Selected Podcast
Matters of the Spine: What is Degenerative Disk Disease & How is it Treated
Your back has cushioned disks to help maintain flexibility, but injury and aging can wear these disks down. Dr. Patrick Hsieh and Dr. John Liu discuss degenerative disk disease.
Featuring:
Dr. Liu is a recognized leader and considered one of the pioneers in minimally invasive surgical techniques for spine. He provides a key leadership role in the development of the leading multidisciplinary
academic spine program on the West Coast through close collaborations with the Department of Orthopaedic Surgery. Dr. Liu, a board certified neurosurgeon, was vice chairman of
spine services and co-medical director of the spine center at Cedars-Sinai. Prior to Cedars-Sinai, Dr. Liu was director of spinal surgery at Northwestern University in Chicago. One of the country’s
preeminent specialists in intricate and minimally invasive spine surgery, Dr. Liu is leading research to study innovative technologies and techniques for the treatment of conditions such as spinal deformities, scoliosis, spinal cord injuries, aging spine and hyperhidrosis. He received his medical degree from the University of California, Los Angeles. After graduation, he completed his surgical internship and residency at Northwestern University Feinberg School of Medicine, Chicago, IL. Dr. Liu went on to complete a fellowship
in Complex Spine Surgery and Minimally Invasive Surgery at Northwestern University Feinberg School of Medicine.
Patrick Hsieh, MD | John Liu, MD
Patrick C. Hsieh, MD is a board-certified neurosurgeon specializing in complex spine and spine tumor surgery. He is a distinguished research scholar and is triple fellowship trained in the areas of minimally invasive surgery (MIS), complex reconstructive spinal surgery and spine oncology. He is the recipient of the Edwin M. Todd/Trent H. Wells, Jr. Distinguished Professor of Neurosurgery award. Dr. Hsieh is well-recognized for his expertise in spinal deformity and spine tumor surgery and travels nationally and internationally to share his expertise with other spine surgeons. Dr. Hsieh focuses on optimizing outcomes based on each patient’s individual needs and often performs spinal revision surgery. He is a leader in MIS treatment of degenerative spine disorders and a pioneer in the technique of MIS for tumor resection. His interests also include the treatment of spine tumors. Dr. Hsieh works alongside the Chordoma Foundation to treat patients from all over the world.Dr. Liu is a recognized leader and considered one of the pioneers in minimally invasive surgical techniques for spine. He provides a key leadership role in the development of the leading multidisciplinary
academic spine program on the West Coast through close collaborations with the Department of Orthopaedic Surgery. Dr. Liu, a board certified neurosurgeon, was vice chairman of
spine services and co-medical director of the spine center at Cedars-Sinai. Prior to Cedars-Sinai, Dr. Liu was director of spinal surgery at Northwestern University in Chicago. One of the country’s
preeminent specialists in intricate and minimally invasive spine surgery, Dr. Liu is leading research to study innovative technologies and techniques for the treatment of conditions such as spinal deformities, scoliosis, spinal cord injuries, aging spine and hyperhidrosis. He received his medical degree from the University of California, Los Angeles. After graduation, he completed his surgical internship and residency at Northwestern University Feinberg School of Medicine, Chicago, IL. Dr. Liu went on to complete a fellowship
in Complex Spine Surgery and Minimally Invasive Surgery at Northwestern University Feinberg School of Medicine.
Transcription:
Prakash Chandran (Host): Your spinal discs are like shock absorbers between the vertebrae of your spine. They help your back stay flexible but as you get older, they can show signs of wear and tear and really cause pain. Let’s talk with Dr. John Lui and Dr. Patrick Hsieh, Neurosurgeons at Keck Medicine of USC affiliated with Ridgecrest Regional Hospital.
This is a podcast from Ridgecrest Regional Hospital. I’m Prakash Chandran. So, Dr. Lui, let’s start with you. What exactly is degenerative disc disease?
John Liu, MD (Guest): Well Prakash, this is a very common problem. As you described it, in terms of a shock absorber, right, it’s kind of like the shock absorber in your car. After some wear and tear, that shock absorber can start to wear down and that’s kind of what the shock absorber – a disc is in your spine is the shock absorbers that’s between the bones in your spine and just with typical aging and just kind of daily wear and tear that we all put on our spines; those discs undergo some degenerative changes and most of the time, it doesn’t cause problems. But when it becomes problematic meaning that it causes more pain for people, and they develop other symptoms, that’s when we call it degenerative disc disease.
