HHC: Learn How to Have a Healthy Back
Thank you so much for joining me today. My name is Dr. Glenn Russo and I’m one of the surgeons who practices at the Connecticut Orthopaedic Institute at both MidState Medical Center and St. Vincent’s Medical Center. I have particular expertise an adult and pediatric spinal surgery, minimally invasive spinal surgery, and complex spinal deformity. Today I wanted to discuss what’s new in the management of low back pain and sciatica? So I wanted to touch on a few things today. I want to talk about low back pain and sciatica. Is it common and where does it come from? What causes these problems? I wanted to go through the different things that we do to assess low back pain and sciatica in the office and I wanted to go through the different treatment options we can offer for the management of these issues. So, low back pain is extremely common. It actually affects 70 to 85% of population and it’s the second most common reason to visit the doctor’s office. It’s a leading cause of disability and actually represents a very significant cost to our healthcare system. So most patients with low back pain usually recovery without any lasting deficits. It tends to be self limited, which means that it recovers over a defined period of time. Unfortunately, recurrence is very common. For some patients they actually have such significant pain that it tends to develop into a chronic pain issue.
So the first step to understanding low back pain is we need to try to understand, where does it come from? And there are a lot of small structures in the spine, each of which can be the source of this low back pain. There’s the intervertebral discs, which exists between the spine bones or the vertebra. There’s the facet joints which are the small articulations between the spine bones themselves. There is the neural structures, which of the spinal cord in the nerve roots as they travel through the spine and there’s the structure surrounding the spine, the musculature the ligaments, and tendons holding the spine together and then it’s always important to think about the other nearby structures that can present as back pain. Things in the abdomen, the chest and then also understand the mental and emotional aspects of back pain. Stress can be a significant contributor. So when we think about these structures in the spine, we need to understand that each one of them can cause pain if disrupted. So, once we understand the different structures of the spine, it’s important to understand that each of these structures can cause pain when thrown out of sorts. And so the different manifestations of that are things like muscular strain or degenerative disc disease which can provoke pain from the discs themselves.
We can see issues with the facet joints and was terms of facet joint arthritis with the breakdown of cartilage in those facet areas. Instability, or a little bit of excess motion, in the spine can contribute to pain. As can pars defects and deformity, like scoliosis, and certainly things like fractures, tumors, and infection can all precipitate spinal pain. So a common question I get asked is “what exactly is sciatica?”. Sciatica is sort of a general term for radiating pain down the leg. Now, the doctor’s call it lumbar radiculopathy, and again, it’s that radiating pain usually in the area of the buttocks down to the thigh, calf, and sometimes all the way down to the ankle or foot. It can be sharp or dull, constant, or it can come and go. The important thing to understand is that sciatica is a symptom and so our treatment needs to be directed at the underlying cause.
So to help better understand exactly what is the nature of the patient’s pain but also understand where it’s coming from, is that we ask a variety questions in the office. We want understand about the onset of the pain. Was it all of a sudden or did it slowly creep up over time? I want to know if the pain is focal. Is it in one specific area? Is it shooting down the leg? Or is it sort of generalized part of the body? It’s also helpful to know is the pain electric? Is it sharp or is it dull? Does it get improved with medication, with stretching? What makes it better? What makes it worse? And most importantly, we want to understand how does it affect your life? So we look for a few different things to try to better understand where this pain’s coming from and ultimately help guide our treatment. We’ll look at your back and look for any areas of rashes or any changes in your skin. We’ll look at your gait to see how you’re walking and try to get a good sense of your overall spinal alignment. We’ll push on your back and try to see if there’s any areas that are particularly tender, and it’s also important to do a good neurologic evaluation. By that, I mean, we will test the strength and sensation in your legs also look at different reflexes. Sometimes we do different provocative maneuvers or look for different tension signs to try to elicit pain, and again, better understand where this pain is coming from. One thing that’s important to keep in mind when we’re examining a patient are different red flags that could suggest a more dangerous or more problematic cause of low back pain and sciatica. One of these problems would be something like a fracture, so when I’m examining a patient, I ask about history of trauma, I pay attention to their age, and also think about the quality of their bone. I look for things like focal pain or focal deformity and I pay particular attention to the x-rays to see if I can identify any fractures.
Another potential problem would be something like an infection. These would be patients who come in complaining of fevers and chills, weight loss, sometimes they have risk factors for immune suppression. They’ll have fever, tenderness to palpation on their examination and they can even show an elevation in their inflammatory markers, things like their white blood cell count on their laboratory work. This is an important thing to keep in mind as well.
