Apr 26, 2022

Interviewer: Before considering surgery for back pain, there could be other options you might want to consider first. Dr. Andrew Joyce is a physical medicine and rehabilitation specialist, focuses on non-surgical treatment of various muscle and spine issues. So here's a scenario. A patient has been told by another provider that their back pain might benefit from surgery. They come to you for a second opinion or just wanting to know if there's something that they can do before surgery. First question is there?

Dr. Joyce: Definitely. In the vast majority of cases, there's something that we can offer to at least try to ameliorate the pain before jumping to surgery. There's a variety of treatments that we look at, whether it be medications, therapies, modalities, or procedures to go and help manage people's pain.

Interviewer: And does that happen often that you end up talking to a patient that has been told surgery is what is going to help with their back pain and have not been told about some of these other options?

Dr. Joyce: Yes. I would say, you know, we're fortunate here at the university because most of the way our referrals are sent in, they get sent to us first to evaluate for non-operative treatments before we decide whether or not the patient would really benefit from surgery. But in the community, that's not always the case. And so it's not uncommon for patients to have back pain or pain originating from their back and sciatica, who see another provider who offers them surgery, and then come to us for a second opinion to see what else we can do.

Interviewer: Let's talk about some of the options that somebody might take. Where do you start that conversation?

Dr. Joyce: The first thing we do is we try to get a comprehensive physical and history from the patient. And what we're looking for is to try to identify what the exact source of the pain is. And so we'll review with you, you know, the history of your pain, where exactly is it located, we'll take a look at imaging, and we'll look at different other medical conditions which may factor into our decision. And then once we've looked at all of that, we'll discuss the different options that we can use for different procedures. And so it varies depending a little bit on which diagnosis we think you have.

Interviewer: And I think a lot of times patients think these non-surgical options tend to be like some sort of like a cortisone injection or something like that, which is definitely an option, but there are other options as well. So walk me through some of those options and how they might apply to a patient.

Dr. Joyce: So the most common injection and the ones that people call, you know, cortisone injections are basically steroid injections. And what matters is not necessarily that you're injecting steroid, it matters where you're injecting the steroids. So we use these steroid injections in various parts of the body depending on where we think your pain is coming from. So if you're having pain that's caused by a herniated disc pressing on a nerve, well then we would do an epidural steroid injection, where we place steroid in and around the epidural space to bathe that nerve and calm down any inflammation and irritation that's happening to the nerve. On the other hand, if you're having pain that we think is coming from your sacroiliac joint, which is a large joint at the base of the spine, then we would inject the steroid into the sacroiliac joint and use that to calm down inflammation and irritation to the area.

Interviewer: And then other than the injections, what are some of the other options that you can offer a patient and what situation with those apply?

Dr. Joyce: Some of the more common things when people have arthritis related pain in their back, we do a series of procedures where we do test blocks to help determine if the arthritis is truly the source of the pain. And those are called medial branch blocks. And if patients do feel substantially better after those test blocks, then there's another procedure called radiofrequency ablation, where we actually burn those little tiny branches of nerves that go to the joints and help relieve the pain. And those can actually be very durable. They can often last anywhere from six months to a year and a half, at which point we can repeat it and get similar pain relief.

Interviewer: And then I've also heard of electrical stimulation. Is that another option?

Dr. Joyce: Yeah, and this is kind of an emerging technology. Spinal cord stimulation itself has actually existed for over 50 years. But in the past 10 to 15 years, there's been huge advances in the technology that we can use for it. Now this is almost never a first line treatment that we use. But for people who are having severe pain in their back and aren't getting better, we can use electricity to kind of help modulate the pain signals. And so that involves putting electrical leads either in the epidural space behind the spinal cord or even more superficially, around nerves in the low back to help block the pain signals.

Interviewer: And then does the type of treatment that we've talked about, we've talked about injections, we've talked about the burning the nerves, we've talked about the electrical stimulation, does that really, really depend on the type of pain somebody has? Or are those options suitable for all types of pain and you just kind of cycle through one after another? I mean, is there some sort of a procedure you like to go through?

Dr. Joyce: No. Yeah, it definitely depends on the type of pain and where the source of the pain is. So, you know, if your pain is coming from purely the arthritis in your back and I do an epidural steroid injection, I'm not expecting you to get substantial relief of that pain. So it really depends on where the pain is. And where this becomes more complicated is when patients have more than one thing going on, right? It's not uncommon for patients to have arthritis in their back, that then causes some pressure on a nerve. And so they have more than one thing going on. And so then, in those cases, we will use more than one of these types of procedures to help with their pain. But really, it depends on what the source of their pain is.

Interviewer: And I'm kind of getting the feeling that back pain can be kind of a complicated thing. I mean, it sounds like you have to know what's causing it and then what treatments are the most effective for that type of pain, depending on what kind of pain, what's causing it, the location. How often just kind of after a couple of visits do patients find relief, versus you've kind of got to look a little bit further in the cases where patients might have multiple things going on?

Dr. Joyce: It depends on the patient. I would say, you know, for many of our more acute patients, so patients who have had pain for between 6 and 12 weeks, those patients tend to, on average, do a lot better, because they haven't had the pain for quite so long and oftentimes it's less complex. But certainly, when it gets more complicated, sometimes it does take a little bit of trial and error and some searching. And sometimes these injections can actually be helpful, both therapeutically to help people with their pain, but also diagnostically to help us determine the exact source of pain and help us get a better treatment program put together.

Interviewer: Kind of a mystery that you have to unravel in that case.

Dr. Joyce: Exactly.

Interviewer: Yeah. And then at what point would you even recommend somebody for surgery?

Dr. Joyce: Most common reasons that I will have someone be seen by surgery is back pain or neck pain going down their arms or their legs, with associated numbness, tingling, and in particular weakness. When people are having symptoms that are causing, you know, objective findings on our examination when they're objectively weak, that's when surgery is most indicated. And that's oftentimes when I will send them to surgeons earlier rather than later because we don't want patients to be left with any sort of neurological problems long term. And surgery is the only way to decompress nerves and help prevent that from happening.

Interviewer: Is weakness generally always a sign you're going to be sending somebody to surgery or not always?

Dr. Joyce: So it depends a little bit on having objective weakness, but also on the pattern of weakness. So we know certain nerves in the body go to certain muscles. And so we'd expect that if a nerve is being compressed and causing weakness, it would affect those muscles that it innervates. And so what we look for is to try to see if the pattern of weakness matches the nerve being pinched. And if that's the case, then surgery might be necessary.

Interviewer: And again, it just really sounds like coming to a specialist like you is really just a great step just to make sure.

Dr. Joyce: Yeah. I think at that point, if there's any concern that you might have weakness, or you're having neurological findings and you're not sure what to do, definitely seeing a specialist, like us, I think makes a lot of sense.

Interviewer: What you described, you know, choosing the right place for an injection, the type of injection you want to use sounds really, really complicated. What do you recommend a patient look for in a provider that's doing that type of work?

Dr. Joyce: You want to make sure that the person who is doing your injection has done hundreds of these types of injections and is well versed with it before you go in with them.

Interviewer: Whether that be through a fellowship that they did, that extra year after medical school specializing in this, or they've done numerous procedures over the length of their career.

Dr. Joyce: Agreed. Yeah.

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