Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole and today we're talking about what's going on in spine surgery today. What's exciting? Joining me is Dr. Tyler White. He's a spine surgeon at Central Nebraska Orthopedics in Grand Island, and is the founder of the Spine Program at the Bryan Facility at Grand Island.

Dr. White, thank you so much for joining us today. I'd like you to start by speaking a little bit about the prevalence and the impact, the general impact of back pain today, because I mean, it's one of the limiting factors that keeps people from work, quality of life, from school. I mean, and unless you've ever experienced back pain, you don't even realize how bad it can be.

Tyler White, MD: Yes, absolutely. No. Thank you guys so much for having me. I appreciate it. First thing I, I always like to bring up is in medical training, they spend such a little amount of time on something that affects so many people throughout our country. I think in my medical training, we spent an entire one day on the entire musculoskeletal system, let alone the spine and spine related pathology.

And so for myself and this community, we have a large portion of our population is engaged in pretty physical type labor. We're a very rural area. We have a lot of more industrial type facilities as well, are some of our major employers. And so people coming down with spine related pathology interfering with their daily life is very prevalent.

I think there's just unfortunately not only a lack of knowledge and training in various medical subspecialties and fields, but there's just a lack of awareness in the general population as well.

Host: What do you see Dr. White as the main causes? I mean, certainly there are so many causes and it's just unbelievable how many ways there are to injure our backs. I mean, really just from bending and picking up our kids to our grandkids, to carrying a milk bottle around, it doesn't even matter. You can like mess with your back with a small move. So when you see people, what are some of the most common causes you see? Are they mostly a degenerative nature? Are they acute from an injury? What do you see most often?

Tyler White, MD: You actually, I think you covered all of it. I would even say all the above answer E. So, I think a lot of people get concerned when somebody discusses going to see the spine surgeon. They think they're going to end up getting a surgery recommended to them, which is in fact not the case typically. I tell folks I average seeing about 45 patients a day twice a week, so I see about 90 clinic patients a week.

I probably only discuss scheduling surgery for anywhere from three to six out of that 90. And so that's just an indicator that the majority of spine related conditions do not require surgical treatment. But what we do see is just a combination of lifestyle factors or other intervenable conditions that we can use to try and prevent various issues.

So, a perfect example would be a healthy body habitus or body weight significantly decreases the amount of stress that the lumbar spine has to bear, which reduces the amount of degeneration that occurs as time goes on. It also reduces the chance of you having what's called a disc herniation, where some of the shock absorbing material pushes its way out of its normal space and hits a nerve and causes sciatica type symptoms down the leg.

Another factor that's modifiable for people is one thing that has been shown to actually speed up degeneration related with age, is actually smoking and nicotine use. There are several physiologic mechanisms on why that happens, and it's one thing I think people are actually fairly surprised when I tell them.

I tell them, if you stop smoking, there's a chance some of your back pain would improve as well. And I think people are surprised to hear that sometimes.

Host: I agree with you, and I've heard that over the years as well. Oh, well why would that affect that? Well, because it affects so many of your organs and it leaches minerals from your bones, so it would certainly make sense. Now I love that you pointed out that you don't recommend surgery right away. I mean, as a first line of defense.

So when we think of the causes of back surgery and your diagnosis, you're going to do some testing first to determine the cause. What kinds of tests can people expect? Do they get an x-ray, an MRI? What are you looking at?

Tyler White, MD: I like to remind people a lot of the times we're doing back or lumbar surgery, we're actually doing it for symptoms, not typically just related to back pain. A lot of times we're seeing more neurologic symptoms superimposed on that as well. So I, hit on one of them earlier, sciatica or what we call lumbar radiculopathy, where you have nerve symptoms down your lower extremity.

Another one is if you have narrowing of the space in your nerves, in your low back, you can come down with something called neurogenic claudication. Where an easy way to summarize that is the nerves in your back have trouble communicating with the muscles in your back, buttock, thighs, and legs. And you perceive that as what we just call walking intolerance, or you get fatigue in those muscles when you walk a long distance. You have to sit down and rest, lean over a shopping cart or sit down and you feel recovery of that and you can keep going. So typically, the way we start working this up are with plain radiograph, plain x-rays in clinic. There's a couple we pay special attention to. We look to see if there's any deformity that could be contributing to these conditions.

We see a fair amount of scoliosis that has progressed into older age. We also look for what we call instability or abnormal motion between segments in the back that could lead to something like pinched nerves. Barring someone recovering and having resolution of their symptoms, eventually we then proceed with getting what would be a lumbar spine MRI.

Which is a way of looking at more soft tissue structures in the low back and specifically, in most cases, we're trying to look at the nerves.

