Search for tag: "spine"

Interviewer: So you or a loved one have opted to have endoscopic spinal surgery rather than one of the more traditional methods. What can you expect on the day of the procedure and afterwards?

We're here with Dr. Mark Mahan. He's an associate professor of neurosurgery at the University of Utah Health. Now, Dr. Mahan, when it comes to endoscopic spinal surgery, what can someone expect, you know, leading up to the procedure, the day after? Where do they start? And what should they be expecting?

Dr. Mahan: The wonderful thing about endoscopic spine surgery is that in, I would say, 99% of the cases, it's outpatient surgery. So that is a little bit of a reframing of what an individual will be expecting, because it's not a traditional come to the hospital, stay there for several days, eat wonderful hospital food, stay in wonderful hospital beds. This is something that you would anticipate going to one of our outpatient locations. A patient would expect to arrive that day. Typical requirements are for, you know, for any surgery are, you know, no eating from the night before, coming in, unfortunately, you know, sort of extra early because we all like to end our days early, and so we try to get started early.

And then you would expect that you're going to be meeting a whole host of new individuals that are going to come in and take care of you. And meaning that we're going to have nurses and others that will come in and check-in and make sure that you're ready. We'll go through a surgical consent. That's an important part for me personally because I want to make sure that everybody understands, ahead of time, both what the surgery entails, what the risks are, what your expectations will be both in recovery as well as long term. And so that we all can meet in a common understanding about what our goals are and what you'd be facing. And then through also about, you know, how to best optimize your recovery long term.

And then after surgery, obviously, these are generally performed under general anesthesia, which is the type of anesthesia where you would have a breathing tube. And so waking up, coming around is usually a time when most people don't remember, fortunately, and then just recovery, make sure that you've, you know, that you're ready to go, you're steady on your feet, that you're eating, you're feeling well, and then we get you back to your car and you can go home.

Interviewer: So how long are you actually in the operating room for a procedure like this?

Dr. Mahan: Typically, it really depends on what the problem is we're seeking to treat. Some of the disc surgeries go really, really quick, like on the order of about half an hour.

Interviewer: Oh, wow.

Dr. Mahan: Now some of the more complex narrowing can be two hours. It really truly depends on what the work that needs to be done.

Interviewer: Now, after the patient is home, what can they expect? We're dealing with pain control, recovery. How long until they're back on their feet, etc.?

Dr. Mahan: Yeah, now, pain control is a particular focus of mine because I really want every individual to really have that smooth glide path because, you know, even though that the endoscopic technique is meant to minimize tissue trauma, it is still a spine surgery. It is still the goal of removing something from your spine. I don't want to make that sound scary, but I don't want to make other people feel like, oh, it's a magical procedure, right? It's not. There's a reality here that we're removing something that's pressing on the nerves and causing pain and discomfort.

And so that you would expect to have some irritation or some discomfort from having something removed from your spine. And so what I do is I do everything I can to possibly minimize it. Number one, endoscopic techniques, minimal incisions, minimal approaches. Number two, often using a lot of numbing medication can really make the recovery much more straightforward. So we'll use a long-acting anesthetic into the muscles of the spine to make them comfortable and relaxed even before we even start doing surgery.

So the first step, block the muscles. Make it comfortable. It also leads to some numbness of the skin where the skin incision is so that that is not too much discomfort. But the block will wear off. So the things that we do is try to, obviously, avoid a lot of powerful pain medications because powerful pain medications can have their side effects and consequences. So we're using things like ice, heat, anti-inflammatories, and then we talk about milder pain medications so that you don't get into the complications associated with strong pain medications.

Interviewer: Now other than the pain management that happens afterwards, when they go home, are they up for a day or two? Are they on their back for a day or two? On their belly? Like, what are you having a patient do to heal up from a procedure like this?

Dr. Mahan: In the majority of the cases, you're doing exactly what you want to do.

Interviewer: Oh wow.

Dr. Mahan: Yeah, the limitations really come down to if somebody has had a disc herniation, we want to minimize the risk of re-herniation, meaning that another part of the disc fractures out and presses against the nerve roots, which can occur. Other than the disc herniations, I want the individual doing as much as they feel comfortable doing. Oftentimes that sometimes means tempering people. I had one patient the day after surgery he asked if he could go on a snow bike up the mountain. And I was like, it was one of those moments where you have that sort of, you know, common sense questions, like, well, just tell me what would happen if you got halfway up there and you had a back spasm? You had difficulty coming back?

Interviewer: Right?

Dr. Mahan: And, you know, he's like, well, maybe that's not the greatest thing to do today. And you're, like, yeah, the day after surgery may not be the greatest day to go nuts. But people will be walking more. People will be doing more activities. And we want that. We want them to go back to the way that they will choose to live their life.

Interviewer: Now, it's impressive that they are kind of up the next day, or a day or two after their procedure. Maybe a little bit tempered from what they were normally doing. But, you know, not going back up and doing crazy mountain biking, or that snowmobile trip, like you mentioned. But how long until a patient is, you know, all the way healed and sees the most benefit from the procedure, and they're back to normal?

Dr. Mahan: That is an excellent question. And it really is patient-specific. So if somebody had a more profound nerve pressure or nerve injury, and it's been there for a long period of time, meaning that it's going to take longer for their recovery, right? So if you've had a problem that is minor in nature, and it's a short duration, your recovery is going to be quick. If you have a very profound problem that is of long duration, you know, there may be a new normal, even with spine surgery. We can't always erase everything that occurs in time, but you know, we're going to try.

Interviewer: If your loved one is experiencing some sort of serious spine issue, perhaps stenosis or herniated disc, you may be looking into spinal surgery. Now, typically you might be imagining your back being opened up for major surgery, but there's another option that is available.

We're here with Dr. Mark Mahan. He is an associate professor of neurosurgery at University of Utah Health. Now, Dr. Mahan, we're talking today about endoscopic surgery for the spine. Why don't you kind of talk me through exactly what happens with an endoscopic procedure like this and how it differs from say what I as a layperson think when I think about back surgery?

Dr. Mahan: Endoscopic spine surgery is very similar to what people would refer to as traditional spine surgery, meaning that we're the same goals. We're there to decompress the nerves and in doing so with either removing disc fragments or treating narrowing that presses on the nerve roots, but doing it in a much smaller, much less traumatic fashion than previously accessed.

For most of us, the spine is really kind of in the center of the body, so getting there is always an art, to put it mildly. The older techniques, they work great for treating their intended targets, but the problem is, is there's a fair amount of tissue trauma involved with getting there.

And I've been intrigued for quite some time of finding a way of doing that same surgery, but in a way that does not cause the same tissue disruption, tissue trauma, and as a consequence, the same sort of pain or disability and recovery.

Like for so many things in medicine, we stand on the shoulders of others. Other pioneers had really developed using endoscopes previously, starting in about the 1980s, to create the same surgical corridor but through a much smaller opening. So now with the modern surgical endoscopes, we get beautiful illumination. We get beautiful magnification. We get beautiful video representation of the soft tissues in a way that we're able to perform those same delicate procedures, but through oftentimes really small, like 7 millimeters size skin incisions. That's, you know, 7 millimeters means it's less than your nail width depending on your fingers, but somewhere between your index finger. That's how big the skin incision is.

