PODCAST: What to Do When Back Pain Hits

ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

TODD ACKERMAN: I'm Todd Ackerman, I'm a former medical writer, currently a editor at Houston Methodist.

ZACH: And Todd, do you have back pain?

TODD: Fortunately, I do not, Zach. I worry a little bit about, at some point having back pain, just ‘cause I know a lot of people who have back pain. My brother, for one, who is a former Paratrooper so kind of a job hazar -- Occupational job hazard but…

ZACH: Yeah.

TODD: He would hit to ground hard and land on his bum, so he has a herniated disc.

ZACH: Okay.

TODD: And it causes him quite a bit of problems. And then just some of my college friends having – Actually, I think they started -- some of ‘em started like in their 40s, where they started having back pain and the spent a lot of time and effort on it. So far, knock on wood, I'm doing okay, but the only times I really feel it is when I'll like run on a treadmill then I can feel it in my back the next day. Maybe when I drive for a long distance, I kinda stiffen up when I get out.

ZACH: On the treadmill, I mean, do you feel the same thing when you're like out on the sidewalk or things like that?

TODD: So, you know, I used to do the treadmill and then at some point I developed like tendonitis and stopped running on the treadmill, and just do non-impact aerobic stuff. But every once in a while I'll make it on it, and if I run that’s when I’ll feel it the next day, so I don’t really do that much.

ZACH: What about posture, how is your posture? Are you a big posture guy?

TODD: I think my posture is good, how about you?

ZACH: You know, I was in a band in middle school and high school, and I think that really helped with my posture. Because when you're playing a musical instrument, you gotta sit up a certain way, and, you know, control your breathing, and that sort of thing. And then that has kinda carried over into my -- As we all do sitting at a computer…

[Laughing]

A lot of the time. I feel like I have a pretty good posture, you know.

TODD: That’s good.

ZACH: So, I feel like that has helped me not develop any back pain. ‘Cause I personally, again, knock on wood -- That’s wood I hope, haven’t had any back pain, personally.

TODD: You're a young whippersnapper, though.

ZACH: Well, thank you Todd, I appreciate that.

TODD: We’ll see if you're doing as well decades from now.

[Laughing]

That’s good you don’t have it, but, you know, back pain is really a big problem out there. It’s the single leading cause of disability worldwide and one of the top five medical problems for which people see doctors.

ZACH: Wow.

TODD: It’s also a huge economic burden. It accounts for more than 264 million lost work days in a year, work hours, productivity, and workers comp are greatly reduced due to the condition. And an estimated $200 billion is spent annually on --

ZACH: 200 billion!

TODD: On managing back pain.

ZACH: Wow. It’s a wide spectrum, right? Because you have like your serious accidents that cause issues with people’s backs obviously, and then you have your, you know, more day to day kind of back pain. So, it’s a wide spectrum. But still, to have that many people and that much money spent on its treatment, those are some big numbers.

TODD: Yes, yes.

ZACH: And that’s what we’re talking about in this episode, “Chronic and Acute Back Pain.” And who did we talk to about this, Todd?

TODD: We talked to Dr. Paul Holman, who’s the head of the Houston Methodist Neurosurgery Spinal program.

[Sound effect plays to signal beginning of interview]

Just to start off , you know, when I googled this subject the first thing was a -- that came up was a overview provided by AI that said back pain’s a common medical problem that can have many causes, but it’s usually not serious. I'm guessing most of your patients would not agree with that last part.

DR. PAUL HOLMAN: Well, I think we see a little bit of a skewed population. So, if the problem has become serious enough to see a neurosurgeon then obviously, it’s not of the variety that most people will experience. So, I think the statistics say that about 90% of individuals will have at least one episode of acute pain, at some point in their life, but thankfully most of that is self-limiting. So, it might be related to exercise or straining to do something around the house, picking up an object, things like that.

TODD: How about chronic pain?

DR. HOLMAN: The statistics now say that about 8 to 10% of the population has some degree of chronic pain and that’s loosely labeled as someone that has pain for more than about six months.

TODD: But it’s only like 10%?

DR. HOLMAN: 10%.

TODD: I've heard the quote, “There are two types of people, those who have back pain and those who will have back pain.” That’s probably not that true or just because of age, at some point you will?

DR. HOLMAN: I think that’s true to a certain extent, like I said, it’s a common thing. But now, as a spine neurosurgeon, we’re seeing the population’s aging, people are much healthier. And so, if you're gonna live into your 70s, 80s, 90s, and be active, at some point, whether it’s your spine or your hips, or knees, there's gonna be some type of a musculoskeletal problem that catches up with you. So, I mean, these are just common things that we see in the clinic.

TODD: Do a lot of people just live with back pain and never seek treatment? Do we have estimates on that?

DR. HOLMAN: I don’t think we really have estimates, but it’s interesting, every patient that I see in my office tells me that they have a high tolerance for pain. So, whenever I hear that it’s always a little bit concerning. But, I do think that, you know, pain is interesting because it’s very subjective. It has a lot to do with how you're brought up as a child, how your parents teach you how to deal with pain. And so, I do think that certain people, unless there's a problem with a neurological issue, something is not moving correctly, they really tend to blow things off. Whereas some people, any degree of pain, it concerns them and they wanna make sure that everything’s okay. So, I think there's certain psychological, cultural things that influence how people seek treatment from doctors or how concerned they get when they get a little bit of pain.

TODD: Are there back pain myths?