Host: Well, nerve issues are certainly a big part of it in sciatica, as you say, it can be so debilitating and painful. So before we even talk about surgery, and I know that's what we're talking about today, but let's talk about some more conservative measures. When you come across someone, you figured out what it is, whether it's stenosis or some kind of a compression injury, whatever the case may be. What are some of the conservative things that you might try with someone with a chronic back pain, maybe arthritis or one of these other issues that you might try first before you discuss with them surgery?

Tyler White, MD: No, absolutely. So typically we recommend an evaluation with a physical therapist. It's beneficial if you have access to where you're practicing as a physician to physical therapists that are pretty familiar with treating spinal conditions. We're very fortunate where I practice that we have a couple physical therapists who, this is the majority of their career is dealing with spinal conditions, so they're quite skilled.

And we typically start with various physical therapy exercise programs. And those exercise programs are geared more towards whatever the pathology we're dealing with would be. And so an example would be if you have a disc herniation in your back that is causing stenosis on a particular nerve root; an example would be we want you to be practicing nerve glide exercises that can help prevent scarring of the disc to the nerve while we wait to see if it heals on its own or not. That's a good example.

Host: Okay. So, we hear about medications all the time and we have to touch on these. And I'd like to touch on injections too, because you know, oh, I'm going to get another cortisone shot. We hear that in the business. We hear that all the time, right?

Tyler White, MD: And that's something that at least for myself, I do have a little level of concern with because epidural steroid injections or back steroid injections, like you might hear colloquially, are very useful for a variety of reasons. One, for certain conditions they can provide quite a bit of relief, and that relief can be long lasting.

And two is they can be very diagnostic for people. And what I mean by that is, well, it might be unfortunate in they receive an injection and it does not last long term for them. But it's useful because if we're still not convinced where their pain is coming from, but we perform a targeted injection and they have a dramatic, although short-lived response to that injection, then that can help give us information to confirm.,

Yes, that's where it's coming from. I think one thing that has been a little alarming, just where I practice, because I am in a relatively rural region of the state, is there are patients that get a large amount of epidural steroid injections for many years, and they never have a firm diagnosis of what is happening and what other treatment options are, and those injections, just like any procedure could have downside too.

So I always advocate for people, you really want to know why we're doing this procedure and what the actual diagnosis is.

Host: That's such a great point, Dr. White. Now, how has spine surgery changed over the years? I mean, really what an exciting time in your field. There's the advent of robotics and so many different types of surgery and minimally invasive. Tell us a little bit about what's going on in spine surgery.

Tyler White, MD: Spine is actually really fun to be a part of right now as a field as a whole. I would call it a relatively young surgical subspecialty compared to some areas. It was not that long ago that we would call it the dark ages of spinal surgery. And the technology changes have been pretty profound. I'm actually a fairly young surgeon.

I'm 36 years old and even in the amount of time I've been in practice and through my training, there's been pretty tremendous changes. Early on in my training, we were still placing lumbar instrumentation free hand. And what I mean by that is when we place screws, if we're performing a spinal fusion surgery, we're doing it by feel and using anatomic landmarks.

That was how things were done when I was at the beginning of my training, which was not all that long ago. Nowadays the Bryan facility at Grand Island Regional Medical Center in Grand Island here where I practice and perform the majority of my operations; we actually have what's called stealth navigation.

Where when a patient comes in for surgery, their body is actually calibrated to a computerized, basically a 3D CAT scanner that puts a computer projection. And so when I'm using instruments that are calibrated to the patient, I can actually see 3D via CAT scan during surgery where I am working in real time.

And so that lets me place implants with complete precision during surgery. It's actually a tremendous progress.

Host: Wow, that's really cool. Dr. White, there's so many things that have made recovery so much easier, not only for the patient, but also the benefits to the surgeon as well. Tell us a little bit about your program, about that spine program at Grand Island Regional Medical Center. Tell us about your team and some of the things that you do there that are really exciting.

Tyler White, MD: Absolutely. I have nothing but fantastic things to say about my team. I love our program that we've developed. So when I first wanted to develop this program, the reason I wanted to come back to Grand Island is I'm actually from here and my wife and I had baby number one on the way, and we wanted to come back and be close to family in my hometown.

Now, this is the new facility that had been built, but they'd never had a spine surgeon before. So we really had our work cut out for us. That involved everything from just building the basic equipment sets. So we had all the tools, to going through the various staff training on not only how to set up equipment in the operating room and what types of technology are available and what we would be using, but even up to the point of training all the nurses that take care of the patients after surgery.

Because I even tell folks, only 50% of your care is the surgery itself. The rest is what happens after. And so part of that has been training not only the floor nurses, but the emergency room physicians on what kind of things we could expect from having a spine program in our facility. And it was actually a very tremendous undertaking, especially for me at the time, I was coming straight out of my fellowship training.

