Episode 30 - Diagnosing and Treating Upper Back/Thoracic Pain with Dr. Scott Otis
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Episode Summary
We have addressed numerous aspects of low back pain from surgical angles to medications, nutrition, and injections on the podcast, but an increasing number of patients are also suffering from mid-back pain or “thoracic pain.”
On this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by Dr. Scott Otis, a physiatrist at the Carolina Neurosurgery and Spine Associates, to discuss thoracic back pain. Dr. Otis attended medical school at The Ohio State University College of Medicine and completed his internship at Riverside Hospital in Columbus. Dr. Otis is currently affiliated with the American Academy of Physical Medicine and Rehab. An expert in electro-diagnostic medicine and interventional spine care, Dr. Otis works out of the main office in Charlotte.
Dr. Otis reveals why thoracic back pain is so challenging to diagnose, any pain experienced in that area of the body are often compensatory issues from neck or low back issues or referral pain from neck and low back issues that present as thoracic spine pain. (4:45) He also discusses non-spinal issues that cause pain and abnormalities, including GI issues, pulmonary and heart ailments, and liver disease. (07:34) The Doctors also cover other ailments including “White Collar Disease” (09:35), poor body posture, and how poor ergonomics in furniture lead to upper back pain. (09:18)
Dr. Otis also examines the methods physiatrists employ to evaluate back pain and stress the importance of ruling out non-spinal causes before arriving at a proper diagnosis. (10:30) Thoracic back pain treatment includes self-care, physical therapy, and in a few extreme cases, surgical intervention. (13:05)
More topics discussed on this episode include:
If you enjoyed this episode of Back Talk Doc, check out our recent episode A Pain in the Neck (and Back!): How Technology, Stress, and Genetics are Leading to Aches and Pains With Dr. Sameer VemuriFor more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
We have addressed numerous aspects of low back pain from surgical angles to medications, nutrition, and injections on the podcast, but an increasing number of patients are also suffering from mid-back pain or “thoracic pain.”
On this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by Dr. Scott Otis, a physiatrist at the Carolina Neurosurgery and Spine Associates, to discuss thoracic back pain. Dr. Otis attended medical school at The Ohio State University College of Medicine and completed his internship at Riverside Hospital in Columbus. Dr. Otis is currently affiliated with the American Academy of Physical Medicine and Rehab. An expert in electro-diagnostic medicine and interventional spine care, Dr. Otis works out of the main office in Charlotte.
Dr. Otis reveals why thoracic back pain is so challenging to diagnose, any pain experienced in that area of the body are often compensatory issues from neck or low back issues or referral pain from neck and low back issues that present as thoracic spine pain. (4:45) He also discusses non-spinal issues that cause pain and abnormalities, including GI issues, pulmonary and heart ailments, and liver disease. (07:34) The Doctors also cover other ailments including “White Collar Disease” (09:35), poor body posture, and how poor ergonomics in furniture lead to upper back pain. (09:18)
Dr. Otis also examines the methods physiatrists employ to evaluate back pain and stress the importance of ruling out non-spinal causes before arriving at a proper diagnosis. (10:30) Thoracic back pain treatment includes self-care, physical therapy, and in a few extreme cases, surgical intervention. (13:05)
More topics discussed on this episode include:
- The effects of Scoliosis and osteoporosis (15:03)
- How to prevent osteoporotic fractures (16:33)
- The role of physical therapy in treating upper back pain (18:33)
If you enjoyed this episode of Back Talk Doc, check out our recent episode A Pain in the Neck (and Back!): How Technology, Stress, and Genetics are Leading to Aches and Pains With Dr. Sameer VemuriFor more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:00
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you and Calculate for over 500 easy-to-use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps.
Intro: 00:30
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly-skilled, and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:05
Welcome to another episode of Back Talk Doc. Today I want to tackle for you a topic that doesn't get a ton of coverage in the world of spine care, but in my clinic, I am seeing more and more of it these days, and that is the idea of upper back pain, or what we call thoracic back pain. We just recently did an episode on neck pain with Dr. Vemuri, my partner. And if you haven't heard that, please go ahead and download that and take a listen to it. We'll link to that in the show notes.
Sanjiv Lakhia: 01:38
Certainly, we've covered numerous aspects of low back pain from surgical angles to medications, nutrition, injections. I kind of look at thoracic back pain, which is essentially if you're not clinical, almost like from where your shoulders are to maybe just about six inches above your waistline. That's kind of our no man's land, but more and more people are having pain in this area. I am delighted to bring my partner, Dr. Scott Otis, onto the show today to pick his brain and help us figure out what is going on with the upper back pain and how to approach it.
Sanjiv Lakhia: 02:17
Scott, welcome to the show.
Scott Otis: 02:19
Thank you for having me.
Sanjiv Lakhia: 02:20
Scott is a physiatrist with our group at Carolina Neurosurgery & Spine Associates. His office is in our main location, in Charlotte. Scott, you joined the group, it was about five years ago now?
Scott Otis: 02:32
Probably six in June.
Sanjiv Lakhia: 02:33
Six in June, yes Fantastic.
Sanjiv Lakhia: 02:36
Scott resides from my home state, which is the state of Ohio, where he did medical school at the Ohio State University College of Medicine. Then he did his internship at Riverside Hospital in Columbus, and ultimately returned to Ohio State for his physical medicine and rehabilitation residency.
Sanjiv Lakhia: 02:55
First, I want to start by my condolences on the national championship game, Scott. It was a good fight and a great year, just didn't turn out the way we want.
Scott Otis: 03:03
We were just happy to be there. Better luck next time.
Sanjiv Lakhia: 03:05
Absolutely, absolutely.
