What is surprising about the diagnoses and treatment of back pain is that out of the millions of back pain sufferers in the world it is estimated that up to half of them (myself included, unfortunately!) never get a medically-diagnosed reason for their back pain. Given the advancements that have been made in the medical field you would think that finding a reason for your back pain would not be that much of an issue, right?
I was alerted to an interview of a prominent back pain specialist through reading Steve Lockharts’ “The Bad Back Book” and was very interested in finding out more about what this Professor of Anesthesiology had to say. His thinking is that 85-90 percent of chronic back pain is due to muscular problems and that when there is a muscle imbalance or strain or where there are one group of muscles more developed than another these ‘abnormalities’ cause “the whole architecture of the back to be askew.”
To my way of thinking this could explain why there are so many individuals that are looking to their doctor for answers and coming away with more questions that answers. Typically a doctor will do what they are trained to do, and that is to use what diagnostic mediums they have available to them to find a ‘medical’ reason for a particular complaint. If the cause is out of their ‘scope’ so-to-speak, is it any wonder that they struggle to get to the root of these problems? Maybe that is an ‘over-simplified’ look at the issue, but by looking at my own experiences with a number of different doctors I think those thoughts are pretty close to the money.
I doubt too many of you are interested in my opinions only so here is a copy of the interview with Dr. Alon P. Winnie. I think you will find it very interesting and as always we welcome any comments you may have on the subject.
Byline: Alon P. Winnie, M.D., is a graduate of Princeton University and received his Doctorate of Medicine in 1958 from Northwestern University Medical School. Following his internship and residency in Anesthesiology, both at Cook County Hospital, Dr. Winnie became a Diplomate of the American Board of Anesthesiology, certified by the same Board in Pain Management, and a Fellow of the American College of Anesthesiologists, as well as a member of a number of professional societies. Included among these are the Chicago Society of Anesthesiologists, of which he was President from 1968 through 1974, the Illinois Society of Anesthesiologists, of which he was President 1971-1972, and the American Society of Regional Anesthesia, of which he was President from 1976-1980. Other scientific society memberships include the American Society of Anesthesiologists, the International Anesthesia Research Society, the American Pain Society, the International Association for the Study of Pain, the Chicago Medical Society, the Illinois State Medical Society, and the American Medical Association.
From 1972 to 1989 Dr. Winnie served as Head of the Department of Anesthesiology at the University of Illinois Medical Center. In 1989 he stepped down as Chairman to become Director of the Pain Control Center at the University of Illinois Hospital; a position he continued to occupy until 1992, when he returned to Cook County Hospital as Chairman of the Department of Anesthesiology and Pain Management, the position which he currently occupies. In addition, he served as Consulting Physician at the West Side Veterans Administration Hospital, the Great Lakes Naval Hospital in Chicago, Portsmouth Naval Hospital, Portsmouth, Virginia and Walter Reed Hospital, Washington, D.C. He is also a member of the Attending Staff at Cook County Hospital, where he was Associate Director of the Division of Anesthesiology at Cook County Hospital from 1965 to 1971.
Dr. Winnie was an Associate Professor of Anesthesiology at Northwestern University Medical School until 1972, Professor at the University of Illinois College of Medicine at Chicago until 1993, and currently Professor of Anesthesiology at Rush Medical College.
Pain.com: How long have you been involved in the study and treatment of back pain?
Dr. Winnie: “I have been involved in the study and treatment of back pain since about the middle of the 1960s, when I was made aware of a study that indicated that there were perhaps non-surgical approaches for a very specific type of back pain. Namely, pain due to slipped discs (herniated discs). I was very skeptical and an orthopedic surgeon and I, and a neurologist did a study to see if the use of steroids epidurally would have an effect. And, in fact, the effect was absolutely dramatic, if the pain was due to a herniated disc. Clearly, if it was due to something else, there would be no beneficial effect, but then that is true of anything. If you don’t treat the cause or you don’t know the cause, then the treatment will be inappropriate. Now obviously, when you see patients to decide who should get this treatment, you have to learn and/or know about other causes of back pain. In the process of developing the treatment that we now call “epidural steroids”, I had to become familiar with the other types of problems that can cause back pain.”
Pain.com: Is back pain preventable?
Dr. Winnie: “Since about 85% of back pain is muscular, then clearly back pain due to muscular causes, can be prevented by maintaining the balance between muscle groups that work against each other to keep the body erect and to function normally. In other words, if the muscles of the belly are under-developed, then the muscles that oppose them, the muscles of the back, are going to be stronger and are going to cause the vertebral column to tend to move backward. Whereas, if you can develop the muscles of the belly which are usually much weaker than the muscles of the back, then you can prevent that imbalance and prevent a lot of back pain. That is why the most common treatment, both to prevent and even treat back pain due to muscular problems, is exercise. William’s Exercises is the name usually applied to them. They are exercises to specifically develop groups of muscles that are under-developed and maintain the muscular balance that keeps our posture and our upright function normal.”
