Are you among the 80 percent of people who experience back pain at some point in their life?
Dr. Chadi Tannoury discusses conditions that can cause back pain, non-surgical treatment options available, and when minimally invasive surgical interventions might be necessary.
Chadi Tannoury, MD
Dr. Chadi Tannoury was born in Lebanon and earned his medical training at the Lebanese University of Beirut, and completed his Orthopaedic residency at Thomas Jefferson University Hospital in Philadelphia and his fellowship training in Spine surgery at RUSH university medical center in Chicago. Learn more about Dr. Chadi Tannoury
Melanie Cole (Host): If you've ever groaned, "Oh, my aching back," and you are not alone, almost everybody experiences back pain at some point in their lives, and if you have experienced back pain, you know how debilitating it can be. Here to tell us about back pain my guest, Dr. Chadi Tannoury. He's an orthopedic surgeon with Boston Medical Center. Dr. Tannoury, what are some of the most common causes of back pain that you see?
Dr. Chadi Tannoury, MD (Guest): Thanks for your question, and there are many causes for back pain. One of them could be trauma, which is a very common cause of back pain. Others are unidentified causes such as wear and tear and some genetic predisposition to back pain. Now if we look structurally at the back, troubles such as fractures may cause back pain. Other troubles such as disc herniation or disc problems can cause back pain and leg pain symptoms.
Host: Since pain in general is somewhat subjective, tell us a little bit about the difference between a chronic pain issue and an acute pain issue, and how do you measure it so that then you can go to the right area to look and diagnose it?
Dr. Tannoury: Great. So the differentiation between acute and chronic is based on the duration. So in my practice, patients with chronic back pain are patients who have back pain for more than six months. Patients that have acute back pain, typically within a few weeks after those symptoms. And acute back pain can go on to become chronic back pain. Luckily, as you mentioned before, 80% to 90% of these back pains when they have been acute, they self-resolve within six to twelve weeks' period. Unfortunately, 5% to 10% of them persist and may go on to become chronic, and in some people, about 30% of the ones who have chronic back pain, they continue to have recurrence of their back pain every once in a while.
Now it depends on the pathology underlying the cause of the back pain, treatment can differ, and can be different from one patient to another. Typically for acute back pain, we don't investigate with radiology or getting x-rays or MRI, but once the back pain persists beyond eight to ten weeks, at that point we'll go ahead and get an MRI, and get some advanced imaging to help us understand what is causing the back pain, and based on that, we can make a recommendation with regard to a treatment plan.
Host: Then let's talk about the first line of defense, Doctor. If somebody has- whether it's acute or chronic, if it's chronic - degenerative arthritis, or scoliosis, or any number of back issues - what is the first line of defense? Do you look to physical therapy or medications? Things that might help with the pain? Or do you talk about epidurals, and injections, and things like that? Tell us how that process works.
Dr. Tannoury: Great question. So as a physician and a surgeon by training, although surgery is always an option that we have in the back of our mind, it's not the first option- it's not the only option we provide the patient with. We understand that twenty- as we said early, sorry 80% of the patients may improve without any surgical intervention, and they may improve- their back pain may improve on its own with activity modification, with physical therapy, with exercise and lifestyle changes.
So with that being said, the first line of treatment would be the least invasive, which is activity modification, physical therapy, exercise, lifestyle modification, weight loss programs. If patients are currently a smoker, and we know there are studies showing that smoker patients, they have high prevalence of having more severe back pain and longer episodes of back pain. So with that being said, we encourage current smokers to stop smoking. That would be the first line of treatment.
The second line of treatment would be modalities, exercise, apply heat and ice, and continue with physical therapy, along with oral pain medication. The choice of the oral pain medication, typically over-the-counter to start with; Tylenol, Motrin, Aspirin, and try not to overdo it because every medicine despite how benign it is, it can cause side effects.
The third line of treatment would be, if there is evidence of instability or scoliosis, or if there is evidence of nerve compression, an epidural injection may help relieve part of the sciatica pain, as well as other different types of injections may help with the arthritic pain in the back.
And the third option- I'm sorry, the last option would be the surgical intervention depending what is the problem. So if the problem is related to a disc herniation or disc fragment causing pressure on a nerve, this can be removed, and that can be done via a surgery we call laminectomy or discectomy. However, if there are instability in the back that can present itself as a slipped vertebra, or scoliosis, or spondylolisthesis - another term of slipped vertebrae. That can be treated with sensation. So the aim is to stabilize the spine and taking the pressure off the nerve root.
