Cancer Of The Spine

(theme music) - thank you everybody for coming. usually i see some of my patients, they don't get enough of me so they like to show up again for more stuff. yeah, there's one, right here. so anyway. i want to talk aboutsome minimally invasive spine surgery today.

it's my professional interest. it's certainly somethingi like talking about. the talk, you have little bits and pieces of it in there, itruncated it a little bit so we could have a little bit of time to answers some questions between the talk on some of this and the spine model, hopefully we can educate you guys on some of the problems and pathology

in your back and so forth. so, when we talk about surgery, it's all about your quality of life. most of the stuff i dois elective surgery. you don't have to have it. you do it because your life is not good because you suffer from pain or some type of disability and what is that pain doing? it's preventing you from doing some things

that you want to do. maybe it's something simple like spending time with your grandchildren. maybe it's other things like you just want to shovel some snow, or do some housework, oreven just do the dishes. i have a lot of patients, all they want to do is just cook a meal and they can't do that.

other people, maybe they just want to go on vacation. i've got a lot of cruisers in my practice. they just want to go on cruises, and some of them have so much pain, they come in and they tell me, "we didn't "even leave the boat." that's not what anybody wants out of life. you shouldn't pay several thousand dollars

to never leave the boatbecause you hurt so much. as far as an introduction,we're going to talk a little bit about the anatomy of the spine, primarily the lumbar spine. that's what most people suffer from. it's probably betterthan 80% of my practice. we'll talk about some of the pathology, you've probably heard aboutsome of these sayings. spinal stenosis, disc herniations,

this long word, spondylolisthesis. and then we'll talk about some alternative treatment options. many of you have probably already had some of the nonoperative optionsand we'll go over those, and that would include the minimally invasive spine surgery, which is my professional interest, and then something called aninterspinous process device,

which maybe if you had a back problem five or eight years ago, they would have recommended something called the x stop. that's what that is. i'm going to show you why that worked, just more from a historical perspective i think it's sort of interesting. so here's the spine, right? when it's out of the body.

cervical, thoracic, and lumbar spine. most people complainabout the problems here in the low back, and we'll focus, again, our talk on that. there are five lumbar vertebrae labelled one through five. so if you have a l1-2 problem, it's these top vertebrae. this is l5, this is s1,so this is l5 and s1.

this is as side view if someone was taking a picture through the side, and this is looking at you back to front. this is what it would look like. this is your sacrum. and this is an actual vertebra. this is looking at it from the side, and this is actuallylooking from the top down. so if we, we look at thisagain, is that side view.

that's what you're looking at there. and then this is the vertebra top view. this would be lookingat it like that, okay? so you see, and the reasoni have this here is, it's all about these holes, okay? we see this hole here. all of the nerves, okay,they start in your brain and they go down a tube. the brain terminates as the spinal cord,

the spinal cord will godown this central hole. that's called your spinal canal. then eventually this spinal cord stops and then it's just abunch of stringy nerves that go down into your legs, okay? so we want this hole to be very big. we want lots of room for the nerves. we're all familiar withthe term pinched nerve? it's because something is in that hole.

maybe it's a discherniation or a bone spur or a tumor, okay? the other hole thatwe're concerned about is this hole. this one, in between here, that's called the foramen. we'll go over this many times. because it's importantfor you to understand. it's all about these holes and how big

these holes are, okay? looking at other things. again, this is a side view of the spine. you see that center hole with all the nerves that come down from the brain? and then these sideholes as the nerve exits. look at the holes here. and again, these holesare called the foramen. the foramen intervertebrale.

that nerve's coming out of here. look at the proximity of this hole to this disc. this disc is what isin between those bones. it's the shock absorberin between these bones. that is a mobile part andallows for motion, okay? and if this discherniates, what that means is some of this cushionis now touching one of those nerves and nowthe hole is smaller.

and that means the nerve is being pinched. so it's all about these holes. it's also about bone spurs. there are these small joints back here called facet joints. maybe you guys have heard this, maybe you've had rhizotomies, or some doctor has "burned the nerves." they're usually burning the nerves

to these small joints in the back. those are called facet joints. but if i get a bone spur because i develop arthritis off this, it's going to touch that nerve and narrow the hole. does that make sense? so definitions. everybody comes in, theysay they have sciatica. we don't use the wordsciatica in spine surgery.

