Prakash Chandran (Host): Most people live their lives without ever considering their spine health, until it becomes a painful issue. Today, however, with more and more people sitting for long periods of time, being proactive about caring for your spine is critical, not only for your mobility, but your overall wellbeing. Today, we'll be discussing tips to improve your spine health, as well as treatment options to help you if you suffer from back pain.

 Joining us today are two experts. The first is Dr. David Benavides, a Board Certified Orthopedic Surgeon at Central Nebraska Spinal Surgery Center, fellowship trained in spinal surgery and board member of Kearney Regional Medical Center. Joining us also is Dr. James Mahalek, a Board Certified Orthopedic Surgeon at New West Sports Medicine.

 This is the Kearney Regional Medical Center podcast. I'm your host, Prakash Chandran. So Dr. Benavides and Dr. Mahalek, really great to have you here today. Dr. Benavides, I wanted to start with you. Why exactly is caring for your spine so important?

David Benavides, MD (Guest): Well, Prakash, I think it's well understood that the spine is actually the backbone, the support of our body that helps us do each and every little thing in life, every one of our activities. And the simple thing of helping our posture and who was never told as a kid, sit up straight, sit up straight, to just being able to bend down, get up, get out of bed, enjoy life.

So that's our spine should be one of the most important aspects of our healthcare. And it ranks up there with taking care of your heart, taking care of your brain. It's just, you need it. You need it to go on through life. Bottom line is that if you got problems with your back that can be debilitating and very important that we make every effort to keep it healthy, just like you would for, like I mentioned, your heart and such. We're going to have our back, our spine for all our lives and we need it, the healthier, the better.

Host: Yeah, that makes a lot of sense to me. And you know, when we talk about spine health, I want to get into some of the tips to maintain that healthy spine. But when do people need to start thinking about this? Is this something that they need to think about in their teenage years? Or is it like people in their forties? When do you normally like to see people start to really paying attention to their spine health?

Dr. Benavides: Well, as I mentioned earlier, I think that thinking about our back starts when we're young and it's not us thinking about it, it's more our parents or our guardians that makes sure that we sit up straight because they know the importance of good posture. And then as we get a little bit older teenage years, we start to make more decisions that can affect us long term.

And it becomes more important at that point to start engaging in good spine care. If it's so difficult to understand that when we're young, I think we understand it more when we're older, when we're hurting more, that I wish we had done this earlier. And so it would be beneficial for everyone to start early. Teenagers would certainly be ideal. But without a doubt, early adult years, when we're a little bit more mature, we can handle things, we can understand better. I think we can engage in that, certainly a lot easier at that point.

Host: So Dr. Benavides what are some tips to maintain a healthy spine?

Dr. Benavides: Well, I alluded to the fact that there's something that's with us all our lives. So, what are some of the things that can make it easier for us? I mean, there's no question, we have a difficult time in this country with weight and the more you weigh, it puts more stress on your back, stresses, pulls the back forward. It puts more stress on the discs. So, if you can keep your weight down at the same time, create a structure around it, that support structure, like putting two by fours around it, making your your belly muscles stronger, your back muscles stronger. And the most important thing that I typically tell people is flexibility.

And particular the hamstrings, the hamstrings either help you or they hurt you. And the more flexible they are, the more you bend at the hips and the tighter they are, the more you end up bending at your discs. And that puts more strain on those.

Host: So, it really seems like to have a healthy spine, there's a support system that has to go around it. And that includes, you know, being at a healthy weight, that includes the muscles potentially even around your abdomen, that includes the flexibility of your hamstrings and really bending over at the hip. So, it's not just the structure of the spine itself, it's everything that goes around to support it. Is that correct?

Dr. Benavides: Very much so, and it's very common to hear people tell you bend at the knees, bend the knees. Well you bend at the knees that allows your hamstrings to give a little bit more to your pelvis. Your pelvis bends at the hips instead of in your back. So, there are just some common things that we need to do to one, have healthy backs and two to minimize stressing them out, hurting them, put them in an unusual situation before you put more stress on the disc spaces.

Host: So, I want to talk about the things that, you know, affect spine health. And so many of us today lead a sedentary lifestyle. Like even for myself, I'm doing these podcasts, I'm sitting down a lot. So, can you talk about how a sedentary lifestyle affects the spine?