So that also means that that translates it's not just the skin incision size, it's because now you're going to go down with a very narrow caliber set of tools. So the things that you're going to be doing is that you're not going to be opening up as widely. You're not going to be disrupting joints. You're not going to be getting as much bleeding because we're constantly irrigating.

In fact, the operative field never actually gets to see air. There's none of the circulating air even in an ultra sterile OR environment that actually makes contact with the tissue. We're using constant irrigation with sealing. And so, again, it provides beauty and clarity to the surgeon but also minimizes any risk of infection or other bleeding type complication with regard to the surgery itself.

Interviewer: And again, as someone who's a layperson who might be kind of curious about this, how long have surgeons in the medical field been doing this kind of procedure? It seems kind of new I guess to me.

Dr. Mahan: I'd say it hasn't been done at a large volume for quite some time. There were some initial pioneers who were in the 1980s when they were coming out with the initial endoscopes who were starting it and trying it.

And you can imagine what using 1980s technology meant kind of dark kind of grainy, not necessarily with the same precision. Things really got a boost I would say in the, you know, the 2010s with the introduction of more modern, you know, high-definition televisions, easier access to those techniques, and then just greater popularity.

So we started seeing that the endoscopic technique was really taking off in Germany, and there there's a couple of key innovations that allowed it to be safe for the spine. So whereas you can think of joints having arthroscopes, those are endoscopes specific for joints, those were a little earlier take on, but they were using really high-pressure pumps and those high-pressure pumps would be dangerous if not lethal in the spine. So we had to really develop lower pressure technologies. You had to develop specific tools sets that were able to do the same sort of meticulous and very detailed work we do with the spine.

We saw that those tools and techniques and instrumentation sets really start about 2010-ish, and so there's a very small fraction of spine surgeons in the United States who are trained to do this, unfortunately, because I think it's the technique that should really predominate. And I do, you know, have the good fortune of being able to go train other spine surgeons on how to do this and adopt this technique, which I really enjoy teaching the other spine surgeons how to do it because hopefully it will become the dominant technique and it's not just a single or specialty practice.

Interviewer: It sounds like this procedure has been getting more and more popular over the last two decades, and you sound confident that it could be the next standard practice for a procedure like this. What is it that you see in this particular type of procedures and what are some of the pros and cons of it that make you think that this is going to be the way that surgery is going to be going?

Dr. Mahan: I really like the fact that it has minimal tissue trauma, which means that it has quicker recoveries. So when you ask about the pros and cons, the certain positive that I particularly love and I particularly enjoy about the surgery is that it provides rapid recovery for my patients. That the next day when I talk to my patients or find out how they're doing, they're describing that they're already back to more activities oftentimes than they were before surgery, which is relatively rare.

When we think about surgery, where most people are like, "Yeah, I've got a down period," and I don't have patients coming back to me with like down periods. They're like, "I'm out walking." I hear reports over and over again. They're like, "I am walking now more like the day after surgery than I was in like the several months leading up to surgery." It is that dramatic as far as differences in outcomes. So that's the most certain person and positive note.

Now, some of the other positives I particularly like, again, its lower blood loss. It has a substantially lower risk of infection. There's a substantially lower risk of a specific complication that occurs in spine surgery and that's spinal fluid in leaks or thecal sac injuries. And that's unique to the endoscopic technique is again, we're using sealing to put a little bit of pressure and create space and so the thecal sac is moved away and so you have less risk of that specific complication.

There are downsides, right? I tell all my patients almost repeatedly, you know, if it's powerful enough to help, it's powerful enough to harm. There are cases where people have injured, you know, individuals with using minimally invasive techniques. Endoscopic spine surgery is no stranger to that.

I would certainly say that I think, in my hands, the complication rate is lower, but it's not it's a freebie. It's not like there are no risks. Secondarily and I think the most of the negatives really accrue to the surgeon. You imagine like if you had to do the same work, let's say it's painting a wall, and you were given the choice of a big paintbrush or a tiny paintbrush, which do you think would lead to be faster endpoint?

Interviewer: It's the big brush, right?

Dr. Mahan: The big brush. It's the big brush. The big brush is going to do something quicker. And so, if you force the surgeon to do the same procedure with tinier tools, it's going to take longer. And the way that the insurance in the United States reimburses surgeons, it's on sort of work product. And so again, they pay you to paint the wall. If you can paint the wall faster, then it can be a choice.

Interviewer: What are the success rates like on a procedure like this?

Dr. Mahan: The success rate on anything in life really kind of depends on what your probabilities of success are. So if I take somebody who has relatively straightforward problem and has a very focal problem that's apparent on MRI and is clear on their physical exam and their description of their symptoms, we're going to have a good success rate whether it's an open technique or an endoscopic procedure.

If it's something that's a little bit more challenging, somebody has multiple problems, multiple medical issues, other interdependencies, you know, things that are going on in their lives that are either participating or motivating the pain, then we're going to be less successful. But so for that, let's take the good situation which is for most people where they are.

This is, you know, somebody who has singular problems, relatively identifiable things that could fix their problem, and they're going to have an 80% to 90% success rate with a surgical treatment and it's going to be durable. We want to do a simple procedure that doesn't necessarily create problems that need treatment later.

There are some spine procedures out there that cause further problems down the road. This is one of the ones that leaves a person essentially with more or less their native anatomy, their normal anatomy. And so the goal there is that the only thing that contributes to future problems is really, you know, the nature of time and body's ability to resist time but not the surgery itself.

Interviewer: Say that a patient has now received their diagnosis, they know they have one of these spine issues like we've talked about earlier. What is their first step? Say they're listening to this right now and they're intrigued about this procedure, what is their very first step to get more information and maybe even meeting up with someone like you or another trained professional?

Dr. Mahan: One of the things that we want oftentimes in medical practice, and this applies to a lot of things, is that we want somebody to ideally for somebody to come to me or to come to one of another trained practitioners. If they've had a degree of workup, meaning that they've been evaluated, they've been seen by somebody, and that the process has already been started.

For example, a classic thing is that sometimes you have back pain that can be treated with physical therapy, some exercises, some stretching, maybe some modest medications, right? We're talking about like anti-inflammatories and other things that can get you back to recovery that you don't need surgery for. And so both insurance and the surgeons really want to have that evaluated ahead of time so that when you're coming to somebody, it's meaningful. It's a meaningful use of the patient's time. That you're not coming to see somebody who's going to talk about surgery when you don't need it.

And so it's not a waste of the patient's time. It's not a waste of, you know, of resources or other things. So an initial evaluation, maybe some time with the physical therapist, trial of medications. And then if those aren't working and the MRI, which is a critical component of all of our evaluations, because that's where we can come back to saying is an anatomical surgery going to fix your problem.

And so we need a view of that anatomy, and fortunately, MRIs just do such a beautiful job of doing that is that. If an MRI shows that there's a problem, then clearly there's something that we may be able to intervene on and achieve a good outcome.

Interviewer: Wow. So it sounds like it's a kind of newer procedure and you've got to find the right doctor to do it, the right surgeon and you got to make sure that you have done your homework, gotten your imaging and your workups and everything but maybe they're curious about this type of procedure and treatment, where is somewhere where they can get more information?

Dr. Mahan: Well, one place to start would be the University of Utah website. We have a lot of wonderful information there that can give you the breadth because no patient has the same and what no problem is the same either. So there's oftentimes very distinct treatments that endoscopic spine surgery may not be for you. I would love to think that it is, but at the same time, realistically, there are plenty of things that may need to be done and it may not be endoscopic spine surgery and so that's a great resource to go to.