Probably the last big red flag that we keep an eye out for is something like tumor metastatic disease. Now questions that might pertain to this are unexplained weight-loss, night pain or history of cancer. Again, I want to look for tenderness to palpation on my examination and I want to really look at my advanced imaging, the x-rays, but also things like CT and MRI to better understand if that could be contributing to the patient’s pain. In addition to a history and a physical examination, we often perform additional diagnostic studies. This can typically include things like x-rays. Sometimes, we may need even more advanced imaging and that typically includes things like MRI, CT or additional bone scans. Sometimes additional procedures are needed. One such study would be something called electromyography. This is also called an EMG, or even a nerve function test. Steroid injections are another diagnostic procedure that we can do. There’s different types of steroid injections. There’s epidural or caudal epidural steroid injections. There’s also transferaminal injections, facet injections and even sacroiliac injections. Each one targets a different area of the spine and gives us different information. There are a number of things that can cause low back pain and sciatica some of the more common ones are listed here.
We can see muscular ligament strain, degenerative disc disease, or lumbar spondylosis, which is really arthritis of the spine. The sciatica, or that radiating leg pain, can be due to nerve inflammation. The cause of that could be something like a lumbar disc herniation, lumbar stenosis, and even something called piriformis syndrome. Once we have a better sense of the underlying cause for patients pain, we can direct the treatments at those issues. Typically we start with activity modification and that means adjusting or changing the activities that are provoking the pain.
We also talk about medications. This means anti-inflammatory medications, like NSAIDs and we’d also supplement that with additional analgesics or pain medications. Things like Tylenol or narcotics. In patients who have significant pain from muscle spasm, we can consider muscle relaxers, and sometimes we even use steroids.
One of the treatments that’s caught a lot of attention in recent years is the usage of medical marijuana to manage low back and sciatic pain. Medical marijuana is a controlled substance in the United States and many states allow the use of it for the management of pain, nausea, and other issues. Cannabis sativa contains many active compounds, but the two compounds that we typically talk about are THC and CBD. CBD is a compound that’s derived from the hemp plant and is legal under federal law to consume. There are a variety of different applications of medical marijuana the most common is pain control. Many people say that it’s actually safer as compared to opiates because it’s less addictive and more difficult to overdose. It tends to be less restrictive than NSAID medications, so we can use it with patients who have kidney disease and are on blood thinners. Medical marijuana can be used for the management of inflammatory nerve pain and is often described as less sedating than narcotics or muscle relaxers. This is an area of active interest and research. As a community, we are learning more about the science and the different medical applications for marijuana. This is also an area that is undergoing active evolution in the regulations surrounding these medicines.
Another very important way we address low back pain and sciatica is with physical therapy. Physical therapy works in a variety of ways. It works to stretch tight muscles, improve flexibility, and also improve nerve gliding, It strengthens the core and together, this helps correct ones stability, their gait, and their posture. Together, these effects will decrease ones inflammation and hopefully decrease their pain. Physical therapy is often supplemented by additional tools, things like ice, heat, massage, ultrasound, sometimes electrical stimulation, traction, and biofeedback.
Dry needling is also known as intramuscular manual therapy. This is performed in addition to physical therapy and this procedure, a small sterile needle, is inserted at different myofascial trigger points. The idea is to stimulate blood flow into the muscle and allow it to relax and improve pain and mobility and this is fundamentally different than traditional acupuncture.
Chiropractic adjustments are an additional treatment option. These are performed by a chiropractor, who’s specially trained in these maneuvers, and adjustment is really a quick, controlled motion designed to correct the alignment of a joint and improves pain, function and helps promote healing. Additional treatments offered by chiropractors can include traction, postural or exercise education, as well as ergonomic training.
Massage is another technique designed to help soothe muscular pain and spasm. Where pressure is applied to the various areas of the muscles and can be done in a variety of different ways. The idea is to reduce inflammation, stress, and promote healing. Spinal injections were previously mentioned as the diagnostic test, but they can also be used as a treatment. In this procedure, we apply the focal administration of local anesthetics and steroids and it’s usually performed with fluoroscopic guidance. Spinal injections are there for both diagnostic and therapeutic. The goal is to take a little bit of medicine and put it in a very specific spot to see if it helps your pain. In that way, we can identify a very specific pain generator. Unfortunately, there’s a limit to how many that you can have. So very often, I’ll have patients come to my office and say “I’m here because another doctor told me I have spinal stenosis”. What exactly is that? Spinal stenosis is the narrowing of the spinal canal and it’s important to remember that the spine is nothing more than a fancy tube and the spine cord and the nerves run right down the center of that tube. On the left, you’ll see a normal healthy spine and the nerves depicted in yellow. However, on the right, you’ll see the canal has been narrowed. It’s narrowed to a combination of things. There’s discerneations, there’s arthritis with the buildup of bone spurs and thickened ligaments, there’s also inflammation itself. All of these things contribute to crowding the canal space and causing its narrowing and that’s what spinal stenosis is.
