Thanks for being here tonight. And I do want to say that
while the talk is entitled Neck and Back Pain in Women,
I do see some men here, which is great. Because pretty
much everything I’m talking about also
applies to men. There– –necks and backs. Yeah. You have the same thing. And pretty much
everything applies. There are just a couple
of things where it’s true that we see these
diseases more in women, and so I’ll touch upon that. But everything is still
useful for you as well. So as I’m sure
everyone here knows, lower back pain is
incredibly common. 90% of adults will
experience lower back pain at some point over
their lifetime. And it’s a major cause
of disability for people who are over the age of 40. The good news is that only a
smaller percentage of people will really have
chronic back pain. So 10% to 20% of people. And the cost due to lost hours
at work is over $50 billion, so we know this
is a huge problem. It’s one of the
most common things that primary care doctors see. And I’m sure that
every single one of you has either had back or neck
pain at some point in your life, or known someone very close
to you who has had it. And so the first
question is, when you have an acute episode of
pain, your back gives out, what do you do? So first of all,
don’t panic, OK? As I said, it’s
extremely common. Everyone will experience this
at some point in their lifetime. Apply heat. Try a non-steroidal
anti-inflammatory medication. So those include Motrin,
Aleve, ibuprofen, naproxen. Those are really
good at fighting the inflammation that is the
cause of a lot of this pain. You can also take
over counter Tylenol. You can try a hot shower
or gentle stretching. The majority of
chronic back pain is really sort of diffuse
musculoskeletal pain. So these things, over
the first few days, should be very helpful for
people who are experiencing these symptoms. Now what are the red flags? What are the things if you
experience these where you need to get concerned, you need to
call your primary care doctor or call someone and start
asking some more questions? So one of them is
if you’re back pain has been going on for
more than six weeks, if you have a personal
history of cancer, if you’ve also been having
fevers, sweats, or chills during the same period of time. If you’ve been losing
weight without trying to. Not that you’ve been on a crazy
diet, having 500 calories a day and you’ve lost two pounds,
but an unexplained weight loss over the past few weeks. If you have a personal
history of IV drug use and you have acute
episode of back pain, that’s more concerning. If you have any weakness in any
specific muscles in your legs. So not that you
feel kind of overall that you have a lot
of pain, but you notice you try to
stand on your toes or you try to move
your feet, and you notice some real weakness
in those muscles. If you have numbness or
tingling in your legs, and if you have any bowel
or bladder dysfunction. So we always ask
about incontinence. So that is are you able to
control your bowel and bladder? Have you ever had any
episodes where you’ve gone and you didn’t even know it? Those are the kind of
things that you should talk to your doctor about. And then unremitting pain. So pain really that does not
get better after these first six weeks, that’s a time where
you should be bringing it to the attention of– start by your primary
care doctor to try and figure out what’s going on. And there’s a lot of different
types of imaging of the spine that we get. And you’re probably
first time going to end up at your
primary care doctor, and they may or may
not order x-rays, depending on exactly what
type of symptoms you describe. And x-rays are actually
very, very useful. As a spine surgeon, I get x-rays
on almost all of my patients, even if they have an MRI. And the reason is that x-rays– you can see on the left, that’s
looking at you from the side, and the one on the right, is
looking at you from the front. X-rays are a great
way at looking at the bones of the
spine and looking at the alignment of the spine. So we can see big
problems with alignment. We can see collapsed discs. There’s actually a
ton of information we can get on a very
quick and easy scan that has a very little radiation. And what you’re
looking at here, that’s one of the vertebral
bodies of the spine. That’s what’s indicated in
blue, that outline, that box. And that’s pointing
to a disc space. So in patients who
have collapsed discs, you’ll see that at some levels,
those heights can be lower. A CT scan is another
type of study that your doctor may
or may not order, and this is basically
like an x-ray on steroids. So it does have more
radiation, but it allows us to look at the
bone much more carefully. So if there– a
lot of times, there can be some small fractures
that we can miss on an x-ray. And so a CT scan,
as you can see, you have a lot more definition,
specifically of the bone. And I think everyone
in this audience can tell that there is a big
difference between these two CT scans. So the one on the
left is a normal scan. And the one on the
right is someone that has a lot of degenerative
changes of the spine. They’ve got collapse
of those disc spaces. That black is air
in the disc spaces. The white is– the
increased white is the inflammation
and sclerosis of the vertebral bodies. So these are all changes that
are very consistent in someone that has severe degenerative
disease of the spine. And the CT scans
also allow us to do these three-dimensional
reconstructions that we sometimes get. An MRI, on the other
hand, is a great study for allowing us to
look at soft tissues. So it lets us look at
the spinal cord itself, the nerve roots themselves. And what you can see
here is, once again, looking at you from the side. So the belly is there. The back is there. And the feet are down there. This is the spinal cord in gray. And the white stuff
that surrounds it is the spinal fluid. And we can slice the MRI
like a loaf of bread. And once again,
look here, this view here shows you the spinal
fluid surrounding all the nerve roots, the bones in
the back, the front. And then all the
muscles as well. So an MRI is a great way to look
at something like a herniated disc. You can see here,
these are normal discs. This is a herniated disc right
here protruding backwards and impinging on
the nerve roots. And you can see it also
on this view right here. That is the disc coming out. So I mentioned at the beginning
that a lot of back pain is nonspecific. But there are some very specific
causes of lower back pain. And these are the cases where,
as surgeons, we can actually help more when there is a
specific thing underlying the back pain. So one of them is a disc
herniation, like I mentioned. And I showed you an
example of an MRI. And disc herniations actually
usually don’t just cause back pain, but leg pain. OK? So pain radiating down from your
back, all the way down the leg in a specific distribution. And many people
call this sciatica. Technically, sciatica
really only refers to one of the nerve roots. But people kind of
use that term to refer to pain which is lumbar
radiculopathy pain, compression of a nerve root in
the lower spine that leads to pain in the legs. I’m sure many of you have also
heard the term spinal stenosis. So once again,
incredibly common. If we got an MRI of every
single person in this room, including myself, we would
all have varying degrees of spinal stenosis, OK? So the question is really
just when is it actually causing problems. And you can have stenosis
of the central spinal cord or canal itself, as
well as the nerve roots as they exit at each level. And in older patients, one of
the more common things we see is spinal stenosis in the center