DR. HOLMAN: I think that one back pain myth would be that, you know, if you have an issue and you get imaging of your back, and it shows that there's five bulging discs that that really means that there’s five problems in your back. Meaning that, anyone that sees a doctor for pain and gets imaging, gets very confused by what imaging means. Because, pictures that we take of the spine in our clinic they don’t really diagnose anything, they're a piece of evidence. So, I think one of the biggest problems is that we have all this sophisticated imaging and people get really confused by what imaging of the spine actually means. That’s -- It’s a little bit, you know, down the rabbit hole, in terms of what we do when we see patients in the office. But I think patients really have a hard time understanding what an MRI scan of the back or the neck really actually means, in terms of what could be wrong with their spine. Like what that means in terms of their pain.

TODD: So, give our listeners a quick primer on the back, the spine, how complex it is, how easy it is for something to go wrong.

DR. HOLMAN: Well, I think it’s a very complex system. It’s an amazing biomechanical system. I would say, unfortunately, when people didn’t live more that 30, 40, 50 years back in the day, the spine wasn’t a big issue. But we know now that once you're into your 30s and 40s, the spine predictably starts to wear out. There's really nothing that we can do to stop that, it’s a degenerative process. But there's a complex set of players, so there's the muscle, there's the disc, there is the bone, there is obviously soft tissue like cartilage and joints. So, unlike, let's say, a hip or a knee which is a single joint, you know, back pain is complex because there’s so many different structures that can cause similar types of pain. And so, it’s the diagnostic piece. Like when someone says, “Why can't they figure out why I have chronic back pain?” It’s actually very difficult sometimes to make a specific diagnosis and that’s pretty counterintuitive. I think most people think that, you know, imaging and the medical technology that we have is so sophisticated that making a diagnosis should be very straight forward, but it actually isn't.

TODD: Is there a lot still being discovered about back issues? How is the field advancing?

DR. HOLMAN: I think there's a lot going on, from a surgical perspective. I would say that in the last 20 years, what I do in the operating room, there's a lot of technology. But I think the thing that’s changed our perception of back pain from a medical perspective is actually alignment. So, if you think about posture, posture turns out to be extremely important for pain because, in the French, surgeons, orthopedic surgeons, there is a couple luminary people that have done a lot of research in this, they call it, “The Cone of Economy.” So, basically your brain is wired to have a very specific energy efficient posture. So, if you have spinal degeneration or you have trauma, or something deforms your spine, the muscles in your back get weak and you start to have poor posture. Anything that knocks you out of this cone, where you have perfect posture, causes you to have to compensate with the muscles and you burn more energy to try to have perfect posture. Your brain wants you to stand up straight, and so that has a big implication when we actually do surgeries for the spine, particularly fusions. How we realign somebody’s spine. If I align your spine and my spine the same way, but we have a different requirement for how our spinal alignment would be optimized, then patient “A” could have an amazing outcome and it be pain free, and patient “B” could have worse pain or chronic pain. That’s, you know, I think one of the things about surgery that’s out there that’s kind of a valid criticism. Patients will hear, “Well, if I have a back operation then you'll need another one, and another one.” It’s kind of this domino effect. And to a certain extent, that’s true, but we've really learned over the, you know, last, I would say, 10 to 15 years that if you do surgery, specifically a fusion, you really have to customize the alignment of the spine. So, we’re doing a lot of patient specific instrumentation, meaning that we customize the hardware that we put into a patient’s spine to optimize their alignment and their posture.

TODD: Are there a lot new treatments being developed still?

DR. HOLMAN: There's a lot of innovation in the space. It’s not necessarily a new thing, but something that’s been, I would say, revitalized is arthroplasty. So, back in the day, before you had hip and knee replacements if you had a bad hip or knee joint, you would get it fused. So, no one would get a fusion of their hip and knee at this point. And in the spine -- like I finished my training in 2003, and that’s when the first spinal lumbar disc replacement became FDA approved in the United States. And we were all were already doing these things in Europe for, you know, 15, 20 years before it was FDA approved in the United States. But it never really took off, it kinda died off for a while. But now, we’re seeing a resurgence of joint replacement in the spine. So, instead of fusing something, you put in a device that allows motion to continue. And obviously, it’s pretty intuitive that if you can treat a problem and maintain flexibility, that's obviously very important for patients. They talk to us a lot about that in the office that, “I wanna maintain my range of motion.”

TODD: You worked with NASA, what'd you learn there?

DR. HOLMAN: Dr. Blacklock was one of my mentors that kinda fostered this relationship. You know, NASA being right down the road from Houston. So, I think the thing that I've learned the most in working with NASA is how important muscle is. So, if you go on Instagram or any social media, and you look at the influencers in the health and fitness space, everyone is talking about how important it is to stabilize your core. So, a human spine is not just this biomechanical relationship between bone and disc, the muscle is extremely important. And so, when astronauts go into space, they get something called space adaptation pain, meaning they go intro zero gravity and the have pain because their muscles start to shrink up. So, when the astronauts kinda set their daily schedule, three to four hours per day are set aside for them to do specific exercises. And they have special machines to do this in space, because if they don’t work on keeping the core around their spine tightened in exercise during their time in zero gravity then they can lose a lot of core strength. And they get, you know, anywhere from 8 -10% of their bone density also, they get osteoporosis essentially. So, we know now that the muscle’s extremely important. And so, when I'm talking to a patient about conservative treatment they just, you know, they're starting to develop a little bit of chronic pain and maybe they don’t exercise regularly. When we send them to physical therapy, and talk to them about core strengthening, sometimes, again, they wanna focus on the fact that they had an MRI scan that shows a bulging disc. But we actually look on our scans now at the muscle, the deepest part of your core, it's actually called the multifidus. So, when we look at an MRI scan in someone that has chronic pain, a lot of times, we’ll see that that muscle has turned into fat. The very deepest part of the core. And so, if you do work with a physical therapist and you strengthen your core, there is a tremendous opportunity to correct, you know, the onset of pain by strengthening those muscles. So, it’s extremely important and it’s something that, it’s not sexy. It takes a lot of work, it takes commitment from the patient, but it is actually a very effective treatment for back pain.

