Mirella Falcone

Good evening, everyone. I hope you're well and welcome to our webinar on treatment for back pain. My name is Mirella and I'll be your host for this evening.

Our expert presenters are Consultant Orthopaedic Spinal Surgeon Mr Omar Mohamed and Interventional Radiologist, Dr Mo Faris. The presentation will be followed by a Q and A session, so if you'd like to ask a question during or after the presentation, please do so by using the q and a icon which is on the bottom of your screen. This can be done with or without giving your name.

If you would like to book a consultation, we have Chelsea from the Private Patient Team on hand to take phone calls after the webinar and we'll provide the telephone number at the end of this session please note the webinar is being recorded I'll hand over to Mr Omar Mohammed and Dr Mo Faris and you'll hear from me again shortly.

Mr Omar Mohamed

Good evening, everyone, I'm going to talk today about what back pain is how do we aim to help patients with back pain how we can also avoid back pain and what treatment options are available to anyone who suffers from back pain. Next slide, please.

Back pain is fairly common probably about eight in ten of us will experience back pain at a certain stage back pain can start without any specific cause back pain can also occur after lifting or handling any heavy object twisting awkwardly can also cause back pain, to be honest in most cases back pain will start without any precipitating factor luckily most episodes of back pain are self-limiting back pain is what is back being back pain is any pain felt from the bottom of the neck down to the bottom the lower back is probably the most sight of back pain neck pain would probably be the next common and then thoracic vein which is being in between the shoulder blades.

Anything in the spine can cause back pain that's why sometimes back pain could be poorly understood and treated as well the spine simply is made of bones which are more or less circular those bones would become vertically are connected by ligaments in between them there is the disc and attach them the muscles and in the middle is the spinal cord and subsequently, the nerves come out from the spinal cord right and left.

Back pain is something that could be dealt with and there are various treatment options for that the problem with back pain is that sometimes we can't localize where exactly is causing the back pain is it coming from the muscle is it coming from the joint or coming from the disc back pain could sometimes be associated with pain shooting down the leg this is probably caused by a nerve which is trapped in the lower back although the problem is in the lower back however you feel the pain shooting down the leg.

Back pain what is the classification of back wheel backpack can be non-specific or specific the majority of back pain is non-specific it doesn't really help with a clear diagnosis however the good news is that there isn't any underlying significant or sensitive pathology so probably about 80 percent of backbeat would fall into the category of non-specific specific causes of back pain back pain can be caused by osteoarthritis as we age the joints lose their particular surface or where they usually move freely and hence we can experience back pain other causes can be for example rheumatoid arthritis osteoporosis where the bones become weaker and then subsequently can fracture very rare causes can include cancer or infection but the majority of the causes of back pain are non-specific when should you ask for medical advice as I said most of the episodes of back pain but these will be self-limiting however if the pain becomes persistent constant getting worse and not improving then this is something that you should seek medical advice for if you have any loss of feeling in the bottom or any weakness in the leg or any numbness this is again something that would warrant seeking medical advice.

What will happen when you seek medical advice the medical practitioner or the specialist will ask you a few questions this is what we call history taking to just know when the pain started how it is progressing after any for example underlying worrying things like for example weight loss fever night sweats anything like that and then after that we might need to request some investigations this might include a blood test a simple x-ray or we might even need an MRI scan how can we treat back pain the first line of treatment is usually to stay active even despite having pain you won't cause any further structural damage and you also need to stay at work painkillers will help as well if this doesn't improve the episode of back pain then the first stage would be asking help from a physiotherapist what we call musculoskeletal rehabilitation after that if there is no improvement there is a rule for spinal injections and Dr Mo Faris will talk about that in a bit of detail very rarely surgery is required for back pain however there are a few cases where a surgeon for back pain can help if there is a weakness or neck pain surgery can help a lot in those instances next ones.