of the lower lumbar spine. And this is the
shopping cart sign. So patients complain that
they’ve got lower back and buttock pain. Their legs really
ache, especially down the front of their thighs. When they go– and it
gets worse when they walk, maybe they walk
five, 10 minutes. They lean forward
on the grocery– on the shopping cart at Whole
Foods, and they’re much better. They sit down and relax
and they’re better. So that is very, very typical
for lumbar spinal stenosis. And then much less
common, but also something that I treat
and enjoy treating is scoliosis or xyphosis. So scoliosis is a
curvature in the plane as you’re looking
at me, so like this. Whereas xyphosis is a
curvature in the plane if I stand to the side like
this, if I have a hunchback. That’s referring to xyphosis. And a lot of times, people
have problems in both planes. Some of you may have also heard
the term spondylolisthesis. And really, what that
means is that when you look at the spine– and this is particularly well
seen on an x-ray or a CT scan– you want to be able to draw
a line clearly right here. You see at this point that
this vertebrae is slightly in front of that. So that line, that curved
line is not in alignment. It’s not in alignment. So sometimes–
most of the times, this actually isn’t a problem. But sometimes it
can be a problem. And you can have
motion, especially as you’re moving
your back, that can lead to significant back pain. Spinal infections,
which you can see here, are also a problem
that can occur in people that have a
history of infections of the bloodstream, IV drug
use, or other situations that can lead to some very,
very significant back pain. And then I’m going to talk
about this quite a bit later as well, osteoporosis-related
spine fractures. So you can see here,
the x-ray on the left, and we have the CT scan on the
right for the same patient, and you notice
how much easier it is to see the bone
on that CT scan, so why it can be very helpful. And this right here is
the compressed vertebrae in a patient that has pretty
significant osteoporosis. And sometimes, you
don’t even need to have a fall to end up with a
compression fracture like this. And then, of course, there’s
also spinal cord injury. This is the neck. So this is the front of the
neck, the back of the neck. And you can see that the
problem is right there where this patient had a
devastating spinal cord injury and ended up paralyzed. So much less common, but
one of the things that, as spine surgeons,
we also treat. As well as neoplasms
or tumors of the spine. Once again, much
less common, but we do see some spine tumors. Primary spine
tumors, and then also tumors that metastasize
from other areas, like the breast, colon, or lung. So I went over a bunch
of these specific causes of lower back pain. But as I started off
at the beginning, really 90% of patients who
present to their primary care doctor with back pain have
non-specific back pain, i.e, really none of these. And as I mentioned, back
pain is more common in women. There have been
several studies that show a higher prevalence,
10% of women versus 6.6% percent of men with severe lower
back pain in a French study. Another study in Germany showed
that the seven-day back day prevalence was also higher
in women compared to men. But there are also a whole lot
of other important risk factors for back pain, including
higher body weight, older age, physical inactivity,
smoking, unemployment, lower socioeconomic status,
uncomfortable working positions, so people
that have jobs that involve
significant heavy labor or uncomfortable
positions like operating. Spine surgeons
actually have a lot of spine surgery themselves. And lifting weights. Why is back pain
more common in women? The very simple answer
is that there’s not one specific reason. This is a little
bit of handwaving. But one of the issues that
we’re really going to talk about is osteoporosis, but
separate of osteoporosis, we do see back
pain more in women. So it could– women when
they’re pregnant obviously have back pain very frequently. Likely has to do
with the distribution of abdominal weight
around the spine. There can also be
perimenopausal weight gain specifically around
the abdomen in women as we get older that
may contribute to this. And then some people
really do talk to me and say that they have
fluctuations in their pain sensitivity based on
their menstrual cycle. And if you do have an underlying
chronic lower back issue, that can exacerbate it. So what are our treatment
options for lower back pain? And this goes back again, this
is applicable to men as well. OK? So the first thing is
assurance and education. So 90% of patients with
acute lower back pain will have stopped
consulting their doctor within three months. And only 5% of people that have
an acute episode where they feel like they can’t get out
of bed, the world is ending will really develop
chronic lower back pain and a permanent
disability as a result of this. So one of the first few things
is just educating patients that this is going
to be all right, and then talking about good
posture, work ergonomics, correct sitting and
lifting positions. So a lot of us these
days have desk jobs that involve staring
at a computer for very long periods of time. So one of the very
simple things you can do is place your computer
screen higher up. So that you’re not looking
down like this with your neck in a hyphotic position,
but rather looking up at your computer screen. For me, personally, that’s
a big source of neck pain. Because when I
operate, I operate like this with a heavy
light and loops on. And I finish a 12-hour case, and
my neck is killing me, right? So these are– there’s
certain things, obviously, that you would change about
your work or your situation, and other things
that you cannot. But these are things that
you should be aware of. Physical therapy is one of
the first-line conservative treatments for any type
of lower back pain that’s lasting more than a few weeks. And what that really involves
is core strengthening. So if you strengthen the
muscles round your spine, that relieves the
pressure on the spine and can greatly improve
people’s outcomes. So specifically, pilates,
yoga, core strengthening. And also, there’s
been some publications showing that aqua therapy
works really well. Because I have patients
that say, I can’t walk. I can’t walk more than five
minutes without severe pain. But you put them in the water,
and you take that pressure off of them, and they’re
able to participate in a full 30 or
60-minute session. And so that can be really,
really good for some patients. I don’t necessarily
recommend this, but this is something that I
did recently, which is a thing. OK, so yoga, good. Goat yoga, maybe not so much. But they really like
the table top position and they crawl on you. Which is really quite fun. Other things other than physical
therapy include acupuncture. Some people may or may not
have tried inversion tables. That can be helpful
for the pain that I talked about that’s the
sciatic-type pain, where you have pain from a
compression of a nerve root in the spine that radiates
down into the legs. And then many people I’m
aware see chiropractors, and people have specific
questions about that. We can maybe address it in the
question and answer session. Weight control is one of
the most important lifestyle modifications that
I tell people who have chronic lower back pain. So we know that
obese patients have higher rates of lower
back pain compared to non-overweight patients. And one interesting
study actually, they had morbidly obese patients
who underwent bariatric surgery for weight loss,
