techniques, as I said, and the one that’s used very commonly is if you have a herniated disc. As you see the rendition on the left side of the screen, the disc has herniated. Remember that sunny side up egg we talked about? The yoke has run out into the periphery and is pushing on that nerve causing compression and what we call sciatica. The center picture shows you that actual rupture as the disc has ruptured through and is putting pressure on the nerve that it’s pointing to with the arrow, that would be the nerve on your left side of your body. The right sided picture shows it too, where we can make a very small incision, use this to that we can funnel down a path to get to the top of the joint and get into where this disk is herniated and remove the disc. This could all be done with a very, very small incision.
Minimally invasive surgery has been helped tremendously by robotic guidance and navigation. Robotic guidance navigation is a way that we can see the 3D anatomy of a patient without having to make an incision. We are basically doing the surgery on a computer and then having the computer put the arm, which you see in the middle of this picture, in the area we wanted to go and we can place our instrumentation, we can take our discs out and it’s very precise. Think of it like a GPS for your car. How many people use maps when they go somewhere anymore? No I remember the days we pull out the map and try to map out our journey. Now we do everything with GPS in our cars. Surgery is becoming that way where we’re, it’s not taking away what the surgeons needs or qualifications are, but it’s guiding that surgeon to become a better surgeon and work through the anatomy of a three-dimensional picture through the robot. This is actually part of the robot machine you see that the there’s an arm there, it looks like a drill, and then you see the computer that’s sitting on the stand. We put your anatomy into the computer and then we actually physically, as we would in the body, we place the screws in the exact point we want them onto the screen that you see, that black screen, and then, when we have you on the table, we push a button and that arm will go to your exact anatomic spot where we can work through there to do our placement of our instrumentation or whatever we need to do. This is a picture of the set up in the room. So as you see, the patient would be lying what we call the prone position or even on the side position, there’s many different ways we can do it now that we have the computer. You have a camera that was attached to a stand that localizes, what they’re called, fiduciary points which is that integrated instrument you see and that is attached to your body. The camera sees your body’s anatomy and then translates into the touch screen and then we play with the touch screen and do the surgery on the touch screen and then when we’re ready to do the procedure we can hit buttons and say “put the screw in at this location”, that arm would come into play and be right over the anatomic spot. That arm is rigid. It will never move you can put all your weight on it so there’s no chance of that getting out of place. This is the actual physical arm and once it locks into place, you can see I can use various instruments to put into the body to do what I need to do whether it’s clean the disc out or put in screws to stabilize the spine. Those balls that are on in front of that instrument is how the camera reads the patient’s anatomy. In a nutshell, these are all the components you see. You have the camera, the touchscreen, and the actual robotic arm all-in-one. This is what’s in the operating room when we’re doing the operation. This is actually showing you the physical outlay where you see the doctors on one side, his assistant is on the other, the patient is lying on, what we call, the prone position, and that arm is hovering over the anatomical spot that we’re going to operate. In the back, you see what’s called the scrub tech. That’s the tech that will tell them, “please give me a size certain screw” or whatever we need and they would put it into the field of that we’re working in. This is just showing you the actual computer. So you can see on the computer, you can see on the top, on the left side, the top you see the patient’s anatomy. It’s looking somewhat like this where you see the actual anatomical levels and then what you see on the bottom or those are the screws. I put those screws in virtually on the computer so that says it’s L3 so then when I’m ready to put the screws in the L3 bone, I hit the computer and say “put the screws on the L3 bone” and the computer arm will go right to that area and will lock right over that L3 entrance point and be exactly how I put the screws on the computer. So why I said that it doesn’t take a place at the of the surgeon, the surgeon still has to know how to put screws in, has to know where the screws, the size of the screw, the diameter of the screws, but we don’t have to do with such that now we’re doing in our three-dimensional CAT scan so the precision of this is definitely increased.
I’d like to personally thank you for joining me today. I hope you found this webinar both educational and enjoyable. We at St. Vincent’s Medical Center Department of Orthopedics and Spine plan to be doing more of these to try to educate our population. I’m very excited to see the things that are happening at St. Vincent’s, building a state of the art institute to treat both orthopedic injuries and spinal injuries. Thank you so much and have a great day.