we use the term radiculopathy. but we're talking about the same thing. radicular pain meanspain that's just shooting down the leg. you call it sciatica, wecall it radiculopathy. and then, stenosis. everybody's got that,everybody's got stenosis on their mri. all stenosis means is pinching.

it's a simple word for pinching. so if you have pinching,you have stenosis. we talked about those holes. so if something's in the holes, maybe it's bone spurs, maybe it's a ligament that's too big because it's worn out, maybe it's a disc herniation,maybe it's a tumor, or whatever it is, allof that causes stenosis. so somebody said to metoday in the office,

"well i have a herniation,but what about the stenosis?" it's the same thing. the herniation is causing pinching, pinching is the stenosis. very simple. big words. silly words, that's what it means. so the aging spine. this is what most of the problems

that i deal with are patients whose spine simply is just getting old. and i use this dog here, and all of its wrinkles because one of my mentors at georgetown, when i was in a room with him and he was examining a patient and the patient said, "doctor, why do i have this stenosis? "why do i have these bone spurs?"

and he says, "you see thosewrinkles on your face, "these are the wrinkles on your spine." and now i use that term in my office, i stole that from him. that's not a wagener original. i use that term because it's true, and i say "you earnedall those bone spurs, "you earned all those wrinkles." whether it's from having a tough job

or a tough life or maybe parents that just passed it down to you, but you earned it. but what happens in thespine as we get older, what happens is, these discs, they're not so tall anymore, they degenerate. they do that, the first thing that happens is you lose water. then there's a changein chemical composition.

it's not the same cartilage in there, it's not the same stuff, so they start to shrink. that's why you get shorter. then you lose the disc height, you lose some cartilage, what happens, and this is a little bit complicated, but bare with me, there are joints in the front and at the same level,

there are joints in the back. if i lose the joint in the front, there's more pressure on the joints in the back because theyall work together, okay? so if i lose this, then all of a sudden these facet joints, wetalked about those before, those will start to takeup more of the stress. then you lose the cartilage, then you get abnormal motion, then extra bone forms.

people always talk about bone spurs and you're not used to hearing about them in the back, but most of you can look down at yourhands as we get older, depending on genetics and occupation and trauma, and all sorts of other things, this is what happens. you lose cartilage, youget abnormal motion, and then your body doesthis amazing thing,

it forms bone to stiffen up the joint so that you can keep on using it. these bone spurs are fine in the hand, no one cares about them. they don't look good, youcan't get your rings off, but it doesn't pinch nerves. in the spine, imagine if we had those same bone spurs right here. plugging a hole, then we'regoing to get leg pain,

and that's what happens. we're all used to seeing the knobby knees, i saw a patient today, true story. he was asking about his arthritis, "what do you mean i have arthritis?" and his knees were showing and i said to his wife, "you didn'tmarry those knees, did you?" she goes, "i've been married for 54 years, "no i did not."

they look different, they were full, they were knobby knees, theywere full of bone spurs. why? you lose cartilage, abnormal motion, the body doesn't like the abnormal motion, it forms bone. so here's the spinal degenerative cascade that we all know about and it's either going to occur at the discor at the facet joints.

we talked about the discs being connected to the facet joints,that front-back motion segment of the spine, and you either will have a facet joint problem or a disc problem, but it all leads to this here, which isage-related changes, dysfunction, herniation, instability, nerve entrapment becauseyou're getting clogged with those holes and then,

stenosis leads to poor quality of life. and here's this time lapse here of this lady, she's walking upright, and then she has problems,she needed to use the shopping cart, and now she's just stuck in the chair, because that's the only place that feels good, when she's sitting in the chair. that maybe you, maybe not.

there are other problemswhere you don't like to sit, like some disc herniations, you hate to sit. here's another picture of the spine. again, this is a cross section, if someone just took a real spine and just cut it right in half, you can see these are big, healthy discs. these are what some ofyour discs look like.

maybe what mine looks like. degenerative, we're shrinking. it's tough to stop the process. this is spondylolisthesis. some of you, i am sure, suffer from spondylolisthesis. and what that means, what that is is one vertebra has moved relative to the other one.

it has slipped. so spondy means vertebra andlisthesis means slippage. so the vertebra has slipped. so if i have all these holes, okay, you can see that here by the way, if i have a hole, even the major tube that goes down, at l4 and another tube of l5 and one slipsrelative to the other one, the hole gets smaller.