Pain.com: What are the basic types of back pain and their cause?
Dr. Winnie: “There are many, many types, but basically they fall into two groups. There are muscular causes and there are bony causes. The muscular causes include muscle strain, muscle sprain, most frequently muscular imbalance where one group of muscles is more developed than another group of muscles. This causes the whole architecture of the back to be askew. The bony causes include slippage of one vertebra on another, which is called spondylolisthesis, such as actual little fractures of parts of the spinal column. Slipped discs, the cushions between two vertebral bodies, the discs, can rupture. They are structured much like a jelly-filled donut. If the jelly comes out, of course the donut goes flat and it no longer can carry out its function. More frequent than the so-called herniated discs (slipped discs) is a condition that develops during aging. The patient develops little cracks in that outer part of the donut and the inner part, the jelly, starts to leak out. The jelly contains some extremely powerful enzymes that cause a terrible inflammation of the nerves. It is this inflammation of the nerves that causes the pain, due to what we call a herniated disc. Because it is an irritation or an inflammation that the disc is causing, we use drugs that stop inflammation, which include the various steroid drugs, the anti-inflammatory drugs. So those are the two basic types, muscular and non-muscular, or muscular and bony causes. Within the bony causes there are lots and lots of rare ones, including congenital problems, spinal stenosis, etc.”
Pain.com: What are the leading causes of chronic back pain?
Dr. Winnie: “Most frequently it is muscular. That’s why, however, it is so dangerous if somebody gets the wrong diagnosis. When somebody has back pain due to muscular problems and suddenly somebody’s trying to operate on their spine, clearly that is not going to restore normalcy or take away their pain. You have to know the correct cause in order to treat it properly. But, as I said, statistically, 85-90% of chronic back pain is due to muscular imbalance.”
Pain.com: How can you tell when back pain is due to muscle pain or due to a more serious condition like disc problems?
Dr. Winnie: “You can only tell that for sure by seeing a physician who will carry out the appropriate work up. Obviously, if somebody is lifting something that is too heavy and jerks and suddenly feels a “pop” in his back and pain shooting down the leg, if he or she knows that those are the signs of a herniated disc, then they kind of know what it is. They still need to go to a physician who will elicit a history. Then the physician will examine the patient to see whether straight leg raising, for example, causes pain. More recently we have things like MRIs and CAT scans that can actually see a herniated disc without having to inject dyes, and so on. We used to have to do myelograms and things like that, which, not infrequently, caused as many problems as the problem they were trying to diagnose. Today with CT scans and MRIs, depending on what type of problem it is, the CT scan more for the bony part of it, and the MRI can actually see soft tissues. But the point is this all goes together. Electrodiagnostic studies can be done to see whether there is an inflammatory problem with the nerve that is causing the electrical conduction down a nerve to falter. All of these things go together like a puzzle to tell the physician, “Aha, this is at the nerve root, or this is at the peripheral nerve, or this is in the spinal cord, or this is up in the neck, or whatever.” Then he puts it all together until he comes up with a specific diagnosis and then you start to say, well, now what are the treatments for this diagnosis, and you carry on from there. It is important that all of us refrain from doing too much self-diagnosis. We need somebody objective to do that and, of course, a physician is usually the best person to do that.”
Pain.com: Can my family physician adequately treat chronic back pain? If not, what kind of specialist should I see?
Dr. Winnie: “Family physicians vary a lot, one from another, and if they have an interest in pain then they make it a point to be familiar with it. If they see a lot of pain problems in their practice, like a family physician that works with a large industrial population, it is hard to say that this type of physician, regardless of specialty, is always adequately trained to treat pain. Certainly, a family physician is a good place to start, because he or she knows what the individual is like normally, without the back pain. If he can’t put his finger on it, he certainly knows what specialist to send the patient to. That will vary a little bit depending on the type of problem that the family physician suggests. If he thinks it is a nerve problem, he may send the patient to a neurologist. If he thinks it is a surgical nerve problem, he may send them to a neurosurgeon. If he thinks it is more a bony problem, he may send them to an orthopedic physician or surgeon. If he thinks it is definitely a muscular imbalance he may send them to a physiatrist and so on. So I think a family physician is always a good place to start. Then he or she can sort out the problem and decide what type of specialist is most appropriate to see and to have treat the problem.”
Pain.com: Does exercise or physical therapy alleviate chronic back pain caused by disc problems?
