Low Back Pain - Nitin Bhatia, MD

Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopodTV. Today I have with me Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon who is the Chief of Spine Surgery at University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. Degree. From there he did orthopedic surgery training at UCLA. From there he finished a spine fellowship at the University of Miami. Today he practices complex spine surgery at University of California Irvine. Good day Dr. Bhatia.

Bhatia: Thank you for having me.

Sechrest: Dr. Bhatia what I would like to sort of spend the next few minutes discussing is your general philosophy about low back pain. This is a condition that is epidemic in the United States. 85% of us, of the population is going to have low back pain. An episode of disabling low back pain at some point in their lives. We're all going to get this for the most part. Tell me what you tall patients when they call or they come in and they're concerned that their back pain is a serious problem and they don't know it. They're having their first episode of back pain. How do you as an orthopedic spine surgeon approach that patient and try to take them through this evaluation and treatment plan.

Bhatia: Well, I am glad you asked. This unfortunately is an extremely difficult problem to diagnose and treat and it occurs to almost everybody. As you mentioned, 85% of the US population will be afflicted with back pain. Every year 15% of the population end up seeing their doctors because of back pain. It is actually the second most common cause of visits to a doctor or visits to a medical specialist behind only the common cold or the flu and it costs the US in the upwards of almost 100 billion dollars a year in lost work productivity as well as medical care. So, why is it so common and what do we do about it? People come to me all the time saying boy my back hurts and it is so bad that I can't do things I want to do and unfortunately it's one of the hardest things to diagnose and treat. It's even harder than say a huge disc herniation or spinal stenosis mainly because it's hard to figure out what's causing the pain.

Sechrest: Well, you're right and I think it's so frustrating for patients. Any of us that have episodes of back pain understand this is a very real thing. I mean, it's there, it hurts and you want to get rid of it and you tend to get very excited about it when it occurs to you because this may be the first time you've really had anything bad that you say, this is disabling. I can't live with this. I think all of us know it's very real. When you see that patient who comes in and says I've got back pain and I think it's really bad, how do you counsel them? Do you immediately go and begin getting x-rays, MRI scans, all of these tests or is there something that we should be doing before we do all those things.

Bhatia: Well, the first thing we want to do is sit down and talk with the patient and see how the back pain started and how long it's been going on as well as the quality of the back pain. So, some of the things to really get an idea of is what started the back pain? You know, I see people all the time who for the weekend went out and decided to play sports and garden in the back yard and move furniture and guess what, their back hurts but we have a very clear picture of what caused it and probably for those people with short term or what we call acute back pain, you don't even need x-rays. Really, just a good course of anti-inflammatories and therapy and maybe rest for a day or two can help them a lot. More troubling is the person who says, you know what I've had this back pain for three months or six months and it keeps on going, it doesn't seem to get better. What do we do with them. And, frequently for them because now it's been going on for at least six weeks or longer, we do get x-rays to make sure there is nothing else going on. Some of the warning signs that we talk about, that it could be something more series, even like a tumor or a fracture and infection is pain that's constant, that occurs no matter what activity they're doing, whether lying down, sitting, standing, exercising and pain that occurs at night all the time and wakes people up or stops people from sleeping. Those are a couple of the real warning signs that in the very small percentage of patient's who have something more serious going on can tip us off that there is something significant.

Sechrest: Now, you mentioned that you get x-rays sometimes but that if you feel like there is not anything to warrant x-rays you don't get them. So, if I'm a patient and I go to my doctor, my primary care physician or I go to an Emergency Room or a Now Care and I'm complaining of back pain and they don't order x-rays, that's no reason to be alarmed.

Bhatia: Correct.

Sechrest: We should not demand x-rays or anything like that.

Bhatia: Correct.

Sechrest: And, what about MRI scans? I mean, you know, it's almost today that if you say you've got a pain you're going to get an MRI scan of that area. What about back pain.

Bhatia: Well, you know, an MRI scan, one of the problems with getting MRI scans is that they're very good pests and we see problems in the back or anywhere in the spine that may or may not be causing the pain. So if you get an MRI scan out of 100 people who are completely asymptomatic probably at least 50% of them, if not more, will have abnormalities on the MRI scan but these people have no pain. What we don't want to do is start ordering tests and then saying, oh this is the cause of your pain and so we need to fix that problem. Now, one thing I want to be somewhat specific about is that when we're talking about back pain in this conversation, I'm really talking about pain just in the low back, I'm not talking about pain that's shotting down the legs or sciatica or numbness or weakness in the legs because that's more of what we call radiculopathy and those patients probably do warrant an MRI scan. But, for the patients with the isolated pain in the low back, which is a very common problem, probably an MRI scan is not something that we obtain very early in the problem.