Announcer: Health hacks with Dr. Troy Madsen on The Scope.

Interviewer: What is today's health hack?

Dr. Madsen: Today's health hack is yoga for chronic low back pain. So here we're talking about people who have had lots of issues, who may have been prescribed even opioids for pain, who have looked into surgery. This was a study in "Annals of Internal Medicine," a few months ago, that looked at patients with this type of pain, chronic low back pain. They placed these patients in yoga classes. Other patients, they placed in physical therapy. Other patients, they just gave some education to, some information. Those who were in yoga did just as well as those in physical therapy. They used fewer pain medications, and even a year later, they saw these same results. They were still doing well.

So I think the big take-home for me from this was if yoga works for you, do yoga. If you're having issues accessing physical therapy, because of insurance issues potentially, consider yoga. Or if you're doing physical therapy, talk to your physical therapist potentially about even supplementing that with some yoga classes. It can make a big difference in the long run for a chronic issue that can cause all sorts of problems.

Announcer: For more health hacks, check out thescoperadio.com, produced by University of Utah Health.

Interviewer: Personalizing treatments for chronic back pain. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking about chronic back pain with Dr. Julie Fritz, Associate Dean for Research at the University of Utah College of Health. Back pain seems to be categorically different than other types of pain. Can you talk about that a little bit? How is it different and why is it different?

Dr. Fritz: Well, there's a couple things that distinguish back pain perhaps from other pain conditions. One is it's an almost universal human experience. Just about everyone has dealt with some level of back pain, ranging from slightly annoying to completely disabling. So there's a shared experience in it that makes it different than a lot of more rare or less common pain conditions.

The other thing about back pain that really makes it challenging is, in the vast majority of circumstances, we don't have a really good idea of what the cause actually is, what tissues involved, where the pain actually originates from.

So, you know, there's a lot of different structures and tissues in the back, and pinpointing what is causing the pain has proved extremely elusive. And without that, it's a challenge to direct treatment in a way that's going to be effective. And that really makes it somewhat different than a lot of other conditions.

Interviewer: Well, yeah, exactly. I have a friend who's gone through surgery, and yoga, and cortisone shots, and any long list of treatments. And she's basically back in the same position she was a couple of years ago in terms of the severity of the pain. And I mean, would you say that a lot of the treatments that are out there today just aren't effective?

Dr. Fritz: There's certainly a lot of treatments that we should just flat-out stop doing and that really are ineffective, even harmful for patients. And the other reality of treatments that exist for back pain is a number of the treatments, some of which you mentioned, are modestly effective for some people. And the real challenge is figuring out what may work for whom, and there's no magic bullet that works for every patient all the time.

So it's another part of the challenge and the frustration for both patients and providers is there's a lot of individualization that needs to go into treatment, but it's very difficult to figure out what you're likely to respond to and what the next patient may respond to, which may be completely different.

Interviewer: And it sounds like this is kind of the motivation for some of your research. Tell me about what you're looking at now.

Dr. Fritz: Yeah, absolutely. So we have this situation of a number of treatments that have small effects across large groups of patients. And the fundamental challenge that we've tried to address is how to better match treatments to patients, which sounds like a fairly straightforward question, and in some ways it is, but it's proven very difficult with back pain for some of the reasons that we've discussed.

So we try to look at various patient characteristics that might help us decide who's likely to respond to what kind of treatment. And what we found, and many other researchers is that, a lot of those factors that seem at least somewhat predictive are not really specifically related to the pain or the physical injury of the back, but often are related to patients' cognitive and emotional responses to pain, how they tend to cope with pain, what their mindset is relative to pain. And this introduces another level of complexity and trying to figure out the best treatments.

Interviewer: So the idea is that, some people just might be more receptive to getting better and other people are . . .

Dr. Fritz: Well, yeah. I mean, I think we'd say it a little bit differently that whenever any of us experience pain, there's a physical response, and there's a cognitive emotional response to the experience of pain. And that involves our relationship to other people, various other stressors in our life. And all of these things can be positive factors towards resiliency in dealing with pain, or they can tend to lead towards more disablement and more suffering relative to having pain.

It's not a situation where we're talking about pain that's of psychological origin, but of a recognition that all of us have a response when we experience pain that encompasses these domains in our life that get outside of the physical.

Interviewer: As I understand it you'll be looking at different types of therapies including things like mindfulness, which maybe it's something the medical community doesn't routinely turn to when they think about treating pain.

Dr. Fritz: Yeah. Pain conditions like back pain are an area where various integrative medicine approaches, what we've in the past called complementary and alternative approaches, may have a really important role. So in the specific instance of back pain as you highlighted with your example, finding a cure is often challenging.

And many people are left to manage their life with some level of intermittent back pain. And strategies like:

• yoga,
• mindfulness,
• meditation,
• other stress-reduction strategies,

can be really helpful for the self-management of back pain to help people deal with flare-ups that inevitably come, or the experience of pain without having to use physician visits, visit the emergency room, take medication, etc.

Interviewer: And so it's not necessarily about sort of solving the problem or curing the problem, but coping with it.

Dr. Fritz: It is for a lot of patients. We certainly, as providers, seek to cure the problem, to get it to go away and not come back. The reality of back pain is that's often an elusive goal. And as providers, we also have to help give patients strategies to better manage their condition given that we know it frequently tends to recur. That's really what we're all trying to do is help people recover, help people live their lives, and do what they want to do despite the experience of back pain.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research show is on The Scope.

updated: January 30, 2019
originally published: December 12, 2017

Dr. Miller: Thin bones and the risk of fracture and what to do about that. We're going to talk about that next on Scope Radio.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Nick Spina, and he's an orthopedic surgeon here at the University of Utah, in the Department of Orthopedics. He's an expert in spine care. Nick, how do you get a fracture when you have thin bones or osteoporosis? What happens? Where do they occur typically in the back? Tell me about that. It's a lot at risk.

Dr. Spina: Yeah. Osteoporotic compression fractures or what we call fragility fractures are probably the most common fracture we see in spine surgery. It tends to be on the more elderly side of the population.

Dr. Miller: At the time when we lose our bone mass.

Dr. Spina: Exactly, at the time when we lose our bone mass. So I'd like to describe them to people to imagine a soda can or a pop can. And each patient's vertebral body is like a pop can. So it has a hard rim on the top and a hard rim on the bottom, and the center part of the can is relatively empty. As we age and we get osteoporosis, the center of the can becomes even more empty. And so, as we stress the top, the can eventually cracks and crushes where our end plates become closer together or the ends of the can become closer together.

Dr. Miller: And so, what happens to precipitate that fracture? My understanding is they could just happen spontaneously if your bone density is so low.

Dr. Spina: Right. Depending on the degree of your osteoporosis or the degree of the strength of your bone, it can happen with just minimal activities such as waking up from sleep, standing, walking. They are commonly precipitated from falls, so patients often come in after a fall from standing or a fall during gardening, or routine activity around the house where they develop an acute onset of back pain.

Dr. Miller: Or one of the favorites from my patients would be shoveling snow.

Dr. Spina: Exactly. It seems no one should shovel snow anymore. That's pretty much a general rule.