What are the important tips to avoid back pain? Most important thing is to keep mobile and active exercise regularly musculoskeletal rehabilitation core strengthening exercises swimming cycling keep fit and active. The old advice is if you have back pain bad then rest, there's no evidence behind that and this has not proven to be of any benefit to patients, that's why if you have pain, you must stay active and keep your activity level you must also look after your back so lifting handling heavy objects or core twisting movements cooldowns all those things should be avoided.

Dr Mo Faris

All right just introducing myself, so hi I’m Dr Mo Faris, I'm a consultant interventional radiologist so what I’m going to be talking about in my part the talk will be the different types of spinal injections so should conservative management i.e. the things that Mr Omar Mohammed has spoken about don't work and we proceed on to doing spinal injections what are our options or what are your options so

I’m going to talk about the different injections and what they will look like and how we perform them and then after that we'll answer any questions so you can see from this slide there's a multitude of different ways we can tackle different pain coming from different areas within the spine so is it related to the facet joints which in essence are the hinges at the back of the spine is it related to impingement from a nerve so commonly a slipped disc would be impinging on a nerve and these would dictate what we can offer and what type of injection was likely to be successful so first would be a nerve block so this is commonly either in the neck or in the lower back most commonly in lower back so most people would know about sciatica where people are said to slip to disc and pressing on the sciatic nerve which then radiates down to the foot so we tackle this with CT guidance and what this will involve is an outpatient procedure come in and we use CT to target it next to the sciatic nerve and then inject a block and the block is a consistency it consists of steroid and long-acting anaesthetic this is a walking walk-out procedure so it's totally in outpatients.

We ask you to sit for 15-20 minutes obviously not drive back home and then you can go home and within a few days we'll see how much of a of an effect it's had because, as Mr Mohammed was saying, that the pain can be quite difficult to be certain where it originates from a lot of these injections are also diagnostic when we say diagnostic what we mean by that is that the cause of the pain so we would suspect say from an MRI there appears to be compression there also may be some degenerative changes also now which part is actually causing the issue so by doing a block or doing an injection we would also be able to see is this the cause of the pain so for example in my own in from a personal opinion from a personal point of view I had sciatica approximately 10 years ago from a slipped disc as a very young man and after a year it was a lot of pain I had an injection performed by one of my colleagues at the time I was at St Thomas’s and it gave me some gave me a reason bound to relief but then started to wear off and after about a year and a half of quite significant pain I was operated on so it gave the surgeon the confidence to know that that's the area to tackle if it needs to if it comes to a point where we have certain is indicated so the injections can be from the neck.

So these are common sorts of neck injections this is a cross-sectional image of a CT scanner and what it essentially involves is that's the front of you you're lying on your back this is the neck that's the trachea the windpipe the white stuff here is bone and this is the spinal cord and that's the cervical nerve coming out and that's the needle itself so you can see the accuracy we can get with these injections this is a pictorial thing of what we're trying to do so if you've got a herniated disc which is compressing on the nerve root and the needle will then inject the steroid and the long-acting anaesthetic as the nerve exits that's just a different approach so these are examples of other blocks so these are all examples of nerve blocks this is the lumbar fifth lumbar um which again you can see what I do is I inject contrast to see exactly where the steroid is going to go and this thing here is the nerve itself so you can see the level of accuracy we can get and what this gives us is a degree of confidence that if you have relief then great this is the likely cause of it if you don't have relief because we can see how accurate we can get to it then we'd have to have a rethink as to what is the actual cause of your pain and that's when I say the diagnostic component to it and is important and that's the classical sciatic nerve so this little looks like a little eye and that's all bone that's in the sacrum this is the back so coming from the back pretty straight forward these injections generally take about 10 minutes and we can target the sciatic nerve very closely and this is exactly what I had and this isn't my CT and I’ve got far more muscle on the back so anyway yeah so we targeted it and then we see how well it works.