and they actually saw that their back
and leg pain improved, and they had
increased disc height. So essentially,
this is just when you have more body
weight, especially more body weight in
the abdominal region, on the spine, that
contributes to pain. Smoking is also linked
with worsened rates of lower back pain and
spine disease in general. So we see higher rates of lower
back pain in people who smoke on a daily basis compared
to those who don’t. It’s associated
with disc disease. And when patients smoke
and have spinal surgery, they do much worse. They have worse outcomes,
higher complication rates, and more pain. And so for patients who are
undergoing elective spine surgery, I and most of my
colleagues at this point will ask patients to quit
smoking and a lot of times nicotine test them in order
to ensure that they really have the best chance of having
a good recovery from a spine surgery and doing
well as opposed to having complications and
not having good pain relief. And there’s not a
ton of data for this. This is really just one study. But at the same time, I don’t
necessarily think it’s harmful. People are taking omega-3
fatty acids for lots of reasons these days. And they are
anti-inflammatory, and so they may help reduce some
non-specific neck and back pain. And there was one study of 250
patients with back and neck pain who took fish oil,
and a good portion of them were satisfied with
their pain improvement. So it may be a very
simple, cheap thing that you may already be
doing that might help. And bone health is
very, very important. So you can see the
osteoporotic bone, which basically just means bone
that is weakened, on the right. And you can see,
unfortunately, as women, as we get– so women are
more prone to osteoporosis, and as we get older, we’re
more prone to this as well. And this can be a big
problem, both in terms of contributing to back
pain, and also contributing to us doing poorly when we do
have spine surgery to treat our back pain. So we know osteoporosis
is really common. 34 million people in the United
States have low bone mass. And 50% of women
over the age of 50 will suffer an
osteoporosis-related fracture in their lifetimes. Each year, the risk of suffering
a fracture from osteoporosis is greater than
the combined risk of suffering a heart
attack, stroke, and breast cancer in women. And when you do have an
osteoporotic fracture, especially in your
hip and spine, what this is showing right here
is that you have an eight– more than eight
times greater risk of death if you have a
spine-related osteoporotic fracture than if you had not
had that fracture in your spine. So it’s not a good thing,
especially not a good thing to have when you’re
older and you have a lot of medical
issues going on. And so there’s a lot of
modifiable risk factors for osteoporosis, and
non-modifiable ones. So we can’t prevent
getting older. We can’t prevent
our race, our sex. We can’t prevent whether or
not our mother or grandmother had osteoporosis. And we can’t prevent
the fact that we’re all going to become
postmenopausal at some point. But the things we can change,
we can quit smoking if we smoke. Steroids, so a lot of
people are on steroids for various reasons, whether
it’s COPD and asthma, arthritis. Those can greatly
weaken the bone. So I’m not saying
that you shouldn’t be on them if you have to be
on them for medical reasons, but if you are, you need to make
sure you’re getting screened for osteoporosis, because
you may have much weaker bone than you know. There are other
medications as well, like anticonvulsants that
people take from seizures, that can impact bone quality. Significant alcohol
use, including wine drinking
several times a week can also contribute
to osteoporosis. Being inactive, being too thin. OK, so I told you,
you don’t want to be– you don’t want
to weigh too much. You don’t to be too thin
either, because that can also predispose you to osteoporosis
and being undernourished. So osteoporosis is
diagnosed with something called a DEXA scan. And this is essentially
just a special x-ray where they compare
your bone quality to either people who are your
age, or healthy 30-year-olds. And they come up with
something called a T-score. So if your T-score is
less than negative 1.5, any positive number,
that’s great. If your T-score is
between negative 2.5– and negative 1.5 and negative
2.5, that’s osteopenia. So that means that your
bone is already weak, and you definitely should be
talking to your primary care doctor or an endocrinologist
about getting treatment for that. And if it’s less than negative
2.5, that’s osteoporosis. And 100%, you should be
doing something about it. The current guidelines are that
all healthy women over age 65 should get a DEXA screening. And you should be
considering this even if you’re younger if
you have a family history, you have a particularly low
body weight, excessive drinking, you have a history of
rheumatoid arthritis, for example, you’ve
been on chronic steroids for any long period
of time, you smoke, or if you have a fracture
in any part of your body that’s really not explained. You didn’t have a fall, you
had a very, very minor trip, and that led to a
significant fracture. I think for men, it is age 75. But I’m not– I would check
with your primary care doctor about that. It’s older. It’s older for men in terms of
when you should get screening. And it’s not done as
frequently in men. So what can you do to
optimize your bone health? Well, some of the
very basic things that you can do, even when
you have great bone health and starting from a young
age is calcium and vitamin D. Weight-bearing exercise
and strengthening. There’s you know pros
and cons, obviously, and so this is something to
discuss with your primary care doctor, but hormone
replacement therapy can be considered
after menopause. But there’s obviously some
disadvantages to that as well. The main medications that
actually treat osteoporosis fall into a few
different classes. One of them is the
bisphosphonates. And these are
medications that prevent, that inhibit the cells that
actually break down bone. So they’re not going
to help you build bone, but they’re going to help the
deterioration and the breakdown of bone that happens as we
get older and some of these are pills, some of
them are injections. There’s a bunch
of different ones. But I’m sure you’re
very familiar with some of these names, including
Fosamax, Actonel, Boniva, Reclast. There’s a lot of ads
on television for them. Prolia is another one
that can sometimes be really nice because it’s
an injection only a couple of times a year,
so you don’t have to remember to take
a pill every day. And that also works
on osteoclasts. The only medications
that build bone, however are these medications
that are daily injections. And the main one right
now that’s on the market is teriparatide or Forteo. Tymlos is even newer. So in spine in
particular, when I have patients who
I’m considering doing a very big spinal
fusion on in more than one or two levels, I will screen all
my patients with a DEXA scan. And if they have
osteopenia or osteoporosis, I will ideally try to get
them on teriparatide or Forteo for a few months before
surgery, and as much as a year after surgery to
strengthen the bone. What we’ve found
in our research is that that improves– when
we’re putting in these screws and rods and asking
your bone to fuse, we have better rates of the
bone actually fusing, screws not pulling out,
screws not breaking if we treat the
osteoporosis first upfront, and then afterwards as well. But I will say that it
is very challenging. This particular medication
is super expensive and not covered by most insurances. And so it can be a really