Sechrest: You know, it's interesting because I think that I see a lot of patient's with back pain and I have this sort of routine that I go through when they first come in and we talk with them and one of the things that I tell them that's always a shock to them is that I tell them, you have back pain, we've done some x-rays perhaps, I've done a physical exam, I've listened to the history and the statistics show that in 85% of the cases I don't know what's causing your pain. And only 15% of the cases, even if I get an MRI scan do I really know unequivocally, for sure that I've found the problem of your back pain and that may be too much. Patients are flabbergasted when I tell them that and they think that physicians should have the answer and know exactly whats causing their pain. Now, one of the problems I see is that I do not think that we have, as physicians, a good idea of the structures that are actually causing the pain. We may guess it and unfortunately we tell patients our guesses and they take it for real. So, let's drop back one step and tell me your philosophy in terms of locating that pain generator. One aspect of that is this whole concept of the muscle strain and you've mentioned the person who goes out over the weekend and really roughs himself up and has back pain. I mean, a lot of people would just say well that's a muscle strain or a back strain. We don't really know what we're talking about but we say that. What's your vision of the sources or the pain generators in the back when you think about the back and you're trying to figure out what's causing this pain. What structures are you thinking are most likely to cause pain?

Bhatia: Well, you know, I think what you just talked about is extremely important. I see patients who come in who are wheelchair bound because of problems with their spinal cord and we can fix them and make them walk again. But, we get people who come in and say I have back pain and we can't fix them and we can't even figure out where the pain is coming from and the reason that it's so difficult is that any structure in the back can cause back pain whether it's the bones, the discs, the facet joints which are the joints in the back of the spine, the muscles, the ligaments can all cause pain that the body interprets in the same way and the patient can't come in and say, you know what doctor, my disc at lumbar 4-5 is hurting me. They just say I have pain in this general area but not only can that disc cause that pain, but the facet joints and the muscles and the ligaments, it's all interpreted the same way by the brain and our tests frequently don't show where the problem is. Even MRI scans which are great tests don't very well show problems with muscles or muscle strains or ligumentous or tendinous injuries in the spine and patients ask me all the time, but the test is so good. And, it is, it's a great test, but in ten years we're going to have tests that make MRI scans look ancient and as good as our technology is, it's not perfect and it can't provide all the answers.

Sechrest: You know, it's interesting too, I think one of the disservices we do for patients and I think some of it is our communication, or lack of communication, when we well that patient we don't see anything on their MRI scan, we don't see anything on their CAT scan, we don't see the cause of their pain. They interpret that to mean that we don't believe they have pain and that's not what I mean usually. What it usually means is that I'm sorry you fall in that 85% category that has non specific back pain and I don't know what's causing the pain. And, we can treat you with a fairly good protocol that has been developed by experience that we know most people get better if they just stick with this but we still don't know what was causing the pain. We don't know what made it go away. We just know that we, in a statically significant number of patients we can make the pain go away.

Bhatia: Exactly. And, that's really one of the frustrating things for these patients is they come in with back pain and they figure with, you know, maybe x-rays and maybe an MRI scan we can make the diagnosis but for the vast majority of them we can't and I think a lot of the patients end up being pushed from doctor to doctor to doctor saying there's nothing wrong, there's nothing wrong, there's nothing wrong and now their in pain and they're frustrated and it's emotionally hard because these people want to get back to their normal life and exercise and work but no one's been able to give them an answer and I think it is very important for us as orthopedic surgeons to let the patients know we know that the pain is real but just that the tests aren't good enough to show where it's coming from and we are the patients advocate and we will work with them through a treatment regimen to hopefully get them better.

Sechrest: Well, and the other trap here, and I think that you and I think a like on this but the patient is frustrated and they just wanting something fixed. So, the old addage of don't just stand there, do something and it's hard to convince patients that sometimes the right thing is don't just do something, stand there because we don't want to do something wrong and they ask us. Well, why don't you do exploratory surgery? Why don't you do this type of surgery? I'm willing for you to do anything, why don't you just something and see if it works? I don't think that's a very good idea and I don't know how you feel about that.

Bhatia: You know what, I agree. Spine surgery works wonderfully well with success rates in the 90 percentiles and if we know what's causing the pain, if we identify the pain generator, once we have it identified, our modern techniques are safe, fast, reliable, they work extremely well. The hard part about back pain is it's very difficult to truly identify the pain generator and we have a variety of tests that work okay including tests like a discogram or even the MRI scan for this problem only work okay. And so, the results of any sort of surgery probably are only okay unless you can really identify that pain generator very confidently.

Sechrest: Well, let's step back and try to take some principles away from this so that patients can really understand how folks like you and I think about this and what we would do for ourselves if we were faced with back pain that's lasted for six months and we're still frustrated we can't quite be as active as we want but we don't know what's causing the pain. I doubt either you or I would jump up and ask for an operation.

Bhatia: Absolutely not.

Sechrest: What would we do?

Bhatia: Well, the fundamental treatment for this is exercise, physical therapy and muscle rehabilitation. So, the goal is to create a stabilizing internal brace by strengthening our core muscles. Our abdominal muscles and our low back muscles that become stronger and can help prevent pain in the low back. As we have talked about before, muscle strain is a very common cause of low back pain. And, we get muscle strain and even problems in the bones, discs and joints frequently because there is either abnormal force applied to normal strength or more commonly in modern society we're not quite as strong as we should be. Our jobs no longer are to be hunting and gathering like they were a thousand years ago, we sit at a desk, we drive in a car, we sit at home on a chair or couch or most of us and myself included aren't doing the kind of exercise that we probably should be and the muscles get a little weaker. So, now we apply a force to them, whether it's from gardening or exercise or whatever it may be, maybe even just normal every day forces and those muscles start to spasm and cause pain. So, if we can make the muscles stronger, we can not only help them heal from this episode, but we can prevent future episodes which is critically important.