Dr. Benavides: It goes back to those same principles we mentioned a while ago. Certainly the more sedentary you are, the greater the chance of gaining weight, because you're not doing much in terms of exercise. Three sure ways of losing weight. Eat less, exercise more or a combination of the two. So, if you're not exercising, the equation changes a little bit. So you end up tending to gain some weight. The inability to be active, you don't tone as much. So, that also adds to the same problems we talked about. And certainly when you're sitting down, what do you do with your knees? You bend them, you shorten up your hamstrings. What happens when they shorten them? They're not as flexible. So, all those points to the same issues we talked about just a second ago.

Host: Yep. Makes a lot of sense. You know, we talked about the different things that you can do to maintain healthy, a healthy spine. Can you talk about maybe some of the most promising innovations in spine health that people should be aware of or that you are using today to help people?

Dr. Benavides: Well, part of it is we try to encourage people to be more active, in general. And that's a very simple process is naturally an innovation. It's a simple process of being good to your back, but when it gets to become a, gets to become a bigger problem, then certainly there are a lot more programs out there from an exercise program. A lot of facilitates that offer things for you to do, go do when it comes to weight loss or options to help with that. But as far as from the spine, if we get to the point of surgery and surgical intervention, now that's a different story. One of the bigger emphasis now is to have what we called motion preservation.

So, we're trying to keep the back active, mobile and not fuse it for instance, not take away a disc, so there's more stress on the other levels. So, one of the things that's out there now is disc replacement. It's not necessarily new, but it's become more of the norm in many ways. From a surgical standpoint, that's one of the more promising avenues that we're taking.

Host: Yeah, but that's something you alluded to is that you really try to do everything that you can to not pursue a surgical option. Right. So that, whether that be exercise or physical therapy, those are really the first order or first line of defense before surgery is considered. Is that correct?

Dr. Benavides: That's true. You want to be proactive in making your spine a healthy component of your body, you will do everything you can to avoid having problems. It's only when you start having problems that we discuss other options, but the idea is to avoid people like me and other surgeons from the standpoint of, hey, be good to your body and hopefully your body would be good to you.

Host: You know, if people are experiencing some of these back pains, but it's not necessarily severe, but they do want to be proactive and not take a surgical route, can you talk about some of the options available to them? Like do chiropractors work, do other types of therapy work that you can speak to?

Dr. Benavides: Well, I can certainly address that in that if my common speech to the patients that we take a simple algorithmic type of approach to things. You go from A, to B to C and the deal with that, hopefully you'd never have to see us because most people with back problems get better on their own, the with time being a week or two weeks, they can, and they can get better.

However, when they come to see us, they're usually hurting for a period of time. They're not coming because they enjoy it. They're coming because they're hurting. So, the way we, our approach to this, the first thing is observation and give it time. Again, most times, most people get better without ever seeing us as the doctors.

Secondly and they can do this at home, anti-inflammatories, non-steroid anti-inflammatories, those would be like the Advils or Aleves of the world, NSAIDs. The idea is to use those for a short period of time to kind of jumpstart the recovery process. The back pain comes from inflammation from an injury, and hopefully that helps calm it down.

After that typically, with all that, with some course of steroids, commonly by pills, but for short course only cause prolonged use for long-term use of steroids can be problematic with many side effects. I tell people the NSAIDs are like using ice in the freezer and the steroids are using dry ice.

Yeah, it is colder and lasts longer, but you can burn your skin so they have more side effects and then, you can add on there modalities such as the therapist or chiropractor anywhere in there. And in particular injections, are a possibility for steroids, for radicular pain. By that I mean, pain goes down the arms or down the legs. But the therapist and the chiropractor, they're very beneficial, especially early on. They can kind of jumpstart the recovery process.

Long-term maybe not so much. It's more of a you have to engage in the program at home. And that's really important that you engage in the home program because that's going to be for the rest of your life. And then ultimately the last option and remains the last choice, except in emergency situations would be a surgical intervention. So you have to exhaust all the others before you think about surgery.

Host: You know, one of the things that I was wondering as you were talking are, you know, that home regimen, the exercises that you can do to be proactive with your spine health. If there's like one exercise that you have seen really work wonders that someone can do on a consistent basis that can really help with that health of their spine, what would that be?