Dr. Winnie: “That kind of depends. We know that with aging, the discs begin to dry out. A little of that jelly evaporates and, to a certain degree, leaks out. Every time a little bit of it leaks out through one of the cracks, there is a little episode of pain. Once we know that the pain is due to a herniated disc or disc problems, physical therapy should be undertaken only under professional guidance because one could make the problem worse with the wrong manipulation or the wrong exercises. If the patient sees a physician who rules out the possibility that exercise could be dangerous, then it is probably best to wait until the acute painful episode is over. Then, to prevent further episodes, physical therapy and exercise can certainly be helpful.
Pain.com: Are over-the-counter medications helpful in treating all back pain?
Dr. Winnie: “Categorically, no. There is nothing that is helpful in treating all of any kind of pain, or all of any kind of disease. Over-the-counter medications for back pain are, for the most part, only two or three groups. One type is just analgesics, which try to take away pain without any consideration of the actual cause. The new series of drugs that we call NSAIDs, which are non-steroidal anti-inflammatory drugs, try to treat the inflammatory process, an irritative process that is causing the particular back pain. That may be beneficial. The NSAIDs also work as analgesics, so you get some generic pain-killing properties with those drugs and some anti-inflammatory properties. Of course, if inflammation is part of the problem, that will be helpful. Since 85% of all back pain is due to muscular problems (muscle strain, muscle pain, etc), then clearly an important group of over-the-counter drugs, are the muscle relaxants or the anti-spasmodics. They tend to relax the muscles and lessen the pull of the muscles that are in spasm because, when muscles are hurting, they go into spasm. If you can relax them, frequently that will minimize if not abolish the pain. All of this provided the pain is just muscular and is not of serious proportions. For example, if somebody just has done too much work using muscles they don’t usually use and they are hurting from that, then over-the-counter medications are highly appropriate. On the other hand, if they were to tear an Achilles’ tendon, then clearly no muscle relaxant is going to help relax that muscle that has been literally torn apart. So, over-the-counter medications are helpful, as long as you don’t take them in too great a quantity. If we don’t get pain relief we tend to take more, whichever type of drug. Many of these drugs, when taken in excess, have sedative and soporific tendencies and can really cause people, when driving automobiles, to have serious problems. Also, even over-the-counter NSAIDs, when taken for a long period of time or in excess, can cause serious side effects involving the stomach, intestines, and kidneys, especially in older people. If the over-the-counter medications don’t help quickly, I think one should go and check with a physician.”
Pain.com: What is the most common use and when are epidural steroid injections indicated for back pain?
Dr. Winnie: “Epidural steroids, since they are anti-inflammatory drugs by definition, are only useful and indicated for conditions that are inflammatory. The steroid, when injected into the epidural space, has direct contact with the inflamed nerve that is causing the pain down the leg, or wherever the pain is, from the herniated disc. That is the reason for putting it epidurally. There are those who feel you can take the steroids systemically. Many people would be prescribed a dose pack of steroids or something like that. The question is can you get a high enough concentration of the anti-inflammatory drug, the steroid, taking it orally? Can you get a high enough concentration in and around the nerve root to really produce the anti-inflammatory effect? We know that we get a much higher concentration when we give them epidurally. That is the reason that those of us that utilize this technique do so. There are physicians who feel that you can accomplish that end by taking systemic steroids.”
Pain.com: How do epidural steroid injections work?
Dr. Winnie: “Epidural steroids literally block the enzyme in the disc that is leaking or extruding the nuclear material (that is the jelly inside the donut). Steroids block the enzymes that are contained in that jelly from causing the release of some painful compounds, like peptides, that irritate the nerve and cause the pain. That is why the relief, when steroids are used properly, is dramatic. It is like throwing a switch. It takes 18-24 hours to get the concentration to the effective point. I have experienced this myself as a patient and suddenly, the pain is practically gone. It decreases very fast. Again, it does not work if it is not an inflammatory process that is causing the problem. If we use it appropriately, it is extremely effective. I emphasize that because it is human nature, since epidural steroids have worked so well for slipped discs, to want to use them for other forms of similar but not identical back pain. If it is not an inflammatory process, the chances are that it is not going to work. Now, it is true that some of the other mechanisms that cause back pain, like spinal stenosis, or even a bony spur that is irritating a nerve can cause an inflammatory reaction in that nerve. To the extent that the pain is being caused by the inflammatory part of the problem, you will get some relief with epidural steroids. The relief will not be as dramatic or complete, but partial relief can be obtained from epidural steroids. There are situations to use epidural steroids other than just herniated discs or slipped discs, but that is sort of the prototype of an inflammatory process that epidural steroids work for best.”