big pain to get people on it. And also, a very
important thing to know is if you have a personal
history of cancer, it is contraindicated. So if you’re thinking
about talking to your endocrinologist–
you can only get a prescription for this
from an endocrinologist. I can’t write it for you. Your primary care
doctor won’t write it. That is something
important to keep in mind. So what kind of– other than the physical
therapy medications that we talked about
and other lifestyle modifications, when we start
getting into interventions, what can we do to help
treat your back pain? So we’ve got a bunch of
minimally invasive procedures. And these are injections
that are usually done by pain management doctors. These people can be
anesthesiologists in training, they can be
physiatrists, which means that they’re people who focus
in physical medicine and rehab. And occasionally,
sometimes neurosurgeons or orthopedic surgeons
do them, but most of us don’t, because most of us
focus on just the open surgery. And it’s important
there actually are a lot of different
types of injections. This is one of the things
that I notice the most when patients come to me. They say, oh, yeah, I got
an injection into the back. Well, there’s a lot of
different types of injections, and how you– what type
of injection you had can really affect
how you respond to it and can tell us a
lot of information in terms of what’s
actually causing your back or your leg pain. So there are epidural
steroid injections. And what this is is they
go in with a needle, usually with
fluoroscopy guidance, so that means that
they’re getting an x-ray to see where they are. And they inject some
local numbing medication, and oftentimes, a steroid in
the area around the nerve roots. There’s also something
called the facet block, and that’s a totally different
place where they go in. They go in on the side where
you have the joints of the bone. And there are some
smaller nerves that innervate that joint. And so that’s a totally
different type of procedure that they can do to help with
a different type of pain. And then they can also do what’s
called a selective nerve root block where that’s also
going in more from the side. And that’s saying, we’ve decided
L3 is really your problem, and we are going to
do a selective nerve root to target and put
numbing medication and steroid around that specific
nerve root and see if your pain gets better. I showed you that
picture of the lady that had the really bad
osteoporotic fracture where her vertebral body was
completely collapsed. When that happens in
the acute setting, a lot of times you might be
a candidate for something called a kyphoplasty
or a vertebroplasty. Which, once again,
is a procedure, not an open surgery,
where you essentially go in with a needle,
inflate a balloon, and fill that with
some cement to increase the height of that vertebral
body that’s collapsed and help with pain control. And here you can see an example. On the left is an
MRI of someone that has a collapsed vertebral
body where that arrow, as you can see,
it’s much smaller than what a normal
vertebrate should look like. And then on the
right, you can see they’ve injected the needle,
they’ve inflated the balloon, and then injected cement
into that vertebral body. And that’s really just to
help with pain control. So I’m a surgeon. What about spine surgery? So I know– I fully realize
that we get a bad rep out there. And that’s because
there are, one, a lot of different
types of spine surgery, but they really need to be
done for the correct reason. So the most important thing
when I see a patient is I first want to figure out what’s
causing their back pain. What exactly is the
source of their pain? Because if we don’t know what
the source of their pain is, then we’re not going to
effectively treat it. And there’s so many
different things, as you’ve seen today talking
to you, that can really contribute to the pain. So when you choose an
appropriate patient, spine surgery can
be highly successful when it’s executed
on the right patient. But it’s critical that we
diagnose correctly and really know what’s causing
the patient’s pain, because risks are
high, complications can be devastating. And then when you get into the– when you get into a sequence
of having several failed spine surgeries in a row, and
I’m sure many of you have some friends who
you’ve had multiple spine surgeries or spinal fusion
surgeries and done very poorly, then they end up on
my doorstep and we’re doing surgery for the
fifth time around. It’s a much more challenging
surgery and a much bigger deal. So one of the things that we do,
I mentioned spondylolisthesis. And you can see on the
far left that x-ray has one of the bones, one of
the vertebrae that’s moving relative to the other one. So that’s a type of
problem that you can only fix with a fusion surgery. You have to immobilize
the spine in order to fix that movement that’s
contributing to the pain. And to do that, we put
in screws and rods. There are a lot of
different types of them. And there are a lot
of different ways that we can go in
from the spine. And so it’s a little
bit of an alphabet soup. We’ve got ALIF, TLIF, PLIF,
OLIF, XLIF, literally going in from the front of the
spine, going in from the side, going in from the back,
going in in between the front and the back, the oblique
lateral interbody fusion. All of these are different ways
that we go in, remove a disc, put some sort of cage
or bone in between to help promote
effusion, and then usually also put in screws and
rods to stabilize the spine. But there are a lot
of different reasons why one particular
type of approach may be better than another. So it’s really
important that you talk to your surgeon about
what approach they’re doing, why they think that one’s
the right one for you, and what some of the
specific risks and benefits are specifically of that
particular approach. So there are– you get
one thing from this, it should be that there
are so many different types of spinal fusions. They are not all the same. And it’s really,
really important to get more information about
what kind of spinal fusion you’re having and why. This is an example
of a lady that I treated this past year
who had really, really severe back and leg pain from– you you can see
here on that scan that that L5 vertebral body
is almost entirely in front of her as one vertebral body. And so this was a very
challenging case to fix, but we’re able to
reduce her back and get her into alignment. And you can see
here the only way to fix that is to put
in screws and rods and bring her back
into alignment. And she did very well. The other cases where we
do spinal fusion cases are in scoliosis cases. So here’s an example
of a gentleman I treated this past year. And you can see on
the far left, that’s an x-ray looking at
him from the front, and he’s got that crazy curve. And you can see
the CT scan here, and there is a ton of
degenerative changes of all the discs, air,
arthritic changes. And he underwent a spinal
fusion to correct that. And then we also– so one of the things that I
specialize in and really enjoy doing is revision cases. So this is an
example of a lady who had had multiple
spinal surgeries, I can’t remember the number,
four or five, on the far left. And she developed
something called proximal junctional kyphosis. So essentially, she went
from being straight. And you can see her
being like this. And that’s as a
result of falling over at the top of her construct. And so the only way to
fix this type of problem is to go in, take out
some wedges of bone, and put in screws and rods
to straighten her out. So you can see how she looks