Sanjiv Lakhia: 03:07
Now, Scott is affiliated with the American Academy of Physical Medicine and Rehab. He's also an expert in electro-diagnostic medicine. He does interventional spine care, and really has just been a fantastic addition to our group and is a pleasure to have as a partner. I know he gets tremendous reviews from patients that go through our office.
Sanjiv Lakhia: 03:27
Talk to the listeners who don't really know you. Tell them a little bit about your path to physiatry and spine care. Go ahead and shed some light on how you got to work at our group.
Scott Otis: 03:36
Yeah.
Scott Otis: 03:36
I completed my residency at Ohio State and went into private practice in Columbus, Ohio, for 15 years, a kind of multi-specialty group with spine as well as orthopedic physicians. My practice was very similar there, that it was pretty much non-surgical neck and low back pain with an emphasis on therapy and conservative measures, injections, and EMGs. When we looked at better quality of life, and better weather and working atmosphere, Charlotte was just a fantastic fit and so we came down here about almost six years ago. We have been very pleased to be here.
Sanjiv Lakhia: 04:15
Yeah, fantastic. It definitely is. Charlotte, North Carolina, is a fabulous place to live. The patient population in this area is great to work with. There's no shortage of spine pain and spine problems, so it's great to serve this community.
Sanjiv Lakhia: 04:31
As we talk about today's topic, which is thoracic back pain, give me a sense, in your day-to-day clinic, your typical workday, let's say, if you see 20 patients, what percent of the people coming in are having pain in that mid-back area?
Scott Otis: 04:45
I would say that a large percentage of patients have some component of pain that is in that mid-back, thoracic area. I would say that of those, only a small percentage, in my mind, actually have primary issues related to that area. I see a lot of either compensatory issues from neck or low back issues or referral pain from neck and low back issues that present as thoracic spine pain, but it's relatively uncommon to have just a primary source of thoracic spine pain in my patients.
Sanjiv Lakhia: 05:17
When I hear that as a chief complaint, I do kind of sink back into my chair because I know it's going to be a challenge at times. You mentioned to me as well, when we talked about this topic for today, that it can be challenging. From a physician lens, a physiatry lens, what makes working up thoracic back pain a little bit more challenging than cervical or lumbar discomfort?
Scott Otis: 05:41
Well, I think when you look at true spinal pathology, when people think of that, they think of herniated disc and those types of things, that's rare. That's only about 1% of true herniations. So, you're really looking at other sources of pain in that region that are not discogenic in nature. It's a spectrum of, when I see patients, of trying to find a true, accurate diagnosis. Then, once you can hopefully have that diagnosis, treat them appropriately, but it's hard for people who have musculoskeletal issues in that area because many a time it's a manifestation of something else going on in their life.
Sanjiv Lakhia: 06:18
Exactly.
Sanjiv Lakhia: 06:19
Now, you touched on a really good point. Thoracic disc herniations are not as common as they are in the low back and cervical spine. Now, I have people listen to this podcast. Some of them are potential patients or just average people looking to improve their health, and the others are clinicians who listen to our podcast. Are you able to explain to people why the incidents of herniated discs in the thoracic region is much lower than the other areas?
Scott Otis: 06:45
I think it has to deal mostly with just the biomechanics of the spine and the fact that the neck and low back are mobile sections and they have a tremendous amount of stress to go through, through the course of a normal day, whereas the thoracic spine, it's bound by the ribs, so it's relatively immobile. The amount of stress that goes through the disc is significantly less, so the incident of herniations is significantly less.
Sanjiv Lakhia: 07:08
All right, so, someone comes in to see you. They say, "Dr. Otis, I'm having pain down between my shoulder blades," or a little bit lower, "for the last three months." What's going on through your thought process in terms of how you want to evaluate that? Number one, let's talk about signs and symptoms of ... You mentioned earlier some referral sources of pain to the upper back that maybe isn't structural from the spine itself.
Scott Otis: 07:34
If you're talking about non-spinal issues causing thoracic spine pain, there are a variety of abnormalities involved in the chest and abdomen that can cause pain in between the shoulder blades: GI issues with people who have ulcers or reflux or hiatal hernias can cause pain in between the shoulder blades; people who have gall bladder disease, liver disease, can have referred pain; people who have a variety of pulmonary and lung issues, heart issues, can all have pain in that region. Certainly, different patient populations, when it comes to cardiac issues, don't necessarily present in your classic sign of chest pressure and left arm complaints. Some of them can present atypically with pain in between the shoulder blades. Those are all things that ... As part of my assessment, we rule out those nasty medical-type things and make sure this is truly a musculoskeletal issue.
Sanjiv Lakhia: 08:25
That's a great point. Actually, sitting here thinking about someone I worked with who, after a while, it turned out in retrospect the pain and the upper back was from ischemic heart disease. They ended up getting cardiac stent placement, and their five-year history of upper back pain went away almost immediately. It was a good learning point. I think the take home there is, not all back pain is back pain.
Sanjiv Lakhia: 08:49
Certainly, this podcast is for informational purposes only. If you're experiencing upper back pain, please make sure you get a general medical evaluation before you try and treat yourself. Having said that, I think those are still pretty rare and not super common. I have someone come in my office who's having an acute event from a GI issue, pulmonary, or cardiac, and it's upper back pain.
Sanjiv Lakhia: 09:14
What are some of the more common causes that you see of upper back pain?
Scott Otis: 09:18
I think that in today's world that we live in, and doing so much in the way of desk and office work, or with the advent of cell phones and people being more and more driven by that as far as our daily activities, we see a lot of white collar disease, as I call it. You're sitting at a desk, a computer, for long periods of time with a desk that doesn't necessarily fit you right, or ergonomically is not sound. Your position of your neck and your shoulders are not optimal. If you're looking at a phone for extended periods of time, you're always in that chin tuck position with rounded shoulders. I see a lot of muscular issues in between the shoulder blades just because of bad body posture and ergonomics.
