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Disc Disorders: Maintaining a Healthy Back
Dr. John Roberts discusses disc disorders, treatment options available at The Christ Hospital Health Network and when to refer to a specialist.
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Learn more about John M. Roberts, MD
John M. Roberts, MD
John M. Roberts, MD earned his undergraduate degree from Harvard University and his medical degree from the University of Cincinnati. He completed his internship at The Mercy Hospital in Pittsburgh, PA, and his fellowship and residency at the University of Pittsburgh.Learn more about John M. Roberts, MD
Transcription:
Disc Disorders: Maintaining a Healthy Back
Melanie Cole: The spine specialists at the Christ Hospital Health Network understand that every back and neck condition is unique. Through careful evaluation, they identify the source of spine conditions and work with the patient to determine the best course of treatment. My guest today is Dr. John Robert. He’s an orthopedic spine surgeon with the Christ Hospital Health Network. Welcome to the show. Explain a little bit about how the discs in the spine can develop issues and what are some of the most common that you see?
Dr. John M. Roberts, MD: Thank you so much for inviting me to be on the show. The discs are the spacers – the cushions in between the vertebral bodies. In my opinion, they're really the unsung hero of the spine. The disc is the primary shock absorber that absorbs all the daily activities that we put our backs through. The thing that I find so fascinating about our discs is that the blood supply to them vanishes when we’re about seven or eight years old. The disc gets its nutrition and oxygen just through the diffusion from adjacent tissues and fluids, which means understandably that metabolically there's not a whole lot going on in a disc, and there's virtually no repair process. Of course, the people that study the disc very carefully would probably be angry with that statement. There is activity metabolically inside the disc, but really nothing that constitutes a healing process. When you consider that in our day to day life, we probably bend over 12,000 to 15,000 times in a year that I calculated once in an 80-year lifespan without being a runner or an athlete – you're going to walk twice the circumference of the earth – and every time your heel hits the ground, it’s like a miniature shockwave travelling through the discs and it causes damage. It just astounds me that the discs don’t deteriorate at a greater rate than they do.
Having said that, they do go bad. It’s often related to things like obesity, poor conditioning, physical demands, i.e. jobs, that you'll go through. I did a calculation once that if you lift as little as 10 pounds 10 times per hour throughout a 40-hour work week and a 40-year work span, you're going to lift the equivalent of five times the Eiffel Tower, one and a half times an aircraft carrier or five times a railroad locomotive. It's pretty impressive what the disc will go through and most people are fine and most people don't have degenerative problems.
Melanie: What a great explanation. Is there a genetic component to degenerative discs?
Dr. Roberts: Yes. There unquestionably is. Where I see it, unfortunately, is in the younger patients who show up in my office with back pain, and when I say younger, these are people in their 20s and 30s. When it's a genetic predisposition, you won't see just one or two discs that have gone bad – they all will have gone bad. It's a little unfortunate or sad from this standpoint. You can usually identify who these people are from the get-go that they don't have particularly robust discs. Everyone assumes everyone's backs are the same, but they're not. Some people have blue eyes; some people have brown eyes; some people have huge robust discs, which are great shock absorbers and some people are rather dysplastic – that's the term we use for ill-formed – it's just not all there. Those are the people that if you could even get a scout x-ray early in their life, you'd say you should not work in a heavy physical job, you should not play high impact sports, you shouldn't be playing soccer, volleyball, and things like that. But unfortunately, because of the radiation and exposure, we tend not to take those survey x-rays and I end up seeing the patient once the horse is out of the barn sort of speak when the discs have failed and the patients come in with quite a bit of mechanical pain.
The treatment for it at that point is challenging because you don’t want to put a younger patient through a big spine operation. We’ll have them lose weight, do core exercising, flexibility and that sort of thing, and that buys you some time – it doesn't make you grow back new discs. I think that there's a huge future opportunity here for science to figure out how we can use stem cell research to rejuvenate the discs. The underlying problem though is that without a blood supply, the discs are relatively inert, so somehow, we have to learn how to turn on the blood supply to the disc. If we can do that, then I think stem cell research has a huge opportunity in regenerating the discs in some of these patients. For the moment, we simply don’t have that skill or expertise.
Melanie: What are some of your most valuable prognostic tools to aid in early diagnosis of some of these issues?