there on the far right. And she’s a good
several inches taller. And you know, I
mentioned scoliosis in one plane, kyphosis
in the other plane, and then we have a
lot of patients who have problems in both planes. OK, so, this is so that
you can see kind of what this patient looked like. And unfortunately, she had
scoliosis from a young age when she was an adolescent. At the time, she was treated
with Harrington rods, which were these rods
that were put in. She had multiple
spinal surgeries. And you can see she still
has really bad scoliosis, and she’s also leaned
forward and shorter. And so we addressed not the
entire extent of the scoliosis at this time. It’s very likely she’ll
need that in the future. But really, the main issue she
was having was standing forward and stooped over like this. So that’s another
type of case where spinal fusion is very useful. So we talked a bit
about back pain. Neck pain is also very common,
although a little bit less common. And overall, about
6% to 39% of people will experience neck pain over
the course of their lifetime. The highest incidence is
between the ages of 45 and 64. So I think we’ve got that age
demographic right here tonight. And the important thing is that
if you do start getting imaging on everyone in this
room, 75%, most of you are going to have some
evidence on x-rays or MRI of some degenerative
changes of the spine. Like back pain, neck pain
is more common in women. And you can see that this is
true across all age groups. And it’s also more
common in certain races. There’s higher rate of neck pain
in patients with no high school diploma. It’s more frequent in the
Western US, don’t ask me why. But other risk factors
include smoking, depression, people who work in awkward
or sustained postures, low income, people who
are widowed or separated, and people who have more
medical comorbidities. So just like the
sciatic pain that we talked about in
the back, where you can get a disc herniation
that compresses a nerve root and leads to pain
going down your leg, the same thing can
happen in the neck. And you can get what we
call cervical radiculopathy from a little disc herniation,
from a disc in the neck that compresses one of
the nerve roots that goes out to your arm. And sometimes, it
can be associated with numbness, weakness. And this may be caused by a disc
herniation, decreased height of a disc, or just some
degenerative changes and arthritic changes
of the spine that we all get as we get older. And there’s also
another thing which is more severe than the
cervical radiculopathy, which is a term we call
cervical myelopathy. So instead of compressing
those nerve roots that come out on the side, you can get changes
in your spine that compress the spinal cord itself. And a lot of times,
these patients actually don’t
necessarily have pain, but they notice that they start
having worsening numbness, tingling in their hands,
difficulty buttoning buttons, opening jars,
gate instability, urinary incontinence. So those are all things that
kind of happen progressively over time and
would definitely be a reason for it to cause
alarm and bring attention to your primary care doctor. Similarly to back
pain, we have a lot of treatment options
for neck pain, starting with assurance and
education, physical therapy. One of the things that can be
very helpful for patients that have cervical
radiculopathy, which is if you have neck pain from
a herniated disc that radiates into your arm, is
something called traction that you can either do with a
physical therapist or at home. And I can talk more
about that in the Q&A if you guys are interested. Similar lifestyle modifications,
including quitting smoking, making sure you have
good bone health, non-steroidal anti-inflammatory
medications that you can take over the counter. And then just like
with back pain, your primary care
doctor may provide you a short course of steroids. They may provide medications
that help specifically for nerve type of pain. These have different
names, including gabapentin, neurontin, Lyrica. They may prescribe you
with a muscle relaxant if they think your pain is kind
of more from a pulled muscle. And there’s a lot of different
medications for that. Some of them include
Flexeril, baclofen. And then there obviously
are the opiates, which we won’t talk about
today, because that’s a whole other topic
of conversation, but one in general that
it’s good to minimize long-term use of opiates for
a variety of their bad side effects. And just like in the
back, there is a bunch of minimally invasive
procedures that you can do for back and arm pain. And these things here
are similar injections that are done, once again, by
the pain management doctors. So the epidural
steroid injections. They can do trigger
point injections where they literally point
to one place, and they say, right there at that one
point in my shoulder blade is where it hurts, and
they literally just inject some numbing medication
into there and see if it helps. And then nerve root blocks where
they target a specific nerve. They’ll say, OK, you’ve got
pain that’s radiating right into here into this finger. I think that’s C6. So I’m going to do an
injection around that. But it’s very, very
important, even more so than in the lumbar spine,
in the cervical spine, everything is
smaller, everything is more delicate, OK? A problem, a complication
from an injection in the cervical spine
could lead to paralysis in the very worst case. So it’s really important that
while these are procedures, they’re not open surgeries. It’s just a minor thing. You go home the same day. It’s really important that
you go to someone good, especially for the
neck injections, because that’s very
high real estate there. And so that is critical. And then we’ve got
our surgical options. So just like in the lumbar
spine where we may do fusions for certain procedures, one of
the most common spine surgeries done in the United States,
I bet most people here know someone who’s had
one, it’s called an ACDF. We go in, take out a
little bit of the disc, replace it with a piece of bone,
and put a plate and screws in. Some patients, including
younger patients, those who only who don’t have
significant arthritic changes of their spine,
may be a candidate for a motion-preserving
surgery in the neck. So this is one of the
procedures that I do. And for the right
patients, it’s awesome. We go in, we take out the disc. Instead of putting in a
piece of bone and a plate and fusing them, you put
in a disc replacement. And there’s some
very good data that shows that this works very
well in appropriately selected patients. The reality, unfortunately,
is that most people aren’t candidates for this. But if you are a candidate
for this type of procedure, it can be a great option. Or we can just go in from
the back, if it’s just one nerve root that’s
causing a problem, drill out a little bit of
bone, and help alleviate some of the pain without
doing any fusions. And then, of course, we’ve
got our fusion options. This is an example of a patient
I treated this past year who had a spinal cord injury. He was in the Bahamas. He fell off of a scooter. He woke up, he was paralyzed. It took him several days to
get transferred to Hopkins, where I was working
at that time. And what you can see here is
that his spinal cord is totally crushed. And so the only
way to fix this is with a surgery where you go
in, decompress the spine, and put in screws and rods. And so he ended up
doing really well. The recovery from this
is a long process. Unfortunately, the
videos aren’t working, but one of the
really nice things was that my office
happened to be right next to the
inpatient rehab at Hopkins. So I could just pop my head
