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Scott Webb: Backward neck pain can significantly limit your ability to get around work and do activities. You love. I'm Scott Webb and we're here with Dr. Brian dial orthopedic and spine surgeon at Eastside neuroscience Institute and Dr. John choy, neuro and spine surgeon also at Eastside neuroscience Institute. So thank you both for joining me today. We're going to talk about back and neck pain. And at 54 years old, I pretty much have both, and it's good to have your expertise and pick your brains today. I'll start with you, Dr. Choi, what kind of pain is caused by the spine and how has treatment for patients experiencing pain evolved over the last 10 years or so?

Dr. Jonathan Choi: The question of what kind of pain is caused by spine disorders is actually a pretty complicated one. There's a lot of parts of this spine. So we've got the bones, we've got the joints and the nerves. And the pain could be coming from any one of those. So if someone has a broken bone, say they fell and fractured a bone, that can cause a lot of pain. We usually brace those fractures or sometimes if it's a really bad fracture, we do a surgery to put hardware titanium screws and rods in to act as an internal brace to help that fracture heal.

The more common kind of pain that people experience is joint pain. That's when the cartilage in between the bones starts to wear out. And unfortunately, that's very common. That usually causes back pain or neck pain, depending on where the worn out joint is. We work with our non-operative colleagues, our physical therapist, our physiatrist to help people recover from that kind of pain, because that usually gets better without a surgery. The type of pain that surgery can help is when a nerve is pinched in the neck or low back. That can happen when one of the discs in the spine bulges out and a pinch is on a nerve or sometimes just the spinal canal itself where the nerves run gets really tight, and that's called stenosis. That can cause pinching on a nerve going down the arm or leg. And surgery is very good for relieving that kind of pain. The question of how has treatment evolved over the past 10 years, I think that there's been more of a focus on minimally invasive treatments where we do the same surgeries that we used to do in the past, but through much smaller incisions. This helps people recover quicker, have much less blood loss or trauma to the muscles surrounding the spine. And that many times helps people just walk right out of the hospital a couple hours after surgery. And if we do a larger surgery that involves a fusion or putting hardware into the spine, before people would stay in the hospital a couple nights. But now, usually people are going home the next day. So that has been a great improvement in the past, I'd say, 10 to 20 years.

Scott Webb: Yeah, it is really amazing, Dr. Choi. And good to know that there's lots of options, therapies, interventions, and it really is amazing that folks are leaving the same day or the next day. And you hit on the buzzwords there, minimally invasive. We all want minimally invasive and smaller scars and faster recovery. So all good stuff. And Dr. Dial, I know there's a lot of myths and misconceptions, so maybe you can go through some of them and dispel some of them for us about back pain, the most notable ones.

Dr. Brian Dial: I think that's a really good question. And back pain in the United States and globally is such a pandemic where, you know, 90% of people will have an episode of severe back pain at least once in their life. And the majority of these go away on their own or considered acute back pain and are largely self-resolving. So when people do have back pain, it's important for them to understand what they can or shouldn't be doing. And largely, the misconception is a lot of people with back pain try to limit a lot of their activity. In some situations, if you're an elderly gentleman or woman who has a compression fracture or an osteoporotic fracture, limiting activity is probably the right thing to do while that fracture heals. But for a lot of the population, if you're just having what we categorize as non-specific back pain, so back pain that's muscular in origin or back pain that's related to maybe some of the mild arthritis in your low back, it's actually important to maintain an active, healthy lifestyle, a lot of the things that treat back pain the best are aerobic activities, doing physical therapy, doing yoga, minimizing some of those vices that are in some people's lives, such as smoking, for example. Weight loss is always great for low back pain as well.

And then, some of it can be activity-related where, you know, if you're a very avid cyclist or something along those lines, and maybe the positioning of your bike is off, so physical therapy can have a huge role, not only in sometimes locating some of that pain and then fixing it, which is why at Evergreen and Overlake, where we have this multidisciplinary approach with both surgical and nonsurgical experts going after some of the pain, we can really treat some of this back pain and neck pain that doesn't need surgery, but it's still causing quite a bit of disability to the patient. So I think we have a good way of kind of attacking some of these symptoms and helping people through their symptoms as well.

Scott Webb: Yeah. So let's talk about some of the treatment options. And I wonder sometimes, and maybe I'm actually speaking about myself here, when we think about the myths and misconceptions, you know, a lot of people I think probably suffer with back pain because they've heard that the options, especially surgical options, don't sound all that appealing perhaps. So maybe in the conversation here and answering this question, you know, what sort of treatments are available, maybe you can also put people's fears aside that anything that you would put them through, physical therapy, surgery, any of those things for spine care, that the benefits far outweigh the suffering that they do on a daily basis.

Dr. Brian Dial: Everybody knows somebody who's had back surgery with a bad outcome. And there's a lot thought out there, that back surgery, people will say ,"I'm never going to have back surgery. It only makes people worse." And unfortunately, sometimes in rare instances that's the case, but the vast majority of people if you're treating the right conditions with surgery are going to do quite well from that surgery.

The other thing to put aside some of people's fears is if they come and see a spine surgeon, the rare instance where someone comes in to my clinic and we're talking about surgery right away. We're always going to try to do the least invasive or the non-surgical treatments first, and then only if all of those fail do we start talking about surgical intervention. So, most people who come into clinic, the first thing we're going to recommend is a course of physical therapy. That's going to a physical therapist where they're going to do a lot of core strengthening, a lot of back strengthening, stretching exercises to see if we can treat the pain that way. If that doesn't fully treat the symptoms, usually the next step is some sort of injection or interventional therapy, which is performed by our physiatry colleagues. And although it's an intervention, it's still much less invasive than doing surgery. And if both of those fall short in treating all the symptoms, then we start talking about surgery, if and only if the patient has a pathology that's fixable by surgery and the vast majority of back pain and neck pain, unfortunately, isn't always treated by surgery.