Host: Understood. And Dr. Hsieh, I want to move over to you. What are some of the symptoms that people experience when they have degenerative disc disease? Dr. Lui mentioned that there’s some wear and tear over time; but when do we really know that it’s getting bad and becoming this degenerative disc disease?
Patrick Hsieh, MD (Guest): Sure, thanks for the question. So, I think that in terms of the wear and tear of the disc spaces, it’s really common with aging and just the duration of the mechanical stress. It really becomes more of a disease when patients are symptomatic and usually the first primary symptom is pain. In your typical mechanical strain or early degenerative disc tears, the pain may only last for a couple days or a couple weeks at most and they tend to get better because your body does have a self-healing process with the degenerative disc process.
But it’s really the patients that have chronic disabling pain that becomes more of a disease process and not only is there pain in some cases but there are patients who develop neurological manifestations of degenerative disc disease that can include weakness, numbness, and loss of function as the result of the disturbances to the nerve roots or the spinal cord.
Dr. Liu: I just want to echo what Dr. Hsieh just said. I think back pain in general is very common, right? So, we all get back pains we get a little too much, lifted too much and usually those are self-limiting, meaning that within a couple of days or a few days it typically gets better. The problem occurs when the times that you want to start thinking about calling your doctor is if the back pain kind of persists and it goes beyond a couple of weeks and that’s the case where typically you may want to notify your primary care physician. The times that we get involved as specialists or spine specialists is when these pains are longer lasting, when they are lasting more than a few weeks or if you start to developing some leg pains or other neurological type of issues and that’s when we get involved.
Host: So, Dr. Hsieh, I want to talk a little bit about the diagnosis process, and I think one thing that I’ve learned here is that there’s constant back pain. I just had back pain recently when I went to the gym. But yeah, you are right, it went away after like two weeks. But if it is persistent and it lasts for around three weeks and let’s say I go into my doctor. Dr. Hsieh talk a little bit about how it is diagnosed.
Dr. Hsieh: Absolutely. So, diagnosis of symptomatic degenerative disc disease generally starts with a physician’s evaluation and in most cases, I think the process starts with a primary care physician but in some cases, it should start with someone who has a little more expertise in evaluation of spine conditions. Now in general, I think the pain symptoms can be separated into two parts or components. There are two parts. The most common symptom of degenerative disc disease is back pain. It localizes to either the neck or the back and as you said in your personal experience, these generally are fairly self-limiting over days to weeks.
Now when symptoms of back pain are more than bearable or if they last more than six weeks; I think that’s really the first time that you should get an evaluation by a physician. But there are some red flags symptoms that you should seek a physician’s advise or a consultation sooner and typically those are the neurological symptoms. The symptoms that lead to weakness, numbness, and as I said earlier, the components of two sides of the pain, it is not just back pain. The other part of the pain is really what we call neurogenically related. And those are typically the pain symptoms that people describe as sciatic like pain where the pain shoots down an arm or a leg from the pinch of the nerve from the degenerative disc disease.
Now again, with pain alone, most of the time you are probably pretty safe for about anywhere from two to six weeks as long as it doesn’t get worse and it’s not associated with weakness or sensation loss.
Host: And Dr. Lui, I’d love to learn a little bit more about the treatment options that are available. Let’s say you go in and you have the evaluation and it is determined that you have something. Maybe talk a little bit first about any nonsurgical treatment options and then we’ve move to the surgical ones.
Dr. Lui: Sure. So, with treatment, we always start off with nonsurgical. Very, very rarely do we actually recommend a surgery right up front. Usually those are for very special occasions where there is some severe nerve compression. But conservative treatment is the most likely is what we are going to do first and when you see your primary care physician, they are likely going to talk to you and do an exam and do some basic imaging and if degenerative disc disease is what we think you have; then typically we will start off with some anti-inflammatory medications. Sometimes if you are having spasms, we may try different medications to try to cut those muscle spasms down. And then physical therapy. So, those are the two most basic conservative approaches. It would be physical therapy to help you to kind of take care of some of the weakness that we all have in our backs and so we try to strengthen some of the muscles around the spine. And teaching you about good posture control and how do you bend and twist and how do you live daily life without causing more problems with your back.