Sanjiv Lakhia: 10:02
Yeah, no doubt. I talked with Dr. Vemuri about the concept of tech neck, which, I think it doesn't just affect the neck. It can affect the entire spinal axis, just the way that you detailed. That's exactly my observation as a common cause of upper back pain.
Sanjiv Lakhia: 10:19
Now, someone walks into your office, what is your typical algorithm for how you evaluate their complaints of upper back pain? Do you jump to an MRI right away?
Scott Otis: 10:30
I don't. My first thing I always do is to get an adequate history. I'm really trying to find out exactly where the pain is, what aggravates it. I'm looking to see what other signs and symptoms that they have because a lot of people who have just routine muscular pathology, I don't necessarily see in my office because people have been seen by their family doctors and had at least basic physical therapy initiated, or they've tried to make their own ergonomic changes. By the time that they see me, they've already been through the normal gamut of workups, so I'm looking more for things that had been missed. Really, for me, thoracic spine pain, I look heavily at the neck first just because there's so many structures in the neck that are going to cause pain in the shoulder blade region that have absolutely nothing to do with the shoulder blade area or the thoracic spine in and of itself.
Sanjiv Lakhia: 11:23
That's a great point.
Sanjiv Lakhia: 11:24
If you're listening out there, and you have pain in the shoulder blade region, and you come to see a physiatrist, and we focus on your neck, it's not because we're not listening to where your complaint is, it's because it's extremely common to get referral pain from the cervical spine. In fact, I would tend to say that it's more common that that upper thoracic pain is more a cervical spine issue than it is a thoracic spine issue. Would you agree with that?
Scott Otis: 11:50
A hundred percent. I've lived through this myself. I had a herniated disc in my neck several, several years ago, and I had no neck pain. All my pain was, it was a knife sticking in my shoulder blade. We see discogenic pain very commonly for scapular pain. It's a very common referral pattern for joint-related issues in the neck and in what I call the set joints. I agree that scapular pain for me is neck until proven otherwise.
Sanjiv Lakhia: 12:16
No, exactly. That's a great point. I think a thorough assessment is ... We always like to say you look at a joint above and below and in this area. I think you look at the spine region above and below as you're evaluating pain in the upper back.
Sanjiv Lakhia: 12:28
You just touched a little bit on the cervical facet joints and evaluation of those. Give us your thoughts on procedures for thoracic back pain. I've done podcasts with Dr. Sumich on epidural steroid injections in general. Dr. Vemuri touched a little bit on cervical ESIs. What's your thoughts on procedures in the thoracic region, whether it's driven at the facet joints, disc, nerve roots? Do you do them as common, and what's some of the differences that people should be aware of?
Scott Otis: 13:05
I would say that it's relatively rare for my personal patients to get thoracic injections. When we look at the causes of pain and what are amendable to injections, like I said, only 1% or so of thoracic issues are disc related. You just don't see a ton of people that true epidurals are helpful. Now, they're certainly there. There's exceptions and there are people who have herniated discs and pinched nerves and radicular pain that the epidurals are very appropriate, but I just don't see a ton of that in my practice.
Scott Otis: 13:36
For joint-related pain and arthritis, facet-type issues, I think that's more common, but again, that's a rare patient that I send for those. The fact that most people eventually do get better with physical therapy and with changes in biomechanics and the way that they do things, I would say that there's probably more of an incidence of costochondritis-type injections. People who get inflammation of the cartilage, where the ribs meet the sternum or the spine, I would say there's probably more of an instance of me sending patients out for those injections than I do truly have for true spinal injections.
Sanjiv Lakhia: 14:16
You touched on a great point earlier, that the thoracic spine is anchored on each side by the ribs. I think that relationship limits some mobility in the facet joints and compression of the disc. Therefore, we will see much less degenerative changes in these areas, and therefore have much fewer incidents of injections and procedures in the thoracic spine. I would totally agree with that.
Sanjiv Lakhia: 14:40
A couple exceptions, though. I would say the thoracic area, I tend to see more of issues in terms of osteoporosis and vertebral body compression fractures. Also, I observed, for patients who have scoliosis, that they can develop some more pathology in thoracic spine just from the abnormal distribution of forces. Do you see that in your clinic?
Scott Otis: 15:03
I do. Scoliosis is a challenge because, as you pointed out, the way that the spine was meant to be used, it's not working that way. I think you can get a variety of musculoskeletal complaints because of overuse. That can be a challenge because you can't fix scoliosis, so you're basically trying to manage it, despite their curvature.
Scott Otis: 15:23
I think that the point regarding the compression fractures is an excellent one in the fact that we see that very commonly, particularly in our aging population, particularly for women who are osteoporotic. We see those thoracic compression fractures pretty frequently. When you look at treatment for that, the mainstay of that for years has been bracing for two to three months in a brace that basically goes from your sternum down to your pelvis. It's a challenge to be in that brace for three months and tolerate that. So, the advent of kyphoplasty or vertebroplasty, which is injections of cement into the fracture, that has really, I think, improved the quality of life and the outcomes of those patients who have those fractures.
Sanjiv Lakhia: 16:08
And of course, prevention is key when it comes to osteoporotic fractures. What are your some of your suggestions and strategies for ... Let's say we have a middle-aged female listening to this podcast, and their mom had fractures, and they don't want to obtain fractures in their upper back. What would be a few tips you could share that could help her prevent developing osteoporotic fractures?