Dr. Benavides: And again, I tell this to patient. I tell this to the patients all the time. If, If you only have an opportunity to do one thing, you learn all these other options and such, if you only have an opportunity to do one thing, that one thing would be to stretch out your hamstrings. By doing so, you take the stress off the discs by allowing more motion that your hips, less at your back. It helps you to minimize the stresses and the injuries to your discs. So the hamstrings can be your best friends or your greatest foe.

Host: Yeah. How amazing is that, a thing that isn't necessarily directly tied visually to the back can be such a support system to it. And when you say stretching the hamstrings, that can be, for example, just putting your leg on a higher surface and really getting that deep stretch and what potentially holding it for what, 30 seconds or something.

Dr. Benavides: The more, the better, but there's a right way and a wrong way. Unfortunately, just to bend down to touch your toes, sometimes you don't stretch the hamstrings, you stress your back. So, ideally I tell people, grab your toes with your knees bent, hold onto your toes and then straighten out your knees and you'll see where the pain of the stretching is in the hamstring from and not in your back. You lock it back in position then, and then the emphasis is on the hamstrings

Host: Okay. Well, Dr. Benavides really interesting conversation. Is there anything else that you'd like to share with our audience today before we close here?

Dr. Benavides: No, I think that I'm a true believer and I think most of my colleagues are true believers, that surgery should be our last option, typically. We're not really knife hungry. We don't want to do that. We want to give you the best chance to do well. And if you're at your wit's end, it's hard to make you worse. But if you're kind of in between, while surgery can make you better, it can still make you worse. So, again, surgery should be our last alternative. And the parting words that I have is the fact that people need to understand that we don't fix people in spine surgery. We just try to make it. So expectation will drive success. You expect to be fixed more likely than not you are going to be unhappy. You want to get better? I think we have a very good chance to be successful.

Host: Thank you so much for Dr. Benavides. So, Dr. Mahalek, I wanted to just start with a more general question around people that are in office jobs. What can someone do, like myself with an office job to prevent spine injury?

James Mahalek, MD (Guest): You know, that's a great question. We see a lot of people, obviously who have those kinds of occupations, and I think the big risk factor for people like that is that they are frequently sitting throughout the day. A physical therapist will tell you that because of our constant or chronic and repetitive hip flexion, that we're at risk for spine and pelvic imbalance.

So, those people that are in those types of positions really need to focus on flexibility, conditioning, focusing on hamstring stretches, gluteus, lower back muscle strengthening and conditioning. I'm a big proponent of telling people that yoga and Pilates type exercises are excellent for them and should really help keep a lot of them out of trouble.

Host: And we also hear about like standing and sitting on a frequent basis, if you are in a desk job, is that something that you'd recommend as well?

Dr. Mahalek: Absolutely. You know, I see a lot of those people get out of their office over the lunch hour and go for walks. I think that's a fantastic way to help break up some of that chronic sitting that they're exposed to.

Host: So, if someone is starting to experience the back pain that we're talking about, what are the first steps that they should take to get it treated and fixed?

Dr. Mahalek: Well, I'm a big proponent of my patients starting off with the simplest things possible. If they have a primary care physician, or primary care provider, whether it's a PA or a nurse practitioner that they feel comfortable with, that's oftentimes a good place for them to begin their evaluation.

Sometimes just simple anti-inflammatory medications and some physical therapy is all it really takes. I think a good number of patients will reach out to chiropractors if they have experience or history with chiropractor. And that's a good place also. Certainly, I see patients as a primary evaluation and I don't require patients to have a referral.

So, there are definitely times where people will pick up the phone and contact my office directly and say, hey, I need to see the back doctor. I've got back pain and we're always willing to see them as a first evaluation as well.

Host: Yeah, that makes a lot of sense. So, really doing everything possible, kind of non-surgical options to really evaluate where the pain is coming from. Is there physical therapy or, you know, structural changes that you can make by way of strengthening to really help support your spine and reduce the back pain. Is that a correct assessment?

Dr. Mahalek: That's absolutely correct. You know, they say that only about 10 to 15% of all patients that walk into a spine surgeon's office like myself end up needing an operation. So, we're talking about 85 plus percent of our back pain and neck pain patients are able to be successfully treated most of the time with physical therapy, exercise and sometimes use of medication.