So, medications and physical therapy are the most common nonsurgical options. And then another conservative treatment would be sometimes an injection may be indicated. Usually I don’t necessarily start that right off the bat. Usually we will try to medications and physical therapy first. And medication also includes sometimes we will use some topical patches too, some heat treatment, sometimes little massages and so it’s soft tissue work. But there’s a lot of stuff that we can try in the beginning stages.
Host: Okay and just to elaborate a little bit more maybe Dr. Hsieh you can answer this. Let’s say you try all of those things. You go to physical therapy. You take the medications and it still doesn’t seem to be fixing the problem. Talk a little bit about the surgical options that are available, that you typically do to help cure or minimize the pain of this degenerative disease.
Dr. Hsieh: Sure. So, in general, most of the time, if symptoms last beyond three months while patients may have exhausted all of the conservative treatments that Dr. Liu had described; we can consider surgery in some situations. And it really has to do with whether or not the symptoms can be explained by what we see in terms of the patient’s physical examination as well as typically some type of imaging like an MRI or a CT or CT myelogram and what we’re looking for is the potential pain generator that can explain the patient’s pain or injury that can be fixed with surgery.
And generally, it has to do with either nerve compressions or mechanical instability of the spine and typically, if we have mechanical compression of degenerative disc disease either from a disc herniation or from overgrowth of bone spurs and ligaments; what we do is a laminectomy or a discectomy which is basically removing the portions of the disc or bone spur overgrowth that relieves pressure off the spine. And in cases where there are instability or mechanical disruption of the spine in terms of stability or alignment; then we may have to do something more complex like a spine fusion.
So, there are a number of pathologies that we are looking for but most of the time, what we are looking for is some type of pain generator or disturbances that we can fix if you will or alter with surgical treatments.
Dr. Liu: I would just like to add in terms of additional – there are some alternative types of treatments even before surgical intervention that sometimes people will try. They may gain success and the reason we say alternatives is because these are – sometimes we don’t really have a lot of medical evidence that may be effective, but people still try them and sometimes it’s helpful. And a couple of these would be like acupuncture or chiropractor and a lot of times people have success with their back pains with those modalities. And there are some clinical trials that may be going on. I know Dr. Hsieh is head of a couple of these clinical trials that are ongoing at USC. I don’t know if Dr. Hsieh wants to make a comment about that.
Dr. Hsieh: Yeah, I think there are some innovative things that we are trying to do to repair and heal the disc. And a couple examples of some of these clinical trials investigative approaches are one which is actually a stem cell injection. For someone who has a single level disc disease that we can identify as the most likely source of potential pain generator; these are basically cells that have been harvested from the disc space itself that by our early investigation and research into the topic that these stem cells should be able to implant into the disc and the hope is that these cells can actually help repair the environment of the disc and provide healing of the disc that an accelerated pace compared to the natural healing process.
There is also a type of nerve ablation if you will. It’s ablation. Basically it is applying thermal energy to a specific nerve that is sensing the pain from the vertebrae, from the pathological process and when you ablate and burn those nerves away; it can abate and subside the pain for patients who have symptomatic back pain. Those are just some examples of the clinical trials and investigative approaches into treatment of back pain besides the surgical treatments.
Host: Wow. I really feel like we are living in the future here hearing about some of these treatment options. So, Dr. Liu, in wrapping up here, I wanted to move it back to you. You mentioned that in physical therapy, you have them focus on posture, and things like how to bend over properly; but I want to talk a little bit about prevention. So, how can people think about preventing the onset or minimizing the severity of degenerative disc disease?
Dr. Liu: Yeah, that’s a very good question and I think we are all going to get degenerative disc disease of some form, hopefully we can try to minimize the amount of symptoms, right? So, this is just part of aging. We all have it. Everybody’s got it. And if I imaged everybody that comes to clinic, we all have some disc degeneration but there are things you can do to try to slow down the process and hopefully never need an operation.
