Managing Back Pain (Upper, Middle & Low) with Robert Bolash, MD

Podcast Transcript

Nada: Hi, thank you for joining us. I'm your host, Nada Youssef, and today we have Dr. Robert Bolash, pain management specialist here at Cleveland Clinic and today we're taking your questions regarding back pain management. So if you guys have any questions, make sure you type them in the comments section below, and we'll read them here live, during the session.

So before we get started, please remember this is for informational purposes only. It is not intended to replace your own physician's advice. Thank you so much for coming in today.

Dr. Bolash: Yeah, thanks for having me. It's a good opportunity to talk about a problem that we see often. A lot of people suffer with back pain. Some people, just for short periods of time, or some people for long periods of time. 

Back pain is a topic a lot of my patients come in with, in fact, it's probably the number one, whether it be the low back, neck pain, or the middle part of the back. There's so many options that we have available to them. So I'm really looking forward to some of your questions that come in across Facebook Live here, to talk about your pain issues and how we can help you get some better care for your pain.

Nada: Great, thank you so much. Well do you want to tell our viewers, what you do and give them your title?

Dr. Bolash: Sure, so I'm Assistant Professor of Anesthesiology at Cleveland Clinic. I originally trained as an anesthesiologist, and then I spent some specialty training in pain management.  And so I work on patients that have a whole host of pain problems, including the back pain, with a whole host of treatments, including interventional procedures, minor surgical procedures, medical management, physical management. There's really a whole lot of options for these patients. And I see patients here at Cleveland Clinic at the main campus.

Nada: Great. Thank you. Well to start off, there are many strategies that I'm sure a lot of patients manage pain. When do we go from a general physician to a specialist? When should we go ahead and see a pain management specialist?

Dr. Bolash: That's a good question. If you're not getting the latitude that you need with the treatment that you're working with at present, and you're ... seemed to have maximized some of your options, that's the point in time when we seek evaluation with a pain specialist.

I tell people that we like to have them come in when they're having some sort of functional impairment related to their back pain problems. So whether that be they can't walk around the mall as far as they used to, or whether they can't go to their kids' baseball game, or they can't do some activity that they used to be able to do. At that point it's really interfering with your life, and it's at that time when we sort of look at what options that we have available to people. And there are so many that I hope we get to talk about this hour.

Nada: Yeah, yeah, and we'll start right now. So I have Michael. Can spinal stenosis be reversed?

Dr. Bolash: That's a good question. So spinal stenosis is a condition where the canal, or the bony portion of the spine narrows a bit, and it happens with time. It's not something that's unexpected, but it's something that you sorta earn throughout your life. So as you go from your forties, fifties, sixties, seventies, eighties, that canal gets a little bit more narrow. And when the canal gets narrow, the nerves get pinched off a little bit, and it causes pain when people are walking for a long period, or standing for a long period of time. 

There are so many options that we have for them, and they can go from the very non-invasive options, like medical management, physical therapy, showing people how to walk in a different way in order to open up that spinal canal. Or there's even interventional options. There's different types of injection type procedures. And even surgical options, that our surgeons sometimes remove part of that bone that's pinching this nerve. So there's a whole host of things there that can be done, from very non-invasive to minimally invasive, to things that are done through a needle, to surgical options. So, a whole host of options. It's a real common thing that we see, especially as people kinda get up there in years with age.

Nada: Great, thank you. And we have Alice. How often do steroid epidurals lead to permanent elevation of pain, caused by bulging discs.

Dr. Bolash: That's a good question, Alice. Epidural steroid injections have a very unpredictable outcome. So if I had 100 people, that all had an epidural steroid injection, and 100 people would have 100 different responses. There are some people that will get months, or years of pain relief. There's some people that'll get weeks of pain relief. And there's other people that'll get forever type of pain relief. So it's really a little bit unpredictable.

We know people that are more likely to have less relief, and some people that we're a little bit more optimistic about. But your case is quite specific, and your outcome may be different that your neighbor's, or someone else down the street, just because of the architecture of your spine.

Nada: So would the treatment for them be different, if it's bigger pain versus smaller pain?