do you agree? it's true, i promise. that's what happens. then you get leg pain. you get those symptoms of stenosis or radiculopathy. you can see that here. you can see one bone's slipping relative to the other one, it gets this kink.

all the nerves are going down this tube and you get a kink there, and that hurts. again, all about the holes. here's another picture. nice beautiful spine. i wish mine looked like this. look how big these discs are. everybody would love tohave a spine like this. in this area here, this isthe end of the spinal cord.

these are all the nerves. god was very kind to this person, gave him a huge hole. we're all born withdifferent size holes, okay? the tube for our nerves. some people are born with really big ones. this person very blessed with how big this hole is, okay? all those nerves arehappy, but if something

were to come from here and go into this area where the nerves are, it's going to hurt. this is a less fortunate person, right? where this is beingclogged by the bone spurs and herniations and so forth. and if we take that same spine, and we cut them up,these are mri pictures, by the way, okay?

when we look at mris as physicians, we look at picturescutting you up this way, and we look at picturescutting you up like this way, like a loaf of bread. these are called axial images. and this is, we're looking at it like this and in our minds assurgeons and physicians we piece together thesetwo sets of 2d images, two-dimensional images, tomake a three-dimensional

image in our mind. and this is looking athere and you can see that big tube, these are happy nerves, that's what i call them in the office. nerves just floating around in fluid. the fluid is good, we wanta lot of spinal fluid. these are happy nerves, but when you get arthritis, these joints here in theback, the facet joints,

they start forming bone spurs and these are less happy nerves. for all the reasons that we talked about. this is a ct scan, someof you may have had a ct scan before, i get a lot of ct scans, and you can see this is that tube there, and here is the tube, lookat these big bone spurs here. those bone spurs are not benign like the ones on your hand,they're touching things.

so what does it all mean, this sciatica, stenosis, spondylolisthesis,pinched nerves, and bone spurs, it leads to arm pain or leg pain depending on where the stenosis is,disability and dysfunction, and it disrupts your life. now we're going to talk a little bit about the disc herniation, stenosis and spondylolisthesisand a little bit more

as far as the clinical presentation. here's stenosis. here's my friend with stenosis. i saw about 15 peoplethat looked just like this today, it's the same story over 60 years old. it didn't start one day, it started over the course of manydays or months or years, and then they just start walking more

and more like this. the wife comes in and she says, "make him stand up straight. "i always tell him he'snot standing up straight." it's always the wives,i'm not really sure, but they're always critical,"stand up straight." and i have to tell them, "he can't." well i'm going to tell you why he can't, but he can't stand up straight.

they usually have backpain with some buttock pain or some leg pain, morningstiffness and aching related to that arthritis, it feels better if they lean forward. it's worse if you lean back. then there's that shopping cart sign, they can't walk very far if they have to walk upright, but if theyget in the grocery store and they grab that cart they can go.

and there are reasons for all this and we'll go over that. degenerative spondylolisthesisis a condition, is a deformity of the spine,but it causes stenosis. so spondylolisthesis causes stenosis and you can see all those tubes of nerves and this is where theproblem is going to be, right there. that's where the nerves are being pinched.

and these people, they'retypically a little bit younger, there's apredisposition for women, i operate on far more women than men for this problem, and theymight be a little heavier, and it almost always is between l4 and l5, almost always, degenerativespondylolisthesis. we do a history andphysical in the office. we'll figure out that localized pain area. they usually don't liketo be in extension.

this is what we call extension, this is flexion. they usually have aforward flexed posture. it's important to do adetailed neurological exam to make sure that everything works right. and then vascular exam. people, they wear out their backs but they also wear outtheir blood vessels. and the blood vessels bring blood, oxygen

to the legs, so in some patients, it looks like they have stenosis, they can't walk far, their legs hurt. but in point of fact, they really have a blood vessel problem. they're not gettingenough oxygen to the legs because the blood vessels are stenotic, they're pinched. so we gotta make sure, in some people,

that there's not two things going on. because a lot of times, olderfolks, they have stenosis in the low back, but they also can have peripheral vasculardisease and you wouldn't want to operate on aback if the real problem was coming at the levelof the blood vessel because you simply weren't getting enough oxygen to the blood vessels. we also do a gait evaluation,

and the other thing is hip osteoarthritis. a lot of times patients will complain they can't walk far andthey have this buttock pain, sometimes it radiateseven into their thigh, and they'll have stenosis, or pinching, in the low back, or inthe low back on mri, and the whole time itwas, maybe they had some pinching in the back, but the real problem was a hip osteoarthritis.