Scott Otis: 16:33
I think first thing I would recommend is just good medical care. There's certainly a familial history with osteoporosis for those. If you are, particularly, post-menopausal female who is white, and is thin, and has a family history of osteoporosis, you're at high risk. If you throw in other medical issues as far as thyroid or parathyroid disease, then I think that's something women need to be actively treating themselves. They need to just have a good medical evaluation. DEXA scan is a very nice way of quantitating bone [inaudible 00:17:06] and if you're at risk for that. The DEXA scan really dictates how aggressive your family doctor would be with that. But any post-menopausal female should be on calcium and vitamin D supplementation. I think that they really want to be aggressive. Having a good core program where they're working on core strengthening would be helpful as we get older. The biggest thing is fall risk, so we're making sure that if need be, therapy is helping with balance and gait disturbances and decreasing those risks of falls.
Sanjiv Lakhia: 17:38
I would add to that, resistance training. I always recommend that even lightweight resistance training with bands or weights, particularly for the arms and the wrists, humerus, and then weight-bearing activity, walking in particular, will help with the lower extremity as weight bearing and resistance builds bone density. I get asked that a lot.
Sanjiv Lakhia: 18:00
One thing to know is swimming will not build your bone density. It's a fabulous activity, and I have a lot of seniors who like to be in water therapy and swim, but I always advise them, "You have to do something above and beyond that to help keep your bone density where it needs to be." That's a big issue that I appreciate you touching on.
Sanjiv Lakhia: 18:19
Back to the thoracic back pain, we did touch a little bit about posture. What do you think about the role of physical therapy for thoracic back pain, and what types of things can a patient expect a PT to look at?
Scott Otis: 18:33
Yeah, I think it's fantastic. I struggle with this as anybody ... I have poor posture. I slouch, I have rounded shoulders. I'm at a computer all day. I could benefit from that as much as anybody. But I think that therapists are very well positioned to help patients with proper exercises to strengthen, particularly, the posterior aspects of the spine and the shoulder musculature, really working on the rhomboids and the muscles that retract the shoulder blades, the lats, looking at areas of tightness of the body that force the spine to be at an abnormal position. Shoulder contractions, hip contractures, where you don't have the full range of motion, is going to put stress on areas that are remote. They have to compensate for that.
Sanjiv Lakhia: 19:21
One of my favorite tools of all time is a foam roller. I mentioned this on my top 10 holiday gift list for back pain. If you haven't heard that podcast, we'll link to that in the show notes. You can do a lot of these gentle kind of antigravity stretches on a foam roller, where you would lay on it with your arms up or to your side, and it'll stretch out your back muscles. It can stretch out your psoas muscles. It's a fabulous tool. It's only 20 bucks. I feel like almost everyone in the world needs to have one and know how to use it. If you suffer from any back discomfort, it's a great place to start working with a physical therapist. They can teach you some of these techniques to use, but a foam roller can be a fabulous tool.
Sanjiv Lakhia: 20:02
I'm the same way as you are, Scott, in terms of posture. Like, even as we sit here and talk, as soon as you say it, I find myself sitting up better in my chair and reminding myself about my posture. I'm actually still going through some physical therapy for my back as well. I've been doing it for a while. I think everyone has a need to develop postural awareness, particularly with what you mentioned earlier. We're in a modern computer society, and everything's in front of us. Having a routine that allows you to reverse that curvature a little bit is going to help with your upper back pain.
Sanjiv Lakhia: 20:35
Now, some other things that I've seen beneficial through PT is dry needling for select trigger points, gentle massage. Some of the physical therapists will do banded exercises for what we call a scapulothoracic stabilization program. This is where he mentioned the rhomboids. Talking about just getting your shoulders retracted and pulled back a little bit so the alignment is better. There's a take-home point there. There's a lot that can be done. If you haven't met with a physical therapist and you're suffering, it's a great starting point.
Sanjiv Lakhia: 21:02
Now, let's say your patient has ongoing upper back pain, PT's not effective, and injections, trigger point shots, things like that aren't working. Is that an indication for surgery?
Scott Otis: 21:14
Yeah. I think that's part of having an accurate diagnosis. You would assume by that point, if they've failed traditional conservative measures, that they've had at least basic radiographic imaging. X-rays, I think are quite helpful as far as looking at bony anatomy and things that are non spinal in nature. Then, obviously, the MRI is key as far as looking at soft tissue with the spine and looking at disc issues and [inaudible 00:21:40] spinal cord issues. I can tell you that, again, rarely is surgery required for thoracic issues, and when it is, it's a challenging surgery just because of gaining access to that area. With the lungs and the ribs, it's certainly a much more technically-skilled surgery than your traditional neck or low back surgeries.
Sanjiv Lakhia: 22:01
That's a great point.
Sanjiv Lakhia: 22:03
In terms of surgery for the thoracic region, in my mind, a patient would have to have an obvious correlating finding on an MRI along with symptoms that match, or some degree of a neurologic issue that can be explained by an MRI of the thoracic spine, that can potentially be remedied by surgery. It's extremely rare. Again, this is something that you want to have a conversation with a physician about, who knows the signs and symptoms of thoracic disc issues, thoracic cord issues, and the like before you ever get entertained for surgery.
Sanjiv Lakhia: 22:37
There you go. I think the take-home point here that Dr. Otis has mentioned is a lot of pain in the upper back, it can be managed through self-care, it can be managed through physical therapy. It's largely not an issue that is overly concerning for most, unless you have some sort of referral pain, and it's extremely common.
Sanjiv Lakhia: 22:55
I would also add that the stress that we're under can also trigger some of the pain and these areas. I think take-home points would be get your neck checked out as well because it can refer pain to that region, get in with a good physical therapist, and, as always, start with a physician who takes a great history. He mentioned that several times folks. That's a sign of somebody who knows what he's doing and knows how to evaluate these sort of conditions.
Sanjiv Lakhia: 23:16
I really appreciate you breaking down the topic of thoracic back pain for our listeners. As we close today, I want to just pick your brain a little bit. I always like to hear a little more about the personal side of the docs that I work with and the colleagues that I work with. What are some of your kind of personal health habits or health routines that you utilize on a day-to-day basis to say sharp and stay in shape?