Dr. Miller: So what happens? Do they have pain typically after that?

Dr. Spina: So the most common presenting symptom is acute back pain. Some of the worst pain you've had in the center of your back. It tends to be localized to the midline or right in the middle. Our muscles also become very inflamed, so it can radiate out towards our rib cage. It tends to be in the mid portion of the back. For women, right around their bra strap, and for men, kind of in-between the shoulder blades.

Dr. Miller: Now, you would find more osteoporotic fractures in women, I would think, right?

Dr. Spina: It does.

Dr. Miller: Osteoporosis is more common in women.

Dr. Spina: It's more common in women. So we do tend to see more osteoporotic fractures in elderly women versus men.

Dr. Miller: So, aside from analgesics, pain killers, that type of thing, what can you do to alleviate the pain or help with the pain?

Dr. Spina: So we sort of take a two-tier approach. One is a reduction in activities and modification of daily living, to avoid those activities such as heavy lifting, bending over at the waist, stressing the spine by bending forward or twisting. And the second would be we occasionally use a brace to provide an external support, kind of external crutch you can think of to keep the spine upright or support it while a bone tends to heal in that compressed manner.

Dr. Miller: What's this brace look like? Is it corset?

Dr. Spina: Yes. It tends to be a corset. It kind of looks like a turtle shell, hard in the front and hard in the back, and it wraps around your torso.

Dr. Miller: And usually, how long would a person have to wear that for that to work?

Dr. Spina: We tend to use them for about two months. And then, we tend to wean out of it because as we put people in braces, their muscles, obviously, become weaker. And having good muscular strength is one of the ways we compensate for having fractures. And so we don't cut them cold turkey. We often ask people to slowly come out of them and wear them when they're upright or up for long periods of time, and then remove them when they're sleeping or sitting.

Dr. Miller: Now, tell me a little bit about what's call kyphoplasty. I understand there's a little bit of controversy about the use of this technique and has been for a number of years.

Dr. Spina: So kyphoplasty and vertebroplasty were very common about 10 to 15 years ago. They sort of exploded in the world of spine surgery. And the procedure itself is directed at restoring the height of that pop can. So what we do is . . .

Dr. Miller: So this maintains height in the patient. So the concept, I guess, was if you increase the height of the crushed pop can, then the person wouldn't lose height.

Dr. Spina: Exactly. And so we insert a probe from the back of the spine into the front, the vertebral body. And there are two different means. One, we use a balloon to try to restore the height of the body. And the second is we just inject a material to try to restore the height. And the bottom line is that we take the empty space in the vertebral body, that space that's crushed down, and we try to stabilize it and if not, restore it by putting cement in the front of the vertebral body.

Dr. Miller: So what is the controversy surrounding this technique?

Dr. Spina: So there have been a couple large studies that have been done, that have looked at patients who have not had vertebroplasty or kyphoplasty and who have, and they haven't shown much of a difference as far as long term outcomes. So, in my practice, we tend to reserve them for those patients with intractable pain after about six weeks of non-operative care.

Dr. Miller: So they have some role in alleviating pain if it's not treated with the standard sort of non-interventional means that you just spoke about a few minutes ago?

Dr. Spina: Exactly. In those patients out of refractory which are very, very few in my practice, tend to see a little bit of benefit from doing a kyphoplasty. But again, we tend to reserve that to those people that fail all the non-operative means which we start with in the beginning.

Dr. Miller: The other point would be that if a patient has osteoporosis, they should also be treated for that with one of the newer medications. I should say newer. The medications have been around now for 10 years, and there's new medicines coming out all the time.

Dr. Spina: Exactly. One of the biggest risk factors for vertebral body compression fracture or fragility fracture is having a previous fracture. So it's our routine practice when we identify these patients to make sure that they have a pipeline of care through either us as treating providers or their primary care physicians to check their bone quality through a DEXA scan and address the degree of osteoporosis that they have.

Dr. Miller: Screening becomes very important in this age group, especially women over 65 years of age.

Dr. Spina: Exactly. Screening is probably the best form of prevention for these fractures that we have.

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Dr. Miller: Kyphosis, or a bend in the spine. What is it? What can we do about it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm Dr. Thomas Miller and I'm here with Dr. Nicholas Spina. He's an orthopedic surgeon here at the University of Utah in the department of orthopedics. Nick, tell us a little bit about kyphosis and what causes that. I understand there are a couple of causes.

Dr. Spina: Kyphosis basically refers to the curvature of your upper back, or your thoracic spine. The body's natural position is to keep its head centered over its hips. In our lumbar spine, we have a curve backward, and then our thoracic spine reflexively curves forward.

Dr. Miller: Sometimes that curve is too accentuated? Too great?

Dr. Spina: Too accentuated or too great.

Dr. Miller: And that's what we call kyphosis.

Dr. Spina: And that is what we call kyphosis. There is normal kyphosis and there’s also increased kyphosis or abnormal kyphosis.

Dr. Miller: And who gets that?

Dr. Spina: So everyone has a natural portion of kyphosis built into their thoracic spine and so some degree of kyphosis is normal.

Dr. Miller: And also protective, right? Because that little bit of curvature actually mechanically increases the strength of the spine, I think.

Dr. Spina: It does. It's naturally biomechanically favorable to have some degree of thoracic kyphosis through the mid-portion of your upper spine. Some patients, though, develop increased kyphosis. And there are a couple causes of that. One is what we think of sort of an inherited or congenital kyphosis. We call it Scheuermann's kyphosis, and that refers to a natural shape of the vertebral bodies where they're angulated or wedged in the front. So they're shorter in the front than they are in the back. And when you have a section of the spine with two or three of these segments in a row, that is considered abnormal kyphosis or what we call Scheuermanna's Kyphosis.

Dr. Miller: And you tend to be born with that or develop it over time?

Dr. Spina: You tend to develop it over time. It's commonly seen in young, teenage males. As males hit their growth spurt, they tend to notice an increased kyphosis, or increased hunchback, per se, through their upper spine.

Dr. Miller: So what is the other group that might have that? Older folks? Older patients?

Dr. Spina: So the second group of patients that typically develops kyphosis tends to be the older population. This is the population who develop osteoporotic compression fractures. It's also the population that sees significant disc degeneration. And so what we like to say is that life is a kyphosing event, and as we age, we all . . .

Dr. Miller: That doesn't sound good.

Dr. Spina: No, no. It doesn't sound good, but it's normal. And as we age, we all develop a degree of kyphosis. So the natural tendency is for us to lean more and more forward as we hit our upper decades.

Dr. Miller:And as we do that, when does it become a problem so that moving around becomes difficult or even one develops pain?

Dr. Spina: So people tolerate different degrees of kyphosis and it all depends on the patient specific. Some patients can tolerate a high degree of kyphosis and it's mainly due to the large muscles that sit next to your spine and try to keep us upright. And so the more kyphosis we have, the more forward our head is, relative to our pelvis, and the more energy we have to expend to stand upright and keep a horizontal gaze and be able to look at where we're going or who we're talking to. So as we get increasing kyphosis, our back muscles have to do more and more to keep ourselves upright and that's when it tends to become a problem and we see increasing pain associated with increasing kyphosis.

Dr. Miller: So can physical therapy assist in preventing forward kyphosis?

Dr. Spina: So physical therapy is a useful tool in treating acquired kyphosis.