TODD: So, what are the risk factors and causes of back pain? Posture’s one from what you previously said.

DR. HOLMAN: Yeah, I think in terms of risk factors, you know, anything that you do from an activity or work perspective that involves a lot of heavy lifting. So, they actually did studies in cadavers years ago like, what movements would cause a disc in your back to herniate? So, it turns out that if you flex your spine, you bend forward, you rotate your spine, and then you put a compressive load. So, think about bending over, turning, and then lifting up something heavy. So, a lot of repetitive motions where you're not engaging your core properly, and doing a lot of straining in awkward rotated positions. So, that’s why, obviously, you know, there's some occupational things, people that do a  lot of lifting as part of their job, they're more susceptible to having, you know, chronic pain. But at the end of the day, there's probably a genetic component to this. There's not a “bad back gene” per se, but we know that these types of degenerative problems run in families. People that have connective tissue disorders where they have maybe a little bit of hypermobility, elasticity in their spine, that’s a risk factor. I would say as you age, untreated osteoporosis. So, I'm a surgeon, but I do focus a lot when I talk to my patients about metabolic bone health. So, taking your calcium, taking your vitamin D, when you become post-menopausal as a woman, getting a bone density test every three years. You'd be amazed at how many 70 year old women I see in my office, and when we talk to them about osteoporosis, they have a great primary care doctor, but they’ve never had a bone density test. And then they come to us, maybe they need surgery, and then we have to spend time giving them medication to strengthen their bones before they can even tolerate a surgery.

TODD: Is a stiff back a risk factor? I ask because I have something of a stiff back. I work out, and I think that kind of strains it, but I do have a pretty strong back. I do back exercises like when I'm lifting, but I always worry that, you know, I just don’t have that patience over time to stretch as much as I should. And so, I just wonder if just that being kind of stiff and not that flexible, it doesn’t bode well for the future.

DR. HOLMAN: Yeah. I think that, I mean, stiffness per se, is like a chicken or an egg type thing. I mean, I think if you have tight hamstrings and, you know -- It’s like the old song from Schoolhouse Rock, you know, “The Leg Bone’s Connected to the Thigh Bone.” Your flexibility in your pelvis, your hips, your hamstrings, that affects the flexibility in the way that your spine works, right. And same thing with your hips and knees. So there's -- The spine doesn't work in isolation of other joints, so I think if people get some arthritis in their back it becomes stiff. But, in terms of your overall level of flexibility, I would say that it’s more important. Anyone that has pain in their back, I do talk to them a lot about stretching because having that flexibility in your hips and in your lower extremities that helps to optimize the, you know, the function of your spine. So, I think the stiffness issue’s more about general flexibility and how that can help to protect your spine.

TODD: Generally, it seems like one of the key things of healthy aging is not being stiff but being flexible. So, it always worries me for that.

DR. HOLMAN: You know, I think hydration, right? And you -- People ask me in the office, okay, “What about supplements?” Like glucosamine chondroitin sulfate, you know, things of that nature. I don’t think there's any really good data that shows that there's any one specific supplement per se that’s, you know, protective, but, you know, people are always interested in things that could protect their joints or optimize -- or slow down the aging process of joints, and the spine in particular. So -- but I do think that, again, optimizing your, just, general metabolic health. So, people that, you know, have diabetes and other conditions of that sort I think they tend to have, you know, bigger problems with chronic pain, they develop neuropathy. So, I do think that spine health, in general, metabolic health those are kinda tight at the hip.

TODD: Should we be doing stretching exercises to prevent ever having back pain?

DR. HOLMAN: Stretching and some degree of core stabilization, and then also weight bearing exercise. So, again, that’s a huge thing. There's a lot of people in the fitness space that talk about how muscle, lean muscle mass, is kind of your armor against aging. And I do think that that is true. I believe that to a large extent. And, again, when we talk about lean muscle we’re talking about the muscle that supports your spine, that optimizes your posture. Because if you don’t have a lot of lean muscle then over time it’s gonna, you know, cause your spine to potentially deform. So, for example, I treat a lot of patients with scoliosis. So, if you have a deformity of your spine, which if you look at the United States, if you're over 60, there is a 10% chance that you have adult degenerative scoliosis. That just means that you have a little curvature in your back 10 degrees, usually not anything serious or something that needs surgery, per se. But if you have scoliosis and you don’t work out, you don’t have a lot of lean muscle, you don’t stretch, you become stiff. There is this cascading effect to where you're more susceptible to having a progression of the deformity. And the more crooked your spine gets the more that it wants to deform. So when we see patients that get diagnosed with these problems, again, we go back to the fundamentals. You have to stretch and maintain flexibility. You need to exercise and strengthen your core, you need to lift weights to maintain your bone density. So, there's all these little things that can help to, kind of, slow down the inevitable process of aging. Because, at the end of the day, you know, when I see -- I've been in practice long enough now where I've seen patients over 20 years. When you see patient’s x-rays and MRI scans and you've seen one that was, you know, today and one that was ten years ago. They're always gonna have more degenerative changes in their spine, that happens, but that doesn’t necessarily mean that it translates into more pain. So, just because the pictures look worse, if you're doing these things to maintain, you know, the optimal function of your spine then you won't necessarily have more problems with pain. You won't be able to do, you know, fewer of the things that you wanna do from an activity perspective like, you know, playing sports, golfing, running, all those types of things.