Scott Otis: 23:41
I do two predominantly. One is that we have two Westie puppies who have lots of energy and need to burn that off. My wife and I do a lot of walks with them. We particularly like to go hiking up in the mountains with them. It's a nice, low-impact way of getting some cardio. My wife has actually just recently bought a Peloton bike, and I've gotten roped into a family challenge that. That's been my cardio here for the last three, four months. I've enjoyed getting back into some of the shape that I used to be in.
Sanjiv Lakhia: 24:15
Yeah, that's big. I think the last time we talked about exercise, you didn't have anything formal, so I'm glad to hear that she's pushing you in the right direction.
Scott Otis: 24:25
She's trying to help.
Sanjiv Lakhia: 24:26
Yeah.
Sanjiv Lakhia: 24:26
Any favorite books on health, life, or otherwise that you want to share, that are on your Kindle or on your shelf?
Scott Otis: 24:34
I was binge watching some Netflix stuff with my daughter, so my reading has kind of fallen behind. Admittedly, my bookshelf has been a little scant lately. The most recent thing I've read was The Whisky Advocate, trying to prepare for, hopefully, a trip over to Ireland and Scotland here when the COVID allows us to do that. I've been doing more research than I have actual, true reading.
Sanjiv Lakhia: 24:58
Listen, I wanted your wellness tips. Learning about scotch, it makes you feel well. It qualifies in my mind. Thanks for sharing that.
Sanjiv Lakhia: 25:07
All right, buddy. I really appreciate your time today. Thanks for letting us pick your brain about a topic that doesn't get a lot of attention. It was great catching up with you.
Scott Otis: 25:15
My pleasure. Any time.
Outro: 25:19
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you and Calculate for over 500 easy-to-use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps.
Intro: 00:30
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly-skilled, and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:05
Welcome to another episode of Back Talk Doc. Today I want to tackle for you a topic that doesn't get a ton of coverage in the world of spine care, but in my clinic, I am seeing more and more of it these days, and that is the idea of upper back pain, or what we call thoracic back pain. We just recently did an episode on neck pain with Dr. Vemuri, my partner. And if you haven't heard that, please go ahead and download that and take a listen to it. We'll link to that in the show notes.
Sanjiv Lakhia: 01:38
Certainly, we've covered numerous aspects of low back pain from surgical angles to medications, nutrition, injections. I kind of look at thoracic back pain, which is essentially if you're not clinical, almost like from where your shoulders are to maybe just about six inches above your waistline. That's kind of our no man's land, but more and more people are having pain in this area. I am delighted to bring my partner, Dr. Scott Otis, onto the show today to pick his brain and help us figure out what is going on with the upper back pain and how to approach it.
Sanjiv Lakhia: 02:17
Scott, welcome to the show.
Scott Otis: 02:19
Thank you for having me.
Sanjiv Lakhia: 02:20
Scott is a physiatrist with our group at Carolina Neurosurgery & Spine Associates. His office is in our main location, in Charlotte. Scott, you joined the group, it was about five years ago now?
Scott Otis: 02:32
Probably six in June.
Sanjiv Lakhia: 02:33
Six in June, yes Fantastic.
Sanjiv Lakhia: 02:36
Scott resides from my home state, which is the state of Ohio, where he did medical school at the Ohio State University College of Medicine. Then he did his internship at Riverside Hospital in Columbus, and ultimately returned to Ohio State for his physical medicine and rehabilitation residency.
Sanjiv Lakhia: 02:55
First, I want to start by my condolences on the national championship game, Scott. It was a good fight and a great year, just didn't turn out the way we want.
Scott Otis: 03:03
We were just happy to be there. Better luck next time.
Sanjiv Lakhia: 03:05
Absolutely, absolutely.
Sanjiv Lakhia: 03:07
Now, Scott is affiliated with the American Academy of Physical Medicine and Rehab. He's also an expert in electro-diagnostic medicine. He does interventional spine care, and really has just been a fantastic addition to our group and is a pleasure to have as a partner. I know he gets tremendous reviews from patients that go through our office.
Sanjiv Lakhia: 03:27
Talk to the listeners who don't really know you. Tell them a little bit about your path to physiatry and spine care. Go ahead and shed some light on how you got to work at our group.
Scott Otis: 03:36
Yeah.
Scott Otis: 03:36
I completed my residency at Ohio State and went into private practice in Columbus, Ohio, for 15 years, a kind of multi-specialty group with spine as well as orthopedic physicians. My practice was very similar there, that it was pretty much non-surgical neck and low back pain with an emphasis on therapy and conservative measures, injections, and EMGs. When we looked at better quality of life, and better weather and working atmosphere, Charlotte was just a fantastic fit and so we came down here about almost six years ago. We have been very pleased to be here.
Sanjiv Lakhia: 04:15
Yeah, fantastic. It definitely is. Charlotte, North Carolina, is a fabulous place to live. The patient population in this area is great to work with. There's no shortage of spine pain and spine problems, so it's great to serve this community.
Sanjiv Lakhia: 04:31
As we talk about today's topic, which is thoracic back pain, give me a sense, in your day-to-day clinic, your typical workday, let's say, if you see 20 patients, what percent of the people coming in are having pain in that mid-back area?
Scott Otis: 04:45
I would say that a large percentage of patients have some component of pain that is in that mid-back, thoracic area. I would say that of those, only a small percentage, in my mind, actually have primary issues related to that area. I see a lot of either compensatory issues from neck or low back issues or referral pain from neck and low back issues that present as thoracic spine pain, but it's relatively uncommon to have just a primary source of thoracic spine pain in my patients.