There's another type of injection so the sacroiliac so this is right in the pelvic area this can be quite inflamed it can be acute so which meaning it can be a an acute inflammation or it can be long-standing inflammation which becomes chronic and the advantage of these is that we start off with the injection and what I’ll talk about is the facets as well so the two with the sacroiliac and the facet what we now do is have them at the innovation procedure so what we do is we start off with a diagnostic facet injection so this is example of what the facet joint is when I said it's the hinges at the back this is what we mean so there's your remnants of the canal and that's your nerve roots and this is actually the facet joints itself so we can target the facet joints with a steroid block to see whether it works this is sort of a more understandable picture so you have innervation of this joint itself with these facet joints and we call it medial branch blocks because the medial nerves innervate this area as well so we can call it either or and we inject it first of all and if you get a positive response and improvement what we don't want to do is keep every few months injecting steroids until into these areas because of the increased risk of localized infection and osteoporosis and so we limit the number of injections and what we do is we do an injection prove that this is the cause of your pain and after which we can then step up to this so this is called facet a radio frequency denervation rhizolysis there's a multitude of different names for it and what we're doing is where we've proven that your pain is coming from particular levels of facet joints we can then burn using a small heat source the nerves that innervate that joint so as we saw previously these are the medial branches and what we do is we target these done under CT again and the small little needles are not much bigger than the needles we use to actually inject steroids into we attach it to a probe and we burn these nerve endings and what we burn is that nerve endings that sense pain but don't supply the muscles so they're the two so we do a few tests to just to check that we're in the right area and this is another sort of example of it so we are we are checking to see which is the pain generating nerves we then target them this is performed without a general anaesthetic this is performed as a day case so what the procedure actually involves is we will get you bring you in we use it again the CT scanner and we pop local anaesthetic into the skin and onto CT then inject the needles and the laser fibres we then test the two tests so we want we want to burn the sensory nerves we don't want to touch the motor nerve so they're the two tests we do and then it's only three minutes but because it's uncomfortable because of the ablation the burning of the nerve endings we give you sedation that's what's called conscious sedation so we're not fast asleep because obviously you have to worry about your breathing if that was the case so we give you enough to make sure you're nice and comfortable everyone tolerates it very well with that combination of sedation and three minutes done and then that's it the difference between the steroid block and the ablation is that the ablation can take up to two weeks to have an effect because you think we're burning the little nerve endings they can get a little bit inflamed so you can get some transient discomfort post procedure for a week or so and then as the nerves die off and hopefully you get an improvement and this improvement is anywhere between six to eighteen months and this is now sort of the this is now the gold standard for long term fasted degenerative change for chronic pain and nice is our national institute clinical excellence.

So what is an impartial government body which looks at the evidence for varying different disease processes and treatments and then try to come with the best possible conclusion it is guidance it's not an absolute and but we tend to go relatively reasonable you follow it so what it has concluded is the radar radio frequency denervation is the gold standard that's the one that has the vast majority evidence behind it what we do to prove it's the case is do an injection so we do immediately we call it a medial branch block as I said it's the same as a facet injection and we inject into the areas we think so the clinical assessment is vitally important and if we get a positive response then that's an indication for a denervation and this can keep I have patients now into eighth ninth year and functioning really well and have a good quality of life back with them with this procedure and they tend to come every sort of 18 months two years have the procedure done and then carry on so it avoids surgery and allows people to actually have a good function back their lives so thank you for listening and if we'll answer some q and a's now. 

Mirella Falcone

Thank you, Dr Faris and Mr Mohammed, we've got a couple of questions here so I will put those to you. The first one is - I get a lot of back pain in bed at night and have to make sure I put some gel on to ease the pain or else I’m in trouble do you have any advice?

Mr Omar Mohammed

If this thing has been long-standing and hasn't been improving, then probably you ought to have some medical advice as to where the speed is coming from you might require an MRI scan to reach a clearer diagnosis.