Sometimes the narrowing of the spinal canal, or that spinal stenosis, can progress to such an extent it can cause compression of the nerves and cause a variety of symptoms. Some of the symptoms of spinal stenosis are things like limited walking capacity or pain when walking or standing upright. Patients complain of heaviness or cramping in the legs, aching in the calves, the thighs the buttocks. Some patients have radicular pain. That’s that sciatica, that radiating pain going down legs. Some patients notice balance issues and some even describe things like numbness and tingling. So there are a variety of treatment options for spinal stenosis. There’s physical therapy, exercise, and weight-loss. We could always talk about oral medications and if that doesn’t work, we can consider facet injections. In patients who specifically have pain in their buttocks and legs, there’s some surgical options for the treatment of their pain.
So surgery is a tool really focused it’s fixing a specific problem. It’s not a last resort treatment option for anybody with back pain. So the right patient really is somebody who has tried and failed an appropriate course of not operative management. It’s somebody who has a fixable problem, which is specifically buttock or leg pain and it’s somebody who has a structural issue that correlates with their symptoms and that’s often nerve compression, spinal instability, or malalignment.
One particular area of interest for me is minimally invasive spinal surgery. Minimally invasive spinal surgery is more of a philosophy and it’s not really about the size of the incision. The idea, is that you want to minimize soft tissue damage. One of the ways we do that is with a smaller incision, but it also means less damage to the muscles, less blood loss, and reduced risk of infection. The idea is to allow for less postoperative pain, get a faster recovery with less rehabilitation. Here’s a patient who I was working with recently. He had an extra foraminal disc herniation causing severe pain and weakness in his legs. We tried a long course of physical therapy, tried a variety of medications, we even tried a couple steroid injections, which unfortunately only gave him a little relief. The MRI on the left shows this patients disc herniations and the x-rays on the right show the fusion we were able to perform. We were able to take all the pressure off the nerve and stabilize that level and we did all this work in the two incisions that you see here. The way we accomplished this is we use small incisions and tubes to help gain access to the spine. It’s through these portals that we’re able to protect the soft tissues and do all the work that we need to. While it doesn’t replace a surgeon’s thoughtful, meticulous surgical technique, there are other tools that we use to help increase the safety procedures. One additional layer safety from this technology is the advance of computer-guided navigation. The panel on the left shows an array attached to the patient and the center panel shows these same arrays attached to our instruments. These arrays are visualized with an infrared sensor and triangulated in space. A computer shows where these instruments are and helps improve the safety of our procedure by giving us a better understanding of where these instruments are in real time. In a similar fashion, robotic-assisted surgery is starting to become popular and it’s another level of safety to build onto the surgeon’s skill set. In the panel on the left, you can see the various tools one utilizes for robotic-assisted surgery and navigated surgery. Looking at the panels on the right, you can see how one can plan out where they want their screws and their instrumentation to be before the surgery is even started. In the image on the left, you can see the surgeon interacting with the preoperative computer plan. In the image on the right, you can see the array attached to the patient and also that robotic actuated arm. You see the arm itself helping guide the surgeon in three-dimensional space and you can also see the arrays on their instruments.
So in summation low back pain and sciatica pain are very common. We can offer an entire spectrum of treatments to help manage your discomfort. These treatments are designs to target the underlying causes of pain. We can offer medications, physical therapy with other adjunctive therapies attached to them, we can use corticosteroid treatments and for the right patient, we can offer surgical options. There is a variety of different techniques and we can offer a minimally invasive spinal surgery and supplement that with computer-guided navigation and even robotic-assisted surgery, all of which are done to help make these procedures as safe as possible. Thank you so much for your time and for your attention. I hope that you found this helpful. Again my name is Dr. Glenn Russo and hope that you’re feeling well and if I could do anything to be of service, please feel free to give us a call. Thank you.