But if you do have the patient who comes in with a large disk herniation pushing on a nerve, causing severe sciatica down their leg, we can very reliably treat that with a minimally invasive surgery where the patient's going home the same day. And after that surgery, almost immediately, their leg pain is gone. They might have some surgical back pain that lasts for a few days to a couple weeks, but it's mild. And almost all of them say it's way less pain than they were having with the acute disc herniation. So if you're treating surgical pathology with surgery, patients are going to do quite well with surgery.

I think to mitigate some of those fears, there's always stuff that can be done short of surgery to help with symptoms. If you have the pathology that can be successfully treated with surgery, come in, we can have that conversation, talk about the risks and benefits of that surgery. And the chances that you're going to improve are really quite good, but there's always non-surgical interventions that can help minimize symptoms as well.

Scott Webb: Yeah, it's certainly worth a conversation to be sure. And Dr. Choi, are there some new and emerging technologies you want to share that are available for those of us who need spine treatment?

Dr. Jonathan Choi: Yes. There's many new exciting technologies that have come out. Some are for the surgeons. Some are actually for our non-surgical colleagues. So I'll talk about both. Traditionally, if we had to operate on a bulging disc in the neck, we used to remove the disc and fuse the joint. Now, that has some major downsides because you lose the motion at that joint that we operate on. And that puts stress on the joint above and below the operated level.

Now, we've got these excellent disc replacements, which are artificial discs. They're approved for the neck up to two operated levels maximum. But what they do is they mimic the original movement of a healthy disc. And we can go in there, clean out the degenerated disc, take the pressure off the spinal cord or the arm nerve, and then put in an artificial disc and that moves almost exactly like the original disc. That's done wonders really because patients maintain their movement in their neck. They don't have stiffness. They can rotate their neck left and right and look up and down like normal. And the recovery is very quick. I think that's one of the key new technologies that's come out.

There are other ones for the lumbar spine. there are some technologies that do help us do better spine surgery. And some of those things are like the minimally invasive surgeries that I had mentioned before. We use a small tube to go down. And using a microscope, we can look through that tube and get all the work done that we used to need a larger incision for. We are also using spinal navigation to act like a GPS to help us know exactly where to put the screws and rods when we do need to put them in. And that increases the safety and actually the speed of the surgery as well. As far as other technologies, there's one that the non-surgical colleagues, our physiatrist and pain management colleagues have been using is called Intracept. It's a device that you can numb up the nerve that does the feeling to the the disc space. So this is the nerve that you get the feeling for the low back pain. Our physiatry colleagues and pain management colleagues, they can go in there and they can numb up that nerve. And that can take away a lot of the back pain. It is an option for some of our patients and it improves their quality of life.

Scott Webb: You know, it almost sounds like science fiction. You know, it sounds like something out of Star Trek or Star Wars, but it's not. It's real, it's happening. It may be happening later today for one or both of you. Really amazing and great conversation today. As we wrap up here, doctor, doc, maybe you can share a case or a story that made a difference in how you practice.

Dr. Brian Dial: A lot of what we do, we're treating people who've had chronic low back pain or chronic disability, but we do occasionally treat patients with more acute pathology as well. I was recently on call. This is just the first thing that comes to mind to show maybe some of the other side of what we do as well, when it's more of an acute pathology. But a young gentleman in his late 30s, software designer here at one of the major software companies. And over the course of one to two weeks, he just noticed his balance was getting worse and worse. He was starting to notice some weakness, but he was one of these workaholic types. So he just was like, "Oh, it's going to get better. I'm, you know, going to keep working." And then, he finally presented to the emergency room and he'd almost completely lost the strength in his lower legs and he was no longer ambulatory. We got an MRI which showed a really large cervical disc herniation pushing right on the spinal cord causing a lot of this weakness. So we took him that same day to the emergency room, removed that disc herniation. We did do what we call an ACDF surgery, which stands for anterior cervical discectomy and fusion. But we were able to remove that disc herniation for him successfully. And over the course of the next probably only two to three weeks with some rehabilitation, he was able to completely return to his baseline strength, completely now exercising, running again.

So some of these patients that we treat, it really can be life-changing for them and they really do need to have some of these spine surgeries. And it's those cases where, as surgeons, we really feel it is what helps you to keep on doing it and those successful cases are really what motivates you to keep going. And it's really great to see patients improve like that. So a lot of back pain and neck pain can be these chronic things. But if you do notice you're starting to have a lot of arm weakness or a lot of leg weakness and your balance is getting off, it's probably a good thing to have these checked out by your primary care physician or someone in the medical field, just to know what's going on. You know, those cases are really what motivates us as surgeons to keep practicing and really helping people in our local community.

Scott Webb: Yeah, I'm sure that's a great story. And the nice thing for both of you and your team there is that, you know, you literally get to see folks walk out, right? So you help them surgically and otherwise, and you literally get to see them walk out and hopefully pain-free or, if there's a pain, it's a short term thing from the surgery and then it goes away. And so I'm sure that's very gratifying and this was really great conversation today, so thank you both.

Dr. Jonathan Choi: Thank you very much.

Dr. Brian Dial: Yeah, thank you so much for having us.

Scott Webb: The Eastside Neuroscience Institute helps improve the quality of life for people living in need of comprehensive spine care and related conditions. To learn more, visit eastsideneuroinstitute.org. institute.org.