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Welcome to UAB Med Cast, a continuing education podcast for medical professionals. Bringing knowledge to your world. Here's Melanie Cole.

Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we explore the assessment and management of patients with spinal disorders. Joining me is Dr. Mark Hadley. He's the Patsy W. and Charles A. Collat Endowed Chair in Neurosurgery at UAB Medicine.

Dr. Hadley, it's such a pleasure to have you join us today. So if I were a referring physician, how can I get my patients to see you? When is it important to see you for an assessment? And what would you like them to do with their patients prior to that referral?

Mark Hadley: Thank you, Melanie. So I deal primarily with patients with disorders of the spinal cord and spinal column, so spinal disease. So the way to get patients in to see me is to make a referral through either the portal or the call center. We don't need the doctor to do it necessarily. We need someone from the office to provide three or four bits of information to help protect the patient from their insurance company, to be sure we have a referral in place.

What we want to do when the patient initially shows to the doctor, that they have a complaint of neck and arm pain, low back pain, whatever it may be, may be a neurosurgical problem involving the spinal cord or spinal column, we want them to initiate medical management, not wait to see the neurosurgeon before they get started.

Most patients who have spinal disease and do get pain don't have surgical problems. So medical management includes use of oral and topical nonsteroidal agents. Oral agents, such as ibuprofen or Naprosyn and/or maybe a short course of oral steroids, but not a steroid injection. Topical agents are those with aspirin, Aspercreme, Bengay, very potent topical nonsteroidals that can be applied topically for aches complaints, cramping, things of that nature.

We want to get them started in physical therapy and the referring doc should do that. Now people think, "Well, I can't go exercise. I can barely walk because of my leg pain." But that's not what a physical therapist does. Physical therapy will recognize what the troubles are, gets you going and ultrasound, heat, ice, stretching, various other things, and build you up to program that may help recondition your musculature and your neck, shoulder girdle and arms, or your core and torso or your legs.

Wait three, four weeks. Patients usually get better and respond to these aggressive medical management therapies. If not, if they don't get better, that's when we want imaging. And the best imaging of course is magnetic resonance imaging. It allows us to see the neural structures, the actual tissues, the spinal column and any trouble compromising the cervical, thoracic or lumbar, either spinal cord in the cervical thoracic region or nerve roots.

If patients have had previous lumbar surgery, I want to make sure my referring docs know that we need patients who've had previous lumbar, not previous cervical, not previous thoracic, but previous lumbar surgery to get an MRI with and without contrast. That's what we need.

Melanie Cole: That was very comprehensive, Dr. Hadley. Thank you. Now, why are you recommending that they do not have cortisone shots or epidurals at that time?

Mark Hadley: Well, first of all, when we study what is most effective and statistically related to good neuromuscular spine health and its treatment, there are five things that are statistically correlated. First and foremost, chronic smoking's bad, but that's in the long-term. My whole family smoked. We take care of people who smoke and there are some things that chronic smoking hinders in the way of healing or results with spinal surgery. But we don't ignore those patients and we don't want them to be excluded from getting good advice. Remember now we're not looking for people to operate on necessarily each time, we're looking for folks we can advise. And again, if 60% to 70% of folks don't need surgery, we want to get them on that path before we start criticizing about habits.

The next thing is weight. Weight's really important, but you know, large people have trouble too. And so we don't worry about weight when it affects the cervical or thoracic regions. I mean, weight's not great for folks and we know that, but that's the spinal cord there. It's in the lumbar spine, the weight-bearing portion of the spine where weight makes a big difference. So weight reduction is a terrific contribution to the medical management of people with low back pain.

Next is exercise conditioning. Most folks don't have an exercise program. And the strength of the human spine isn't the bones. It's the musculature. And after about age 25, if you're not focusing on your neck, shoulder girdle and arm musculature, if you're not focusing on your core or torso musculature, front, back, sideways, all four quadrants, then you're deconditioned. And therefore, the spine’s going to settle. It's going to have more aches complaints. So those are key principles.

The fourth piece, it's statistically related, we've already touched on. That's oral and topical nonsteroidals. Used regularly, these are not going to cause organ dysfunction, unless there's ongoing organ trouble. In other words, Tylenol, for example, it's processed and metabolized in the liver. So if you've got liver troubles, you know, no Tylenol. Ibuprofen and Naprosyn are metabolized in the kidney. So folks with one kidney or, you know, they generously donated one, kidney disease, these folks shouldn't be on those agents, but everybody else is going to take them. People worry, "Well, taking too much, it's going to ruin my kidneys." You're not going to be on them that long. But in a short course, I mean, athletes use them months and months at a time to help themselves. So that's an important piece.

The final piece to answer your question, and I'm sorry, is that epidural steroid injections were designed, they are given by pain management specialists and it's a big blast of steroids, which by the way, is not good for people. And it's in the epidural space. That means below the bone and above the dura that lines the nerves, the spinal cord, et cetera. These are given to reduce the likelihood of surgery. That's the plan.

In fact, when we've done controlled studies published in big journals, like the New England Journal of Medicine and others, patients who get steroid injections don't have less surgery, they have more and don't do as well. So they're proven negative, although they're very commonly used. And then there's a small percent of patients who get injured by the actual injections themselves.

So that's my approach. I'm not criticizing others who recommend these epidural injections, but that's not the first way to start in my view.