These would include, work on your core strengthening and do the physical therapists will teach you how to strengthen your core area. So, you could be in great shape in terms of running and cardiovascular wise, you are doing great, but then your core could be weak. So, do core exercises that help you strengthen your core area. I think that’s very important. Don’t gain weight. Really stay within your ideal body weight. I think that’s another big piece in terms of how to prevent these from getting out of control. So, I think the more excess weight you carry, it will put more strain on your spine. So, try to lower that risk.
Don’t smoke. So, if you are a smoker, you are at a higher risk for having more problems with degenerative disc disease. And because smoking can actually affect the blood flow to the disc itself and so that can potentially be a significant factor in terms of having chronic back pain. And so those are kind of three things that I think we can all do for ourselves.
Being careful with your posture. So everybody has got bad posture, right? So learning what good posture is, how do you bend and twist. There’s a good way to bend, there’s a bad way to bend. So, you just try and limit in terms of your risk for developing more problems in the future. So, if you kind of just keep those things in mind, smoking, your weight, your posture and just try to maintain a good core. Those are all good things to try to prevent this becoming out of control.
Host: All right Dr. Hsieh and Dr. Liu, really appreciate your time today. That’s Dr. John Liu and Dr. Patrick Hsieh, Neurosurgeons at Keck Medicine of USC affiliated with Ridgecrest Regional Hospital. Thanks for checking out this episode of Ridgecrest Regional Hospital Podcast. For more information on the Neurosurgery Spine Clinic at RRH in alliance with Keck Medicine of USC visit www.rrh.org/treatment-care/neurosurgery. If you found this podcast helpful, please share it on your social channels. We would love that. And be sure to check out the entire podcast library of topics of interest to you. Thanks and we will see you next time.
Prakash Chandran (Host): Your spinal discs are like shock absorbers between the vertebrae of your spine. They help your back stay flexible but as you get older, they can show signs of wear and tear and really cause pain. Let’s talk with Dr. John Lui and Dr. Patrick Hsieh, Neurosurgeons at Keck Medicine of USC affiliated with Ridgecrest Regional Hospital.
This is a podcast from Ridgecrest Regional Hospital. I’m Prakash Chandran. So, Dr. Lui, let’s start with you. What exactly is degenerative disc disease?
John Liu, MD (Guest): Well Prakash, this is a very common problem. As you described it, in terms of a shock absorber, right, it’s kind of like the shock absorber in your car. After some wear and tear, that shock absorber can start to wear down and that’s kind of what the shock absorber – a disc is in your spine is the shock absorbers that’s between the bones in your spine and just with typical aging and just kind of daily wear and tear that we all put on our spines; those discs undergo some degenerative changes and most of the time, it doesn’t cause problems. But when it becomes problematic meaning that it causes more pain for people, and they develop other symptoms, that’s when we call it degenerative disc disease.
Host: Understood. And Dr. Hsieh, I want to move over to you. What are some of the symptoms that people experience when they have degenerative disc disease? Dr. Lui mentioned that there’s some wear and tear over time; but when do we really know that it’s getting bad and becoming this degenerative disc disease?
Patrick Hsieh, MD (Guest): Sure, thanks for the question. So, I think that in terms of the wear and tear of the disc spaces, it’s really common with aging and just the duration of the mechanical stress. It really becomes more of a disease when patients are symptomatic and usually the first primary symptom is pain. In your typical mechanical strain or early degenerative disc tears, the pain may only last for a couple days or a couple weeks at most and they tend to get better because your body does have a self-healing process with the degenerative disc process.
But it’s really the patients that have chronic disabling pain that becomes more of a disease process and not only is there pain in some cases but there are patients who develop neurological manifestations of degenerative disc disease that can include weakness, numbness, and loss of function as the result of the disturbances to the nerve roots or the spinal cord.
Dr. Liu: I just want to echo what Dr. Hsieh just said. I think back pain in general is very common, right? So, we all get back pains we get a little too much, lifted too much and usually those are self-limiting, meaning that within a couple of days or a few days it typically gets better. The problem occurs when the times that you want to start thinking about calling your doctor is if the back pain kind of persists and it goes beyond a couple of weeks and that’s the case where typically you may want to notify your primary care physician. The times that we get involved as specialists or spine specialists is when these pains are longer lasting, when they are lasting more than a few weeks or if you start to developing some leg pains or other neurological type of issues and that’s when we get involved.
