Scott Webb (Host): This episode of Putting Your Health First is brought to you by Health First Health Plans offering affordable health insurance for all ages. To learn more, visit myhfhhp.org. That's myhfhp.org. And today we're discussing the latest in spine surgery with orthopedic spine surgeon Dr. Richard Hynes.

 This is Putting Your Health First, the podcast from Health First. I'm Scott Webb.

Doctor, it's nice to have you here today. We're going to talk about spine surgery and everything about spine surgery. I've got a lot of questions for you and it's great to have you here, your time, your expertise. So let's just start here. Maybe the one that would, you know, be on the minds of most listeners, like when we're trying to figure out, okay, who's looking for a spine surgeon? What usually leads someone to a spine surgeon? Is it the symptoms? Are there some red flags? Like, how do, how does a patient know it's maybe time to be seen by someone like yourself?

Richard Hynes, MD: Yeah. That's a great question because I tell patients that they have to convince me that they need surgery. I don't try to convince them. And what that means is that they are having so much trouble, that they most likely have already tried chiropractic care. They tried pain management. They get their own medical doctor to help them.

And if they break through all that, they know. This, this is really a problem. And then they start scouring around for experts and they ask who can we see? Usually it's in the community that they're in, if it's a routine problem, and then may be like in a university setting or a specialty center if it's something very complicated.

But that's a very common pathway. And the patients really, you know, they know and they do a good job, most of them coming in with good questions. And then I can tell they've done a lot of homework when they do that.

Host: Yeah. And Doctor, I'm thinking about conditions like herniated discs, degenerative disc disease, scoliosis, spinal stenosis, you know, the greatest hits, if you will.

So what's actually happening in the spine with these types of conditions, and why do some of them end up needing surgery?

Richard Hynes, MD: I'm going to try to give you a shorter answer to a very long answer. The spine has not been that well designed, and I don't hope I don't pay a price for saying that. In the evolution of spine, you know, we went from walking to standing and so, it put tremendous pressure on these discs in the standing position for humans.

Not that it doesn't happen in four legged animals. It does, like doxins, have a lot of disc herniations, but it's more in the humans and it happens in two places, mostly in the neck and the low back because they're unprotected areas from loads, like your head loads, your, the disc in your neck and then wears them out.

And then in your low back, it's the weight from your head down to your waist that's loading those discs, which is much, much more, a hundred pounds, maybe even more. The thoracic spine is protected by the ribs. We see about 5% of our problems for disc problems there, and the discs have a natural propensity to just wear out over time, and it happens to everyone.

You, if you take MRI scan of a guy on the street or a woman on the street, you're going to find and if they're over 25 years old, you're going to find some signs of disc degeneration. Little bone spurs, a change in the amount of water in the disc. It's common, but the number of people that actually end up with surgery is actually relatively small, when you really look at the numbers. It sounds like it's a lot. Hundreds of thousands of people have surgery for disc problems every year. But when you look at 350 million Americans, if you look at the population, it's actually most of the spine problems can be treated without surgery, and that's the first good news.

When you need surgery, you need surgery, and that's going to be a smaller population.

Host: Right. Yeah. And doctor, is it the, the PT, injections and other types of treatments, is that how a lot of folks are able to avoid surgery?

Richard Hynes, MD: Yes, actually physical therapy is almost always a good thing. The injections can be useful and helpful if it's, if it's done correctly and, it's well-thought through. There's also radiofrequency ablation that the pain doctors do that can help, you know, keep some of the pain in the joints of the spine down.

 Those are the more powerful methods. You know, and I say therapy. I also include the chiropractors. I think that a good chiropractor can do us a lot of good, and you may not hear that from spine surgeons very much, but I'm one of the earliest members of the North American Spine Society. The number one society in spine, the largest one, and it was the tenet of it was to include all specialties, physical therapists, chiropractors, orthopedic surgeons, neurosurgeons and physiatrists.

Everyone treating the spine from some angle, pain specialists. And so there's a, it's a whole big team out there that's trying to keep the patient away from the spine surgeon. And I'm all for it. All for it.

Host: Yeah. Yeah. As you say, there's a big team working sort of against you, but you're all, it's all for the common good, right? It's all to help patient's and their families. And, you know, some of the things I'm thinking about common, let's say spinal procedures, whether that's fusion, discectomy, laminectomy, maybe you could break down some of these procedures as best you can in audio form, and you know what you do and how you do it.