Dr. Bolash: Sure. You know we do vary based on your response to the previous epidural steroid injection. So someone who maybe gets, let's say, a year-and-a-half response out of an epidural steroid injection, their treatment may be quite a bit different than the person that only gets, let's say a week, out of ... of pain relief out of an epidural steroid injection.

You know, it's not really feasible to come in every single week for something like that. So we do vary it based on the response that people had to previous injections.

Nada: Okay, great. Thank you. And we have Vanessa. What's your opinion of ... is it fluxion versus extension for lower back pain?

Dr. Bolash: Yes, so flexion versus extension. So flexion is when we're bending our spine forward, like someone's hunched over. And extension is when we're arching our back backwards. Depending on the pain pathology that you have there, Vanessa, there's certain positions that can help or harm different ways. 

So, let's say you have the same pain problem that Mike had called in with earlier, the spinal stenosis. Those patients do a little bit better with flexion activity. Why? Because with flexion, with bending forward, it's really opening up the spine, to allow that nerve to have a little bit more space to move around. So it really depends on your pain problem, in order to determine if you should be focusing more on the flexion-based exercises, or whether you should be focused on the extension-bases exercises. So, it's a good conversation to have with your physician, and your physical therapist, as well.

Nada: Perfect. Thank you. And moving on to Liliana. When you are diagnosed with DISH, what is the approach to treat it?

Dr. Bolash: Yeah, that's a good question. So, DISH is not a very common disease, but it certainly is one that we see from time to time, and is resulting in a significant amount of pain for some patients. 

Again, we have a whole host of options for these patients. We first typically start with conservative options like medical management, physical modalities in order to help you get moving a little bit more. To help you function a little bit more. If that's not getting you where you need to be, then we actually look at minimally invasive strategies to address the DISH disease. All the way up to even surgical options for that, as well.

Nada: And I have Danny. How can I relieve ... is it sacro?

Dr. Bolash: Sacroiliac? Yeah, sacroiliac is a real common one. I'd say definitely one of our top three causes of low back pain. So if you have sacroiliac joint pain, Danny, you're not alone. 
A lot of options for that. So medical and physical modalities are a reasonable thing to start with. We then often would address that joint pain with a corticosteroid or a steroid injection, to see whether or not we can help calm down the inflammation that you have in that joint. 

You know, when that's not getting people long-term relief for the sacroiliac joint pain, sometimes we can even do something that's called a radiofrequency. It's when we use a heated needle around the nerves that go to that joint, in order to keep the pain away for a longer period of time. So radiofrequency ablation is a technique that can really can some people with sacroiliac joint pain some long-term relief.

Nada: Great. Excellent. Thank you.
And then we have Karen. Any remedies for back pain for renal patients?

Dr. Bolash: Yeah, Karen, you hit the nail on the head there. You really do have to be careful. If you are a renal patient, there are certain medications that either need to be avoided entirely, or dosed differently. 

Now, what's going on with that? Some medications can really injure the kidney, especially if you have real borderline kidney function. You want to avoid certain classes of medicines. Those would be the things like the Motrin, Advil, Aleve, that you can buy over-the-counter. They can really actually injure the kidney a bit more. 

There are some other medicines that, for renal patients, we have to dose in a different way. Why is that? Because your kidneys may not be functioning as well as someone else, and so your body's excreting the medicine at a slower rate. And so we make a dose adjustment, based on how well or how poorly your kidneys are functioning. And so we can often plan strategies for these people. But definitely mention the renal issues to your pain physician, or your internal medicine physician, who's treating you for back pain issues, because it's gonna require some adjustments. 

A lot of the interventional procedures are an option for patients with renal issues, as well. But again, make your doctor aware of all your issues related to the kidneys.

Nada: Thank you. Very good information. And then we have Valerie. What are my options for degenerative disc disease?

Dr. Bolash: Yeah, degenerative disc disease is an interesting one there, Valerie. With normal aging, our discs tend to degenerate a little bit. So when we're young, and we're in our teens and twenties, or even early adulthood, your discs have a lot of water within them. And then over time, they unfortunately, they dry out a little bit. And as the disc dries out, it loses a bit of the height. And sometimes, when the height gets lost, we can have pain resulting from the disc, where some painful nerve endings grow into the disc. Or we can have pain from the holes in the side of the spine, the pinching off the nerves on the side.