Dr. Roberts: To really catch it early means that MRI scanning is wonderful. It shows us so much information. If a younger person has an acute injury back pain and we obtain an MRI and we can identify that they're one of these individuals at risk, that’s always a good prognostic sign that you can try and change their lifestyle before they really get into trouble. The biggest thing is just as I was saying earlier that you really want people to keep their weight down. There's no question that obesity is one of the major contributing factors to disc failure. Muscle toning is another. A third thing, which is really not spoken of, is cigarette smoking. There is a very definite correlation between disc degeneration and smoking. It's rather ill-defined at the moment. It's a combination of ingestion of the nicotine – we're not quite sure how that works – and there's a very clear correlation between your carbon monoxide levels. As I said, on a good day, a disc is struggling to get oxygen without a direct blood supply, so it gets it from the surrounding tissues, and if you are a fairly habitual and strong smoker, your body is filled with carbon monoxide. The disc is just starving for air and it really accelerates the failure of the discs.
Melanie: Speak about your first line of defense once you determine what's going on if you're working with the patient as far as medications or injections and when does it become surgical.
Dr. Roberts: In the early stages, we'll work on core strengthening, weight loss, and flexibility. It's rather amazing how tight most people's hamstrings are. To me, the hamstrings are the strongest muscle group in the body, and if you have a sedentary job or you're traveling quite a bit, your hamstrings will naturally become tight. The tight hamstrings basically enter a tug of war with your back. It puts a lot of strains on the muscles, a lot of strain on the disc, so one of the very early steps in dealing with this is making sure the patient is flexible. We'll send them through a round of therapy, I believe very strongly in either Pilates or yoga, to help overcome the stiffness, and that very often will eliminate much of the back pain.
Of course, we always use a combination of anti-inflammatories, muscle relaxers, and that's just a temporary thing. As time goes on, let's say the patient's disc is already destroyed and they go on and have increasing mechanical back pain, the way I would describe this problem is that it begins with periodic episodes of back pain that are usually self-limited, will quiet down over time, and the patients will tell me that their episodes come more often, last longer, and take longer to resolve. Eventually, pretty soon, they're dealing with a degenerative disc pain that's with them 24/7. Their typical scenario or description of their pain when it reaches that end-stage is they'll awaken with tremendous back pain in the morning; that's because while they're asleep, the muscles aren't supporting the back in any fashion. Once they get up on their feet and they're mobile, just the hydraulic effect of the muscles pressing in on the abdomen support the back, patient will feel better, and then as the day goes on, the pain will intensify to where they come home from work and they sit in the couch recliner just because it hurts too much to do anything. Of course, we always try the rehab, the strengthening, the muscle relaxers, and anti-inflammatories, but there's a point beyond which their pain just becomes intolerable. At that point, that’s when you consider surgery.
We do have disc replacements on the market. The catch 22 is the disc replacement is only of value if you can catch the disc degeneration before they have secondary degenerative changes in the facet joints at that level. The disc replacements are really only indicated for a single level disease. Usually, by the time the patient gets to me as a spine specialist, they've been the gamut through therapy, they have arthritic changes that are secondary, and we end up doing spine fusions on those individuals once they've gotten to that point.
Melanie: What's life like for the patient after something such as a spinal fusion?
Dr. Roberts: It depends dramatically upon the age of the patient, the health of the patient, the physical status of the patient, and also the number of levels that are fused. I have patients that are playing collegian football that has had single level fusions for congenital problems. It's a little different from someone with a degenerative disc. When you do a single level fusion for degenerative disc disease, most of the patients really don't notice any less motion or activity level. They're free to go back to just about everything, with one exception. One thing I'll point out. It always frustrates me when I hear about a celebrity from TV or radio who has, for instance, a hip or knee replacement and they're promoting they're jogging in a marathon. To me, that's ridiculous. The reason to go through these procedures is God forbid so you never have to have anything else done. Why put it at risk by going out and running in a marathon?
I think that the goal of an operation like a joint replacement or a spine fusion is to allow the patients to live a happy, successful life, but taking down their activities a notch or so. By taking it down a notch or so, with a spine fusion, even if it’s a single level, unless it’s a congenital problem, I’ll usually advise the older patients to stay away from running sports and racket sports; focus on low impact core strengthening and flexibility and try to avoid ever having any more surgeries. On the other extreme, we’re seeing quite a few patients in their 70s, 80s, even 90s, who come in and they're frustrating they can't walk 18 holes of golf or they can't carry their golf bag. Well, I take my hat off to them, but we’re really facing a fairly healthy older generation, and when their backs go back and you need to do a fusion, it’s usually a much more involved process, and the same rules would apply. Once it’s fixed, you're not doing it so they can play 18 holes of golfs; you're doing it so they can enjoy the remainder of their life and hopefully have no other problems.