Dr. Miller: So that would be in the first group that you talked about.

Dr. Spina: That would be in the first group. Either the young group or also the older patients that tend to go on to develop kyphosis. The back muscle's job is to keep us upright and looking forward. And the stronger those muscles are, the more we can compensate for increasing degrees of kyphosis. So our body's natural job is to compensate for our alignment, but the energy it takes to compensate is directly related to the degree of kyphosis that you have.

Dr. Miller: So, as an orthopedic surgeon, when do you decide to intervene in cases that are severe? Or do you?

Dr. Spina: So treating kyphosis is a very difficult subject and it's a very difficult task. We tend to intervene when everything else fails, as in a lot of other areas of orthopedics. We tend to start with physical therapy. We tend to start with trying to help people compensate for their natural alignment. When they cannot compensate any longer or their pain becomes debilitating, we consider intervening.

And the problem with interventions for kyphosis is they tend to be on the larger scale. We don't have a simple surgical tool or a simple intervention that can correct kyphosis. It often involves a multi-level thoracic fusion with some type of procedure where we cut the bone and realign it. And so it's a pretty large endeavor that we try to reserve as a last resort in treating patients with acquired kyphosis.

Dr. Miller: So what would you say to patients that are looking to prevent kyphosis from becoming worse?

Dr. Spina: So . . .

Dr. Miller: How do they do that?

Dr. Spina: Yeah.

Dr. Miller: Because I think a number of people that might be listening may not know when to seek assistance or seek advice.

Dr. Spina: So it's sort of a three-fold way to try to prevent kyphosis. In my mind, it all starts with activity and, as we age, to try to stay as active as possible. The second aspect would be trying to keep your core musculature and your paraspinal muscles as strong as possible. And so that would be through a course of increased physioactivity, core strengthening programs, a program that can be shown through physical therapy. And then, finally, it's to keep an eye on your bone quality. Osteoporosis is a significant risk factor and contributor to increasing acquired kyphosis, due to vertebral compression fractures.

Dr. Miller: So in that last category, having bone density studies done according to when you should have them done, if you're 65 and older or if you have risk factors, then that would help determine if you have a risk of vertebral fracture, thoracic fracture. And you could begin to intervene to prevent those fractures with certain medications.

In the second group that you mentioned, this is the physical therapy that you prescribe. Now, you have a set of physical therapists that work at the orthopedic center and I'm sure that other physical therapists in the valley, you prescribe certain therapies for your patients with the physical therapists.

Dr. Spina: We do. We work closely with the physical therapist based on the presenting symptoms. And often times with kyphosis, we focus on an extension strengthening program, so, an effort to strengthen the paraspinal muscles that run along the spine through a postural-based exercise program. We also, as patients, we also focus on flexion, because flexion is also involved in the core muscles of the abdomen, which all help stabilize the thoracic and lumbar spine.

Dr. Miller: In the first group, you mentioned the thing that I love is "use it or lose it." So what type of physical therapy would you . . . not physical therapy. What kind of exercises? Would you just recommend walking? Is that good enough?

Dr. Spina: So walking is great. Any exercise is better than no exercise. But, ideally, as we age, the lower impact exercises are great and exercises that incorporate a lot of muscle groups are great. So I try to encourage people to get into a pool when they can. If they are unable to swim, just walking laps in a pool also helps. The reason is it takes gravity out of the picture and so the stress on the joints is much lower, but you're still getting that resistance that strengthens the muscles. And it also works on your balance.

Dr. Miller: So the bottom line is if you're worried about kyphosis or the development of kyphosis, stay physically active. That might be your number one preventative treatment. The second thing is if you are developing kyphosis, you can see an orthopedic specialist or a sports medicine specialist who understands spine and then go to a physical therapist for focused treatment. And then the last piece would be to make sure that you don't have osteoporosis through appropriate screening.

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Announcer: Is it bad enough to go to the emergency room? Or isn't it? You're listening to ER or Not on The Scope.

Interviewer: All right. Today's ER or Not, back pain. Should you go to the emergency room for back pain? Dr. Troy Madsen from University of Utah Health ER or Not.

Dr. Madsen: So this is going to come down to a few things, and these are basically a few things that you should go to the ER for. Number one, did your back pain start because you were directly injured on your back? That's something you should go to the ER for because you very well could have a spinal injury. That's a very serious thing.

Number two, are you having symptoms like, losing control of your bladder or your bowels? Maybe you didn't have a direct injury to the back, maybe you're just having pain in your lower back and you cannot get to the bathroom quickly enough, you just can't hold it, you're urinating on yourself or you try to go to the bathroom and you really can't urinate. That is something that also you need to go to the ER for.

So that's second thing, the first thing's probably kind of obvious, you figure, "Okay, if I've been injured, let's say I fell or something hit me on the back, I'm having pain right on my spine, probably need to get some X-rays or a CT scan," but the second thing it's kind of an unusual thing but something I always think about, It's a term, it's something medical condition called cauda equina, and what that means is cauda equina's Latin for the horse's tail.

So if you look at the spine it's just kind of a cord that goes down and then at the end of the spine it all spreads out and looks like a horse's tail. This is where all these nerves take off and spread out there. So down there at the bottom part of the spine, the low back, if you get a disc that's pushing in or something that's pushing in on the spine, that's a surgical emergency. You need to go to the operating room and get that repaired and treated and the typical symptoms that people have with that are low back pain, and then they say, "I cannot hold it, I can't get to the bathroom quickly enough," or, "When I try to go to the bathroom I just can't urinate, I feel like I have to go and nothing comes out."

In my mind, that really raises concern for that, and the way I diagnose that is an MRI. And that's something you would need in the ER. So those are the two things that would say go to the ER for.

There are lots of other types of back pain, maybe you've lifted something, you've got a back strain or a sprain, maybe you've got a herniated disc. We do see lots of people with chronic back pain where it flares up. These are all things that could probably be treated through your primary care doctor or even through an urgent care. But in terms of the things that are really serious, those are the things I recommend watching for.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 11, 2018
originally published: August 12, 2016

Dr. Miller: Surgery for spinal scoliosis. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Darrel Brodke, he's an orthopedic surgeon at the University of Utah. He's also a spine specialist. Darrel, after conservative therapy some patients may not do as well as expected and they end up in your hands again where you may advise surgery. Tell us a little bit about that expectation and what happens.

Dr. Brodke: Patients often with adult scoliosis often caused by degenerative disease, degenerative disc disease, and therefore in a subsequent deformity also have other problems related to that lumbar spine. Specifically low back pain and pain radiating into their legs. They may also have pain with associated numbness and weakness and fatigue. All of that may progress despite non-operative treatment, despite physical therapy, medications, even injections. And it's then that we start to talk about surgical intervention. And surgery often necessitates a big surgery, not a little surgery, and by big surgery I mean surgery that may take many hours and require several days in the hospital and several months of recovery.

Dr. Miller: This is because you're operating on multiple levels of the spine, trying to straighten that curve that shouldn't be there.

Dr. Brodke: Exactly. We're working both on making room for the nerves, decompressing anything that's pressing on the nerves, and then straightening the spine and holding it there with metal instrumentation: screws and rods and spacers.

Dr. Miller: So this is a long surgery, but I imagine the recovery is also long.