Host: So, Dr. Hsieh, I want to talk a little bit about the diagnosis process, and I think one thing that I’ve learned here is that there’s constant back pain. I just had back pain recently when I went to the gym. But yeah, you are right, it went away after like two weeks. But if it is persistent and it lasts for around three weeks and let’s say I go into my doctor. Dr. Hsieh talk a little bit about how it is diagnosed.
Dr. Hsieh: Absolutely. So, diagnosis of symptomatic degenerative disc disease generally starts with a physician’s evaluation and in most cases, I think the process starts with a primary care physician but in some cases, it should start with someone who has a little more expertise in evaluation of spine conditions. Now in general, I think the pain symptoms can be separated into two parts or components. There are two parts. The most common symptom of degenerative disc disease is back pain. It localizes to either the neck or the back and as you said in your personal experience, these generally are fairly self-limiting over days to weeks.
Now when symptoms of back pain are more than bearable or if they last more than six weeks; I think that’s really the first time that you should get an evaluation by a physician. But there are some red flags symptoms that you should seek a physician’s advise or a consultation sooner and typically those are the neurological symptoms. The symptoms that lead to weakness, numbness, and as I said earlier, the components of two sides of the pain, it is not just back pain. The other part of the pain is really what we call neurogenically related. And those are typically the pain symptoms that people describe as sciatic like pain where the pain shoots down an arm or a leg from the pinch of the nerve from the degenerative disc disease.
Now again, with pain alone, most of the time you are probably pretty safe for about anywhere from two to six weeks as long as it doesn’t get worse and it’s not associated with weakness or sensation loss.
Host: And Dr. Lui, I’d love to learn a little bit more about the treatment options that are available. Let’s say you go in and you have the evaluation and it is determined that you have something. Maybe talk a little bit first about any nonsurgical treatment options and then we’ve move to the surgical ones.
Dr. Lui: Sure. So, with treatment, we always start off with nonsurgical. Very, very rarely do we actually recommend a surgery right up front. Usually those are for very special occasions where there is some severe nerve compression. But conservative treatment is the most likely is what we are going to do first and when you see your primary care physician, they are likely going to talk to you and do an exam and do some basic imaging and if degenerative disc disease is what we think you have; then typically we will start off with some anti-inflammatory medications. Sometimes if you are having spasms, we may try different medications to try to cut those muscle spasms down. And then physical therapy. So, those are the two most basic conservative approaches. It would be physical therapy to help you to kind of take care of some of the weakness that we all have in our backs and so we try to strengthen some of the muscles around the spine. And teaching you about good posture control and how do you bend and twist and how do you live daily life without causing more problems with your back.
So, medications and physical therapy are the most common nonsurgical options. And then another conservative treatment would be sometimes an injection may be indicated. Usually I don’t necessarily start that right off the bat. Usually we will try to medications and physical therapy first. And medication also includes sometimes we will use some topical patches too, some heat treatment, sometimes little massages and so it’s soft tissue work. But there’s a lot of stuff that we can try in the beginning stages.
Host: Okay and just to elaborate a little bit more maybe Dr. Hsieh you can answer this. Let’s say you try all of those things. You go to physical therapy. You take the medications and it still doesn’t seem to be fixing the problem. Talk a little bit about the surgical options that are available, that you typically do to help cure or minimize the pain of this degenerative disease.
Dr. Hsieh: Sure. So, in general, most of the time, if symptoms last beyond three months while patients may have exhausted all of the conservative treatments that Dr. Liu had described; we can consider surgery in some situations. And it really has to do with whether or not the symptoms can be explained by what we see in terms of the patient’s physical examination as well as typically some type of imaging like an MRI or a CT or CT myelogram and what we’re looking for is the potential pain generator that can explain the patient’s pain or injury that can be fixed with surgery.
And generally, it has to do with either nerve compressions or mechanical instability of the spine and typically, if we have mechanical compression of degenerative disc disease either from a disc herniation or from overgrowth of bone spurs and ligaments; what we do is a laminectomy or a discectomy which is basically removing the portions of the disc or bone spur overgrowth that relieves pressure off the spine. And in cases where there are instability or mechanical disruption of the spine in terms of stability or alignment; then we may have to do something more complex like a spine fusion.