Melanie: What about above and below where you fused? Do you see issues coming on down the line with the discs that are above or below what you fused?
Dr. Roberts: We do and we call that transitional segment disease. It is a very real phenomenon. It probably occurs at a rate of about 18% of all patients in whom you do a fusion. There are several factors that really dictate the likelihood of adjacent segment disease. One would be obesity, one would be failure to do their core exercises going forward, one would be the longer the fusion the greater the stress you're transferring and the greater the likelihood of the transfer stress and degenerative change, and something else that we’re really focusing on today is that it is critically important when you do a fusion to reestablish the normal contour of the spine, that the lumbar lordosis roughly equals the equal and opposite thoracic kyphosis – the zig equals the zag. When you do a fusion, it’s very important to recreate that sagittal alignment so that the person has normal alignment and you're not concentrating or focusing stress on a misaligned level that’s not part of the fusion.
Melanie: That’s a good point. Thank you for making that. What does current research indicate for future developments in treatments? Give us a little blueprint for future research and spinal treatments.
Dr. Roberts: As I said, with stem cell treatment, we need to learn how to develop a blood supply in the disc again and then that will open that whole realm of treatment. From a surgical standpoint, we're certainly moving towards minimally invasive surgery with the use of robotics. We use robotics now in screw placement and that is certainly improved the precision of what it is that we do. We are using custom-made 3D printed carbon cages, which we put in through the front, through an abdominal approach, and that helps us to reestablish the normal contour of the spine. That's been a tremendous development in improving a person's post-operative function and diminishing the likelihood of that transfer stress that I talked about if the doctor does a fusion and does not establish the normal anatomic curves.
Melanie: In summary, please tell other physicians what you'd like them to know about disorders and when to refer to a specialist.
Dr. Roberts: I think it's very important to focus on weight loss through whatever safety measures, core strengthening, cessation of smoking, I think that physical therapy, as I said for core strengthening, hamstring stretching is vitally important, and I believe Pilates and yoga are also great adjuncts in treating degenerative problems. I think that the referral to a specialist should take place when just very simply you ask the patient how much is this impacting your lifestyle – are you missing days from work, are you able to function at home, is there stress in the family because your back hurts so much and you're not being a functional member of the family? When it's beginning to impact all those elements of one's lifestyle, I think it's time to get more information and perhaps come up with a more definitive treatment plan.
Melanie: Thank you so much for being with us today. You're listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Roberts and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
Disc Disorders: Maintaining a Healthy Back
Melanie Cole: The spine specialists at the Christ Hospital Health Network understand that every back and neck condition is unique. Through careful evaluation, they identify the source of spine conditions and work with the patient to determine the best course of treatment. My guest today is Dr. John Robert. He’s an orthopedic spine surgeon with the Christ Hospital Health Network. Welcome to the show. Explain a little bit about how the discs in the spine can develop issues and what are some of the most common that you see?
Dr. John M. Roberts, MD: Thank you so much for inviting me to be on the show. The discs are the spacers – the cushions in between the vertebral bodies. In my opinion, they're really the unsung hero of the spine. The disc is the primary shock absorber that absorbs all the daily activities that we put our backs through. The thing that I find so fascinating about our discs is that the blood supply to them vanishes when we’re about seven or eight years old. The disc gets its nutrition and oxygen just through the diffusion from adjacent tissues and fluids, which means understandably that metabolically there's not a whole lot going on in a disc, and there's virtually no repair process. Of course, the people that study the disc very carefully would probably be angry with that statement. There is activity metabolically inside the disc, but really nothing that constitutes a healing process. When you consider that in our day to day life, we probably bend over 12,000 to 15,000 times in a year that I calculated once in an 80-year lifespan without being a runner or an athlete – you're going to walk twice the circumference of the earth – and every time your heel hits the ground, it’s like a miniature shockwave travelling through the discs and it causes damage. It just astounds me that the discs don’t deteriorate at a greater rate than they do.
Having said that, they do go bad. It’s often related to things like obesity, poor conditioning, physical demands, i.e. jobs, that you'll go through. I did a calculation once that if you lift as little as 10 pounds 10 times per hour throughout a 40-hour work week and a 40-year work span, you're going to lift the equivalent of five times the Eiffel Tower, one and a half times an aircraft carrier or five times a railroad locomotive. It's pretty impressive what the disc will go through and most people are fine and most people don't have degenerative problems.