TODD: How about sleep position?

DR. HOLMAN: I would say probably two or three times every time I'm seeing patients in the office, people say, “Okay, what is the optimal mattress? Should I have this type of a pillow?” I think that there's no real data behind that, but I would say more people that have chronic issues with their back will tell me that they prefer a stiffer mattress, something that, you know, has more support. I mean, obviously, sleep, again, is tied in with chronic inflammation. So, it is important for your general health to, you know, to get, you know, probably seven, eight hours of sleep. But in terms of like a specific position, I don’t think that that’s -- There's really any hard science to say that if you sleep or use a specific type of support that it’s better than another. You know, two people can tell you the opposite thing in terms of what works for them. But we will see patients maybe that have spinal stenosis which is a degenerative process that narrows your spinal canal. Sometimes they sleep with a pillow between their legs and it flexes the spine and opens up the space for the nerves. So, people are pretty intuitive. They learn these little tricks, not necessarily because a doctor told them that, but they figure it out for themselves like how to, you know, optimize their sleeping position so that they, you know, they get restful sleep and they don’t wake up three or four times per night in pain.

TODD: I've read that if you don’t have back pain, sleeping on your back is better, if you do your side is better. There's no evidence, really, to support those?

DR. HOLMAN: No. Lot of snake oil.

TODD: Yeah. So, what are the best ways to sort of self-treat mild or early stage pain, so it doesn't progress to the point that you need to see your doctor?

DR. HOLMAN: When somebody has an acute episode of pain, the staples of conservative treatment are obviously anti-inflammatories, right? So, using ibuprofen, Motrin, for any type of acute pain is helpful. One of the common sense things that people don’t think about when we say “rest,” I would say it’s avoidance of activity. So, let's say you're a runner and you're running 20 miles per week and you start having pain that’s associated with running. If you just say, “Hey, I'm gonna keep pushing through the pain,” and maybe not kinda change your schedule, so “I'm gonna have more rest days, I'm gonna cut down on the mileage.” Anything that you can identify from an activity perspective that exacerbates your pain, it doesn’t mean that you have to stop playing golf, or you have to stop running, but you have to be realistic and say, “What is the amount of rest, or can I modify the activities that I’m doing so that I allow my body to recover. And then the next time I do it, I'm not in as much pain.” So, I think -- There’s some of these little things that are very intuitive that people just don’t wanna accept that sometimes you have to kind of alter the way that you're, you know, stressing your spine to be able to, you know, cut down on some of the issues with chronic pain. But, in terms of like conservative things like I said, just anti-inflammatories, you know, using topical things. You can buy anti-inflammatory topical creams that you could put on your back. There is obviously patches, lidocaine patches, things of that nature that are super effective. When people start having more chronic pain and they get muscle spasm, there's something called a tens unit which is basically a little electrical stimulation of the muscles that it’s like kind of getting a massage. Some of the self-care things that you can do, go and get a massage, you know, once a month. You know, that’s super effective for some people that just have a lot of muscle tension. Because, pain in the back is not always something that’s structural, it can be muscular. We carry a lot of the stress from work and life in our shoulders, in our back, so sometimes just, you know, things like acupuncture, a massage, chiropractic care. There's a lot of things that people can explore that, you know, can help to minimize your level of pain that you have to deal with.

TODD: How about something like meditation?

DR. HOLMAN: That’s something that I'm trying to explore myself. I think that’s super helpful in terms of, you know, again, just saying to yourself -- Let's say you've developed a little bit of chronic pain, meditating and being able to kind of clear your mind and say, “Hey, this is not a big deal, and I'm not gonna let this defeat me. I'm gonna keep doing things that I need to do and want to do.” I think that kinda falls under the category of cognitive therapy. I mean, some people will actually go to, you know, trained specialists for behavioral therapy, learning how to psychologically deal with chronic conditions like pain. So obviously, doing those things yourself and just spending just 10 or 15 minutes, you know, it’s setting your intentions for the day, and saying, “Okay, I'm gonna -- Even though I have some pain, I'm not gonna be inactive, I'm still gonna, you know, do these specific things that can help, you know, just with your overall mindset.”

[Music to signal a brief interjection in the interview]

ZACH: Because Dr. Holman mentioned the benefits of meditation for back pain, we checked out what the science has to say. Turns out there's no shortage of studies on the subject. The most comprehensive was a 2022 pain medicine meta-analysis of studies that used meditation therapy to help those who suffer from chronic low back pain. The studies enrolled more than 1,100 patients and focused on pain intensity, quality of life, and pain related disability. The researchers found ten trials showed meditation significantly reduced chronic low back pain intensity compared to non-meditation therapies. Seven trials showed meditation significantly reduced chronic low back pain bothersomeness in patients, and three trials showed meditation therapy significantly improved patient quality of life. “Essentially,” they said, “Meditation helped individuals change their relationship with pain by allowing them to acknowledge and accept sensations without reacting excessively.” The bottom line from all the studies, meditation based therapies constitute a safe and effective alternative approach to chronic low back pain management.

TODD: After the break, we’ll be back with Dr. Holman talking more about acute and chronic back pain.

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[Sound effect signals return to the interview]

TODD: What are the signs it’s time to see a doctor?