Mirella Falcone

Thank you, Mr Mohammed. Next question, I had right-side denervation of the facet joint a year ago which sadly didn't help my chronic back pain my question is what, if any, are my options in the future to be able to resolve my pain something it'd be an interesting one to know?

Dr Mo Faris

Because what I call commonly find is if we do one side there's normally one side worse than the other so you do one side and it unmasks pain on the other side and sometimes people will be unsure whether it's worked at all and so I tend to do with those ablations on both sides and I think unless Omar’s different opinion I would suggest either a revisiting depending on whether the injection itself initially works so if the steroid injection worked but the rhizolysis didn't work I normally would be quite happy to do a second rhizolysis to see whether you get a larger burn area and actually get some relief so it really depends on whether the injection the steroid injection gave any relief whatsoever if not then it would suggest that the it's either wrong targeting the wrong areas or the wrong parts or whether it's not actually related to the facet joints and whether there's another disease process or something else going on or whether it's related to nerve impingement instead because pain is non-specific it can be quite tricky to know exactly which is the cause of the problem.

Mirella Falcone

Thank you. Next question, I had a total hip replacement about seven years ago and have suffered from sciatic pain ever since, is there anything I can do to improve the pain?

Mr Omar Mohamed 

yes definitely if the pain is shooting down the leg and if it's in a specific area then this could indicate that there is a problem in the lower back what we commonly call sciatica it's a slipped disc it's not a slipped disc but part of the disc is a strong fibre string and inside is a jelly-like material and sometimes the outer tough ring will give way and part of the jelly will come out and press on a nerve hence you having pain shooting down the leg to be able to reach a definite diagnosis then probably I would advise an MRI scan to look into any pressure on the nerve in your lower back which could account for sciatica.

Mirella Falcone

Thank you. Next question, how many courses of radiofrequency injection can I have in my lifetime? 

Dr Mo Faris

There is no limitation on it depends on whether it works so it can be your chronic management and for you, for your lower back pain so because the limitation the limitations are with steroids we don't want to be keeping repeatedly putting steroid injections into people's backs but the radio frequency ablates the little small sensory nerves they grow back depending on how quickly they grow back is how long the relief is obtained for and after which when it starts to come back you can pre-perform the ablation so as long as it's working it can be repeated.

Mirella Falcone

Thank you. The next question is from mike can you enumerate the risks of the nerve-blocking procedure?

Dr Mo Faris

So, the risks are depending on which area so if we tackle the lower back the risk is we make the pain worse and so there's an irritation of the nerve and they in 12 years of that it's probably maybe a one to two per cent risk of making the situation worse by irritating the nerve with the needle. There's a theoretical risk of infection simply because you're introducing a needle into a sterile area and that's essentially about it with the lower back there is a theoretical risk of a stroke with the cervical blocks and that's only because there's been one case of it and performed it wasn't performed in the CT which is what I performed them under it was that procedure was performed in the fluoroscopy but there was a theoretical risk of a stroke and because of the vertical artery which runs adjacent to the nerves that's about it so they are pretty straightforward procedures there's no procedure which is without risks and but it's a very straightforward procedure which is hence why we perform as an outpatient procedure so you literally come in and we do the procedure you wait 15-20 minutes in the waiting room and all being well you go home. 

Mirella Falcone

Thank you very much. The next question is from Anna. Do you have any experience with the alexander technique said to change the way the back is used? 

Mr Omar Mohamed

Yes, lots of patients report very good improvement with the alexander technique and it is certainly something that you should try in the first instance. It's also worth noting that the radiofrequency denervation is part of the treatment it is not aimed to be the sole treatment for back pain so you have the innervation you have an improvement in your symptoms then you can focus more on your core muscles strengthening them for example by the help of a physiotherapist or for example by joining a pilates class swimming as well is very good for strengthening the core muscles. 