Dr. Brodke: Yes. The surgery itself can take many hours. It varies depending on how many levels of the spine are involved and how much we need to do. The recovery, likewise, can vary but usually is on the order of months, not on the order of hours or days.

Dr. Miller: So tell us how you advise, sounds like the rehabilitation after the surgery is a significant part of the treatment. So do you send a patient to just physical therapy or do you send them to a physical therapy physician? Tell us a little bit about that.

Dr. Brodke: Postoperatively we're working with physical therapy immediately after surgery. While still in the hospital, patients are getting up and walking and learning techniques of movement and balance with a physical therapist. Once they leave the hospital, some patients go straight home and can walk as their main therapy and their therapy for the next few months as the bone is healing is walking. Some patients aren't quite ready to go home and will end up in a rehab facility where they work every day with physical therapy until their strength and balance has come around.

Dr. Miller: And that's very intensive

Dr. Brodke: It can be very intensive, several hours a day work in order to get to the point where they're ready to be walking around the home and even outside the home.

Dr. Miller: Now you mentioned you put some hardware in the back and to straighten the spine, I think you use metal rods and hooks and things like that and it sounds kind of daunting and it actually really helps straighten that spine.

Dr. Brodke: Yes, it does sound daunting and it's rather impressive when patients and their families see the X-rays but the screws and rods that we use, mostly made out of titanium today, really help us straighten the spine and hold it there while the spine is healing from the surgery.

Dr. Miller: So the hardware once it's implanted doesn't cause pain. It actually helps prevent it.

Dr. Brodke: Exactly. It helps prevent the pain, it helps hold the position that we want to hold, and it doesn't really hurt long-term either. Most patients don't need their hardware removed. It just goes along for the ride for the rest of however long that ride is.

Dr. Miller: So for our audience, it sounds like a small number of patients would need to have surgery to repair scoliosis. Basically this is a long and complex procedure followed by several months of rehabilitation but at the end of that if everything is going correctly you're going to feel better, you're going to have a better . . . going to have less pain, and you're going to be more functionable with your life.

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Dr. Miller: Sciatica. What is it? What do you do about it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an orthopedic surgeon and a spine specialist, and we're going to talk a little bit about sciatica. What is sciatica? What does that mean, Ryan?

Dr. Spiker: Sciatica is a pain that originates in the back but shoots down the legs, often just one of the two legs, often down the back of the leg and can go all the way to the foot.

Dr. Miller: What does that feel like? Is it a dull pain, shooting, electric . . . I mean, what would a person feel if they had sciatica?

Dr. Spiker: For most people it's kind of an electrical type sensation, a sharp pain that kind of shoots down the leg in a pretty clear distinct path that connects from the back all the way down into the leg.

Dr. Miller: Who gets sciatica? Would it only be somebody that has a traumatic injury or can it just happen?

Dr. Spiker: Sciatica is most common from degenerative conditions which are nontraumatic conditions where people are out working in the yard doing their normal activities and suddenly will feel this sharp pain. It can come from a disk herniation.

Dr. Miller: What's that? What is a disk herniation? We always hear about disk herniation, but what really is that?

Dr. Spiker: Yeah, that's a great question. So disk herniations are very common and fortunately they usually don't pinch nerves, but when they do, when a disk herniates from its normal position and pushes toward the nerve, it can cause nerve pain and that nerve pain can be described as sciatica.

Dr. Miller: So the disk is, it seems to me, to be kind of a shock absorber between the bones or vertebrae in the spine. Is that what that is?

Dr. Spiker: Correct, so the disk is between the two bones in the spine in each segment, and so our spine is full of different bones with discs in between and if that disk has damage to it, which can be traumatic but most likely is degenerative and most commonly seen in patients as they get older, they can start to rupture and have some of the material from inside the disk push out.

Dr. Miller: How do you describe the nerves traveling out of the spine? Do they travel out between the disks and the bones? What does that look like?

Dr. Spiker: Yes, between the bones are the disks and then between each level there's a nerve that will exit, so between each level of the spine there's a unique nerve that will exit and that nerve can be pinched from the disk.

Dr. Miller: Are there certain levels of the spine that are more susceptible to sciatica, or not sciatica but disk herniation that would cause a compression of the nerve?

Dr. Spiker: Yes, the lower spine, the lumbar spine is by far the most common, and even within the lumbar spine it's usually the bottom, the lowest part of the spine, in the L4, L5, S1, the very bottom part of the spine is the most common area, and that leads to compression of the nerve roots which shoot down the back of the leg and that's where we most commonly hear the symptoms of sciatica being, shooting down the back leg.

Dr. Miller: You mentioned that this is due to a degenerative condition so would we more likely see sciatica in someone who is older or younger, or what?

Dr. Spiker: It depends on the cause. With disk herniation sometimes we do see that in younger patients, even in their 20s, 30s, 40s. Other causes where arthritis or kind of slow processes are causing nerve compression, we see that in older patients or what we think of as lumbar spinal stenosis which is kind of more generic stenosis than just from a disk, and we'll see that in older patients. We see the symptoms of sciatica in all age ranges but different causes.

Dr. Miller: Sciatica is usually described as a pain, but can there be weakness associated with it?

Dr. Spiker: Absolutely, and that's something that is often missed by patients. When they initially describe their symptoms they'll have weakness in their leg without significant pain and it's unclear why, and it can come from nerve compression either in the lumbar spine or elsewhere.

Dr. Miller: So let's say a patient is out shoveling snow and all of a sudden they have this pain radiating down the side of their leg. It's pretty intense. What should they do?

Dr. Spiker: So first things first, taking a little bit of rest for a few days and if the symptoms aren't severe often they'll improve on their own. If it's persistent, getting worse day to day or associated with severe weakness or changes in their bowel or bladder function then they need to see someone immediately there in the emergency room or in clinic to get x-rays and get evaluated to see if there is significant nerve damage.

Dr. Miller: When you say rest, you mean they should just get in bed and lie in bed for a few days?

Dr. Spiker: Not necessarily lying in bed. As long as they're able we encourage people to be up and walking and moving as early as possible, but minimizing lifting, twisting, bending. The physical function is a little bit less aggressive in those first few days.

Dr. Miller: I think going to bed and just lying down used to be the old treatment, and it was found that people got pretty weak over time pretty quickly if they did that, so it got to the point of stay as active as you can as much as you can tolerate the discomfort.

Dr. Spiker: Absolutely, absolutely.

Dr. Miller: So should patients take any kind of medication for sciatica while they're waiting for it to naturally heal?

Dr. Spiker: If they can tolerate anti-inflammatories, it doesn't have any contraindications with their other diagnoses or medications, it's a great first-line treatment to calm down the inflammation and often helps with the symptoms and allows them to be functional, allow them to walk and move and heal on their own. There are other medications but that's probably the first step, and then getting into physical therapy as soon as possible to really get as much as we can out of our own bodies before we move on to more aggressive treatments.

Dr. Miller: More aggressive treatments would be . . .

Dr. Spiker: It includes injections, a steroid injection can help calm some of that inflammation, and in rare cases sometimes people do need surgery.

Dr. Miller: How many people who have sciatica eventually go on to surgery? It's not that many.