There's a whole lot of treatments. Again, I feel like I'm going back to the same ones. We have the medical management. We have the physical management. We have interventional management. And in some patients with degenerative disc disease, there's surgical options as well, but I'd really probably try to exhaust the other options, because spine surgery with degenerative disc disease is not quite as successful as some other back pain problems. So try the conservative things first. 

Nada: Okay, great. And then I have Wendy, her left lower back goes numb after a short walk. Does she have a herniated disc, and how does she know?

Dr. Bolash: Yeah, you know Wendy, there's a whole number of reasons why you can have numbness after going for a walk. One potential option is that you have a disc problem. The other potential option is that you have a nerve problem. And there's a whole lot of things that could potentially be going on there in the low back.

You know, when we hear someone describe numbness, especially with activity, it's something that we do like to check out. So I would actually have an evaluation for that to see what's going on, what's the source of the pain. And then really have a strategy that targets the source of your pain. If we just throw things at you, willy-nilly, it's likely that you're not gonna get as good a relief as if you really have a targeted treatment. 

So, first comes understanding the pain problem, from the symptoms that you have. Then may come physical examination, where we're examining and testing your muscle strength. We're looking at sensory deficits, or your ability to feel areas that are numb or not numb. We might even look at some advanced imaging, like MRI, cat scan, x-ray, and things like that. And then really go after the main cause of the numbness, for you, to really target your pain problem.

Nada: Now when parts of our back goes numb, what exactly is happening? Is this a pinched nerve? Is it muscle? What is that?

Dr. Bolash: Often times, it's a pinched nerve. Not always, but often. And I'll give you an example. You know, sometimes you fall asleep with your arm hanging over a chair, or you hit your funny bone, and things like that. You have that nerve-type pain, and you know what it feels like. Or maybe you have a cavity, and the dentist is in there, and he touches the nerve. You know what that zinger feels like. That's typically the description of nerve-type pain. 

And so we ask patients, when they come in for the visit, we say tell us about your pain. And so, when a patient comes to us, they say, well you know pain is pain. It's sorta all the same to me. Well we actually ask you to sorta describe it, because those words, if you say you get electrical sensation or burning sensation, that tells us about a nerve pain. But if you said you had achy pain in your low back, or pain that changes with the weather, it would tell us about a totally different pain problem, and we could really target your pain treatment based on the type of pain problem that you have.

Nada: Great, thank you. And I have Tosca. I'm 83, I don't think it's a good idea to undergo surgery but my lower back pain is not good. Hard to walk, and I have bladder cancer. Underwent a spinal fusion when I was 33 years old. What to do?

Dr. Bolash: Yeah, you know Tosca, there are certainly a lot of options for you. You know, surgery is not right for everyone, and I always think about what's the least invasive option that we have for you. 

There are people that have had pain that persists even though they had a back surgery. I know you had yours about 50 years ago, more than 50 years ago. So I do think having an evaluation of your spine, physical examination, a little bit of a description about your pain, looking at the things that you probably haven't gotten you where you need to be. I certainly think, actually, there are options for you, that can really be tailored to your specific pain problem.

In your case, Tosca, I'd probably actually seek an evaluation with a pain physician, because it sounds like you're a little bit more complicated with having had the back surgery before. If you're in Cleveland area, we'd be happy to see you here at the Cleveland Clinic.

Nada: Great, thank you. And then jumping off to Dave. What are your thoughts on chiropractic care for lower back pain?

Dr. Bolash: Yeah, there's some patients that really get response from chiropractic manipulation. Those are the patients that typically would describe that they have achy pain, they have pain that changes with the weather. They have pain that just sits in the low back. Those are some patients that are really interested in the physical modality for the management of their pain. And we see people do quite well.

You know, I look at these pain problems as sort of a soup, a little bit. You know, you throw a little bit of chiropractic in, you throw a little bit of physical therapy, maybe you throw some medication in, maybe you throw in interventional pain procedure, like an injection. And if each one helps you 20 percent, the final soup at the end is the culmination of all those together. 

So, I think if you're getting some good results with chiropractic treatment for the low back, I think that's a reasonable option. 