Dr Mo Faris

That's my experience as well so from a personal point of view I had my sciatica operated on and decompressed but after which I had lower back pain and functional exercises kept it at bay, so it was quite painful afterwards but it gave me the ability to then perform a functional exercise such as pilates and I did a lot of kettlebell swings I found was very useful and that the core stabilizer and becoming stronger stopped the pain.

Mirella Falcone

Thank you very much, next question. My husband is a lorry driver who has suffered from sciatica for years he's tried physio but to no avail, what's the next step?

Mr Omar Mohamed

There hasn't been any movement with what we call conservative management then the next step would seek advice from specialists again an MRI scan will be indicated over here to look into if there is any nerve which is compressed in the lower back accounting for this idea. We do know that certain jobs people who do certain jobs are more prone to back pain and problems with the risks one of them is unfortunately HGV drivers.

Mirella Falcone

Thank you very much. The next question is from Jean. I have had compression fractures in T5 and T6 due to osteoporosis and get a lot of pain in that area would an injection help me? 

Mr Omar Mohamed

I would suggest that the first line of treatment is to deal with the underlying problem which is a treatment for the osteoporosis you should, in the first instance, get a scan it's a type of scan that tells us how bad the osteoporosis is and subsequently you should be put on the appropriate medication for that. Also, I would like to stress the importance of a healthy diet and regular exercise all those things are very important for improving the quality of the bone. Coming back to your question about injections first of all if there is still a fracture which hasn't healed this is the option of injecting cement into the bone to help with the symptoms. However, if when you get an MRI scan and it shows that the fracture has healed, yes, sometimes when a fracture happens there is a bit of stress on the joints what we call the faster joints and targeted injections there can help improve the symptoms.

Mirella Falcone

Thank you. The next question is how soon can I drive after treatment for a slipped disc?

Mr Omar Mohamed

It depends on your sentence, for example, some patients with a slipped disc will have weakness in this instance we do not advise any driving but if you have for example a nerve block injection to block the pain and you have good improvement in your symptoms then and you can stop the car in case of an emergency then, by all means, you can go fairly quickly back to driving. For patients who have surgery for a slipped disc, the advice is usually four to six weeks but again it's depending on how quickly they have an improvement in the symptoms.

Mirella Falcone

Okay, the next question is from Kim. What is the best way to defend, sorry, and differentiate whether hip pain is coming from the hip or spine femoral nerve? 

Mr Omar Mohamed

This will require a good history taking from a specialist. An examination would be very important also to differentiate between whether the problem is coming from the hip or the spine after history taking and examination you will require investigations. Depending on what the specialist feels if the problem is coming from the hip, then we'll investigate the hip further.

Mirella Falcone

Thank you. The next question is from Carol. My back pain is when I stand up from sitting and can be particularly bad if I have previously been standing or walking for a long time. I have to gradually straighten up before being able to move.

I think that means what kind of advice would you give? 

Mr Omar Mohamed

Again, it depends on how long this has been going on have you tried any for example physiotherapy have you seen a specialist you might need if it's strong standing some investigations perhaps to start with an x-ray.

Mirella Falcone

Okay, next question. I work as a plumber so always lift heavy items and bend down. I have lower back pain all the time, how can I manage this without affecting my job, should I be doing any particular exercises to help? 

Mr Omar Mohamed

Yeah, heavy manual jobs and specifically what you are doing you will have back pain. I think in the long term the best option is to focus on your core muscles or what we call musculoskeletal rehabilitation. There is a very good website called backcare.org.uk but if you just google back care exercises, it will take you straight away to that website and then you can find very useful exercises and tips for back pain. 

Mirella Falcone

Thank you, a few more questions to go. I'm 30 weeks pregnant and have terrible back pain I'm worried that it won't go away after I give birth what are my options to help relieve the discomfort?

Mr Omar Mohamed

Usually, the pain is related to the pelvic hurdle, and it is well documented in pregnancy that back pain tends to improve after pregnancy if it doesn't then there are a few options again the first line of treatment would be input from a physiotherapist if there is no improvement then we can investigate this further.