i can't tell you how manytimes i've seen someone who had a low backoperation but they needed a hip problem or visa versa. they had their hipreplaced, in point of fact it was coming fromtheir back all the time. the reality is, when youget to be 65 years old, some of you are over 65,you don't have one problem. the days of one problem,those are long gone, those happened decades ago.

when you're 30, you've got one problem. when you're 60 or 70, you've got 10. and there might be a primary problem, but we just kind of chip away at. you're a project. you guys keep the lights on here at coordinated health. that's what i say. but all these parts, they wear out,

we're not meant to live this long, right? we're not meant to liveto 70 and 80 years old. i never dreamed that i would be operating on 80-year-old people. we weren't in my training10 or 15 years ago. 80-year-olds weren'tgetting back operations. you'd be surprised how many 80-year-olds, every week we operate on 80-year-olds because they want to get around.

they've got stuff to do, right? so the studies we get. you'll get some x-rays in the office if you haven't had them. some people get ct scans to evaluate for some of this pinching and stenosis, an mri, and sometimes they'll come in with what's called an emg or nerveconduction velocity test to help pinpoint where the pathology is.

we looked at those mris before, again, you can see thisis where the nerves are, major problem right here,and a little bit here, and a little bit here, that's stenosis. that's what it looks like on an mri. mri looks at the soft tissues more than it looks at the bone. almost everybody wants an mri if they can, and those are those axial cuts

we looked at before, again stenosis. the natural history. what that means is what if we did nothing? we just took a bunch of patients and we followed them with spinal stenosis. what would happen? would they get worse,would they get better? we would they end up in a wheelchair, as some doctors suggest?

and the reality of itis most don't get worse, most don't get better. they just stay the same. i guess that's good news, right? if you're okay with how you're living. but most don't get worse. everybody's worried that they're going to be in a wheelchairor something like that. i don't get excited about stuff like that

for your standard,run-of-the-mill stenosis. the reality is most don't get worse. you're not going to get better, but you're not going to get worse. what about a disc herniation? this is typically ayounger crowd of people. it can be, we've seen it, i think i did a disc herniation on someone in their 80s, but generally 80-year-oldsdon't have discs

like a 20-year-old. they don't have those big, juicy discs like we saw earlier. they have degenerated discs, they don't have this watery, gelatinous disc, so theydon't get disc herniations. they get the bone spursand things like that. so usually it's a 20- to 40-year-old. usually they just wake up and there it is.

it's god's gift for you for the day and it can present as back pain, but it's primarily leg pain. you can see this disc coming in and touching these nerves. generally there's not a problem with bowel and bladder function, but for an enormous disc herniation, you can have a problem with that.

most of them, they like to stand. that's my experience, they hate to sit. a true hot disc, you know right away because you walk in theroom and they're standing in the corner, even if they have to wait for me for quite some time. they're standing. it's not because they're bored, they don't want to sit.

sometimes if they cough or sneeze, it can cause that lightningbolt type of pain in their leg. and again, here's anotherpicture of that mri, you guys are going to be experts. look at these happydiscs, all full of water. this kind of bright signal, and look at this big disc. this is a very, very unhappy person, i promise you and theymay come in like this.

they don't want to be towards the side of their pain. they may have some numbness or weakness, and we've gotta workthose up with an x-ray and an mri. another example of a disc herniation. this is that axial cut, you can see that clear-cut disc herniation there. the treatment for allof this general stuff,

we almost always, unlessthere's a reason to operate, start you out with antiinflammatories, or something like that. sometimes you'll take oral steroids, that six pills, five pills, four pills, many of you have probablybeen on that before. we like to send people for therapy, for stretching, conditioning,strengthening of posture. sometimes we'll give people braces.

