Transcription:
Neck and Back Pain Basics: What You Need to Know

Melanie Cole (Host):  According to the American Academy of Orthopedic Surgeons, low back and neck pain are among the most common physical conditions requiring medical care. They also greatly affect the ability to work and manage daily activities of life. The latest Global Burden of Disease study reveals that back pain has the second highest number of disability adjusted life years in the United States. My guest today is Dr. Oliver Tannous. He's an orthopedic spine surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. Please explain a little bit about your role in spinal surgery for the listeners.

Dr. Oliver Tannous (Guest):  Hi, Melanie. Thanks for having me and thanks for the introduction. So, I'm an orthopedic spine surgeon which means that my area of expertise involves anything regarding the spine--anything from the base of the skull down to the tailbone. So, the three levels of the spine that I engage in clinically are the cervical spine, which is the neck; the thoracic spine, which is the back; as well as the lumbar spine, which is the lower back. 

Melanie:  Dr. Tannous, unless people have actually suffered back pain themselves, they don't quite understand the debilitating effects that it has. Speak about what you've heard from your patients about the lasting effects it has on their daily quality of life.

Dr. Tannous:  Oh, absolutely. I mean, neck and back pain is unbelievably debilitating and I see patients come into my clinic every single day with such changes in their quality of life and they can't do the things that they want to enjoy. They can't pick up their grandchildren, they can't drive to the gym, and it really affects their overall sense of confidence, their sense of happiness, and they typically come to me with sort of that depressed mood and it's up to me to figure out what's going on and how to guide them in the right direction; get them back to healthy living and quality of life.

Melanie:  So, when should a person have that initial conversation with you to check if they need or need to consider spinal surgery?

Dr. Tannous:  To answer that question, we first have to figure out what's causing that neck pain or that back pain. The good news is that the vast majority of the time, 90+% of the time, when people have acute neck or back pain, meaning new onset of neck or back pain, typically there's nothing surgical to do for the spine. The pain is typically coming from muscle strain, or maybe a sprained ligament within the spine, or maybe some good old-fashioned arthritis that the vast majority of the time gets better with non-operative treatment modalities.

Melanie:  So, what do you tell them about what they probably should have already tried before they consider spinal surgery? Some non-surgical approaches?

Dr. Tannous:  Absolutely. So, the great news is there are so many things that non-surgical spinal specialists have in their armamentarium. Typically, when someone goes and sees their primary care physician, or maybe the pain management physician, or whoever it may be that sees the patient first, there are so many things that can be done to help alleviate the pain. The first thing that typically most physicians do is they start the patients on anti-inflammatory medications; then, at the same time, they typically start a course of physical therapy to work on strengthening, stretching, ergonomic exercises, posture training; things that a lot of people sort of, in their 20s to 60s, experience as general decline when they maybe aren't as healthy, or aren't fit, or aren't as flexible as they once used to be. If that fails, then, typically, if there's some significant pathology that we see on the MRI, we can send the patients to pain management where they can consider some steroid injections into their spine and that can really have long-lasting, beneficial pain relief for those patients. And, finally, once they've failed all other options is typically when they come to me as the spine surgeon, to look at their spine and talk about surgery as potentially an option to make them better.

Melanie:  So, what are some signs they should be aware of that they need to consider surgery if they've tried all those other options?

Dr. Tannous:  Let me give you a quick rundown of the types of patients that I see in my clinic. The most common reason that I see people in my spine surgery clinic is arthritis of the spine. When people have arthritis in their neck or in their back, in and of itself, that arthritis doesn't necessarily mean they're going to have symptoms, but when it becomes so severe and it grows, it starts pinching on the nerves within the spinal cord or the nerves coming out of the spinal cord. When that happens, typically people come and they have either arm pain, when that pinching is happening in the neck; or leg pain, when that pinching is happening in the lower back. I also see younger patients who don't have arthritis who may have just a disc herniation. Typically, it happens with squatting or with heavy lifting, and they'll get sort of this sharp, shooting sciatic pain running down their leg, and the good news is, the vast majority of times that gets better without needing surgery. I also see patients with spinal deformities who can't stand up straight and then patients who have maybe tumors in their spine, infections in their spine, or fractures in their spine. So, that's sort of the gamut of the types of patients that I see in my clinic.

Melanie:  People hear the words “spine surgery” and they get nervous. What types of spine surgery are you doing today? What's new and innovative in the world of spine surgery?