Sanjiv Lakhia: 05:17
When I hear that as a chief complaint, I do kind of sink back into my chair because I know it's going to be a challenge at times. You mentioned to me as well, when we talked about this topic for today, that it can be challenging. From a physician lens, a physiatry lens, what makes working up thoracic back pain a little bit more challenging than cervical or lumbar discomfort?
Scott Otis: 05:41
Well, I think when you look at true spinal pathology, when people think of that, they think of herniated disc and those types of things, that's rare. That's only about 1% of true herniations. So, you're really looking at other sources of pain in that region that are not discogenic in nature. It's a spectrum of, when I see patients, of trying to find a true, accurate diagnosis. Then, once you can hopefully have that diagnosis, treat them appropriately, but it's hard for people who have musculoskeletal issues in that area because many a time it's a manifestation of something else going on in their life.
Sanjiv Lakhia: 06:18
Exactly.
Sanjiv Lakhia: 06:19
Now, you touched on a really good point. Thoracic disc herniations are not as common as they are in the low back and cervical spine. Now, I have people listen to this podcast. Some of them are potential patients or just average people looking to improve their health, and the others are clinicians who listen to our podcast. Are you able to explain to people why the incidents of herniated discs in the thoracic region is much lower than the other areas?
Scott Otis: 06:45
I think it has to deal mostly with just the biomechanics of the spine and the fact that the neck and low back are mobile sections and they have a tremendous amount of stress to go through, through the course of a normal day, whereas the thoracic spine, it's bound by the ribs, so it's relatively immobile. The amount of stress that goes through the disc is significantly less, so the incident of herniations is significantly less.
Sanjiv Lakhia: 07:08
All right, so, someone comes in to see you. They say, "Dr. Otis, I'm having pain down between my shoulder blades," or a little bit lower, "for the last three months." What's going on through your thought process in terms of how you want to evaluate that? Number one, let's talk about signs and symptoms of ... You mentioned earlier some referral sources of pain to the upper back that maybe isn't structural from the spine itself.
Scott Otis: 07:34
If you're talking about non-spinal issues causing thoracic spine pain, there are a variety of abnormalities involved in the chest and abdomen that can cause pain in between the shoulder blades: GI issues with people who have ulcers or reflux or hiatal hernias can cause pain in between the shoulder blades; people who have gall bladder disease, liver disease, can have referred pain; people who have a variety of pulmonary and lung issues, heart issues, can all have pain in that region. Certainly, different patient populations, when it comes to cardiac issues, don't necessarily present in your classic sign of chest pressure and left arm complaints. Some of them can present atypically with pain in between the shoulder blades. Those are all things that ... As part of my assessment, we rule out those nasty medical-type things and make sure this is truly a musculoskeletal issue.
Sanjiv Lakhia: 08:25
That's a great point. Actually, sitting here thinking about someone I worked with who, after a while, it turned out in retrospect the pain and the upper back was from ischemic heart disease. They ended up getting cardiac stent placement, and their five-year history of upper back pain went away almost immediately. It was a good learning point. I think the take home there is, not all back pain is back pain.
Sanjiv Lakhia: 08:49
Certainly, this podcast is for informational purposes only. If you're experiencing upper back pain, please make sure you get a general medical evaluation before you try and treat yourself. Having said that, I think those are still pretty rare and not super common. I have someone come in my office who's having an acute event from a GI issue, pulmonary, or cardiac, and it's upper back pain.
Sanjiv Lakhia: 09:14
What are some of the more common causes that you see of upper back pain?
Scott Otis: 09:18
I think that in today's world that we live in, and doing so much in the way of desk and office work, or with the advent of cell phones and people being more and more driven by that as far as our daily activities, we see a lot of white collar disease, as I call it. You're sitting at a desk, a computer, for long periods of time with a desk that doesn't necessarily fit you right, or ergonomically is not sound. Your position of your neck and your shoulders are not optimal. If you're looking at a phone for extended periods of time, you're always in that chin tuck position with rounded shoulders. I see a lot of muscular issues in between the shoulder blades just because of bad body posture and ergonomics.
Sanjiv Lakhia: 10:02
Yeah, no doubt. I talked with Dr. Vemuri about the concept of tech neck, which, I think it doesn't just affect the neck. It can affect the entire spinal axis, just the way that you detailed. That's exactly my observation as a common cause of upper back pain.
Sanjiv Lakhia: 10:19
Now, someone walks into your office, what is your typical algorithm for how you evaluate their complaints of upper back pain? Do you jump to an MRI right away?
Scott Otis: 10:30
I don't. My first thing I always do is to get an adequate history. I'm really trying to find out exactly where the pain is, what aggravates it. I'm looking to see what other signs and symptoms that they have because a lot of people who have just routine muscular pathology, I don't necessarily see in my office because people have been seen by their family doctors and had at least basic physical therapy initiated, or they've tried to make their own ergonomic changes. By the time that they see me, they've already been through the normal gamut of workups, so I'm looking more for things that had been missed. Really, for me, thoracic spine pain, I look heavily at the neck first just because there's so many structures in the neck that are going to cause pain in the shoulder blade region that have absolutely nothing to do with the shoulder blade area or the thoracic spine in and of itself.
Sanjiv Lakhia: 11:23
That's a great point.
Sanjiv Lakhia: 11:24
If you're listening out there, and you have pain in the shoulder blade region, and you come to see a physiatrist, and we focus on your neck, it's not because we're not listening to where your complaint is, it's because it's extremely common to get referral pain from the cervical spine. In fact, I would tend to say that it's more common that that upper thoracic pain is more a cervical spine issue than it is a thoracic spine issue. Would you agree with that?