we'll send you to physical therapy for what's called a tensunit, it's an electrical stimulation unit, sometimesthat can be helpful. we modify your activity. if you have a real bad disc herniation, i shut you down, don't have you pick up anything more than five or 10 pounds if it's an acute disc,especially if it's extruded. and then finally injection therapy,

which i'm generally a proponent for, particularly for a disc herniation or bad stenosis. try the corticosteroids unless there's an indication to not do that. i certainly don't think it hurts, i have plenty of patients, absolutely, they know someone who had them and it didn't work for them and they

have a back problem so it's not going to work for them. and i say the same thing to all of them, they have a problemand you have a problem. and they have a car and you have a car. what's the likelihood thatyou have the same car? the back has so many different problems, you can't assume that yourneighbor's back problem that was fixed by the chiropractor

is going to be the samething as your back problem. even if you think youhave the same symptoms. maybe, but it's not likely. so i always say try those shots unless there's a reason otherwise,and only your physician can tell you that. the operative treatment. there's many things wecan do for these problems. we're kind of lumping everything in here.

so i'm just giving youguys a broad overview. you won't be able to perform the operation after this talk, butyou'll learn a little bit more about your back. what are called fenestration procedures, this is what's called the laminotomy, a microscopic discectomy. it just means we make alittle hole in the bone. why do we make a hole in the bone?

most disc herniations happen in this tube. god did something very smart. he put all of our important structures and he surrounded them with bone. the rib cage protects our veryimportant heart and lungs. the skull protects ourvery important brain, and our nerves are protected by bone. so the fenestration procedure simply means we make a hole in the bone.

that's where the disc herniations are, that's typically where the bone spurs and the pinching is. and that's what's called the laminotomy. sometimes we have to take down a portion of the joint. the other thing we used to do, or we still do, is called the laminectomy. that's a bigger hole and i'm going to show

you what that looks like here in a second. and then we developed someof these other procedures called laminoplasty andminimally invasive surgery, which are a more focused type procedure, as far as making these holes and making smaller incisions. so this is what a laminectomy is. this is looking at the back, like this, and a laminectomy simply means

this portion, this is the back, you can feel these bones in the back of most of us, all we do, essentially, is take this bone off. so the tube is crowdedand we take off the roof. if this roof was down here, if i take it off, i canstand up and be happy. that's the way i think about it. that's a laminectomy.

they've been doing that procedure for 60 years and it can work. it's worked well for a lot of people. the problem is, you gottamake a big incision. you can see, and you have to take off some of these important structures. sometimes it's absolutely necessary. and looking at you from the axial cut, you can see, it's this bone that needs

to be taken off. sometimes there's no avoiding this, but in some patients i think there is. that old way is like throwing the grenade in there. you strip a lot of muscle down. that muscle is never quite the same. a lot of surgical trauma,blood loss and so forth. the minimally invasive spine surgery

looks for an alternative treatment. and probably the first known device was this device called theinter-spinous process device. that didn't work for everything, but it worked for your run-of-the-mill older patient stenosis. might have worked, i should say. and then that being very least successful for some period of time has led

to more, what i call, tube surgery. i think that's the classic,minimally invasive surgery. the small incisions,done through the tube, the microscope, and we'll go over someof the benefits of that. the diagnosis that can be treated here are disc herniations and stenosisand spondylolisthesis. the benefits of such procedures are less pain, less bleeding,shorter hospitalization,

i've certainly found fewer infections because there's less trauma to the body, improved results, certainlyfrom an earlier standpoint, and then earlier return to function if you're an appropriate candidate. this interspinous processdevice was interesting and i wanted to bringit up because i think it's going to helpillustrate one of the points. it's largely fallen outof favor for a variety

of reasons, because idon't think it worked for the long-term. but some of you may have heard of a device called the x stop and i still have some of my olderpatients that will come in asking about the x stop. and what this did was it took advantage, if you had this pinching,that people felt better if they leaned forward.

so we have these spinousprocesses back here, and if you just separated them, it would just be like at that one segment you were leaning forward. so surgeons thought it'd be a great idea if we stuck something inthere to hold that there. and they were right in theory. you can see the illustration here. that if you had this littlepinching of this area,

if you put some block in there, it would kind of straighten things out as far as your nerves, and for certain patients with mild to moderate stenosis, this did work, and this is what that used to look like, if youever heard of an x stop. this is an example of an x stop. there were other proprietary names for it, but this is essentially what it was.

and you can see, we'retalking about these holes, and what these lines are showing is how much these holes actually increase from preoperative to postoperative when you put that block back there. it hopefully illustrates the idea of just making these holes bigger. that's all i do, i make the holes bigger. and there's a two levelexample of someone.

you can see how muchbigger that those holes got within the foramen. but again, that's largelyfallen out of favor, i'm showing you more froma historical perspective and that patients oftenstill come and ask for this. what about minimally invasive surgery? what this is, we make a small incision, we use a lot of x-rayduring this procedure to localize and create afocused surgical corridor.