Nada: Very, very good to know. Thank you. And then we have Randy. Can you please explain microdiscectomy, and I've heard that this minimally invasive procedure has helped others with issues similar to mine. Thank you.

Dr. Bolash: So yeah, Randy, I'm not a spine surgeon, but I can tell you what I know about microdiscectomy. Microdiscectomy is using smaller tools, smaller incisions, and even cameras with scopes sometimes to remove small portions of the discs. 

Why a lot of people have pain after back surgery is actually not because of the work that's done on the bone or the nerve or the disc. It's actually because the surgeon needs to remove the muscles off of the spine, in order to get down to the target that he or she is working on. 

So the idea with the microdiscectomy is to use these microscopic instruments, to do the least amount of disruption to those muscles, and tendons, in order to help your recovery, even speed along quicker. We see this in other fields as well. They used to, when they took someone's gall bladder out, they used to do a big incision underneath the ribcage, and people would be in the hospital for a long time. Now, when you get your gallbladder out, they make a little puncture incision, and it's this camera. So the back surgeons have just started doing this for the spine as well.

Nada: And the recovery is much less painful?

Dr. Bolash: Usually, it's less painful and quicker, too.

Nada: Wow.

Dr. Bolash: Getting them back onto their feet, doing some therapy afterwards.

Nada: Great. That's amazing. And then we have Marcy. What do you do when you have epidurals, trigger points, opioids do not help with your pain from degenerative disc disease and fibromyalgia?

Dr. Bolash: Yeah, so Marcy, it sounds like you have two different pain problems that are treated in, potentially even two different ways.  We treat the degenerative disc disease a little bit differently than we treat fibromyalgia, so maybe we can certainly take them one at a time. 

Nada: Okay.

Dr. Bolash: So when we think about the treatment for fibromyalgia, that's a condition where people have a hypersensitivity to pain. Or their pain volume is way turned up. Meaning that, they're feeling painful sensation that other people aren't feeling. For instance, if I touch my hand and I touch your hand, you're feeling that sensation as a little bit more painful than I'm feeling it, just as light touch. It's almost like the volume on your pain sensor is turned up a little bit.

We use different types of medications, different types of physical modalities in order to help people with fibromyalgia, or chronic widespread pain. To help turn down that volume a little bit. A lot of that is medical treatment, and things that you're able to do for yourself. So a lot of the physical modality is looking at exercise, looking at your exercise program. Looking at real gentle types of reconditioning activities, to help with the fibromyalgia.

With the degenerative disc disease, sometimes if we have the ability to identify which disc is causing you pain, we can often do a very targeted procedures based on those discs. But we use medications for that, as well as physical modalities. And at times, surgical modalities. But, it sounds like you're two pain problems at the same time that might be treated in slightly different ways. So a little bit more complicated one, as well.

Nada: Mm-hmm (affirmative)-Sure.  And then Sharon. I'm gonna need your help with this one. 

Dr. Bolash: Yeah.

Nada: So I'm gonna need your help here. Spondylolisthesis, grade three with stenosis and DDD be helped and how?

Dr. Bolash: Yeah, spondylolisthesis, that's a tough one. It took me a couple years to pronounce that one, as well. Grade three with stenosis. 

So, let's talk about that word. Spondylolisthesis. If you've ever seen a brick wall, when they build a brick wall, they put the one brick square on top of the next brick, on top of the next brick, on top of the next brick, so that the whole wall is straight up and down. When we have something called spondylolisthesis, one of those bricks is slid forward a little bit. So let's think about our spine. Usually, our spine has each bone lined up one on top of the next, on top of the next, on top of the next. But with spondylolisthesis, it's as if one of those bones is slid forward a little bit. And when it's slid forward a little bit, it can cause pinching of the spinal cord. Pinching of the spinal nerves, that go down to the legs, or even if it occurs up in the neck, it can even go up to the arm. 

The grading of that is grading its severity. So, a grade three spondylolisthesis is certainly something that you want to have evaluated because that tells us that you have quite a bit of slipping of the vertebral body. 