Richard Hynes, MD: I always say to patients, there's three things that spinal surgeons do. They decompress. That's your discectomy. Removing a disc, laminectomy, removing some bone to make more space for nerves. Those are very common procedures. The other things we do, we stabilize. Broken discs that are unstable. They cause pain, so we do fusion, and that's uniting two bones together around a damaged disc that's causing pain, and it turns into a living bone with the patient's own stem cells. A living bone is better than a, a bad disc, although the price to pay is stiffness. But we also have the advent of arthroplasty, which is, uh, mechanical devices that actually replace the disc and actually maintain some of the movement, and they're having an evolution.

Just like all the different types of, like the hip replacements, the knee replacements. We're seeing this in the spine, in the low back, and then also in the neck, with some significant success. So Those are the two things we do. The third thing we do that's been very recent in the last 10 to 15 years, we balance, we balance the spine.

You can't just fuse it, you can't just decompress it. You have to make sure that patients in good alignment. Or you'll, or it will add to the problem in the future. And that's created a whole new series of types of operations and technology like robotic surgery and endoscopic surgeries using little tiny, tiny little tools through little tiny nicks in the skin to get into the disc to fix problems.

All these are evolving now. And it's, it's amazing the way in which it's going to affect the betterment of spinal care when it comes to doing procedures or surgery in the future. But if the patient would focus on I'm, I need a decompression, I need something decompressed, or I need something fused, but I need to be in balance, then they're going in with the right questions whenL to the spinal surgeon.

Scott Webb: Right. Yeah. Gotta be in balance. And you kinda gave us a sense there that, you know, things have changed and evolved and improved, whether it's because of robots or otherwise. Let's talk then about the safety, the technology, the patient outcomes, how things have evolved over the last decade or more, and maybe even involving minimally invasive surgery.

Richard Hynes, MD: Oh yeah. I mean the, the safety has skyrocketed with the advent of what's called navigation. Because we, we don't need much on the way of x-rays or radiation in the OR. So we basically operate from images of the patient made by a computer assessment of an MRI scan or an x-ray that's done. And what's really propelled us in just the last few years is the robotic navigation. That's using the robot.

And the difference is, in the spinal literature, if you look at it, what it's showing all around, all the spinal surgeons that are using robots, 99% accuracy in putting in pedicle screws. Pedicle screws are our biggest, strongest armamentarium for spinal surgeons in correcting problems in the spine, including fusion and deformity.

99%. That's phenomenal. Now, if you use a freehand technique where you're not using a robot, it can be as high as 90-91%, which is very good. If you are using fluoroscopy or x-ray, you're in the eighties. And so, I presented this information at the Scoliosis Research Society in Scotland to the European surgeons.

And I was trying to encourage them to jump into robotic surgery because I asked them if you were having screws placed, which is one of the most common things we do; do you want your surgeon to be 99% accurate or 91% accurate? What would you choose for yourself? So they think about, do your patient's get something less than you, or are you going to treat them as good as you treat yourself?

And so get out there and learn robotic navigation and adopt robotic surgery.

Host: And, you know, doctor, uh, we think about recovery, right? And I'm sure recovery has improved thanks to minimally invasive spine surgery, robots, you know, all the above.

So what does a typical recovery timeline look like? And, maybe what are some of the factors that might help someone to bounce back quickly? Is it just being in better shape when they have the surgery? Like how does that work?

Richard Hynes, MD: The answer is yes. You really hit on something important. The, the better you go in, the better you come out. If you're not healthy, going to have more complications. That's all there is to it. Patients come in with terrible problems and they're at the age 60 to 95, where they have the heart disease and the hypertension and all the other problems. Diabetes. Their BMI, their weight is way up. All those things add to the risk you take with surgery. So patients can do an awful lot for themselves by getting in the best health before they have any type of surgery like this. I think what really tells you that safety is improving is that there's a big movement from the inpatient hospital setting for spine surgery to the outpatient ambulatory surgery setting.

Surgery's gotten so much safer. I routinely have done, I have had two surgery centers and done fairly significant spinal surgeries in outpatient setting. The patient's go home the same-day. That attests to the improvement and the safety, the protocols, that help us take care of patient's afterwards.

Now, when you ask about how long does it take, well, it's going to really depend on what you get

Host: Like a timeline? Yeah. Okay.