Dr. Spiker: Correct, it's a small percentage and it's hard to know because so much sciatica resolves before people even come to a physician, but even in people who come to see a spine surgeon like myself, it's by far the minority who end up needing spine surgery

Dr. Miller: That's really good news. So I think the bottom line for the listeners would be that if you have sciatica, it suddenly develops, to plan on waiting it out for a week or two because things generally progressively improve and to use nonsteroidal anti-inflammatories like ibuprofen, Naprosyn or aspirin to treat it, and then if it's not getting better to seek care from your primary care physician or perhaps even a physiatrist. Would that be right?

Dr. Spiker: Absolutely.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: March 12, 2019
originally published: June 21, 2016

Dr. Miller: Scoliosis - A Bend in the Spine. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Darrel Brodke. He's an orthopedic surgeon and a spine specialist here at the University of Utah. Darrel, what is scoliosis exactly?

Dr. Brodke: Scoliosis is a curve in the spine. Technically it's a curve that goes sideways in the spine, because our spine naturally curves in the forward-backward plane, but sideways it's supposed to be straight.

Dr. Miller: How do we get scoliosis, which sounds kind of abnormal?

Dr. Brodke: Yeah, there are a number of ways to get scoliosis. The most common, frankly, is arthritis in the spine as an older adult. That is a very common way to get scoliosis as an adult. But what we commonly think of when we think of scoliosis is teenaged kids with a curvature in the spine that was picked up by the school nurse. That's called, the most common version of that, adolescent idiopathic scoliosis, and it's also fairly common but not quite as common as the degenerative kind in the elderly.

Dr. Miller: So we hear that a lot of people have scoliosis. Do the majority of those people not have problems, they just live with the scoliosis?

Dr. Brodke: Absolutely. In fact, most kids and adults with scoliosis often find out they have scoliosis because they're being evaluated for a different problem and never really had known that they had scoliosis before that evaluation and it doesn't really affect them in any way.

Dr. Miller: It doesn't change their lifestyle, doesn't impact their livelihood.

Dr. Brodke: Exactly.

Dr. Miller: And it doesn't progress?

Dr. Brodke: It doesn't progress in most people.

Dr. Miller: Now the other type of scoliosis you mentioned is due to arthritis, so as patients are getting older that sounds a little more concerning.

Dr. Brodke: It can be. It can also be fairly benign. It can be an incidental finding when somebody is being evaluated for low back pain, for a muscle strain, for example, and it might have nothing to do with the low back pain. Alternatively, it may be very involved in the patient's problem in their low back, for example, when there's involvement of nerve compression, and we often see that in degenerative scoliosis.

Dr. Miller: Now patients that have scoliosis who don't have any problems, I suppose they would not need to see anyone. When would a person with scoliosis need to see a spine surgeon such as yourself? Would it be because of pain or limited mobility?

Dr. Brodke: There are probably two main reasons and then a third that's common. I'll start with that third. The common reason is because they're concerned about it. They don't know very much about it and they want to talk to somebody who treats this regularly and would like to get more information. That's a very common reason to see a physician, and that's a completely valid reason. Most of those appointments are about patient education and reassurance and they don't lead to surgical intervention.

There are times when the scoliosis can be a problem and should be seen by a specialist that sees and treats and operates on scoliosis. Probably the most common in adults, the adult scoliosis form, is when the patient feels very out of balance, either forward or sideways in a way that they can't straighten up, or they feel like their pain radiates down their legs and/or they have numbness and weakness in their legs and they can't do the things that they would like to do.

Dr. Miller: So treatments would include graded therapy. So you'd start conservatively or do you need to go to operative therapy?

Dr. Brodke: We will almost always start conservatively with physical therapy and medications like ibuprofen or naproxen, anti-inflammatory medicines, and sometimes we'll escalate to an epidural steroid injection or a little bit more aggressive treatment of pain. And if all of those fail we may talk about surgery.

Dr. Miller: So the small percentage of patients with scoliosis would go on to surgery?

Dr. Brodke: That's correct.

Dr. Miller: So to wrap that up for our audience, basically scoliosis is a fairly common condition especially in the younger patients or in younger people, and usually is not progressive, does not cause symptoms, and you live with it without any trouble whatsoever. But in some people it is problematic. It can impair function, it can cause pain, and for that reason you would see a spine specialist and they would prescribe variable therapy from conservative therapy, including physical therapy and non-opioid analgesics such as ibuprofen and Naprosyn, and then a few would need surgery ultimately.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: June 25, 2019
originally published: June 14, 2016

Dr. Miller: What is spinal stenosis? Could you have that as a problem? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists with Dr. Tom Miller" is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an Orthopedic Surgeon and a Professor of Orthopedics here at the University of Utah. Ryan, what is spinal stenosis and who gets that?

Dr. Spiker: It's a great question. Spinal stenosis is very common, especially as we age. So in the elderly population, what happens is you get some reason for compression of the nerves in the low back. This is often from arthritis, degenerative changes, and slowly that compression can lead to pinching of the nerves in the low back, which leads to weakness and pain in the legs.

Dr. Miller: So the anatomy is . . . tell me about that. The spinal cord goes down through the vertebrae, which are the bones of the spine and they travel through a tunnel. And what happens? That tunnel becomes narrow, is that what happens?

Ryan. Absolutely. So at the bottom of the spinal cord, there are still nerve roots and all those nerve roots end up innervating our legs, providing sensation and strength to our legs. And in that bottom part of the spine, just above the pelvis, it's common for arthritis to lead to hypertrophy or thickening of the ligaments, thickening of the disk and then compression of those nerve roots. And that compression leads to the pain that often shoots down into the legs.

Dr. Miller: So is spinal stenosis then a condition that someone who is a farmer or a laborer would get more commonly than somebody who was maybe working at a desk, or does it matter?

Dr. Spiker: So it does matter. There's some effect of environment so what we do. Sitting is actually very bad for our backs and so that can be a risk factor in and of itself.

Dr. Miller: So a clerk or a professional who's sitting a lot might be at greater risk than even somebody who is out working all day?

Dr. Spiker: Absolutely. Depending on the type of the work and there are also some genetic risk factors that we've studied here at the U that have been shown to impact how often family members will get spinal stenosis.

Dr. Miller: Well, tell me a little bit about what the symptoms are.

Dr. Spiker: The most common symptoms are pain or weakness or heaviness of the legs and it's usually worse when people are standing up and walking and improved when they bend forward. So if they're using a shopping cart or if they're using a walker, it feels much better. But again, it's worse when they attempt to stand up straight or extend their back.

Dr. Miller: What kind of pain is it? Is it a burning pain in both legs generally, if they're walking more than a block, I mean if it's severe?

Dr. Spiker: Often, people will describe some burning sensation. Commonly, it's a heaviness. It's a feeling that their legs are disconnected from their body. It can be a sharp pain that shoots down the spine. There's some variation with nerve pain, but invariably, it's worse with walking and usually goes down the back of the legs and can go all the way down into the feet.

Dr. Miller: What age groups are most susceptible to spinal stenosis?

Dr. Spiker: So, for most patients, it's as they get older so usually in patients that are 50 or 60 or above. Certainly, there are causes of spinal stenosis such as fractures or really large disc herniations that can occur in a younger population, but the vast majority of patients are a little older.

Dr. Miller: In a previous talk, we talked about sciatica and how that's caused by disc herniations mostly. Would spinal stenosis be more common or less common than disc herniation-related sciatica?