Host: So, then what makes someone a candidate for a surgical procedure? I imagine it's someone that has tried everything and it's just not working for whatever reason, but maybe you can speak to some of those criteria.

Dr. Mahalek: Sure. You know, I think the success of spine surgery is completely predicated on the indication and spine surgeons are good at treating nerve compression. So, as a general rule, patients that are good candidates for surgery are those that have failed all other forms of conservative treatment. And that oftentimes includes chiropractic care, physical therapy, sometimes medications, and sometimes we perform spinal injections to try and help alleviate patient's suffering before they consider an operation. We certainly need to consider the whole person and general medical conditions and comorbidities and illnesses play into a role as to the candidacy of somebody for an operation.

So, we want to make sure that the whole person is healthy enough to go through an operation and recover from that. But as a general rule, if somebody has sciatica type pain or pain that radiates from their neck down their arm or down their legs, or they suffer from balance issues, weakness, trouble with walking, standing; those are the patients that are most often the best candidates. Now, on the other hand, patients that have emergency conditions, those are patients that we take to the operating room urgently, regardless of those other things, if they fit the correct criteria for requiring an emergency treatment and that's done with the goal of either reversing or limiting the ongoing damage that they've suffered, whether it be from a accident or an injury or even the occasional football game. Since I'm part of a sports medicine practice, we tend to see a fair number of athletes.

Host: Yeah. And I imagine that the trauma cases that you're talking about are the majority, or make up the majority of the surgeries that you do simply because you were mentioning that the majority of people are able to help and cure themselves with these therapeutic more conservative options. Is that correct?

Dr. Mahalek: Yeah. I think that the degree to which trauma is involved in your practice probably has a lot to do with your environment. We live in a town where we have a level two trauma center and we have helicopter and ambulance service. So, we, and also being along a very busy interstate, that is not an uncommon thing.

There have been some in recent years, some good studies that have come out that have shown that patients that we would have treated with surgery in the past, actually have done better with just conservative treatment. So, some of our decision-making as it goes, when it comes to surgical treatment of the trauma patient is changing as well.

And that's the great thing about medicine is that as we strive toward evidence-based medicine and what's best for our patient; there's a whole world of people that are out there studying these things and then communicating them through our journals with the literature and presenting those findings at our meetings. So, it's an ever-changing landscape.

Host: So, I'm just talking about surgery more specifically. I just want to know at a very high level, what are the most common types of surgical procedures that you do? And then also talk about you know, recovery time and the typical outcomes.

Dr. Mahalek: Yeah, that's a great question. Probably the most common things that I get asked from my patients. The most common surgery that I would guess any spine surgeon and certainly that I do, is what we call a decompression operation. And whether that's done in the neck or the back, the surgery essentially involves removing an offending compressive agent that's affecting the spinal cord or a spinal nerve. So, frequently that would be a ruptured or herniated disc. I've heard people refer to it as a slipped disc. There are times that as we age, we form excessive bone. I think people, lay people frequently will say things like bone spur. We will call them osteophytes.

But whatever it is, if it's causing compression against nerve tissue and it's resulting in pain, numbness, or weakness, that cutting away of that tissue is probably the most common thing we do. A lot of times it's labeled as a laminectomy, which is removal of the backbone of your spine in order to get access to the nerves and relieve that pressure.

When it comes to recovery, we see kind of a wide range of what's involved. There are some surgeries that I perform like a micro discectomy that's done through a 18 millimeter incision. It's an hour procedure, it's done as an outpatient. And technically those patients don't require much of any recovery. I do limit them a little bit for the first couple of weeks in order to allow the tissues to heal, but they're able to get back to normal activity pretty darn quick.

When we talk about more invasive operations or surgeries that involve fusing or welding parts of the spine together, as a general rule, I tell people that they're walking for the first six weeks. They're starting some light exercise at six weeks. I tell them they can typically run a vacuum at that point. And as they approach three months, we start changing our focus into strength training and strength conditioning, resistance exercises. And that's about the point where they're ready to run a self-propelled lawnmower. So, between that three month mark, and whether it takes them a total of six or 12 months to totally heal and rehabilitate, they're focusing on kind of their occupation or personal and social life activities to gauge what's required to get them back to normal.