Richard Hynes, MD: Yeah. So if you have a little disc removed, you're going to get better in a few weeks. If you have a big spinal fusion, because your back is bent and you can't stand up straight, you're going to spend six months to a year making that work. That's the two, two kind of extremes.

Host: Yeah, the extremes, uh, of the spectrum there and yeah. Because I think people who might be considering this want to know, well, when can I get back to work? When can I play pickleball? You know, when can I exercise again? You know, all that stuff. And as you say, there's going to be a range, right?

Richard Hynes, MD: Well, I'm glad you brought a pickleball because we're having a plethora of pickleball injuries, in spine and orthopedics in general. It's, it's amazing. You can almost write a chapter on what's going to happen to you if you play pickleball. So, you know, yeah. If you want to get back to sports and activities, you have to choose the right type of surgery, number one, because they all don't do the same thing.

You have to decide, am I having surgery because of pain? And that's all I'm interested in, is getting out of pain, or am I interested in returning to soccer? Returning to the military, returning to skydiving. These are different procedures to get you to the place you want to go, and you have to thoroughly ask those questions and really investigate the procedure you're having to make sure that you're getting the one that actually is going to make you satisfied.

I mean, if you really expect to play sports again, and you have a surgery that takes your pain away, but you, every time you try to kick the ball, you're getting pain. You have not been successful. So this is part of the discussion between the patient and the doctor, I think is most critical.

Host: So, doctor, let's talk about physical therapy, but like more on the post-op side of things. So post-op, rehab and what role that plays in helping patients to get better, get back to doing stuff. And you know, really like maybe the importance of sticking to the plan, which might be easier for some than other's.

Richard Hynes, MD: You know, that's such a great question about what, what are you going to do after you have these surgeries? Well, you know, it's interesting. The transformation in my 40 years in, in spine has gone from intense postoperative hospitalization for long periods of time. Intense therapy, really brutal long-term postoperative courses to now outpatient surgery, and almost no therapy in many of these operations.

So this has been a huge change in the last 30, 40 years. Having said that, the amount of therapy is going to be directly proportionate to two things. The intensity of the surgery you have, whether it's a little decompression, a little removal of disc, or is it going to be a 10 level big scoliosis fusion to correct your spinal deformity, which is going to involve perhaps even rehabilitation in a rehabilitation hospital after you finish the hospital course of 3, 4, 5 days. You're not ready to go home, so you get transferred to a rehab facility. And there's a lot of intense therapy there until you're really on your own, able to get up, go to the bathroom, cook your meals, get yourself taken care of at home without a lot of assistance.

And then there's also home therapy. The, the hospital can send out their home therapy team, which includes physical therapists, nurses, occupational therapists, nutritionist. And they can come out to the home. And help people that live in their home, and not have to spend a lot of time in the hospital or a lot of time in rehab. But it's going to be directly proportionate to the intensity of the procedure and the problem that you have.

And that's going to be combined with what's your general health going in and what's your general health coming out. That's the entire ball of wax as far as rehab.

Host: Yeah, and I wanted to stick with that because, my mom has been telling me, doctor, my whole life that spinal stenosis runs in our family. And I don't know if that's true. But you know, when I think about family history, genetics versus lifestyle, I feel like not maintaining a healthy weight, not being active, you know, not having good posture as I don't right now, as I'm speaking with you, as I'm leaning forward.

My posture is just horrible. So I feel like we do most of this stuff to ourselves, but from an expert, maybe you can set the record straight. Is that a thing? Is there family history, genetics involved, or is it mainly what we do to ourselves?

Richard Hynes, MD: Scott, I think your mom was right. And it to, and because you'll be happy to hear that that mom was right. Um, the, the, a lot of it really is preordained. And the reason I, can tell you that is, is that I've had people that are the best athletes in the world take great care of themselves.

Bodybuilders, you know, these are real athletes and they get the same problems that someone who has done nothing to help themselves. And then people that are small and thin get the same problems that someone who's very big and heavy. So that tells me that of course, there's a genetic predisposition.

It's the way we're built that is partly the, the blame and the aging process itself causes the disc to wear out. When the discs wear out, the space around the nerves, stenosis, the word you used. That's the space around the nerves closing in. That comes from the disc. It all goes back to that disc. So if your genetics has strong collagen, strong material to make that disc with; you're less inclined to develop something like spinal stenosis, compressed nerves, disc herniations and deformity. Part of it, yes, there's gotta be also, what environment are you in? Like, what have you done to yourself?