Melanie: What a great explanation. Is there a genetic component to degenerative discs?
Dr. Roberts: Yes. There unquestionably is. Where I see it, unfortunately, is in the younger patients who show up in my office with back pain, and when I say younger, these are people in their 20s and 30s. When it's a genetic predisposition, you won't see just one or two discs that have gone bad – they all will have gone bad. It's a little unfortunate or sad from this standpoint. You can usually identify who these people are from the get-go that they don't have particularly robust discs. Everyone assumes everyone's backs are the same, but they're not. Some people have blue eyes; some people have brown eyes; some people have huge robust discs, which are great shock absorbers and some people are rather dysplastic – that's the term we use for ill-formed – it's just not all there. Those are the people that if you could even get a scout x-ray early in their life, you'd say you should not work in a heavy physical job, you should not play high impact sports, you shouldn't be playing soccer, volleyball, and things like that. But unfortunately, because of the radiation and exposure, we tend not to take those survey x-rays and I end up seeing the patient once the horse is out of the barn sort of speak when the discs have failed and the patients come in with quite a bit of mechanical pain.
The treatment for it at that point is challenging because you don’t want to put a younger patient through a big spine operation. We’ll have them lose weight, do core exercising, flexibility and that sort of thing, and that buys you some time – it doesn't make you grow back new discs. I think that there's a huge future opportunity here for science to figure out how we can use stem cell research to rejuvenate the discs. The underlying problem though is that without a blood supply, the discs are relatively inert, so somehow, we have to learn how to turn on the blood supply to the disc. If we can do that, then I think stem cell research has a huge opportunity in regenerating the discs in some of these patients. For the moment, we simply don’t have that skill or expertise.
Melanie: What are some of your most valuable prognostic tools to aid in early diagnosis of some of these issues?
Dr. Roberts: To really catch it early means that MRI scanning is wonderful. It shows us so much information. If a younger person has an acute injury back pain and we obtain an MRI and we can identify that they're one of these individuals at risk, that’s always a good prognostic sign that you can try and change their lifestyle before they really get into trouble. The biggest thing is just as I was saying earlier that you really want people to keep their weight down. There's no question that obesity is one of the major contributing factors to disc failure. Muscle toning is another. A third thing, which is really not spoken of, is cigarette smoking. There is a very definite correlation between disc degeneration and smoking. It's rather ill-defined at the moment. It's a combination of ingestion of the nicotine – we're not quite sure how that works – and there's a very clear correlation between your carbon monoxide levels. As I said, on a good day, a disc is struggling to get oxygen without a direct blood supply, so it gets it from the surrounding tissues, and if you are a fairly habitual and strong smoker, your body is filled with carbon monoxide. The disc is just starving for air and it really accelerates the failure of the discs.
Melanie: Speak about your first line of defense once you determine what's going on if you're working with the patient as far as medications or injections and when does it become surgical.
Dr. Roberts: In the early stages, we'll work on core strengthening, weight loss, and flexibility. It's rather amazing how tight most people's hamstrings are. To me, the hamstrings are the strongest muscle group in the body, and if you have a sedentary job or you're traveling quite a bit, your hamstrings will naturally become tight. The tight hamstrings basically enter a tug of war with your back. It puts a lot of strains on the muscles, a lot of strain on the disc, so one of the very early steps in dealing with this is making sure the patient is flexible. We'll send them through a round of therapy, I believe very strongly in either Pilates or yoga, to help overcome the stiffness, and that very often will eliminate much of the back pain.
Of course, we always use a combination of anti-inflammatories, muscle relaxers, and that's just a temporary thing. As time goes on, let's say the patient's disc is already destroyed and they go on and have increasing mechanical back pain, the way I would describe this problem is that it begins with periodic episodes of back pain that are usually self-limited, will quiet down over time, and the patients will tell me that their episodes come more often, last longer, and take longer to resolve. Eventually, pretty soon, they're dealing with a degenerative disc pain that's with them 24/7. Their typical scenario or description of their pain when it reaches that end-stage is they'll awaken with tremendous back pain in the morning; that's because while they're asleep, the muscles aren't supporting the back in any fashion. Once they get up on their feet and they're mobile, just the hydraulic effect of the muscles pressing in on the abdomen support the back, patient will feel better, and then as the day goes on, the pain will intensify to where they come home from work and they sit in the couch recliner just because it hurts too much to do anything. Of course, we always try the rehab, the strengthening, the muscle relaxers, and anti-inflammatories, but there's a point beyond which their pain just becomes intolerable. At that point, that’s when you consider surgery.