Now, your question was what can be done about that? There's a whole lot of treatments that come from the surgical arm. Moving that brick, or moving that bone back into place to align it with the other ones of the spine is an option for some patients. For other patients, who a surgical option isn't something that they're a candidate for or not something that they're interested in, when that vertebrae has slid forward a little bit, it puts a little stress on structures of the spine that usually aren't stressed, and we can develop pain as a result of stress on those structures. So often times we can often target those particular areas that have more stress than the average vertebral level, and really target those as well. 

For you, I would certainly see a pain specialist, and perhaps even a spine surgeon to evaluate your spondylolisthesis.

Nada: Great.  And then I have a question from Anne, that I think maybe is similar. I have vertebrae pressing on my spine. Is surgery my only option?

Dr. Bolash: No, Anne. Surgery is an option, but not the only option for you. There are a number of things that we can do in order to stabilize your spine, in order to strengthen the muscles of your spine, in order to help decrease pain that you may have as a result of the spine issue that you're suffering with.

It'd be interesting to know the area where you have that pain problem, and certainly the treatment may differ, depending on that area. And to the degree to which you're suffering with the pinching. 
Sometimes when we have very severe amount of the nerve being pinched, people can lose control of their legs. Or they can lose control of muscle tone, and so we treat that a lot different than if you just have it incidentally found on an MRI, or you've been suffering with pain.

So it really depends. There's a couple of these things called red flags, for low back pain. So if you have low back pain that you're not able to control your urine, or not hold onto stool, you're having accidents, that's the kinda thing we want to see people in the emergency room right away. Because that tells us about a problem that's going on quickly. Where if you had back pain that's associated with fevers, or an infection, could potentially have infection or bacteria in your spine. Something again, that we really want to address quite quickly.

If you're not able to, if you wake up one day and you're not able to move your legs or walk or something like that, again that's something that we need to address right away. It wouldn't be something that I just call up and say let's take an appointment in a month, that's something that we need to really intervene on quickly.

Nada: Interesting. Good to know. Thank you. And then I have Debra. What can be done for lumbar stenosis? from neck to SI along with spurs? In pain constantly. I have medication sensitivity, and I've had ablation of lumbar spine. No relief from those. What can be done? I'm not living my life like I want.

Dr. Bolash: Yeah so, Deb, it sounds like pain is really impacting you quite a bit. You're losing some of the activities that you really like to do. 

It sounds like you have a couple of problems. So if you have a problem with the sacroiliac joint, we did touch on that one. That was pain resulting from the joint where the spine meets the pelvis. There's a number of interventional options that we have available for you as well. 

Stenosis is a different issue. Stenosis is describing pinched nerves, or describing the spinal canal, or the spinal cord even potentially being pinched off. So again, we have physical treatments. We have medical treatments. We have interventional treatments. And you've mentioned that you don't want surgery, but we have surgical treatments as well. So many different ways that we have, and we tailor each person's pain treatment to really what resonates with them.

So there's some people that say, like she said, she has multiple medical sensitivities. So people may say, you know, I'm not interested in trying a medication, I'm gonna try the physical modalities, or I'm gonna try the injection type modalities. Or the people that'll come to us and they'll say I never want to have surgery. And we say, okay that's fine, let's work on some of the treatment strategies that we have. 

So we really tailor based on the patients. So if you and I have the same pain problem, and you wanted to do certain things, and I wanted to do certain things, we could sometimes make a pain treatment that works for me, and one that works for you even if we have, even if they're totally different.

Nada: Interesting. That's very good. I have Alison. I've read that injections can cause bone density to decrease, resulting to disability, to fractures, and injuries. Can you speak to this? I've had two in my lower back.

Dr. Bolash: Yeah, Alison, good question there.

So what you're mentioning is the administration of steroid that we sometimes give within these injections. So steroid is just like taking steroid orally. When we give steroid we get the good effects of the steroid, and we get the bad effects of the steroid. And so if you ever see these people that have terrible asthma, or COPD, and they're on steroids for a long period of time, they get all the side effects, which come with steroids. One of which is, decrease in the bone density, over time. You can get thinning of the skin. You can get retaining of water. You can get susceptibility to infection. 