Like if you, if you've been a command sergeant, major jumper in the military, and I did some of that airborne, I hit the ground at 20 miles an hour. You, you do that 500 times, you know it's going to have an impact on your genetic predisposition. So yes, mom is right. A lot of, I think you're just, you're just the way it's going to be.

You're born with it. Your way you take care of yourself is going to play a role. And then the environment you've been in all of your life is going to also add to that deterioration.

Host: Sure. Doctor, let's do a little myth-busting. I like to bust myths when possible. Are there some common myths or misunderstandings about spine surgery that maybe you've always wanted to have a platform to you know, kind of set straight.

Richard Hynes, MD: I hadn't thought about that, but I, I'll give you one. And that, may not surprise you. What's the difference between an orthopedic spinal surgeon and a neurosurgeon who does spinal surgery? That's the, I have patients, and it's not so much now, but I would say 20, 30 years ago, they would come in to come talk about surgery and they say, well, you're an orthopedic doctor.

Now should I be seen a neurosurgeon for my spine? And it's interesting that you go back in history. Well, most of the big spinal surgeries were done by orthopedic spinal surgeons. The orthopedist, not neurosurgeons. Neurosurgeons dealt mostly with the brain, but the intersection was the nervous system and the, and the neurosurgeons were, would go into the spinal cord and remove tumors and this sort of thing in the spine, but the spinal surgeon would rebuild it and there was a team play, back in the eighties, nineties, early two thousands of orthopedic does the big, you know, construction screws and the, they cement things together and fuses, and the neurosurgeon does the delicate decompression and this and that. So I was one of the first surgeons trained in a joint neurosurgery and orthopedic spinal surgery program at Harvard.

It was both. So I was trained in both specialties. Although I'm an orthopedic based surgeon. Today, the difference is getting less and less and less and less, and most, I would say topnotch spine surgeons, whether you're orthopedic or a neurosurgery, you do all of it. You don't have to have the other specialty there.

That's been an evolutionary change. And so no, you don't need to see a neurosurgeon. You need to see the right surgeon. You don't need to see an orthopedic surgeon. You need to see the right surgeon.

Host: I just want to finish up, doctor, I've already excited about the future of spine surgery, as I can tell that you are, but just, uh, any other developments, exciting, promising things where you're just like, I can't wait to share this with folks when they're out of the testing phase and I'm actually, you know, able to do them.

Richard Hynes, MD: Well, I can share several things I would say in the scope of the spinal world. Endoscopic surgery, robotic surgery, of course everyone knows AI is going to influence and affect everything.

It's really valuable. AI is, every time I plan my robotic surgery, it's on a CAT scan. AI can use that information. And now after I've done so many of these, it actually plots exactly what I want on any particular CT or MRI for me. And then I make suggestions if I don't like I move it and I change a little this or that, but it's almost always knows now exactly where everything should go in a spinal surgery without me even planning it because it's monitored what I've done in hundreds and hundreds and hundreds of surgeries. That's very exciting. That's going to be very, very good. And then personally, I have invented many things, and I'll just bring up one that's at Holmes Hospital.

It's an operating room bed that the patient goes to sleep on that allows me to move the patient in space 360 degrees, safely. What that does, it allows all sorts of different opportunities for the surgeon. When we work, you want to work in a comfortable position, whether you're hanging drywall or you're doing surgery.

If you're hanging drywall wrong, you're going to get tired. You, if you're, if you're standing wrong or your neck is in the wrong position in surgery, you're going to get tired. So my theory was, well, let's start moving the patient around, which is physiologically really good for them. And then bring the surgeon to the patient and that I, I have been very successful with now over 1500 patients and now getting ready to go out and hopefully I can get this to everyone, but right now you have to really come to Melbourne, Florida to to, experience that.

It really does have a great future, and it's going to be very big one of these days.

Host: Right. Yeah. Well, it's been so great to have your time. You know, I do a lot of these and when I get to the end of most of them, I figure we've probably covered most things. We're good. We can say goodbye. This is one of those where I feel like we could talk for hours and you just this, you know, never ending wealth of information and passion and expertise and all of that.

But for today, we're going to put a period at the end of the sentence. Thank you so much.

Richard Hynes, MD: You're welcome, Scott.

Host: And when back pain strikes or problems persist, it's time to learn more about your options to feel better and live well. For more information and to schedule an appointment with a spine specialist, visit hf.org/spinecare.

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