over every once in a while. So he came in totally paralyzed. About five weeks later, he
was using this special walker, which is an upright walker. And then seven weeks later,
right before he went back, he was walking, and it
was awesome to see him. So just in the last
couple minutes, because I want to leave
time for questions, a little bit about the
future of spine surgery and some of the
latest techniques that we’re using now
here at Stanford, and some of the things that
my colleagues and I do. So minimally invasive
spine surgery, I’m sure you’ve read
a ton about this. I’m sure everyone has seen
the Laser Spine Institute billboards with the supermodel
and the bikini with a Band-Aid. She looks great. She’s on the beach. There are a lot
of different ways of defining what quote unquote,
minimally invasive spine surgery is. But essentially,
what it means is trying to minimize the amount
of blood loss and muscle retraction. So sometimes what this
means– and you can see this on the left– is that you do a laminectomy
or a decompression of the spine going through a tube. You can do minimally
invasive fusions. So that’s what’s shown
here in the middle, where all of these screws are put in
with different stab incisions. It’s a minimally invasive
fusion to try to decrease the amounts of blood loss. And these are all
things that I do. Keep in mind though, that while
minimally invasive surgery does usually tend to have
smaller incisions, it can end up being a
little bit of a train track, especially if you have
some of the larger ones. Motion-preserving
spine surgery is also really good in appropriately
selected patients. And unfortunately, most
patients aren’t good candidates for this. But this is like the
cervical disc replacement that I mentioned, which
is a great surgery for the right patient. And then this is something
that I do routinely in my spinal fusion surgeries,
but we use image-guided spine surgery. So this has been the standard
of care in brain and cranial surgery for many, many years. And so there are a
lot of technologies that allow us to either
get a preoperative scan and register, or an
intraoperative CT scan, and use instruments
so that we ensure that we are putting in our
screws into the correct places. And then Nora mentioned
this, but robots are also on the scene. Cool, sexy new toy. My mentor at Hopkins invented
the ExcelsiusGPS, which is one of the– it’s
the latest spine robot to come out onto the market. And so we did the first
case with that back in October of 2017. It was a big ordeal. There were lots of people there. But essentially, what
it enables you to do is it enables you to put in
navigated screws in the spine. So take home messages, low
back pain, extremely common, but can be very
complicated to treat. Surgery is simply another
way to manage back pain that should be used
as a last resort option. Staying active and
focusing on low impact aerobic activities can help
maintain long-term back health. Osteoporosis is an extremely
common disease of aging women, and osteoporotic spinal
fractures put patients at increased risk
of death, and so prevention is the
best treatment. Surgery is used selectively
for spinal fractures due to osteoporosis, and has
significant associated risks. And then finally,
regarding neck pain, it’s less common than back
pain, but still very prevalent. Like back pain, there
are multiple conservative treatments that should be tried
before surgical intervention. And there are a lot of
new surgical approaches, including minimally
invasive spine surgery, motion-preserving spine
surgery, computer-navigated and robotic solutions for
both neck and back surgery. Thank you very much. [APPLAUSE] OK, so I’ll take any questions. So what is the medicine
you can use for neck pain? So her question was,
what is the medicine you can use for neck pain? Do you mean if you just
start having some– that you have some
chronic neck pain? OK, so probably one of the
first things I would take is just an over-the-counter
ibuprofen, or Aleve, or naproxen, OK? Those are all available
at your CVS or Walgreens. And those are the
medications that are non-steroidal
anti-inflammatories. So those are the
best first choice. And what were you talking
about, the traction? Traction. So this is for pain that
radiates from your neck into your arm, OK? And that is if it–
so when that is a true cervical
radiculopathy, that’s usually caused by compression
of the nerve root as it exits the cervical
spine and goes out. And so there are home
traction devices. There’s one called the Saunders
Cervical Traction Device. I don’t have any– I do not get any royalties from
them or anything like that. But essentially, what it
does is provide a little bit of distraction this way, OK? So that opens up the space
around the nerve root and can alleviate some
people’s symptoms. So it can be very
effective when done for the appropriate
reason, ensuring that you don’t have any severe
stenosis or other things that would contraindicate it. And the most important
thing is that if that is worsening your pain,
you should stop right away. OK? Of course. In the cervical
radiculopathy, can you have the numbness or the pain
in the hand without having pain in the neck? Yes. So his question was in the
cervical radiculopathy, can you have numbness
and tingling in the hands without having pain in the neck? Yes, you definitely can. Yes. Thank you so much, doctor. It was very good to hear all
the background behind this. My question is, my mom has had
back pain for about four years. And recently when we visited a
chiropractor who did an X-ray, he said that she had with
potentially subluxation. I didn’t hear that
word come up here. I wanted to get a little bit
better understanding of that. OK, great. So the question,
just to repeat, was that her mom has had
back pain for four years. And she saw a chiropractor
who got an X-ray that mentioned the term subluxation. And she wanted to
know what that means. So with the
subluxation, most likely what he or she is
referring to is, like, the spondylolisthesis
that I mentioned, so that one of the bones is
moving relative to the other or not appropriately in a line. And so, for that, one of
my main recommendations would be, one, that she
should get something called flexion and
extension X-rays, which means bending as far forward
and extending as far backwards, to see if that subluxation
that he’s talking about, if that spondylolisthesis
moves, OK? If you do see movement when
you’re flexing and extending your back, then
that could be a sign that there’s a problem
that could potentially be treated surgically. If it’s not moving,
then it’s much less likely to be amenable
to surgical treatment. So that’s one of the first
things that you can do. But I think it
would definitely be reasonable to ask for a
referral to a spine surgeon if that is something that the
chiropractor has told your mom. Yes. About what he was asking about. I recently went
to a chiropractor to have a back rib
put into place. And in doing that,
he did something with my neck which left me with
a lot of neck pain and pain, especially in this finger. And he said that would
go away, that somehow, it would go away as soon as the
pain in my neck had gone away. I don’t know what he did. And I’ve never had
anything like that. And I didn’t come into
the office like that. But it’s still there after
more than two months. And I just wanted a next step. And I like to take care
of things naturally rather than surgically. So what can I do? So the question was that
she went into a chiropractor and had some manipulation in
her back as well as her neck. And this was two months ago. When she had the manipulation