we don't want to make a big incision like you saw there with the laminectomies, we want to be focused, like as sniper. and we use x-rays in the operating room, we make the appropriate incisions and what will end up happening is we find the area where we want to operate, we put successive dilatorsthrough skin and soft tissue, which would include the muscle,

until we get it big enoughwhere we can put a tube in. the tube obviously is smaller than your standard incision in most cases. once we have that, you can see, this is an x-ray of that tube. once we have that, we can roto-rooter, or make that hole a little bit bigger. this is an example of thatin the operating room, that's me and you cansee, using this technique

and different types of instruments, using an operativemicroscope to keep everything nice and safe, that we cango ahead and address things. this happens to be a discherniation by the way. you can see how soft and bulbous that is. we can take out a chunk of disc that might be pressing on a nerve. that's the real disc herniation from one of the operations that i did.

and those patients do quite well. other things that we cando through this small tube is take out what's calleda subtotal discectomy if we want to knit the bones together. some of you might know that as a fusion. we can, through that tube,create an environment where not only can we get the pressure off the nerves, but we canalso create an environment where those bones don't move anymore.

we talked about the patientsthat have spondylolisthesis where the bones arealready starting to move. and sometimes when weroto-rooter out the holes, it starts to fall even more so we have to knit the bones togetherin that particular situation. that also can be done through a tube. so the old way, this iswhat this looks like, this is conventionalspine surgery right here. it's called an open procedure.

and that would be a bigger incision, and some muscle stripping. in the new way, involvesa much smaller incision. again, if you are theappropriate candidate. and some of those peoplewould literally go home with a bandaid. the old way, grenade. i came up with this guys. it's real fancy.

all by myself. see that, i did all that, all by myself. it is good, thank you. so the pros of usingthese tubular retractors and so forth, i think there's certainly the benefits of minimallyinvasive surgery. the less bleeding, less pain,shorter hospitalization, and so forth. the cons, you can'thelp everybody with it.

and i don't try to help everybody with a small incisionthat's going to produce inadequate results. some people, the pinching is too great, where it's just not a good idea to do it through the small incisions. how do i know, i've done it. i've done thousands ofprocedures through a tube and i'll be the first one to admit,

there are some you'lllook back and you say, "that was a bad idea." it took too long, didn't go as well as you wanted it to go. didn't hurt anybody. you hurt my neck, you know,i was there for a long time. and so there are some things that just, you can't let technology trump reason, and there are some thingsthat are simply better

with an open procedure. so there are some limit indications. sometimes there's justtoo many levels involved. i've done minimally invasive surgery that involved five levels of the back, l1 to s1, okay? in some patients, that's okay. in other patients, they simply don't have the body habitus, thedeformity is too great,

there's some reason why itdoesn't make a lot of sense. maybe you have a bad scoliosis. and i love doing scoliosissurgery minimally invasive, but sometimes just becauseyou can do something doesn't mean you should do something, and that, i have to say,comes from experience and there are some people who i just say, "i don't think it's a good idea for you." and then you're notgetting any other surgery

that's different thanwhat the standard of care would be, that might befound in any textbook that any spine surgeon mightread on a regular basis. you're getting what isthe standard of care. this is slightly different than that. and a lot of surgeonsdon't do this in the area because there is a steep learning curve. i certainly can tell youit took me a long time to become very proficient at this,

but fortunately i'vebeen doing this operation for what i consider a long time. and i've done thousands ofprocedures through the tube. so for me, it's not that big of a deal, but if you're used todoing surgery one way and it takes you an hour and a half to do an operation and you're having what you consider reasonable results, why would you want tochange to an operation

that might take you four or five hours for your first 10 or 15? as a surgeon, that'snot a really big sell. who would want to do that? you have to be willing to struggle through those first cases. and i hate to be so candid about it, but yeah, surgeries arestruggles, we're surgeons, we're human beings andsometimes the new stuff

takes a little bit longer. but generally speaking i certainly feel like i have a good ideaof what's going to work, when it's going to workand why we should do it one way or the other and itreally comes from experience. so, i think one of the great things about minimally invasivesurgery is this hospitalization. with an mis decompressionsometimes you can go home the same day, even an mis fusion,

worse case scenario a1-2 day hospitalization versus the old way, i'llconsider it the old way, it's probably a misnomer, i shouldn't call it the old way, i'llcall it the standard way, there often times a four orfive day hospitalization. you get up a lot faster, moving around. you need less pain medication and i think it improves function, decreased leg and back pain.