Melanie Cole: Well, thank you for that. So, Dr. Hadley, then if you've tried all this aggressive medical management, you've tried physical therapy, the referring physician has worked with this patient and physical therapy and weight loss and smoking cessation and weight training and anti-inflammatories, all of these things, then what's next?

Mark Hadley: I'm sorry, if someone gets a pinched nerve in their neck and down into their arm, that pinched nerve pinched from only a second or two can hurt for 12 weeks. We don't expect them to hold those patients off for 12 weeks. But what we want them to do, my point is get them started, get them into us at three or four weeks. If it troubles, see them back. "I'm feeling better, doc," well, then keep going. But if they're not feeling better, get that imaging and get them to us.

Our job then is to push them medically if they haven't been through it. And again, the idea is to put them on a medical management course, something consistent, low weight, low impact, but all of those things, non-steroidal, oral and topical agents, exercise conditioning, and maybe some weight control. We make them stop smoking. And if that doesn't work and the imaging demonstrates concordant abnormality on the imaging that fits with their symptoms, their complaints and their examination findings, well, that's when we start to think about potential surgical options. We want to do surgical treatment last, not first. And unfortunately in today's world, surgery gets done right away sometimes when it doesn't necessarily need to be right away.

Melanie Cole: Understood. You made that very clear that they should wait. And so that's really good advice for referring physicians. I'd like to touch on something that you haven't mentioned yet, and that's the psychological aspect of any of these back issues, whether it's lumbar or cervical, the pain, the mobility loss, work, wages or so much that goes into back issues.

So until they get to see you and even after, what is it you'd like them to know about dealing with that portion? Because obviously, Dr. Hadley, some of these other modalities that you're recommending will also help with some of the psychological issues they may have as a result of their back. But what can you tell referring physicians about that aspect?

Mark Hadley: Well, you know, that gets to the point where the referring physician and we have so many in my practice, so many wonderful men and women who send their patients to me and I'm honored. And again, I'm not trying to find patients to operate on. Sometimes it's my turn to advise. If they have a small dilated canal in their spinal cord or a Chiari malformation, these are just various neurosurgical things that don't need surgery. It's a little hard for the family doctor or the intern as the referring physician to make that definitive discussion. And they want to hear it from somebody who deals with this more frequently. And I'm one of those.

So it's good to let patients know, "Look, this is a minor, maybe congenital problem, does not need surgical treatment. Here's how you can best manage that" and allay their fears. We don't want to scare patients. We want to reassure patients. We want to give them confidence.

The other thing I find that having done this now for so many years is this medical plan. This requires patients to engage and participate, not go to therapy two days a week. There's nobody in the planet whoever worked out two days a week and got themselves back in shape, but to learn something from therapy, for example. Get the benefits of the heat, the massage, the ultrasound, the other things, and then training, but then do these things on their own every day.

Patients want to be empowered. They don't know what to do. They'd been told if you slip and fall on the ice, you're going to be paralyzed, or when you get in a minor fender bender. Those things just aren't true. So we educate. We try to, in a very friendly way, be confidants and collaborators with the patient, with their condition and let them know, "Look, this is unlikely to be a permanent problem. And there are ways that we can help."

And patients liked to have something to do to help themselves rather than just sit around and take a pill or get a shot. They want to engage. Most of them do. And many of the patients get globally healthy, globally better with medical management, rather than having to press on to surgery.

The patients we see who are the chronic pain problem patients, the failed back syndrome patients, or either deformity patients, which is very challenging to treat even with surgery, or those who have been treated with surgery and not effectively treated, and we've changed sagittal balance, we've changed the dynamics of spine relative to the pelvis, those are the chronic pain patients and those are real tough to treat. Better not to treat and push hard medically. And then be certain that folks who are performing the surgery are considering the entirety of the spinal column, its dynamics, its balance, its curvature before proceeding with an operation that needs all of those considerations included.

Melanie Cole: That's great advice for referring physicians about dedicated patients and that the outcomes are better. As we wrap up, what would you like the message, the main message of today's podcast to be, Dr. Hadley? For those referring physicians, what would you like them to take away from this? And if there's any exciting research, you'd also like them to know about, now's the time.

Mark Hadley: Well, we'll do the latter later because there are things that we're working on. But first thing is, thank you. You know, we're one of the resources in the region in the United States that is focused on assisting patients with neuromuscular spinal cord, spinal disorders. You got many options there. We take your referrals seriously. We try to get them in a timely way, and then we try to help you manage them.

And when I started this conversation with you, Melanie, I outlined things that if I were a patient and I go to see my doctor, I want my doctor to get me started on the medical management, get me initiated, get things rolling, and then check back. No better? Then I want go see Dr. Melanie Cole or whomever, she recommends IC for my trouble; Dr. Mark Hadley or one of the other clinicians up here.

With that, we've already got the patient with an idea about what can be done for them to help themselves. And then we can help focus their activities, their medical management even further and help design a surgical strategy, preferably more minimal than maximal that will optimize their outcome.

So thanks to the referring folks. We're here to help and help educate, not steal your patients. And we will follow those patients when we become co-managers, co-collaborators in their good health.

Melanie Cole: What a great segment. It was so informative. Thank you so much, Dr. Hadley, for joining us today, and I hope you'll join us again and update us on some of the exciting research in your field.

And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.

That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, you can always visit our website at UABMedicine.org/physician. Please remember to download, subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.