We do have disc replacements on the market. The catch 22 is the disc replacement is only of value if you can catch the disc degeneration before they have secondary degenerative changes in the facet joints at that level. The disc replacements are really only indicated for a single level disease. Usually, by the time the patient gets to me as a spine specialist, they've been the gamut through therapy, they have arthritic changes that are secondary, and we end up doing spine fusions on those individuals once they've gotten to that point.
Melanie: What's life like for the patient after something such as a spinal fusion?
Dr. Roberts: It depends dramatically upon the age of the patient, the health of the patient, the physical status of the patient, and also the number of levels that are fused. I have patients that are playing collegian football that has had single level fusions for congenital problems. It's a little different from someone with a degenerative disc. When you do a single level fusion for degenerative disc disease, most of the patients really don't notice any less motion or activity level. They're free to go back to just about everything, with one exception. One thing I'll point out. It always frustrates me when I hear about a celebrity from TV or radio who has, for instance, a hip or knee replacement and they're promoting they're jogging in a marathon. To me, that's ridiculous. The reason to go through these procedures is God forbid so you never have to have anything else done. Why put it at risk by going out and running in a marathon?
I think that the goal of an operation like a joint replacement or a spine fusion is to allow the patients to live a happy, successful life, but taking down their activities a notch or so. By taking it down a notch or so, with a spine fusion, even if it’s a single level, unless it’s a congenital problem, I’ll usually advise the older patients to stay away from running sports and racket sports; focus on low impact core strengthening and flexibility and try to avoid ever having any more surgeries. On the other extreme, we’re seeing quite a few patients in their 70s, 80s, even 90s, who come in and they're frustrating they can't walk 18 holes of golf or they can't carry their golf bag. Well, I take my hat off to them, but we’re really facing a fairly healthy older generation, and when their backs go back and you need to do a fusion, it’s usually a much more involved process, and the same rules would apply. Once it’s fixed, you're not doing it so they can play 18 holes of golfs; you're doing it so they can enjoy the remainder of their life and hopefully have no other problems.
Melanie: What about above and below where you fused? Do you see issues coming on down the line with the discs that are above or below what you fused?
Dr. Roberts: We do and we call that transitional segment disease. It is a very real phenomenon. It probably occurs at a rate of about 18% of all patients in whom you do a fusion. There are several factors that really dictate the likelihood of adjacent segment disease. One would be obesity, one would be failure to do their core exercises going forward, one would be the longer the fusion the greater the stress you're transferring and the greater the likelihood of the transfer stress and degenerative change, and something else that we’re really focusing on today is that it is critically important when you do a fusion to reestablish the normal contour of the spine, that the lumbar lordosis roughly equals the equal and opposite thoracic kyphosis – the zig equals the zag. When you do a fusion, it’s very important to recreate that sagittal alignment so that the person has normal alignment and you're not concentrating or focusing stress on a misaligned level that’s not part of the fusion.
Melanie: That’s a good point. Thank you for making that. What does current research indicate for future developments in treatments? Give us a little blueprint for future research and spinal treatments.
Dr. Roberts: As I said, with stem cell treatment, we need to learn how to develop a blood supply in the disc again and then that will open that whole realm of treatment. From a surgical standpoint, we're certainly moving towards minimally invasive surgery with the use of robotics. We use robotics now in screw placement and that is certainly improved the precision of what it is that we do. We are using custom-made 3D printed carbon cages, which we put in through the front, through an abdominal approach, and that helps us to reestablish the normal contour of the spine. That's been a tremendous development in improving a person's post-operative function and diminishing the likelihood of that transfer stress that I talked about if the doctor does a fusion and does not establish the normal anatomic curves.
Melanie: In summary, please tell other physicians what you'd like them to know about disorders and when to refer to a specialist.
Dr. Roberts: I think it's very important to focus on weight loss through whatever safety measures, core strengthening, cessation of smoking, I think that physical therapy, as I said for core strengthening, hamstring stretching is vitally important, and I believe Pilates and yoga are also great adjuncts in treating degenerative problems. I think that the referral to a specialist should take place when just very simply you ask the patient how much is this impacting your lifestyle – are you missing days from work, are you able to function at home, is there stress in the family because your back hurts so much and you're not being a functional member of the family? When it's beginning to impact all those elements of one's lifestyle, I think it's time to get more information and perhaps come up with a more definitive treatment plan.
Melanie: Thank you so much for being with us today. You're listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Roberts and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.