Sechrest: Yeah, I would agree. I think that one of the big problems is there is this standard sort of belief that all acute back pain, 95% of it gets better in six weeks no matter what you do, whether you treat it or not. What the follow on to that though is that most back pain is recurrent so 90% of those folks are going to have another episode and the best you can do is probably reduce the number of those episodes. The other thing that you brought up, the whole hunting and gathering and strength. A lot of people think about physical therapy and back rehab as a strengthening process. I think it is also critical that people understand how much those hunting and gathering people moved. They had activity and it wasn't just strength but it was movement as well. So, part of the whole physical therapy thing is to get people active. It brings up a concept of fear/avoidance behavior and I think that's a critical thing for people to understand. If we hurt, if we think we're going to hurt and we stop moving we're going to hurt more and you have to sort of get past that and not stop doing things because you fear to do them and that's a critical piece that physical therapy can help us overcome and get us back moving.

Bhatia: Exactly and that's why, you know, patients will come to me and say, boy I've got back pain and we talk about an every day exercise program that I have all my patients start at home and they say well I don't need to go to the physical therapist but I think it is very important to work with the therapists at least in the short term so that they can reteach the patients how to move and that it's okay to move and go back to normal activity and once they believe that, and sometimes it only takes a few sessions, sometimes it takes a little longer, they can do every day activity and exercise on their own. But, for people whose back pain has gotten bad enough where they end up in my office or in their primary care doctor's office, this is a life change. Every morning you have to wake up and do some activity and exercise. Every day it's something that you have to make part of your regular routine like brushing your teeth or the pain will recur.

Sechrest: I agree. Let's talk a little bit about surgical decision making and because some people it is appropriate. We have found the pain generator and it is appropriate for them to consider surgery. When do you begin to counsel patients that perhaps they are better off with surgery and what I'm really looking at here is principles. You know, what sorts of things do you say, now is the time for you to consider surgery?

Bhatia: Well, I think that the very important thing is you have to confidently identify the pain generator and that's not just a dark disc on an MRI scan because everybody gets dark discs. It's a very identifiable cause of pain and then it has to be affecting the patients life significantly and finally, the pain that's coming has to be relayed back to that first identified cause. Once the patient has significant pain from an identified pain generator then they probably are a surgical candidate. Now, fortunately usually back pain is not associated with significant nerve problems or risk or paralisis or anything like this, so surgery is essentially elective if it is needed at all. So, if the patient's quality of life gets bad enough and they have a significant lesion or a significant problem that can be treated with surgery, then they probably are a surgical candidate.

Sechrest: You know it's interesting because I think a lot of people come to us thinking I have back pain, I've had back pain for three months, I need surgery. I mean, I'm due to have surgery. How many patients with back pain, the percentage wise do you really think need surgery?

Bhatia: Very, very low. I mean, in my practice less than 1%.

Sechrest: So, less than 1 in 100 of the patients that you and I see really have to have surgery and need surgery and are better off with surgery. 99% are probably better off treating it conservatively. Well, I think we're definitely on the same page with that. Any other comments or any other things about back pain that you feel like patients need to know when they're faced with back pain and are trying to make decisions about what's appropriate, should I be worried, should I go see a doctor, should I consider surgery?

Bhatia: Well, I think for the patients who are having pain that's ongoing and not getting better, I think it's reasonable to see a doctor, especially their primary care doctor and then get involved in the team approach towards it. So, frequently this approach is headed by their primary physician with physiatrist or pain management doctors, physical therapists and possibly a surgeon involved to try to make sure they get appropriate treatment. Fortunately with this team approch and with a life long commitment to rehab of the muscles and an exercise program, the vast majority of patients don't require any surgery and can live an essentially pain free life but it does take work on the patients part. They have to be willing to commit to that exercise program, they have to be willing to commit to putting their own time in. For the rare patient who does have one really, really bad level and everything else looks great and we can really identify where it's coming from, they do have successful surgery but it's a very, very small percentage and I would tell most patients who have back pain probably the best treatment is conservative care.

Sechrest: So really, if I could summarize, most people don't need surgery, most back pain probably will get better on it's own. That doesn't mean you don't need to do anything, that means that you need to use it as a wake up call and understand that you can do some preventative things. Back pain that is worrisome is those things that you talked about the red flags, pain at night, pain that doesn't go away and then I think we also need to talk about nerve injury. If you've got any sort of weakness, numbness, bowel or bladder complaints, that's a reason to be concerned. But, if it's just back pain and you don't have any of those things, you can probably expect that you won't need surgery but that you probably ought to get busy on your health and get a good program and expect it to improve your situation. Is that accurate.

Bhatia: Well summarized.

Sechrest: Okay, thank you very much.

Bhatia: My pleasure.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.