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Melanie Cole (Host): Low back pain is one of the most common ailments that we face, and how can you tell when low back pain signals something that might be more serious. My guest is Dr. Adam Shimer. He's an orthopedic surgeon at the UVA Spine Center. Welcome to the show, Dr. Shimer.What are the most common causes of low back pain? Everyone suffers from it, and it also keeps millions of people home from work. It is one of the main reasons people lose work time, too. What are the main causes that you see?

Dr. Tim Showalter (Guest): Well, I'd like to first thank you, Melanie and Radio MD for having me on. I think you touched on many important points of low back pain. It is the second most common cause of missed work, secondary only to the common colds. It is also one of the leading causes of disability for those at working age. It has not only an impact to the individual but also significant societal and economic impact.
I think the most common causes of low back pain are those that are not concerning from an emergency standpoint. Those can be simple muscle strains, tendon pulls. One of the more common reasons is what we call degenerative disc disease. Those discs are the cushions in between the bones of the spine. Those, over time, much like you can get arthritis of the hip and knee, can lose some of their mechanical properties and begin to collapse. You may have heard the term "black discs" or "degenerative discs" or "slip discs." Unfortunately, we have a bunch of terms describing more or less the same thing.

Melanie: Now, is there something we can do, Dr. Shimer, to reduce our risk for low back pain? I mean proper lifting techniques, or if you know that maybe you're subject to arthritis, osteoarthritis or something, that you can keep yourself strong and healthier? Is that going to help?

Dr. Shimer: Yeah. I tells folks that it seems cliché, but really doing what your mom told you to do: eating right, getting good sleep. Losing weight is one of the key ones that is difficult to talk with patients or folks about. But if you can take off 10 percent of your overall weight, you decrease the strain on your back a considerable amount. Also, smoking. It's not commonly known that smoking is one of the leading causes of increasing the rate of disc degeneration, and folks who smoke have an increased rate of back pain. So I tell people they really need to increase the healthiness of their lifestyle: better eating habits, get good sleep, stop smoking, lose weight, and exercise, cardiovascular, low-impact exercise. These are all really the hallmarks of decreasing your chance of having back pain.
Melanie: Are there any signs or symptoms that might signal that it's a more serious condition?

Dr. Shimer: Absolutely. There are conditions such as kidney stones. There are conditions such as aortic aneurisms. These can be more significant things, and you really want to look for any other concerning symptoms, such as recent, unintended weight loss, fevers, chills, rapidly progressing back pains. It's not bothering you one day, and then, three hours later, it's incapacitating. Any weakness of the legs or any change in the ability for you to control your bladder. I think that those examples are really kind of the basic spectrum of things that should be what I call red flags. If either the patients themselves or the primary care physicians, in their assessment of the low back pain, hear those, they really need to be a little bit more concerned and maybe increase the acuity of their evaluation.

Melanie: Dr. Shimer, if a patient is experiencing low back pain, what is the first line of defense if they come to see you? Do we start with anti-inflammatory medications? Surgery would seem to be -- of late, people would like to make that the very last option, for if it is something serious, disc-related. But what do you do first for low back pain?

Dr. Shimer: Surgery should absolutely be the last option. I think that, as you have been going since starting me off, handed me the ball and allow me run, but I think anti-inflammatory medications, and that's as tolerated. Certainly, people's stomach can get upset on those. Or if they high blood pressure, those can be some relative contraindications. But as their medical condition allows anti-inflammatories, and those can even be over the counter, such as naproxen or ibuprofen. Also, some good low-impact cardiovascular aerobic exercise. What we want to try to get people to do is strengthen their core. That should really be a flexion-based protocol, so not a whole lot of back extension or stretching your back up, because that puts more strain on the spine. So things to really strengthen the abdominal muscles help back pain quite a bit. And then, really the number one thing is time. This is what I tell patients: patience. I tell patients patience. But they just need to give it a little bit of time. And 95 percent of back pains spontaneously resolves within a week or two. The olden days of recommending prolonged bed rest, so, "Go home and lay in bed for a week," are gone. That is the worst thing to do. You really want to keep patients up and active and sit and decreasing the inflammation associated with back pain with simple, over-the-counter medication.

Melanie: What about decompression exercises? There's kind of a movement towards almost back to the old school of traction, but this decompression, sort of lengthening out those discs so they're not compressing on each other so much.

Dr. Shimer: Yeah. There's a few. Not only manual manipulation, it can be done by osteopathic doctors and chiropractors, which I'm never against. I think alternative, non-surgical interventions, if they work, are fabulous. And if people feel better, it works. There's also some more machine-based intervention, such as [VACS-D], that are traction-based devices, but they can charge patients quite a bit out of pocket. And from what I know, the evidence behind them, the peer-reviewed literature is pretty limited. I usually lean my patients more towards physical therapy, core strengthening. If they want to have some sort of manipulation, more doctor-based manipulations instead of being placed on a machine. But that's just my opinion.

Melanie: If they do have to have surgery, what treatment options are available? We don't have a lot of time, Dr. Shimer, but what kinds of surgery are we seeing now?

Dr. Shimer: I really try to limit surgery for the end of the line. We predominantly as spine surgeons focus on leg pain from sciatica, or disc problems that are pushing on nerves. Back pain itself from degenerative disc disease is really usually poorly responsive to surgery. For that reason, we do all of the things that we talked about in the previous nine minutes or so to really get patients better.I always say the most minimally invasive surgery is no surgery at all, try to get them better without surgery.

Melanie: Which is certainly the best option. Now, there are some minimally invasive things that you can do that might give some temporary relief?

Dr. Shimer: Well, hopefully we choose a procedure that leaves the lowest surgical footprints, so the least damage to the muscle and surrounding tissues. But achieving this surgical goal, and the goal is to get people lasting relief. So if someone has a disc that's bulging and pushing on a nerve, giving them intractable leg pain, we can go in with very small instruments in a microscope and very expertly remove that small piece of disc that's pushing on the nerves. Patients about 85 to 90 percent of the time get good to excellent durable results. I'd like to think that a well-chosen spine surgery that's well-performed, patients get really nice relief, pretty predictably.

Melanie: Now, in just the last 30 seconds or so, Dr. Shimer, explain to patients why they should choose UVA Spine Center for their care.

Dr. Shimer: I think it's a combination of things. I believe that UVA itself as an institution has really topnotch academic physicians and surgeons that are up to date not only on the newest technology that may be pushed through advertisements but really the most up-to-date evidence-based, peer-reviewed medical care. So what you're going to get is care that is based on science, not based on advertisement, not based on the shiniest new implant. But really, we can look you in the eye and say, "This is the best care."

Melanie: Care based on science. I love that. You're listening to UVA Health System Radio. For more information, you can go to uvahealth.com. That's uvahealth.com. This is Melanie Cole. Thanks for listening.