Scott Otis: 11:50
A hundred percent. I've lived through this myself. I had a herniated disc in my neck several, several years ago, and I had no neck pain. All my pain was, it was a knife sticking in my shoulder blade. We see discogenic pain very commonly for scapular pain. It's a very common referral pattern for joint-related issues in the neck and in what I call the set joints. I agree that scapular pain for me is neck until proven otherwise.
Sanjiv Lakhia: 12:16
No, exactly. That's a great point. I think a thorough assessment is ... We always like to say you look at a joint above and below and in this area. I think you look at the spine region above and below as you're evaluating pain in the upper back.
Sanjiv Lakhia: 12:28
You just touched a little bit on the cervical facet joints and evaluation of those. Give us your thoughts on procedures for thoracic back pain. I've done podcasts with Dr. Sumich on epidural steroid injections in general. Dr. Vemuri touched a little bit on cervical ESIs. What's your thoughts on procedures in the thoracic region, whether it's driven at the facet joints, disc, nerve roots? Do you do them as common, and what's some of the differences that people should be aware of?
Scott Otis: 13:05
I would say that it's relatively rare for my personal patients to get thoracic injections. When we look at the causes of pain and what are amendable to injections, like I said, only 1% or so of thoracic issues are disc related. You just don't see a ton of people that true epidurals are helpful. Now, they're certainly there. There's exceptions and there are people who have herniated discs and pinched nerves and radicular pain that the epidurals are very appropriate, but I just don't see a ton of that in my practice.
Scott Otis: 13:36
For joint-related pain and arthritis, facet-type issues, I think that's more common, but again, that's a rare patient that I send for those. The fact that most people eventually do get better with physical therapy and with changes in biomechanics and the way that they do things, I would say that there's probably more of an incidence of costochondritis-type injections. People who get inflammation of the cartilage, where the ribs meet the sternum or the spine, I would say there's probably more of an instance of me sending patients out for those injections than I do truly have for true spinal injections.
Sanjiv Lakhia: 14:16
You touched on a great point earlier, that the thoracic spine is anchored on each side by the ribs. I think that relationship limits some mobility in the facet joints and compression of the disc. Therefore, we will see much less degenerative changes in these areas, and therefore have much fewer incidents of injections and procedures in the thoracic spine. I would totally agree with that.
Sanjiv Lakhia: 14:40
A couple exceptions, though. I would say the thoracic area, I tend to see more of issues in terms of osteoporosis and vertebral body compression fractures. Also, I observed, for patients who have scoliosis, that they can develop some more pathology in thoracic spine just from the abnormal distribution of forces. Do you see that in your clinic?
Scott Otis: 15:03
I do. Scoliosis is a challenge because, as you pointed out, the way that the spine was meant to be used, it's not working that way. I think you can get a variety of musculoskeletal complaints because of overuse. That can be a challenge because you can't fix scoliosis, so you're basically trying to manage it, despite their curvature.
Scott Otis: 15:23
I think that the point regarding the compression fractures is an excellent one in the fact that we see that very commonly, particularly in our aging population, particularly for women who are osteoporotic. We see those thoracic compression fractures pretty frequently. When you look at treatment for that, the mainstay of that for years has been bracing for two to three months in a brace that basically goes from your sternum down to your pelvis. It's a challenge to be in that brace for three months and tolerate that. So, the advent of kyphoplasty or vertebroplasty, which is injections of cement into the fracture, that has really, I think, improved the quality of life and the outcomes of those patients who have those fractures.
Sanjiv Lakhia: 16:08
And of course, prevention is key when it comes to osteoporotic fractures. What are your some of your suggestions and strategies for ... Let's say we have a middle-aged female listening to this podcast, and their mom had fractures, and they don't want to obtain fractures in their upper back. What would be a few tips you could share that could help her prevent developing osteoporotic fractures?
Scott Otis: 16:33
I think first thing I would recommend is just good medical care. There's certainly a familial history with osteoporosis for those. If you are, particularly, post-menopausal female who is white, and is thin, and has a family history of osteoporosis, you're at high risk. If you throw in other medical issues as far as thyroid or parathyroid disease, then I think that's something women need to be actively treating themselves. They need to just have a good medical evaluation. DEXA scan is a very nice way of quantitating bone [inaudible 00:17:06] and if you're at risk for that. The DEXA scan really dictates how aggressive your family doctor would be with that. But any post-menopausal female should be on calcium and vitamin D supplementation. I think that they really want to be aggressive. Having a good core program where they're working on core strengthening would be helpful as we get older. The biggest thing is fall risk, so we're making sure that if need be, therapy is helping with balance and gait disturbances and decreasing those risks of falls.
Sanjiv Lakhia: 17:38
I would add to that, resistance training. I always recommend that even lightweight resistance training with bands or weights, particularly for the arms and the wrists, humerus, and then weight-bearing activity, walking in particular, will help with the lower extremity as weight bearing and resistance builds bone density. I get asked that a lot.
Sanjiv Lakhia: 18:00
One thing to know is swimming will not build your bone density. It's a fabulous activity, and I have a lot of seniors who like to be in water therapy and swim, but I always advise them, "You have to do something above and beyond that to help keep your bone density where it needs to be." That's a big issue that I appreciate you touching on.
Sanjiv Lakhia: 18:19
Back to the thoracic back pain, we did touch a little bit about posture. What do you think about the role of physical therapy for thoracic back pain, and what types of things can a patient expect a PT to look at?
Scott Otis: 18:33
Yeah, I think it's fantastic. I struggle with this as anybody ... I have poor posture. I slouch, I have rounded shoulders. I'm at a computer all day. I could benefit from that as much as anybody. But I think that therapists are very well positioned to help patients with proper exercises to strengthen, particularly, the posterior aspects of the spine and the shoulder musculature, really working on the rhomboids and the muscles that retract the shoulder blades, the lats, looking at areas of tightness of the body that force the spine to be at an abnormal position. Shoulder contractions, hip contractures, where you don't have the full range of motion, is going to put stress on areas that are remote. They have to compensate for that.