So, there are a number of pathologies that we are looking for but most of the time, what we are looking for is some type of pain generator or disturbances that we can fix if you will or alter with surgical treatments.
Dr. Liu: I would just like to add in terms of additional – there are some alternative types of treatments even before surgical intervention that sometimes people will try. They may gain success and the reason we say alternatives is because these are – sometimes we don’t really have a lot of medical evidence that may be effective, but people still try them and sometimes it’s helpful. And a couple of these would be like acupuncture or chiropractor and a lot of times people have success with their back pains with those modalities. And there are some clinical trials that may be going on. I know Dr. Hsieh is head of a couple of these clinical trials that are ongoing at USC. I don’t know if Dr. Hsieh wants to make a comment about that.
Dr. Hsieh: Yeah, I think there are some innovative things that we are trying to do to repair and heal the disc. And a couple examples of some of these clinical trials investigative approaches are one which is actually a stem cell injection. For someone who has a single level disc disease that we can identify as the most likely source of potential pain generator; these are basically cells that have been harvested from the disc space itself that by our early investigation and research into the topic that these stem cells should be able to implant into the disc and the hope is that these cells can actually help repair the environment of the disc and provide healing of the disc that an accelerated pace compared to the natural healing process.
There is also a type of nerve ablation if you will. It’s ablation. Basically it is applying thermal energy to a specific nerve that is sensing the pain from the vertebrae, from the pathological process and when you ablate and burn those nerves away; it can abate and subside the pain for patients who have symptomatic back pain. Those are just some examples of the clinical trials and investigative approaches into treatment of back pain besides the surgical treatments.
Host: Wow. I really feel like we are living in the future here hearing about some of these treatment options. So, Dr. Liu, in wrapping up here, I wanted to move it back to you. You mentioned that in physical therapy, you have them focus on posture, and things like how to bend over properly; but I want to talk a little bit about prevention. So, how can people think about preventing the onset or minimizing the severity of degenerative disc disease?
Dr. Liu: Yeah, that’s a very good question and I think we are all going to get degenerative disc disease of some form, hopefully we can try to minimize the amount of symptoms, right? So, this is just part of aging. We all have it. Everybody’s got it. And if I imaged everybody that comes to clinic, we all have some disc degeneration but there are things you can do to try to slow down the process and hopefully never need an operation.
These would include, work on your core strengthening and do the physical therapists will teach you how to strengthen your core area. So, you could be in great shape in terms of running and cardiovascular wise, you are doing great, but then your core could be weak. So, do core exercises that help you strengthen your core area. I think that’s very important. Don’t gain weight. Really stay within your ideal body weight. I think that’s another big piece in terms of how to prevent these from getting out of control. So, I think the more excess weight you carry, it will put more strain on your spine. So, try to lower that risk.
Don’t smoke. So, if you are a smoker, you are at a higher risk for having more problems with degenerative disc disease. And because smoking can actually affect the blood flow to the disc itself and so that can potentially be a significant factor in terms of having chronic back pain. And so those are kind of three things that I think we can all do for ourselves.
Being careful with your posture. So everybody has got bad posture, right? So learning what good posture is, how do you bend and twist. There’s a good way to bend, there’s a bad way to bend. So, you just try and limit in terms of your risk for developing more problems in the future. So, if you kind of just keep those things in mind, smoking, your weight, your posture and just try to maintain a good core. Those are all good things to try to prevent this becoming out of control.
Host: All right Dr. Hsieh and Dr. Liu, really appreciate your time today. That’s Dr. John Liu and Dr. Patrick Hsieh, Neurosurgeons at Keck Medicine of USC affiliated with Ridgecrest Regional Hospital. Thanks for checking out this episode of Ridgecrest Regional Hospital Podcast. For more information on the Neurosurgery Spine Clinic at RRH in alliance with Keck Medicine of USC visit www.rrh.org/treatment-care/neurosurgery. If you found this podcast helpful, please share it on your social channels. We would love that. And be sure to check out the entire podcast library of topics of interest to you. Thanks and we will see you next time.