DR. HOLMAN: If you have pain that becomes chronic. So, you have your first episode and you think it’s no big deal and then something that last for a week turns into two weeks, turns into six weeks, you know that might be time to potentially, at least, talk to your primary care doctor. Anything neurological is probably something that's a little bit more serious. So, when I say neurological, let's say that you’re getting loss of sensation in your foot or in your arm, you're getting some weakness. You are walking, you're kinda tripping over your foot, or with your upper extremities if you start to have coordination issues like, you know, dropping things, difficulty buttoning your shirt. So, anything that is neurological should be a little bit of a red flag that maybe it’s not something that’s a minor issue. Maybe you need to get it checked out by your doctor. Because some people that have problems with their spine that are neurological they actually don’t have pain, and so, obviously, you might not go and see somebody ‘cause you don’t have pain. But at most -- I would say a majority of people that have issues that need to see a surgeon, there is an association between pain and some type of neurological dysfunction. So, those are important red flags.

TODD: Does physical therapy work for a lot of patients?

DR. HOLMAN: Yeah. I would say that most people that we see in the office with an acute episode of pain, if you treat them with anti-inflammatories, you send them to physical therapy, and they do a lot of things in physical therapy. They’ll, you know, put heat or ice on your back depending on how acute it is. They’ll do massage, they’ll do therapeutic exercise. So, the physical therapists are excellent. They look at patients through a completely different lens than a spine surgeon. They're looking at your muscles, they're looking at the way that you move, they're looking at your range of motion. And so, they try to give you exercises to correct some of those muscular imbalances. But that is literally the gold standard for, you know, the treatment of any type of acute or chronic pain, is to start with physical therapy and look at kind of the whole person. Look at their muscular function, look at their flexibility. And the physical therapist -- It would be great if you could do that as much as you want. Insurance is typically gonna limit your access to physical therapy to maybe, you know, six or eight weeks, but once your go through therapy, at the end of that work with the specialist your goal should be, okay, these are the things that I know are gonna help and then you have to develop your own routine, take it home, and then make it a part of your daily, you know, self-care program. So, if you get a lot of benefit with an acute session of PT and then you just stop doing it then you're probably gonna potentially relapse and have more problems with chronic pain. But, if you keep stretching, if you keep working on your core, then you're more likely to have long term success.

TODD: I had a pinched nerve in my neck that wasn’t causing back pain but was causing arm pain. They said if it was just a little bit lower it would’ve caused back pain. We went right to the surgery, the doctor just said therapy isn't really that good for this. Is that the case ever with pinched nerves and back pain?

DR. HOLMAN: Surgery is, you know, a very important part of taking care of spinal problems, but if someone doesn't have a bad neurological deficit, meaning they come into my office and they have a weak arm, to use your example, or they're losing coordination. Even someone that has a pinched nerve, you can treat that conservatively, so an example would be traction. So if you have a bulging disc in your neck, sometimes you use a little, literally, it’s, you know, putting some type of a device around the neck and then hanging weight over a pulley stretching the neck. They do that a lot in physical therapy, but you can buy traction units online now. That’s been around for forever. So, I would say when I do a -- I'm gonna do clinic later on today, I'm probably gonna talk to at least two patients that will tell me, “Six weeks ago, I had this horrible pain shooting down my arm. If I could’ve seen you the next day I would've signed up for surgery because it was a 10 out of 10. I mean, it was like the worst pain I've ever had. And, yeah, I took some -- I talked to my doctor, I took some anti-inflammatories, it didn’t really work. And about a week before I came in to see you, for no reason, the pain just went away.” And so, then they say, “But I wanted to keep my appointment, I wanted to come in and talk to you about, like, why did this happen? Is it gonna happen again?” So, a lot of, you know, seemingly serious neurological things that are not associated with weakness, but just pain shooting down the arm or leg. So, in the lower extremities we kinda loosely call that sciatica, but the medical term of that is actual, radiculopathy. Radiculopathy means you have a pinched nerve in your spine that’s causing an electrical pain to shoot down your arm or leg. Sciatica is just the sciatic nerve is irritated for some reason. So, those terms are actually slightly different things. But, no, even people that have nerve pain a lot of times physical therapy or conservative things can make that go away.

TODD: And how about pharmalogic treatments and injection-based treatments?

DR. HOLMAN: If I tell a patient that I'm gonna give them an anti-inflammatory and that’s gonna make their pain go away and they see their MRI scan and they say, “Well, there's this thing pressing on the nerve, I don’t understand how taking some medication’s gonna make the pain go away.” It turns out that pain in the nerve is actually not caused by the mechanical compression, it’s caused by inflammation. So, if you rupture a disc, there is an intense inflammatory response. So, if you take medication or get an injection of a steroid and it reduces the inflammation around the nerve, if you theoretically did an MRI scan after the pain went away by taking medication or doing an injection, it would look exactly the same. And the reason why the pain is better is because the inflammation is gone. When we see patients in the ER that have acute nerve pain the most effective treatment for that is actually oral steroids. Steroids are the most amazing medication that we have in medicine. They treat so many different things including acute nerve pain. The problem with steroids is you can't take them chronically because then they have a lot of side effects. But, nothing makes nerve pain or back pain go away faster than a short course of an oral steroid. Which is kind of like a over the counter anti-inflammatory to the tenth power.