but i also do open procedures,there's no question, it works. with the right operation,the right patient, the right indications,we get great results with the open procedure as well. and that's what i've got for you. i'd like to open it upfor a few questions. i do have some place tobe, but you guys came and i really appreciateyou coming to the talk.

and usually people,patients have questions. they're never satisfiedjust with what you say. so i'd like to open itup for a few questions to myself, or on your way out my nurse practitioner, jennifer, she knows everything that i know. she loves to answer questions,especially phone calls. - [voiceover] nice wayto put it on her, doc. - that's right, that's whyshe gets paid the big bucks,

that's why she's here,she's earning her nickels. but what questions do you have for me, either about a spine problemor minimally invasive surgery, yes mam. - [woman in yellow] i know ihave more than one problem, i already know it, i am a patient here - is that a problem? (laughing) that's your first problem?

- [woman in yellow] they'vebeen helping me, okay. - perfect. that's what we want to hear. - [woman in yellow] i am going to need another hip done, i do need another hip. but i also have got a bad back problem and i have spurs, i saw them on a ct scan. do they ever get to apoint where they need to be removed or doesanybody ever remove those?

do they have to be removed? - [doctor] you're talking about spurs in the back? - yeah, i saw them. - [doctor] first you need to be evaluated. generally speaking, i'm going to paint in broad brush strokes, for my practice, i don't know anything about you, per se, but generally speaking

everybody who's over theage of 50 or 60 years old is going to have spurs. most of them are not symptomatic. for whatever reason,some of them either get too big or you do somethingto exacerbate a problem and some of them can become symptomatic, but as long as everything works and you can get along, i'm going to make a general, a general statement and say,

they certainly don't have to be removed. it's part of the normal aging process. if you didn't have bone spurs and had both hips replaced,which means for whatever reason, you probably formed more arthritis than the rest of us, i'd be surprised if your back looked normal. so i don't, it's normal for you, but i don't think just abone spur has to be removed.

- [woman in yellow]okay, they usually don't cause an, i have otherproblems with my back too, stenosis... - you bring up a good point,because a lot of people will say we talked about these problems, you know you're 60 years old and you have five or ten problems. do i get my hip first ordo i get my knee first. that's a complicated issuethat should be discussed

by both the spine surgeonand your orthopedist, which one gets done first. and again broad brushstrokes, i don't know anybody's specific situation, i say get the hip or the knee done first unless the back's problem would prevent you from performing the rehab for the hip and the knee surgery. that's just my feeling.

- [woman in yellow] ihave dr. scarpino and i did get the left one done in december and hestrongly suggested to me, he knows i have back problems,but that i get the hip, and you know what, he was right. i mean i didn't walk inhere looking too great, but i am a lot better off than i was. - he's a great doctor. - [woman in yellow] and i think when i get

the left one done i willstand even straighter-- - and that's a possibility as well, - [woman in yellow] andi am aware i'll have to deal with the back after that. - maybe you've compensated so much because of the bad hip that in fact it's aggravating the back. because our hip and our knee replacements, i think they're simplerthan anything in the back,

i know they are, they'vecome a lot further. it's a simpler joint. you only have one leftknee and one right knee, we've got how many joints in the back? we can't replace all ofthem, but it's a great operation, i truly feelit's one of the best operations out there as far as decreasing your pain and improving your function. that's why i so readilytell patients, "get your

"hip or your knee done." it's so routine, if that'swhat's holding you back get that done first,unless it's so much pain coming from your back youcouldn't do that knee rehab. especially for knees,the rehab is so critical for a good outcome, in that situation i'd say get the back done first. yes. - [woman] i have a pacemaker.