Sanjiv Lakhia: 19:21
One of my favorite tools of all time is a foam roller. I mentioned this on my top 10 holiday gift list for back pain. If you haven't heard that podcast, we'll link to that in the show notes. You can do a lot of these gentle kind of antigravity stretches on a foam roller, where you would lay on it with your arms up or to your side, and it'll stretch out your back muscles. It can stretch out your psoas muscles. It's a fabulous tool. It's only 20 bucks. I feel like almost everyone in the world needs to have one and know how to use it. If you suffer from any back discomfort, it's a great place to start working with a physical therapist. They can teach you some of these techniques to use, but a foam roller can be a fabulous tool.
Sanjiv Lakhia: 20:02
I'm the same way as you are, Scott, in terms of posture. Like, even as we sit here and talk, as soon as you say it, I find myself sitting up better in my chair and reminding myself about my posture. I'm actually still going through some physical therapy for my back as well. I've been doing it for a while. I think everyone has a need to develop postural awareness, particularly with what you mentioned earlier. We're in a modern computer society, and everything's in front of us. Having a routine that allows you to reverse that curvature a little bit is going to help with your upper back pain.
Sanjiv Lakhia: 20:35
Now, some other things that I've seen beneficial through PT is dry needling for select trigger points, gentle massage. Some of the physical therapists will do banded exercises for what we call a scapulothoracic stabilization program. This is where he mentioned the rhomboids. Talking about just getting your shoulders retracted and pulled back a little bit so the alignment is better. There's a take-home point there. There's a lot that can be done. If you haven't met with a physical therapist and you're suffering, it's a great starting point.
Sanjiv Lakhia: 21:02
Now, let's say your patient has ongoing upper back pain, PT's not effective, and injections, trigger point shots, things like that aren't working. Is that an indication for surgery?
Scott Otis: 21:14
Yeah. I think that's part of having an accurate diagnosis. You would assume by that point, if they've failed traditional conservative measures, that they've had at least basic radiographic imaging. X-rays, I think are quite helpful as far as looking at bony anatomy and things that are non spinal in nature. Then, obviously, the MRI is key as far as looking at soft tissue with the spine and looking at disc issues and [inaudible 00:21:40] spinal cord issues. I can tell you that, again, rarely is surgery required for thoracic issues, and when it is, it's a challenging surgery just because of gaining access to that area. With the lungs and the ribs, it's certainly a much more technically-skilled surgery than your traditional neck or low back surgeries.
Sanjiv Lakhia: 22:01
That's a great point.
Sanjiv Lakhia: 22:03
In terms of surgery for the thoracic region, in my mind, a patient would have to have an obvious correlating finding on an MRI along with symptoms that match, or some degree of a neurologic issue that can be explained by an MRI of the thoracic spine, that can potentially be remedied by surgery. It's extremely rare. Again, this is something that you want to have a conversation with a physician about, who knows the signs and symptoms of thoracic disc issues, thoracic cord issues, and the like before you ever get entertained for surgery.
Sanjiv Lakhia: 22:37
There you go. I think the take-home point here that Dr. Otis has mentioned is a lot of pain in the upper back, it can be managed through self-care, it can be managed through physical therapy. It's largely not an issue that is overly concerning for most, unless you have some sort of referral pain, and it's extremely common.
Sanjiv Lakhia: 22:55
I would also add that the stress that we're under can also trigger some of the pain and these areas. I think take-home points would be get your neck checked out as well because it can refer pain to that region, get in with a good physical therapist, and, as always, start with a physician who takes a great history. He mentioned that several times folks. That's a sign of somebody who knows what he's doing and knows how to evaluate these sort of conditions.
Sanjiv Lakhia: 23:16
I really appreciate you breaking down the topic of thoracic back pain for our listeners. As we close today, I want to just pick your brain a little bit. I always like to hear a little more about the personal side of the docs that I work with and the colleagues that I work with. What are some of your kind of personal health habits or health routines that you utilize on a day-to-day basis to say sharp and stay in shape?
Scott Otis: 23:41
I do two predominantly. One is that we have two Westie puppies who have lots of energy and need to burn that off. My wife and I do a lot of walks with them. We particularly like to go hiking up in the mountains with them. It's a nice, low-impact way of getting some cardio. My wife has actually just recently bought a Peloton bike, and I've gotten roped into a family challenge that. That's been my cardio here for the last three, four months. I've enjoyed getting back into some of the shape that I used to be in.
Sanjiv Lakhia: 24:15
Yeah, that's big. I think the last time we talked about exercise, you didn't have anything formal, so I'm glad to hear that she's pushing you in the right direction.
Scott Otis: 24:25
She's trying to help.
Sanjiv Lakhia: 24:26
Yeah.
Sanjiv Lakhia: 24:26
Any favorite books on health, life, or otherwise that you want to share, that are on your Kindle or on your shelf?
Scott Otis: 24:34
I was binge watching some Netflix stuff with my daughter, so my reading has kind of fallen behind. Admittedly, my bookshelf has been a little scant lately. The most recent thing I've read was The Whisky Advocate, trying to prepare for, hopefully, a trip over to Ireland and Scotland here when the COVID allows us to do that. I've been doing more research than I have actual, true reading.
Sanjiv Lakhia: 24:58
Listen, I wanted your wellness tips. Learning about scotch, it makes you feel well. It qualifies in my mind. Thanks for sharing that.
Sanjiv Lakhia: 25:07
All right, buddy. I really appreciate your time today. Thanks for letting us pick your brain about a topic that doesn't get a lot of attention. It was great catching up with you.
Scott Otis: 25:15
My pleasure. Any time.
Outro: 25:19
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.