TODD: Yeah, when I had the pinched nerve, before we knew it was a pinched nerve, I took Prednisone at one point, didn’t touch it. That’s unusual or usually…

DR. HOLMAN: Yeah, I would say that most people that have nerve pain if they take an oral steroid like Prednisone or something called a Medrol dose pack. People know about the Z-pack, you know, when they're sick, and they also know about the dose pack when they need steroids. They're usually somewhat better the problem is that, a lot of times a patient will tell me, you know, “I felt amazing when I was on the steroids and then as soon as I stopped them two or three days later the pain came back.” And that’s why injection therapy could theoretically be the next step in that scenario because what you're doing is instead of taking the medication, you know, systemically, you're getting a very high concentration of the steroid and you’re – Typically, a radiologist or a pain management doctor, they’ll inject that near the nerve that we think is inflamed based on the anatomy and the imaging. And so, you're getting a super high concentrated dose. And sometimes that is more effective than just taking, you know, pills by mouth.

TODD: And is there any cumulative effect from doing a lot of those?

DR. HOLMAN: So, we typically will tell patients that in a twelve month period, you probably shouldn’t get more than three or four injections. And the reason for that, again, is because if you're constantly giving your body a steroid, it can shut down your body’s own production of steroids, so that’s your adrenal glands. And then the other thing is chronic use of steroids can actually cause osteoporosis, it can cause worsening of your blood sugar control. So, people that have diabetes, it can cause their hemoglobin A1C, everyone kinda knows that’s the test that the doctor screens how well you're controlling your blood sugar. So, like, I said before, I mean, steroids are the best and the worst of the medications that we have for a lot of conditions, but yeah, a lot of injections, a lot of oral steroids, they can have some pretty profound side effects.

TODD: So, when is surgery gonna be appropriate?

DR. HOLMAN: So, I would say -- There is a couple different scenarios. If someone has a bad neurological deficit right off the bat. So you herniate a disc and your foot is paralyzed, so that's called a foot drop, that’s pretty much a scenario where most spine surgeons are gonna tell a patient, “You should have surgery right away.” It’s not app -- It’s actually not appropriate to treat it conservatively. If somebody has a chronic pain and they’ve maximized all the conservative treatments, so they've gone through physical therapy, they have taken medications, maybe they’ve done injections, and they have nerve pain that just will not go away. I think anyone that’s actually had nerve pain has a lot of unique insight. It's very, very difficult to actually have nerve pain and to live with that over an extended period of time without doing, you know, something to get rid of it. It’s not like the pain from arthritis, not that that’s a trivial thing, but actual nerve pain is very, very severe, it can be very excruciating. And then, you know, for what I do, I mentioned that I do a lot of scoliosis surgery. If you had the deformity of your spine and it progresses, it’s very interesting. When you go to the doctor and they have you fill out all these forms, right, you have these questions and you check the boxes, right, and they seem like these stupid questions, most of those forms that you fill out are actually what we call, outcome measures. So you -- Depending on which box you check you get a score, it tells you how much the medical problem that you're dealing with is affecting your quality of life. So, if you checked zero, or the first box, it would mean that there's 0 out of 50. They're typically scored 0 to 50, the problem isn't affecting you at all. If it’s 50/50 they mean it’s the most severe, debilitating problem that you can imagine. We use the same outcome measures in the treatment of back pain patients, as we do for other conditions. So, if you look at someone with adult scoliosis that has a severe deformity, on average, the way that they score their quality of life, how it’s affected by these severe spinal conditions, it’s similar to someone having bilateral, both sides, below the knee amputations, who’s blind. That’s literally been documented. And I bring that up just because, you know I think it’s important if you're, you know -- People sometimes are critical of other friends or family members that have chronic pain and they say, “Oh, they're always complaining about their back and I'm tired of hearing about it,” and all this kind of stuff. I think people don’t actually realize, in people that have some forms of chronic back pain, I mean you're really dealing with a very, very serious medical problem. And that’s why people wind up having, you know, complicated surgeries because their quality of life is literally, it’s nothing. They can't do anything. They can't do the things that they wanna do, they can't play golf, they can't run, they can't do different sporting activities, and they can't do the things they need to do. They can't, you know, manage their own house, they can't do yard work. They can really do nothing, the problem becomes, just, super incapacitating.

TODD: So, what are the types of surgery? Is there much minimally invasive options?

DR. HOLMAN: Surgery is interesting in that there's – Every -- I would say, every operation on the spine is complicated. There's always risk involved even with what is perceived as a simple surgery or a minimally invasive surgery. So, I think that’s important for people to understand that the decision to have surgery shouldn’t be taken lightly because every operation can have potential complications. Having said that, for most simple problems like a herniated disc, a bulging disc, or something called spinal stenosis, which is where with aging your spinal canal gets narrowed by wear and tear, the thickening of the ligaments or bone spurs, things of that nature. Thirty, forty years ago, we would make, you know, a six or eight inch incision to do an operation to fix something like that. In 2024, we’re now doing a lot of minimally invasive surgery. Actually, particularly at Houston Methodist, we’re an early adopter I would say, in the United States for endoscopic spine surgery. So, it used to be if you could do one of these operations with an incision that’s an inch long that was like, people were amazed by that. With endoscopic minimally invasive surgery, we can actually take out a bulging disc through an incision that’s essentially a third of an inch. We have 4K visualization in these scopes. So, amazing technology that’s really shrunk down the footprint. So, we always wanna fix the problem. If you can do an operation through a super small incision, but you don’t get the same amount of relief of the pain, you don’t have as good of a surgical outcome as you would if you used an incision that was a little bit bigger then it’s pointless, right?  But we have the technology because of, like I said, camera technology. It’s the same thing with phones, right? You have this amazing resolution on digital cameras, and things of that nature, but we’re able to do these minimally invasive operations a lot because of the optics in the kind of, the application of endoscopy to the spine.

TODD: But surgery’s a good option? You said -- You mentioned early about there's often a need for follow-up surgeries.