So you mentioned a lowering of bone density. Certainly with repeated injections, and high doses of steroids over long periods of time, you can get weakening of the bones themselves. That's why, when you're meeting with your pain physician, or meeting with any of the physicians that are treating you for back pain related conditions, they're really looking at the treatments that you've already had. The treatments that they're entertaining, and whether or not the risk and the benefit makes sense for your particular condition. 

So for instance, I think we talked earlier about a person who asked, I think they said, how long should I expect to get relief from an epidural injection? Well, we gave two examples. The first one we said, someone got about a year-and-a-half relief, and someone got about a week relief. If we did that person who had a week's relief, if we had them come back to the office every single week, for a whole year, over years, we'd be giving them so much steroid, that we'd probably flip that risk benefit equation for them. Where it would be more risky to give them all this steroid, because of osteoporosis, because of weakening of the bones versus the person that comes in every once in a while, when they have an acute flare-up of chronic low back pain.

Nada: Great. Thank you so much. And then I have Patricia. I just had a back fusion on my L4 - L5, with a bone graft from my hip. It's been four weeks and my hip is still very painful. How long until it doesn't hurt so painfully. I do not believe in taking pain pills.

Dr. Bolash: Yeah, that's a good question there, Patricia.

At times, when the surgeons do something called a spinal fusion, they fuse the bones with a piece of bone that's taken from somewhere else. Sometimes, they'll take it from a cadaver. Sometimes, they'll take it from yourself. It sounds like you had the bone that was taken out of your pelvis, which is a common source of where they take the bone piece from.

It's interesting. Sometimes, we swap one pain problem for another pain problem. So it sounds like you got really good relief from your back pain, and now you're sore from the area where they took this bone graft from. But you're only about four weeks out, and so I'd be really optimistic that you're gonna improve. Because it takes a long time for a bone fracture to heal.

If you think about it, if your broke your arm or you broke your leg, or something like that, they don't just put the cast on for a couple of days or a week. They're letting it on for a couple of weeks at a time. Why? Because it takes bone a long time to heal, compared to if you just got a cut on your skin, which heals pretty quickly. 

So I'd be reassured that you may be improving with time. You're only four weeks out. I'm glad your back is feeling better, and you're hopefully on your way to recovery from the hip pain, too.

Nada: Yes.  Okay, and then we have time for just one more question. I have Edward. I'm always freaking out about becoming addicted to painkillers after surgery. Has anything changed to reduce the odds of becoming addicted?

Dr. Bolash: Yeah, so it's a good question, and we have a lot of people concerned about this. We do use pain medication, and particularly the opioid class of pain medication after surgery. For post-operative pain. 

We can do a very simple risk assessments for people's likelihood or not likelihood for becoming dependent on opioids. And these are actually simple, little, five-question tools that we can use in order to determine whether or not you're high-risk, medium-risk, or low-risk. If you're at very low risk of becoming dependent on one of these medications, they're probably quite safe to use. 

If you're at very high risk, like maybe you've had an addictive problem in the past, or you have a family history of it, severe addiction, or certain mental health conditions that come along with it, it may be that we need to tailor your pain care path in a little bit different way. And you know, at Cleveland Clinic, I saw this week, they're actually doing a number of surgeries and using opioid-free pain relief. So a lot of these nerve blocks, a lot of these catheters. So there's so many options. 

So I wouldn't be apprehensive if surgery is something that you need. I think that working with your surgeon, working with pain specialist at the hospital, in order to find a way that's the safest to manage your post-operative pain, and that's gonna be effective for you. 

Nada: Great. Thank you.  Okay well, that's all the time that we have for today. So you have the floor, is there anything you want to tell our viewers before we let them go?

Dr. Bolash: Well, I think if you're suffering with a pain problem, that is limiting your ability to do some sort of activity that you like to do, whatever that may be, and it's really putting a crimp in your style, I think it's worthwhile to have an evaluation with one of the pain specialists. 

If you're in the Cleveland area, or close to one of the Cleveland Clinics that are across the country, or even internationally, I would be happy to see you or have one of my colleagues see you, to see if we can't get you some better relief.

Nada: Great. Thank you so much.  And for more health tips and information, make sure you're following us on Facebook, Twitter, Instagram and Snapchat. Cleveland Clinic, just one word. And thank you so much for watching. We'll see you next time.