of the neck, since then she’s had new pain in the
neck and, specifically, numbness, tingling,
and pain as well, and pain into her index
finger on her left arm. What should she do? So it sounds very classic
for a cervical radiculopathy. So you know, it might have
been a little bit of a twisting motion that aggravated a tiny
little disk or a little bit of degeneration
that you have there. So as long as
things are constant and not getting significantly
worse, one of the first things you can get is get
an MRI of the neck, just to make sure that there’s
nothing super alarming, OK? Then after that, you know,
when I see patients that have cervical radiculopathy, my
recommendations are, well, you know, everyone comes
to me with an MRI– so that’s kind of the baseline–
as long as there’s nothing super alarming on it– non steroidal
anti-inflammatories, OK? Sometimes I recommend
a medication called gabapentin
or Neurontin, which is a nerve pain medication. It’s not an opiate. It’s not addictive. And that is specifically to
help with that radiating pain into the finger. Doesn’t help with neck
pain or things like that. That being said, I would
say, realistically, maybe it works 30%, 40% of the time. But for the patients that
it works, they’re a wonder. They say, wow, gabapentin
is a miracle drug. That’s great. The rest of them say, yeah,
it really didn’t do anything, and it made me
feel really tired. And so, I say, OK,
stop taking it. Cervical traction– but once
again, I’d be very cautious, especially, since you
had this experience after the chiropractor– can be helpful for
cervical radiculopathy and physical therapy. So those are kind
of the first things. But given that it’s been
going on for two months, I would recommend just
getting an MRI just to make sure there’s nothing horrible. As long as it’s just a
tiny disk herniation, then all of these things would
be appropriate next steps. OK. Thank you. Of course. Yes. I’d be interested
in your comments on things that many of us
to do as a first resort, like, say, replacing a
pillow with something that’s marketed as being really
good for the neck, or getting seat cushions, or
a lumbar cushion in our car if we don’t have a really
great driver’s seat. Are those just
stopgap measures that are perhaps going to keep
us from having as much pain? Is there a downside
to using those? They’re obviously
not like the kinds of treatments and interventions
you’ve been talking about. But they’re quick. And they’re cheap. Yep. Great question. So her question,
just to simplify, is, what about a
lot of the things that we do for
back or neck pain, like getting a special
pillow, lumbar support, things like that? Is there any harm
to doing this is? It just a stopgap? And the answer is
that there’s no harm. And those things are great. So as I said, because, you
know, 90% of back or neck pain is nonspecific, i.e., It’s not
any of these specific reasons. And it should not be treated
with surgery at any stage. The types of things
you suggest are great for non-specific
back pain. So in general, if you
find, for example, that you have a certain
mattress, and you sleep on it. And at home, you seem to always
wake up with lower back pain. This is my husband right now. We just went away on a trip. And he was like, I don’t
have any back pain. And we came back
a few days later. And he was like, I think
we need a new mattress. And I’m like, you know, try it. One of these last talks,
someone actually said, what’s the right mattress? I do not know, OK? But in general, slightly firm,
but whatever works for you. So if those pillows work for
you, if that lumbar support works for you, great. Yes. So do you have any
comments about these things like massages and chiropractor? Because those are not
medical doctors doing it. So his question is,
do I have any comments on massages and chiropractors? So first of all, massages. Full disclosure. I get Thai massages
about once a month. And I get really, really,
really intense Thai massages. You know the ones where
they step on your back? So I’m not recommending those. But in general, I think massage
is fine for the type of pain that most people have. If you do have severe stenosis
or something like that, it’s probably not great
to have the Thai masseuse walking on your back. But take that with a
grain of salt, as I said. Because I get them myself. Chiropractors. So that’s a little
bit of a mixed bag. And in general, in my field,
kind of in my training, I was sort of
raised, so to speak, with a little bit of
an anti chiropractor take, which is what you’ll
hear from most surgeons. The problem was they in
my neurosurgery training I did take care of a
couple of patients that had a stroke in the brain
from a neck manipulation from a chiropractor
that led to a dissection of the vertebral artery. And one of those patients
ended up passing away. So that is a very,
very rare complication. But it is one. That being said, I recently
went out to a chiropractor here locally. Because, you know,
most of my patients have seen chiropractors. And I actually didn’t
really know what they do. Their training is so
different from ours. The terms that they use are
totally different from ours. And so, I was like,
OK, I just want to learn what are all
the things that you do. So I think a lot of
the things that they do are very reasonable. A lot of them focus
on physical therapy. And they’ve got stretching. I mean, I don’t know
if the stimulation– the electrical stim– does
anything or the percussion. But those aren’t
particularly harmful. So if they make you
feel better, great. I would be very cautious when
they do those manipulations, especially in the neck. That’s where I get very worried. But what I can’t say
is that I definitely have a ton of patients
that see them. Sometimes they do
provide relief. I worry about the
neck manipulations. And if there are any
red flag symptoms, you need to get some imaging
before you subject yourself to treatments by a
chiropractor to make sure that there’s nothing that
is not going to be worsened by their treatments. Can you say something about
acupuncture or acupressure [INAUDIBLE]? His question was, what about
acupuncture, acupressure? So I don’t do that. I’m trained in Western medicine. That being said, I personally
have tried acupuncture. There is some data that
it is very effective. And there’s nothing
harmful about it. So patients ask me. And I say, if they want to do
acupuncture, I say, go for it. If it helps you, wonderful. How do you feel about the use
of a TENS unit for back pain? The question was, how do I feel
about the use of a TENS unit? There’s no reason not to try it. Quite honestly, the efficacy
is probably not great. But similar to, for example,
acupuncture or something, or taking fish oil, I view it
as something that’s not harmful. And if it does benefit
you, that’s great. And a lot of my
patients have tried all of these things,
chiropractor, TENS, braces, pillows, mattresses,
physical therapy before they come to see me. So it’s not harmful. Yes. How common is adjacent
segment disease? The question is, how common
is adjacent segment disease? So for those of you who
aren’t aware of what that is– so basically, what that means is
that when we do a spinal fusion surgery, one of the most
common complications is adjacent segment
disease, which means that the
level of the spine above or below develops
degeneration and can end up needing more spine surgery
or, like, an extension of the fusion. So that depends on the type
of surgery that you have. And so, yeah. I would say it depends on the
type of surgery that you have. There’s a lot of things that
we do to try to prevent it. So for example, taking a