DR. HOLMAN: One of my lines that I think I learned from one of my mentors is I always tell patients, when you have an operation on your spine you can never fix tomorrow’s problem today. Meaning that if you have surgery you're never guaranteed that it’s going to be the last operation that you'll need. And the reason for that is that you're trying to hit a moving target. We are treating a degenerative problem. A degenerative problem is something that gets worse with age. So, every day, every week, every month, every year that you're alive, doing normal things, you're burning some tread off the tires. So, for example, if you have a herniated disc and you have surgery because it’s significant, it can't be treated conservatively, the literature says that there is a 10% risk that the same disc will re-herniate. So, we kind of jokingly call it the Tiger Woods syndrome. So, Tiger Woods had, we believe, three, maybe four recurrent herniations of the same disc and then he wound up having that disc fused, and then he did great after his fusion, won another Masters. And then, I think three years later, he herniated the disc above his fusion. So, whether you have a minimally invasive, small operation, or let's say you have a fusion, a fusion means that you put hardware and some type of bone grafting material into the spine to stiffen it to make it more stable, that can transfer the burden of movement to other levels. And then sometimes people will break down and need to have more of their spine fused. So, that is a concept that we really spend a lot of time educating our patients about is that we don’t wanna do surgery if we can treat something conservatively. But if you need surgery, we design the operation that’s gonna fix the problem that’s gonna get you back, hopefully, to a better functional quality of life. But you have to understand that there's no perfect operation and there's always a chance that there's something else that can happen down the road. And, you know, we try, through clinical research, and just, you know, looking at how what we do affects patient outcome so we've gotten better. Like I had mentioned earlier, I would say 20 years ago when I was training, we didn’t think all -- at all about spinal alignment, so when we did fusions we just thought that if you put rods and screws in, you made something that was hyper mobile, something that needed to be stabilized. If you made it stiff, then that was all that we needed to do to get a good outcome. But now we know that if you do a fusion of somebody’s spine, if you don’t specifically align their spine to optimize their posture, there is a tenfold increase of a chance of another surgery in a short period of time. If we do an operation and I get somebody ten years to where they don’t need another surgery then that’s -- We kinda consider that, like, a very good outcome. But, even patients that have successful surgery sometimes if they live long enough and they're wearing out their spine they just have other problems, and they can't avoid needing another surgery.

TODD: In summary, is there anything you wanna say? I mean, what do you hope people will take away from this conversation, both those hopeful about not having back pain and those already dealing with it?

DR. HOLMAN: If I were just talking to people out there that have issues with their back I would say, first of all, you know, you do have to take some level of personal responsibility for the issues you may have with your spine. Meaning, if you're starting to have a little bit of pain you have to look at your habits with regards to nutrition, exercise, core strengthening. If you are not optimizing those things and spending time, so getting your weight down to where it should be from an ideal perspective, putting the work in, doing stretching, exercising to strengthen your core. If you don’t do those things then surgery is not gonna be the end all, be all. I think a lot of people just rely a little bit too much on going to see a doctor to fix the problems that they can probably manage with some hard work on their end. The other thing I would say is, for people that do all the right things and they’ve tried conservative options and they're strengthening their core, they're taking anti-inflammatories, they’ve worked with a chiropractor, they're doing all these things that they can do to manage their problems. If you go and see a spine surgeon and you get an MRI scan, you have to realize that what the MRI scan says is not necessarily the end all, be all. I think a lot of patients get really hung up on scans. It’s just one piece of evidence that has to be, you know, pieced together. Just because you have an abnormal MRI scan, you have chronic pain, that doesn't mean that you should have surgery. I think that’s a huge thing for me, is making sure that people have the right expectations when they go and see a spine surgeon. It always kinda baffles me if someone has chronic pain and they come to see me and I say, “Hey, listen, there is nothing structurally that's really super abnormal with your back, I think if you do these thing that you can improve your quality of life. You might not be pain free.” If people are angry or disappointed that’s -- I don’t understand that. So, surgery is not appropriate for every patient, and I think we have to, as spine surgeons, realize that we have limitations. We can't treat every person that has chronic pain. Sometimes surgery is not the right thing. The first rule of medicine is to do no harm. So, if I tell a patient, “Hey, I don’t think that surgery is the right option for you,” then that, as a patient, that should mean a lot because we always wanna do the thing that’s in the best interest of the patient.

TODD: Alright, very good. I think that’s all I have. I appreciate you taking time out of your schedule to educate us all out these matters.

DR. HOLMAN: Awesome. Well, it was great to get to meet you, and appreciate the time.

[Sound effect signals end of interview]

ZACH:  Alright so, take aways, Todd, from your discussion about back pain.

TODD: Well, my first one was certainly the role of muscle. I had not realized this before, but I was especially impressed by his talk about his work at NASA.

ZACH: Yeah.

TODD: Where the astronauts did the core strengthening exercises for three to four hours while they're in space so that their muscles don’t shrink and cause them pain.

ZACH:  You know, I wanted to be an astronaut when I was a kid.

TODD: Really?

ZACH:  I wasn’t that great at the math so that was a --

[Laughing]

I quickly found another career path which here I am. But, working out three or four hours a day, oh man that’s, that’s another strike against being an astronaut, that looks exhausting.

TODD: Yeah, and all on your core. I mean…

ZACH:  Yeah.

TODD: It’s not like you're exercising everything, it’s…

ZACH: Right.