Host: Wow, that's an excellent description, Dr. Tannoury, of the different types of techniques. Tell the listeners a little bit about the difference and the benefits of a minimally invasive procedure. First is traditional. People get a little scared when they hear the word 'back surgery,' but surgery has changed. It's not our grandmother's back surgery anymore. Tell us what's going on in the field, and a little bit about the differences between the two.
Dr. Tannoury: True. Well, thanks for your question. So as you mentioned, technology has influenced the surgery we do these days. Take for instance the telephone. You know, nobody has the big phone that we used to have in the past, now we do have the smartphones. And technology with its development as well has affected the way we do the surgery these days.
So back in the day, we used to have big, large incisions to target small pathology, and nowadays we are able to do a small incision to target the same pathology. The problem with the bigger incision, it's thought to be associated with collateral damages, and that collateral damage happens at the level of the soft tissue and below. That protects the spine, so that includes the muscles, and the nerves, and the soft tissue that surrounds the spine, and in order to access the spine, depending on the size of that incision, it may affect the healing time and the pain and the bleeding that occurred during the surgery and after the surgery.
So a smaller incision is associated with less muscle dissection, less bleeding, less pain after surgery. So it may impact an earlier recovery and less pain during the recovery period so the people or the treated individual may bounce back from the surgery quicker and faster, and re-integrate in the work force, and become productive again.
So that's the premise of the minimally invasive surgery, but I want to caution one thing. There are some studies done on one level fusion and one level decompression, whether it's done via minimally invasive or traditional open surgery, and there are some virtues to the minimally invasive surgery, but up to this point we have not mastered one technique that would present itself as significantly improved from another technique that's minimally invasive. Because we do have now many minimally invasive approaches, and although all of them, they show a trend toward improvement in pain after surgery, less bleeding, faster recovery, we haven't really found the one technique that is going to be the standard of care yet.
Host: Such an interesting field that you're in, Doctor. As we wrap up the segment - it's great information - tell the listeners what you'd like them to know about preventing back pain and possibly acute episodes, as you were discussing. What you'd like them to know about keeping a healthy back, and the role that exercise, physical therapy, yoga, meditation, stretching, and even healthy eating have on our backs, and how we can help ourselves.
Dr. Tannoury: Excellent question. So as we mentioned earlier, 70% to 80% of the time, the back pain is going to resolve. Unfortunately, in 10% to 30% of the time, it may persist and it may recur. Now conditions that may affect the severity of the back pain include medical conditions, lifestyle, occupation, as well age and genetics. So while there are modifiable factors that we can influence in order to improve the back pain or make the recovery faster, there are other factors that we cannot modify.
Let's talk about the modifiable factors. These include the medical conditions underlying diabetes, obesity, and smoking. Those affect the severity of the back pain and they have potential to increase the episodes- the length of the episode or the flare-up of the back pain. So if we're able to have a patient control their diabetes, follow nutrition consultation, as well as a smoking cessation program, that may help with improving their back pain.
Even there was a study done recently in Korea on patients above the age of I believe fifty or sixty, and they have shown that for the ones who walk at least ninety minutes a week, they have a better pain control of their back pain compared to ones that they don't walk or they walk less than ninety minutes a day- ninety minutes a week. So that amounts to about fifteen minutes a day.
So this is just to give you a simple example that even something as simple as walking fifteen minutes a day may improve your back pain symptoms.
Other options would include as well changing in the job environment. Some people are exposed to different job environments, and those can be modified in order to prevent aggravation of underlying conditions in the back and the lower back. Psychological disorder, depression, anxiety; those can be controlled with medication, also they may reduce the back pain symptoms. As you mentioned, exercise and yoga, physical therapy, weight loss; they all fall under the same category of becoming healthier for a better back and better neck pain symptoms.
Host: I agree completely, Dr. Tannoury, and thank you so much for joining us today and sharing your expertise, explaining what's going on in the field of orthopedic surgery and back pain management, and giving us some great advice and tips on keeping a healthy back so that maybe we don't even have to discuss surgery with our physician.
Thank you again for joining us. This is Boston MedTalks with Boston Medical Center. For more information, you can go to www.BMC.org. That's www.BMC.org. This is Melanie Cole, thanks so much for listening.