Dr. Tannous:  Well, that's a good question. The easy answer is there are so many new technologies out there in the terms of motion preservation; in terms of it used to be back in the day when someone had to have a spinal fusion, you would take out a disc and put a big piece of bone in there to lock them up. For the most part, we still do that on a routine basis, but there's newer technology now in terms of disc replacements where you can put an implant in where it preserves that motion. Instead of having to fuse someone, you can put a disc replacement that maintains the motion. We're doing it much more in the neck, but the technology is advancing and there are hopes that it will be widely available in the future for the lumbar spine as well. I also do a lot of procedures using tubes, minimally-invasive techniques, so instead of having to make a big, traditional, mid-line incision, I can target the area involved and put a tube down into the spine which is what people think of as laser spine surgery, although no one ever uses a laser in the spine. You place a tube down into that level that you want to target, and you can decompress the nerve and give quite significant pain relief, once you decompress the nerve.  And then, we also have other techniques to fusions from a minimally-invasive approach, where traditionally, we used to do fusions with big, open incisions and big muscle dissections, and patients end up with quite a few weeks of post-operative pain and nowadays, what we're finding is that the pain levels are markedly diminished, people are getting out of the hospital earlier, and they're, overall, doing quite better than they did ten or fifteen years ago with some of these new technologies that are out there.

Melanie:  As people grow older and they shrink, their body shrinks, they have this compression. So, sometimes, as you stated, there are just pains that go along with aging. Tell us about some of the decompression procedures. What is life like for people after these procedures?

Dr. Tannous:  So, you're talking about compression fractures that people get. So, if you think of maybe your grandmother, or maybe your grandfather, and you knew them when they were younger and they were taller, and then, over time, they develop maybe the hunchback and they slowly lost height. For the most part, people who have that, they don't have pain, or maybe they have aches here and there, it's not an issue. There's another subset of patients who maybe they become osteoporotic and now they have a fall, or maybe they went on a bumpy car ride and often they have this acute pain, this worsening pain, that comes on very suddenly. And then, we get x-rays, and we find that one of their vertebral bodies, one of the segments in the spines has collapsed. It's called a “compression fracture”. But, again, the good news is that the vast majority of those patients, they get better with time, the fracture heals with time. When it doesn't, that's when they usually come to me because it's been six to eight weeks, they're still having pain, maybe we get an MRI and we find that that segment is still lighting up on the MRI, meaning there's still motion. It's still active. It's still the source of pain. We have a really nice procedure called a “kyphoplasty”, where we can put a couple of needles right into that fracture site, inject some cement, and it is almost instant pain relief. People wake up from that procedure, they stand up, and they feel quite a significant difference in their pain level, and they can get back to their quality of life.

Melanie:  And you mentioned range of motion, because that is something that people are concerned with when they hear the words “back surgery” and specifically in the neck. So, how do you maintain that range of motion so that they can still turn their head and drive after the procedures?

Dr. Tannous:  We're getting to some of the more intricate nuances and it's very patient-specific. In younger patients who need a cervical spine procedure to decompress their spinal cord or decompress their nerves, if it involves one or two levels, then the nice thing is we can use disc replacements as an option. So, instead of having to fuse that level and lock up that one or two levels, we can now use disc replacement to preserve the motion that went in those two segments. It does two things. Number one, it preserves motion; number two, if you think about it, when people have a fusion, all that motion and stress that used to happen at those levels now goes to the level above or the level below. It puts increased stress on the other levels of the spine versus when you maintain their motion and you put a disc replacement, what happens is, there's now less stress on the adjacent levels, or there's less stress on the level above or the level below, and we're finding that this may have some very significant, positive, long-term effects on people.

Melanie:  In just the last few minutes, Dr. Tannous, what are some things that people should look for before considering spinal surgery?  What do you tell them every single day and what do you want them to know?

Dr. Tannous:  Yes. I'm a very conservative surgeon. Obviously, I love to operate; it's how I make my living, but I, first and foremost, want to make sure that my patients have a very successful outcome if they ever consider surgery. So, the first thing that I tell patients when they come to me—because, by the time they come to me, everyone has an MRI that shows something significant. Everyone has symptoms that are significant, and maybe they haven't tried everything out there. So, a lot of times, when I see patients for the first time, I end up sending them back to physical therapy, or I send them back to pain management for some more injections. Maybe I tell them to try to lose some weight and see how that goes. I really try to do everything absolutely possible to avoid surgery. If that all fails and they come to me for surgery, then we sort of discuss what the goals of surgery are. Typically, when people have arm pain or when they have leg pain because the nerves are being pinched, as spine surgeons, we are very successful at treating arm pain or leg pain that's coming from a pinched nerve from the neck or in the back. When people have only neck pain or only back pain without arm pain, arm numbness, or arm tingling, our success rates for treating just neck pain or just low back pain aren't quite as good and the reason is because there are so many levels that are involved. So, you're not going to fuse the entire spine just hoping to get the one level that may be causing the most pain. At that point, it's a lot more of a conversation in terms of what to expect from surgery; if surgery is right for the patient. So, I really spend a lot of time talking to my patients, explaining the MRI images, explaining my clinical findings, and really trying to come to a plan, because at the end of the day, when I operate on someone, we're doing it together. Yes, I'm the surgeon, but the patient has to have the very best interest in their health, and their recovery, and the surgical process. I take that very seriously and I spend a lot of time counseling them on what to expect and how to optimize themselves pre-operatively.

Melanie:  Thank you so much for being with us today, Dr. Tannous. You're listening to Medical Intel with MedStar Washington Medical Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.