TODD: It’s mostly your core. But, it’s another testimonial to the importance of strength training. So, I'm heartened I've been doing that all these years. I mentioned that I have a bit of a stiff back and I was relieved to hear that doesn’t necessarily predispose me to anything. But, I do do my share of back exercises there so…

ZACH: You always make sure you stretch before you exercise?

TODD: No I'm not good at that, I'm sorry.

ZACH: No? Okay, no. Didn’t we have a whole podcast about that?

TODD: Yes.

ZACH: About stretching. Didn’t you always give me a hard time for not following through on things we talk about on this podcast?

TODD: Yeah, that’s true.

ZACH: Alright.

TODD: Yeah so you --

ZACH: Well let me know.

TODD: Yeah. You can go --

ZACH: Next time you work out I wanna -- Facetime me, I wanna see you stretching.

[laughing]

So. And, you know, you talk about how big a condition that back pain is in the world. Dr. Holman brought up something interesting that had not occurred to me. Two hundred years ago, three hundred years ago, not a problem because people were dying in their 40s, 50s, probably that was your life expectancy. But now as people can get into their 40s, 50s, 60s, the spine issues become a problem because late -- It’s just  you -- The wear and tear on your body. You're around longer, you're using it longer, right? I mean that’s part of aging.

TODD: Yes, it’s a degenerative disease. So, I was actually surprised that he said it can really start in your 30s.

ZACH: Yeah, I'm worried now.

TODD: Yes. Well that’s what I was saying. May --

[Laughing]

Maybe you should start thinking about it. I was struck by his openness to acupuncture, chiropractic, meditation.

ZACH: Yeah, because, as we learned, so much of it has to do with the muscle. That all makes sense because massage, I think that speaks for itself. But, you know, even meditation, relaxing, your muscles get more relaxed. That makes a lot of sense. I've never done acupuncture, Todd, have you?

TODD: I have.

ZACH: Really, how did that go for you?

TODD: Well, I'm a believer in acupuncture. I don’t know that I would see it as a great fix for back pain but I take his word for it.

ZACH: Okay, no that’s interesting. Again, I've never been in a position where I needed it.

TODD: Yeah.

ZACH: But I've not gonna -- I mean the needles intimidate me, but, you know, if it works, it works.

TODD: I've done my share of massage, that’s certainly good for aches and pains and joints.

ZACH: Yeah.

TODD: So that would -- That doesn’t surprise me.

ZACH: Yeah.

TODD: But meditation, that’s that whole body, mind thing. But, I'm sure it works for some people, I don’t know if that would work for me.

ZACH: It’s all connected, Todd.

TODD: Yeah, yeah. How about what his thoughts on sleep position? Did those surprise you?

ZACH: Yeah. I... Really don’t think about how I sleep. I go to sleep really easily, right, so I don’t really think about, “I better get into this position so I can fall asleep.” So, I don’t put a lot of thought into it. But I feel like I'm usually a fetal position guy, which could curve my spine one way or curve it the other. So, I guess, if I balance out each side I guess that works out, I don’t know.

TODD: Everybody does seem to think putting a pillow between your legs is good for…

ZACH: Yeah. I've never…

TODD: Yeah, I haven’t tried that either but I guess I'm going to.

ZACH: Yeah, I mean, If I started -- if I started to have, you know, back pain, I would explore these things probably, but since I don’t, I've really haven’t had to. But it’s good to know that there’re some mundane, you know, if you wanna call it that, options to kind of help yourself out, like, you know, pillow position, put it in certain places, that sort of thing. I would totally try it if I needed to.

TODD: Yeah, yeah.

ZACH: What is your normal sleep position?

TODD: Stomach.

ZACH: Stom --

[Laughing]

That’s why -- You're crazy man. How do you --

[Laughing]

TODD: I think they say something like 10% of people go to sleep that way.

ZACH: I --

TODD: I think I sleep my share on my side, but I need to fall asleep sort of on my stomach.

ZACH: How do you breathe?

TODD: I tilt my head.

ZACH: Okay. Talk about back pain, you're gonna have neck pain doing that.

TODD: That -- Say that’s possible, can happen.

ZACH: Alright.

TODD: I don’t know.

ZACH: We should do another podcast on sleep positions.

TODD: Yeah.

ZACH: Stay tuned, everybody.

TODD: Yeah. The other thing that impressed me, that he said, when he was talking about the level of pain and some severe cases. And he mentioned that the pain scoring that some of these patients gave for their pain was the equivalent of having both legs amputated at the knee and being blind. That’s what their quality of life was.

ZACH: Yeah. And he also said that his patients saying, you know, a lot of them say they have a high tolerance for pain so imagine that. So multiply that, probably twice as much, right? That’s incredible.

TODD: Probably not those same patients, but I was too impressed that he said that most people say they have high tolerance for pain.

ZACH: Yeah.

TODD: I don’t have high tolerance for pain.

ZACH: Really?

TODD: No.

[Laughing]

ZACH: I would like to think so. Depends on the pain, anyway.

TODD: When I had a pinched nerve and it was causing just arm pain it was excruciating.

ZACH: Yeah.

TODD: I couldn’t sleep with it and so no, I had no tolerance for that.

ZACH: Hm.

TODD: Anyway, but one message that I took away from it is that if you're starting to have back pain, you know, you can let it resolve itself for a couple weeks but if it goes on too long you need to see your doctor because --

ZACH: Right.

TODD: The longer it goes on, the harder it is to treat.

ZACH: Alright, well I learned a lot, you learned a lot, hopefully our listeners learned a lot about back pain and ways to alleviate, and treatments for it.

TODD: Yes.

ZACH: Alright, well that's gonna do it this time for On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings so until next time, stay tuned, and stay healthy.