Pain.com: What are the side effects or dangers of epidural injections?
Dr. Winnie: “Since steroids are anti-inflammatory, we rely on our immune response system to fight off bacteria. Part of an infection is an inflammatory response. If there is a steroid on board, that suppresses the inflammatory response and enhances the possibility of infection. One of the things we worry about and we are very careful about is absolute sterility so that we don’t get something like an epidural abscess. If the needle should happen to hit a blood vessel, we can get bleeding in the epidural space and some neurological dysfunction due to that, so we are very careful about that. Those are the major technical or mechanical problems that are very serious but, fortunately, very, very rare. The other types of side effects that one can get from epidural steroids are the side effects of all steroids. People have heard of Cushing’s syndrome from taking steroids for long periods of time for many medical problems. If one administers too large a dose or too many doses of steroids, then one sees the signs of systemic steroid overdose. There are quite a few of those, but that is a dosage problem with the drug. This is quite infrequent unless one gives the steroids over and over and over, and that is not something that is done very often.”
Pain.com: Is there a limit to the number of injections you can have at a one site in a year? A lifetime?
Dr. Winnie: “We deliberately limit the number of injections on the basis of our experience. The combined experience of pain practitioners who use a lot of epidural steroids has taught us that if we don’t get pretty good relief in two or three injections we probably won’t get a lot more relief. I’m talking about two or three injections within a two or three week period of time. We probably won’t get a lot more relief by going to a fourth, fifth, or sixth, although occasionally it is indicated and we do, and it works. Now, if we go beyond that number, whether it is within a month, six months, or a year, we start to accumulate the steroids in our bodies, and we can develop some of the serious side effects of steroids. Again, it is a complex problem of endocrinology, but if we give too many steroids, we can cause a problem in a diabetic, for example, because it has to do with glucose (sugar) metabolism. If we give too many steroids, we will suppress the body’s own production of steroids because the body’s sensors note that there are plenty of steroids and they don’t need to make any more. Then when we stop administering steroids from the outside, the patient is left with no steroids at all because his own body is no longer making them. Those are the kinds of things we can get into, other than some rare complications like problems with the hips, problems with osteoporosis, etc. Now we are talking about very, very large doses.”
Pain.com: What are some recommended alternative treatments used for back pain other than surgery and narcotics?
Dr. Winnie: “It depends upon the cause of the back pain. All pain, not just back pain, all pain can be minimized by the use of narcotics. Of course, this doesn’t treat the cause of the pain. We are just sort of kidding our bodies and ourselves, because we are letting the cause of the pain persist and using narcotics to reduce the pain. Narcotics are a real gift when we need them, but we shouldn’t need them for prolonged periods of time. Surgery, on the other hand, is only indicated for certain types of back pain, the bony types. That is why orthopedic surgeons do those procedures. The most common procedures are called laminectomy and discectomy. That is unroofing the spinal canal to take out the disc material that has been extruded and that is irritating the nerve roots and causing the pain. There are alternatives to that. Epidural steroid treatment is one of them. For many years, since 1934 to be exact, because it was appreciated that a herniated disc was causing the pain, it seemed totally logical to take out the disc.
However, we used to simplistically think that the herniated disc was pinching the nerve, and that is certainly not the case. The herniated disc is irritating the nerve. Whether it compresses the nerve to a certain degree really is rarely the major problem. It is the irritation of the nerve. For that reason, it is not really basically a surgical disease except in certain situations. If you have a herniated disc that is causing loss of function, that is paralysis, loss of bladder control, loss of rectal control, that is a surgical emergency, because there is no time to wait for the swelling to go down and the irritation to discontinue. There are situations (absolute indications) when there are no alternatives to surgery. There are two popular alternatives to surgery. We have talked about one, epidural steroids. The other enjoyed a brief period of great popularity but is now less popular, and that is the use of chymopapaine. This is an enzyme that is injected into the disc in the hopes that it will dissolve the disc. Instead of cutting it out, we dissolve it away, and therefore take away the role of the disc in causing back pain. These are the two major alternatives. Now, that is for discogenic pain. If, on the other hand, the pain is due to spinal stenosis or to slippage of one vertebra on another (spondylolisthesis), or little fractures of the pedicles (the little posterior support arches of the back), these require surgical intervention if conservative therapy does not succeed. However, fortunately, these are rare. If, on the other hand, a person’s back pain is muscular in origin, there is virtually no role for surgery and no role for narcotics, but a role for physiatry, exercise, etc.
Whether there are alternative treatments available depends on what the cause is. Like everything in medicine. If we know the cause, and there is a treatment for the cause, we can cure it. If we don’t know the cause and we use the wrong treatment, clearly it is not going to be successful.
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