simple surgery like an ACDF, the Anterior Cervical
Discectomy and Fusion surgery, which is the most
common spine surgery done in the United States. There are certain
technical things that we can do to try to prevent
adjacent segment disease. One of the reasons why the
cervical disk replacement has become very popular
is because it actually has lower rates of
adjacent segment disease. What happens is that when you
fuse a segment of the spine, that spine is no longer mobile. So it puts unnatural forces
on the spine above and below. And that’s what causes
adjacent segment disease. So the concept behind
motion preserving surgery is the spine is still
moving mostly normally. So that is decreased. That being said,
it still happens, despite all these things that
we do to try to prevent it. Yes. A couple of questions. In relation to the fish
oil, does flaxseed oil work? Do you know? Is there any study on that one? So she asked– she’s
following up on the fish oil. And she says, does
flax oil work? I’m not familiar
with a study on it. The main question I have
is about the trigger point injection. I was scheduled. I saw the pain
clinic in February. I started having pain
last October, my neck, going down my arm and
numbing and tingling. Primary care– we ended up. He said if I wait to get
you into a neurologist to get the nerve conductivity
test, it might take a while. So I did it through
a chiropractor that he knew that
was trained in it. Results from that said
I had carpal tunnel. But I then was waiting to get in
for a cancellation at the pain clinic and saw them. They did an X-ray. Before the X-ray, I saw
the pain psychologist. It was a medical
evaluation appointment, and came away from that saying
we could try the trigger point. It was scheduled for a week ago. I had to cancel. Now it’s– I’ll be out of
the country for a month. It’s scheduled for May. It is important that
I see them again before I do the trigger
point to make sure that we’ve got the actual point? I’ve started therapy
for my this part. But I haven’t been able
to start for the shoulder. But I am doing some
of the recommended. And now, since you said,
in paralysis, I’m like, eh. OK. So that was a long question. So I’m not going to repeat it. But have you ever had
an MRI of your neck? I have not had an
MRI on my neck. I’ve had the MRI of
my this part of me. Because I am a breast
cancer survivor. OK. So I think the next step would
be to get an MRI of your neck. That’s the next step. And a lot of times
these things– so it’s very common to have
an EMG that’s equivocal that shows that someone may
have a cervical radiculopathy and a mild or moderate
carpal tunnel. I mean, that’s a
super common thing. So kind of teasing
out what’s going on. But if you’re still
having neck pain, pain that’s radiating down your
arm, I think it’s worth– Taking gabapentin and all that. And I think it’s very worthwhile
to get an MRI of the neck, especially. Because I would
want your injection to be targeted at the place
that you have the pain, OK? So if it’s a disk herniation
causing a C6 radiculopathy, they shouldn’t do
a trigger point. They should do an epidural
steroid injection at C6. So that’s the next step. Yes. I see older people who
are really hunched over. And I saw an image
on the screen. Are these people candidates
for this type of surgery? So the question is
that he sees people who are very hunched over. Are they candidates for
this type of surgery? And the answer to that is
that it really depends, OK? So I have to see every patient. I don’t have a specific age
cutoff for when I will or won’t operate. And that’s because there are
80-year-olds who run marathons. And there are 50-year-olds
who have severe heart failure and are on oxygen who wouldn’t
even be able to have a one hour spine surgery safely. So it depends on the patient. It depends on what their other
medical comorbidities are. It depends on what
they’ve done so far. How much is this
impacting their lives? And I’m thinking
very specifically of a patient I saw in
clinic just yesterday. Horrible kyphoscoliosis,
I mean, completely leaning over to the side. But you know, one,
needs to get optimized in terms of her bone health. So I’ve sent her
to endocrinology. She’s going to go on that
medication for at least six months before we
consider doing anything. Two, needs to quit smoking. And three, need to be,
you know, convinced that they’re medically stable
enough and healthy enough to handle a big
surgery, but that you have to be willing to weigh
the risks and benefits. So usually, I like that
they’ve done physical therapy, that they’ve tried other
things to help their pain. Purely just for appearances
is not a good enough reason to put someone through a huge
spinal surgery like that. Because it is a really big deal. You know those
surgeries I showed you? They take 8, 10 hours. Patients are in the
hospital for 5 to 7 days. And then they go to
rehab after that. It’s a long recovery process. So it needs to be in a
patient that, I think, can handle it medically
safely and that’s really tried all other options to treat
their debilitating pain that’s really impacting
their quality of life. I think we have
time for one more. There’s a lady way back. Oh, OK. Sorry about that. Which one? That lady. In the hat? Yep. Yes. Sorry about that. That’s fine. I’m way in the back. Two real quick questions. One is, what does it mean
if you can hear your neck– a scraping noise when
you turn your neck? Is that something that
should be looked into? And I hear constant scraping. If I turn– you
can’t hear it now because we’re in a big room. But if I’m quiet, I can
hear that scraping noise. So her first
question was, if you can hear a clicking or
a scraping of your neck, is that a bad thing? Should I look into that? I would say that that’s
very common it sounds like you probably have a little
bit of arthritis of your neck. As long as you don’t have severe
pain, any weakness, numbness, tingling, I wouldn’t
necessarily do anything further. The other question is, if you
head compression fractures due to osteoporosis, and you had
a perfectly straight spine up until then, and
you were 5 foot 6, and now you’re 5′ 2 and
1/2,” should you be sleeping somehow– why would you still be
allowed to sleep on your side when it makes the spine
curve while your sleeping? That eight hours, is that bad? So her question is, if you’ve
had a couple of osteoporosis related fractures that have
made you go from 5′ 6″ to 5′ 2″, is it a problem if you’re
sleeping on your side at night? So it’s really hard to
change how people sleep. And honestly, I
don’t necessarily think that that has a big– [INAUDIBLE] the curvature. Yeah. So what are the things that
you can do in your situation? So the things that
you can do are, one, you can make sure that you’ve
spoken with your primary care doctor and endocrinologist
and are on the best medication to strengthen your bones, OK? In the acute
setting, when someone has an acute compression
fracture with severe pain, sometimes I’ll
recommend a brace, OK? But only in the acute setting. I mean, if these fractures
happened years ago, and you’re doing fine, and
it’s just your posture, we don’t really
recommend braces. And then in– But they said don’t
wear them at night. Yeah. Yeah. The other thing
is the kyphoplasty or the vertebroplasty. But once again, that’s
in the acute setting, OK. Yes. Thank you very much. OK, great. Thanks very much for coming. [APPLAUSE]

1 thought on “Stanford Doctor Discusses Neck and Back Pain in Women”

  1. How old is this video? Seems like the info is out of date. Happy to hear you don't just operate on everyone and that your selective.

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