Dr. Spiker: So similar in different groups. So at a national level, certainly more common to have spinal stenosis than disc herniations that would cause somebody to see a spine surgeon like me. Most spinal stenosis patients will have some progression over time or continue to have symptoms, whereas most patients with disc herniations will get better on their own and this won't require to come in to see a spine surgeon.

Dr. Miller: So tell me about the therapies, treatments, for spinal stenosis. Obviously, it depends on the severity of the problem.

Dr. Spiker: Absolutely. So our first line treatments are anti-inflammatory medications, non-steroidal anti-inflammatories.

Dr. Miller: Ibuprofen, naproxen, aspirin, things like that.

Dr. Spiker: Exactly. They help calm down some of the inflammation from the area of compression. And then getting people into physical therapy to help strengthen their core, take some of the stress off the bones and the nerves of the back.

Dr. Miller: Would you say that physical therapy is kind of an underused and underappreciated modality?

Dr. Spiker: Absolutely, absolutely. And often, I would say 60, 70, 80% of patients that I see in my clinic have not yet undergone physical therapy and anti-inflammatories. And sometimes, these simple interventions can really change the quality of their life.

Dr. Miller: How long would it take before someone would know if physical therapy was actually working?

Dr. Spiker: It's a great point that it does take time so often the first few weeks can be frustrating because it's difficult and it can cause some pain, but usually, within six to eight weeks, people start to see the fruits of their labor.

Dr. Miller: In your experience, when then do you start talking about a surgical solution to the problem?

Dr. Spiker: So surgery is always the last option, it's never the first option. And fortunately, we can usually get people better with the anti-inflammatories, the physical therapy, some nerve medications, neuromodulatory medications like gabapentin, sometimes even injections. If all of these fail and the symptoms are progressive and really causing a change in their quality of life, that's when we talk about surgery.

Dr. Miller: And surgical outcomes, how well does it work?

Dr. Spiker: So surgical outcomes are excellent in well-selected patients. So in patients that have gone through the right preoperative therapies and interventions, it ends up about 80-85% of people are much better after surgery than they were before.

Dr. Miller: That's a great outcome.

Dr. Spiker: Yes.

Dr. Miller: And over time, does that hold?

Dr. Spiker: It does. So we have great data up to about eight years now showing that people have continued benefit with surgical intervention for at least eight years and we certainly think longer.

Dr. Miller: Well, thanks, Ryan. So for our audience, basically surgery is the last option, but it has an excellent outcome. But prior to surgery you want to think about a good trial of physical therapy and the use of over-the-counter non-steroidals like ibuprofen and naproxen just to try to control the pain while you're testing physical therapy and working with your therapist.

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Dr. Miller: CSM. What is that? We're going to talk about that next on Scope Radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Erica Bisson. She's a neurosurgeon and also specializes in spine surgery. What is CSM?

Dr. Bisson: CSM actually stands for Cervical Spondylotic Myelopathy, which is a lot of words, but let me just break it down. What it means is that your spinal cord is being pinched in your neck. When I say pinched, the canal is being narrowed and that causes spinal cord dysfunction. Essentially, the messages that are coming from your brain and going out to your arms and legs aren't getting there in a timely fashion.

Dr. Miller: Now, who gets that?

Dr. Bisson: So the average age for patients who have CSM is in the 50s and 60s. We do see older individuals as well, but this is a degenerative process. This is something that happens as we age.

Dr. Miller: Now, do you go in surgically and open the space around the spinal column in order to create room for it to operate and function?

Dr. Bisson: That's exactly what we do. So when we approach this surgically, our main goal is to give the spinal cord room to move. If you look at an MRI or an image of an individual who has CSM, often you see bone spurs and other abnormalities that are causing the narrowing of the spinal canal so we have to either remove the bone spurs or open up the bone in some way, shape or fashion to enlarge that spinal canal so that the spinal cord itself gets completely surrounded by fluid and has a cushion enabling it to move properly.

Dr. Miller: If a patient has spinal cord dysfunction or CSM as you've called it, what are the symptoms that they might have? How would they know if they have this particular problem?

Dr. Bisson: Well, I'll tell you, the symptoms can be a little bit vague. Having said that, there are specific questions that I tend to ask patients to try to better understand if they're having symptoms from spinal cord dysfunction. Things that we talk about are problems with balance, so patients often have balance difficulty, their walking doesn't feel quite right. The other thing that patients mostly complain of is dropping things or loss of hand strength. They also complain of loss of dexterity. You know, it's funny, some of my patients tell me, "I feel like I'm telling my hands to do something, but they're not just quite doing it." Other patients tell me, "You know, I go to pick up my pen or I go to pick up my change of the counter and it slips out because I'm not quite able to tell what I'm picking up. I'm not feeling or sensing it."

Dr. Miller: Sensation in their fingertips. But isn't that also a problem of aging? Don't we get a little bit of that with aging? How do you tell it apart?

Dr. Bisson: Great question. You absolutely . . . so all those things, balance, loss of hand strength can be a problem with aging. What I'll comment is that I often have people who come in and have an MRI and I'm trying to differentiate them. You know, nationally and internationally, we're trying to find some kind of measure or test where we can say, "Ooh. That's CSM for sure." We don't have that yet. People are inventing all sorts of tests and new techniques to try to understand that, but it's the constellation of symptoms together.

They also, patients, find that they, if you examine them their reflexes are a little brisk. That's something we call Upper Motor Neuron Disease. Or that they're having spinal cord problems so we see this thing called hyperreflexia or abnormal reflexes where their knee jerks or their arm jerks a little bit too much, relative to normal.

Dr. Miller: If you do reparative surgery on these patients, what's the chance of recovery from the symptoms that they have?

Dr. Bisson: Tom, that is a fantastic question. And historically, if you review all the literature, which I have done time and time again on this topic, we have always told patients that the ultimate goal of the surgery is to halt the progression of the disease. The natural history of this disease process is that patients will get worse over time. So when we intervene, we open up that spinal canal and give room with a hope that we stopped them from getting worse, not that we're going to improve . . .

Dr. Miller: . . . what's happened already.

Dr. Bisson: Exactly.

Dr. Miller: But there's a good chance the progression would cease.

Dr. Bisson: Yes, absolutely. And what I will also tell you is anecdotally, after having seen many, many patients through this, over the last many years that I've focused my career around this, I do notice improvement. And I constantly am amazed at the recovery that I see. So while I tell every single patient going into surgery, "My goal is to stop the progression," anecdotally I see improvement. And I see vast improvement, which is so encouraging for me.

Dr. Miller: Now, there are different approaches as I understand, we talked about this a little bit before. I mean do you tell patients that there is a best way to perform the surgery? Is that something that you talked to them about? Or do we even know that?

Dr. Bisson: That's a great question. I would tell you that in some patients there is an optimal way. When we approach the neck for spinal surgery, we can either come in through the front of the neck or from the back of the neck and each has its pluses and minuses. There are some patients that only can have surgery from the front because different issues with their neck, the alignment or how the neck is curved and there are some patients who are most appropriate for the back. The vast majority or a good majority of patients can actually do either way, front or back. That happens to be a question that PCORI, which is the Patient-Centered Outcomes Research Institute set up by the government and through the ACA funded a large study that we here at the University of Utah are participating in, looking at the answer to that exact question.

Dr. Miller: So this may tell us in the end whether one approach or the other, back or front is best?

Dr. Bisson: Absolutely and we're very much looking forward to that.

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