Mirella Falcone

The next question is from Amy. I have had pain at the lowest part of my spa spine after I stand a long time in a fixed position e.g. work in my kitchen. The x-ray result was explained to me is then the degeneration of the bone or the things around or between the bones any suggestions for treatment.

Mr Omar Mohamed 

We just have to be a bit careful where is the pain coming from because the lower back can be actually yes from the facet joints, or it can be coming from the sacroiliac joint. The sacroiliac joint is the joint which joins the pelvis to the axial skeleton or the vertebral column. Both of them there are treatment options for both of them if there hasn't been any improvement with conservative measures then definitely and we are sure where the pain is coming from the target injections there for the facet joint what Dr Mo Faris has explained can help and for the sacroiliac joint under CT guidance can also be beneficial, but in the first instance we need to know where the pain is coming from.

Mirella Falcone

Thank you, next question. Would you recommend acupuncture?

Mr Omar Mohamed

Acupuncture is not recommended by NICE however lots of patients do have improvement from acupuncture so I would advise yes to give it to you. 

Mirella Falcone

Thank you, the next question is from David. Do you recommend treatment from a chiropractor? 

Mr Omar Mohamed

Yes, I have seen lots of patients who have had improvement from seeking a chiropractor unfortunately there isn't one thing that would work for all patients, but something will work for one patient, and I would advise if you saw a private practitioner on an osteopath one session the pain is worse than stop.

Mirella Falcone

Thank you, next question. Is there anything I should avoid in my diet to prevent back pain? 

Mr Omar Mohamed

So, a healthy diet is very important. There isn't anything specific however we know that the vertebral column of the acid skeleton is like a crane this screen is in the back and it is supported by the back muscles the more weight and load you put in the front the more the crane suffers in the back so healthy diet looking after your weight is important.

Mirella Falcone

Next question. I'm 54 and a regular horse rider and have started to get backache is there anything I can do to stop it from getting worse?

Mr Omar Mohamed

I would recommend you carry on riding I am myself or rider and I compete regularly. Look after your back, do core strengthening exercises, join a pilates class, swim regularly and front cross stroke, all those things can help a lot. Painkillers can help a lot in the first instance. If this doesn't help, then there could be a road for targeted spinal injections.

Mirella Falcone

Two more questions to go. Next question, I'm terrified of needles, will I cope with facet injections? 

Dr Mo Faris

Yes, is the answer and so we commonly have people with needle phobia and if someone is extremely bad with their needle phobia, then we can actually give some sedation and that would just take it from a straightforward outpatient procedure to a day case procedure so they would just recover for a few hours afterwards so and we do have the option to give some sedation for the injections. We give the sedation always for the rhizolysis, and the denervation but we do have the option to do that. 

Mirella Falcone

Thank you. The next question is the last question we have. Would losing weight help relieve my back pain I have a BMI of 40? 

Mr Omar Mohamed

The answer is yes, definitely because you're putting a lot of stress and load on the vertebral column in the back so off-loading this pressure will help a lot with your back pain. So, seeking advice from a dietitian for example in the first instance is also a very important role for bariatric surgery to help improve your symptoms in the long term. 

Mirella Falcone

Thank you very much, thank you, Mr Faris and Mr Mohammed. If you would like to book your consultation, please contact us on the number on your screen until 8 o'clock tonight where Chelsea will be on hand to answer and take your details or between nine to five Monday to Friday. Just to highlight that due to demand for appointments with our back pain specialists please book as soon as possible for availability in June and July. 

You will receive a short survey and I would be grateful if you could spare a few minutes to let me have your feedback on today's webinar. 

Our next webinar is on the 16th of June with our experts who will be discussing indigestion and bloating. 

On behalf of Mr Mohamed, Dr Faris, myself and the team at Benenden Hospital, I would like to say thank you very much for joining us this evening and we look forward to you joining us again soon, many thanks.