Host: Yeah, I think that makes a lot of sense and sets a good expectation for people to realize that it isn't a one week or two week recovery time. This is something that can take quite a while. And it's a partnership, you know, you, as the surgeon are going to do your work, but the patient needs to be consistent to really get the most out of the surgery, wouldn't you say?

Dr. Mahalek: Absolutely. And I think, you know, we try to make it clear to the patient that this is not done for our benefit. This is really being done for their benefit. And when we lay out those expectations and they're acknowledged, we tend to have the best results.

Host: Now, you know, when people hear that recovery time, some of them might be like, oh, I don't know, is it worth it? Even though I'm having this back pain, is it really worth going through a procedure? So, I'd love for you to maybe share an example of how a procedure has helped improve the quality of life of one of your patients.

Dr. Mahalek: Sure. Yeah, there's lots of examples of that. There's a gentleman who came to see us from Missouri, who has had multiple surgeries and his last operation was done actually in Omaha and he did not have a very good result, unfortunately. He had a very early breakdown of the segments of his spine that were immediately above where his fusion was performed and he came to me on a referral of a friend and his name was Steve and I assessed Steve and evaluated him. And, you know, here's a guy who's just four to six months out from a very large back fusion operation, but he was unable to even progress through the rehabilitation and healing phase because he still had so much trouble surrounding his original surgery.

He unfortunately had spent a full week in the hospital after his original surgery, which is longer than they expected him to. And had to rely on some medication in order to try and even make the days tolerable. So, I evaluated him and told him that realistically, I think that he needed a much bigger surgery and that we needed to extend this up into his mid back. He put his trust in me and my team and we took him to the operating room and he did fantastic. We extended his back fusion up several levels into his mid back. We cut the pressure away from the spinal cord and the nerves that were under severe distress. And he was out of the hospital after a bigger surgery, just after two days.

He's returned back home to Missouri and he sends me x-rays remotely because he's such a distance away, it's not realistic for him to travel. And I provide him with his rehabilitation plan and exercises electronically. But he's doing fantastic. And he's a guy who had given up on walking any significant distances and now that's coming back into his life. So he's very happy about that.

Host: Yeah, it's always cool to hear those success stories. So, Dr. Mahalek, just before we close here today, one question I always like to ask is in all of your experience, if you could leave the audience with one tip around something that you know to be true with regards to being proactive about their spine health, what might that be?

Dr. Mahalek: Yeah, I'm so glad you asked me that question, because this is conversation I have 20, 20 times a day with patients. People come to surgeons because we're taught or we're led to believe based on I think just a general rule of, you know, somebody has appendicitis and a surgery takes care of it. Somebody has a gallbladder attack and surgery takes care of it. We oftentimes look for somebody else to fix our problem. We say, here's, I want you to operate on me and fix me. I want you to give me a pill and let it fix me. I want a shot to fix my problem. Truly, there is no magic surrounding spine health and success.

And it really boils down to healthy lifestyles. If people put good nutrition into their body, if they take care of their bones, if people exercise on a regular basis, if they avoid things that we know that are huge risk factors for our health and our spine, such as smoking and if they manage their weight at a reasonable level, those are all things that we can do on our own that are going to keep us out of trouble from the standpoint of suffering with spine problems. Now there are going to be people that do all the right things and still end up having back or neck issues. And those people are great candidates to be treated and fixed, but there's no magic. It's you take good care of your body and your spine, and it's going to take good care of you.

Host: Well, I think that's perfect advice and just a good reminder that there are no silver bullets in life that you have to be consistent, exercise, eat right to really stand the best chances of avoiding that operating room, is that fair?

Dr. Mahalek: You're going to be in the best position possible, not only to avoid the operating room, but should you have to endure an operation you're going to do well and recover just fine.

Host: Well, I think that is the perfect place to end. Dr. Benavides and Dr. Mahalek, thank you so much for joining us today. Find out if it may be time to see a specialist using our comprehensive spine risk assessment, you can visit Kearneyregional.com/spine.

That's spelled K-E-A-R-N-E-Yregional.com/spine, to take our free risk assessment and get personalized feedback about your spine Health.

Thanks for listening to this episode of Kearney Regional Medical Center's podcast. If you found this podcast helpful, please share, rate and review it. I'm your host, Prakash Chandran. Thank you so much. And we'll talk next time.