So it was a large amount of work, but in the end, we've been extremely fortunate that we have had an excellent team of very skilled individuals who are very motivated. I think that's the biggest thing is you can't teach motivation. And we have a lot of very motivated individuals who are motivated to make this happen.

And I think one of the best things we have going for us is what I would call consistency. I work with the same team, day in and day out every week. I like going into the OR and knowing I'm having my same scrub tech that knows these surgeries like the back of her hand, and at some point we make the joke, she knows what tool I need before I do sometimes, and so having a cohesive team that just at a certain point has been so familiar with the process, really results in good quality care for your patients.

Host: Wow. I agree with that completely. And what a comprehensive team that you have where everybody knows what everybody else is doing and really keeps it together to make the patient feel so much safer and secure and they're really in good hands. Tell us a little bit about patient selection. Who is a candidate for surgeries?

I know it varies across the board, Dr. White, and it depends on the situation, but when you look at somebody, there are certain people maybe that you're going to say, no, this isn't something, but, oh yes, this is going to help you so much. Tell us a little how you help working with the patient in that shared decision making.

Tyler White, MD: So assuming we're discussinga more elective or planned conditions, you know, just ignoring all the emergent conditions that are out there, if we're just discussing on planning an elective procedure for a patient's spine, one thing we like to make sure is taken care of before proceeding to the operating room will be any, what I would call modifiable risk factors that could jeopardize their recovery.

So a good example is if somebody is having lumbar fusion surgery, you want to make sure they're not using nicotine products of any kind, patches, gum, cigarettes, anything like that before surgery because that will drastically interfere with their bone recovering after surgery. Another example would be if a patient is diabetic.

We like to really make sure their blood sugar control is optimized before surgery because poorly controlled blood sugar in the perioperative window has a very high association with infection risk. And so, what I like to do is what I call modify all risk factors that we can, that are changeable before surgery, and that may even include weight loss as well.

And so we have a kind of a running algorithm on, okay has this patient crossed this benchmark and this benchmark? Are they a healthy candidate for a good recovery from surgery?

Host: All those are so important. Now, tell us a little bit about surgery itself. Recovery. What's it like for the patient. Back in the day, right? If you had back surgery, you were in bed on your stomach or on your back for weeks on end. Now do you get them right up? When can they go home? Tell us a little bit about some of those optics.

Tyler White, MD: Yep. It's pretty interesting. I think a lot of patients are surprised when I tell them when they wake up from surgery, they're going to be up and walking that day with physical therapy and how important it is for their recovery. And I think some people are so used to hearing, oh, you had a back operation, you're going to be in bed for three weeks.

I think that's how things were back in the eighties, they're a little surprised to hear, nope, you're going to be walking the hallway and maybe doing the staircases today. And I think they're a little surprised to hear that. So with today's technology for both surgical techniques as well as implants being so stable and predictable, we're able to mobilize patients a lot faster.

I think, to be honest, it's fairly rare that I have a patient stay more than two days in the hospital. Average would probably be overnight for a lumbar fusion, maybe two nights. But in general, they're up and walking pretty much immediately. People are encouraged to walk. It's part of their recovery.

Now, they do have certain restrictions, obviously, like with weightlifting. However, I think people are surprised by how fast they're encouraged to mobilize after the operation.

Host: Wow. The technology in your field right now Dr. White is just amazing. If you had to give one best piece of advice to people, when you see them out and about and they find out what you do for a living, what is it you tell people about keeping a healthy back? So maybe they don't need to come see you and consider spine surgery.

Tyler White, MD: I would say keeping a healthy body mass index, or BMI. And if you're curious as to what your BMI is, it's pretty easy. You can Google a BMI calculator online and you can plug in your height and body weight and it can tell you what range you're in, but there's pretty good evidence that says keeping a healthy body mass index below certain point reduces strain on your back and prevents it from progressing to some more degenerative conditions.

And I hit on the other one earlier. I think people are really surprised to hear the nicotine use is a big one. That, and then this is one that I just deal with so many physically active younger people, if you are into the high intensity exercise programs, make sure you're lifting weights with really good form.

I see a lot of high schoolers trying to do dead lifts or certain types of back squats and they're doing really high weights with poor form and they end up with injuries. And so I always caution people if you're going to do those activities, you could do them, just make sure you're using excellent technique and form with a good coach before you do them.

Host: That is great advice and you and I should do another podcast strictly on that and weight training.

 But thank you Doctor so much for joining us today and really just sharing your incredible expertise, but also your enthusiasm and compassion.

I imagine your patients feel very lucky to be with you. Thank you so much for joining us today, and I'd like to thank our Bryan Foundation partner, Pinnacle Bank. To listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast.

I'm Melanie Cole. Thanks so much for joining us today.