- yes, my favorite. are you on a blood thinner as well? - [woman] no. - oh, that's good, i like you more. - [woman] i know it's l4 and l5, what about surgery with pacemaker? - we do it all the time. i don't love it. usually because peoplewho are on pacemakers

are also on a bloodthinner and that increases the possibility of sometype of catostrophic surgical complication, so i don't love it, but the other issue isfolks with pacemakers can't get mris. and i hate that. and here's why, this isthe way i think about it. i think that an mri can really pick up 95, 99% of your problem.

that's good, we can see lots of stuff. a ct scan, i think it's 70%of the pinching is seen, which means we're operatingwith 70% of the information. if i give you a road map to my house, that mri, by the way, isa road map to your back, if i gave you a road map to my house, but i'm going to leaveout 30% of the streets, you might be pretty confused. you might not even find your way there,

and that's the issue wehave, that's the issue that i have with a ct scan. so firstly, i need to tell you that, and then we have to do a good history and we've gotta see what we can see. some ct scans are better than others in so far as quality, youcould see some more stuff. sometimes with peoplewith ct scans i think surgeons are a little more aggressive

because they're afraidof missing something, because they don't haveall the information. so, i think you can be helped, you're just more complicated thanthe person sitting next to you, that's it. it's not a reason not to have surgery. you're just difficult,as my mom would say. - [woman] there's one in every crowd. - there you, there's not one, not here.

yes, mam. - [woman in yellow] what is a rhizotomy and how successful is it? - you know, i don't do rhizotomies, dr. goldberg in thisoffice does rhizotomies and dr. stoll and dr. kooch and dr. mazza, within coordinated healthall do rhizotomies. but here is the idea. there are small nerves thatgo to the facet joints,

here and here and here. those nerves are for pain, they're called the medial branches, so you may have heard it as a medial branch block. and what happens is, if you have pain coming from arthritis in the facet joint, which is typically painwhen you go into extension, now there are other things that cause pain when you go into extension, but back pain

when you go into extension and you grind or load those facetjoints, you may benefit from a rhizotomy and itwill burn the small nerves. you're not burning these big ones. you're foot won't workif you burn this one. but the small nerves thatjust go to the joint. and if you burn thosenerves, and by the way, they're just guessing where it is, based on their understanding of anatomy

and using the x-ray, andthey put little probes on there and they heat the probe up to a certain temperatureand they just hope that you have normalanatomy like we learned about in medical school and they will burn those nerves. they come back, that's theproblem with rhizotomies. it's not a permanent solution. that's the good news and the bad news.

you don't want somethingtotally permanent, but the bad news is,if it gives you relief, it comes back. hopefully, and in my experience, six to 12 months, best casescenario, for those nerves. assuming that yourpathology is only coming from the facet joint. make sense? yeah, if you have a rhizotomy.

yes, sir, do you have a question? - [man] i have your typical herniated disc at (mumbles), he saw it on an mri. it started about late december and going into the third month now and conventional therapy, i had an epiduraldone, i had some relief with that, and actually i've gotten a lot of relief from a chiropractorrelieving the pressure. - i love our chiropractors, so don't think

that just because i went to medical school and i'm a surgeon that idon't like chiropractors. i think chiropractorshave a tremendous amount to offer for neck and back. no question. - [man] (mumbling) but good day, bad day, good day, bad day and it'll come back and very painful downthe legs, sciatica thing, and my question is when do you determine

that surgery should be done? it's more of a solution with surgery than it is with any of theconventional therapies. when do you determine? - it's a great question. my patients always want meto tell them what to do. and i don't want totell anybody what to do. it doesn't work at home,believe me it doesn't work at home, and it's notgoing to work here either.

so here's what i do. and this is just my style. i'll tell you what's in the book. a book is written by lotsof really smart people, they come with an idea ofthis is how to treat this, and then together we go through and decide do you fall into one of the categories. so the reasons, assuming,i mean i could throw up your mri and in fiveseconds i could tell you

i'm not operating on this, okay. you're not saying theright thing, it's not going to make sense, sothere's a lot of variables, but the book answer is this, we operate on a disc with failureof nonoperative treatment for six to 12 weeks. some say six, some say12, let's just say 12. any functional deficit. what that means is youcan't move your foot up,

you can't climb stairsbecause you have weakness, that's a good reason to operate. incapacitating pain,which is a bit subjective. what hurts me, i don't knowwhat incapacitating means, but i know it when i see it. i don't, incapacitatingmeans that you can't go out and play golf, that would be incapacitating for youif you love to play golf, but right now you look like you're fine,

it doesn't look incapacitating to me. but if you have a narcotic requirement and you can't do thethings you want to do, maybe that's incapacitating for you. any progressive numbness,tingling, or weakness. so yesterday everything worked great, today now the foot is numb,or something like that. any bowel or bladder dysfunction, and i'm hesitant to saythat to a group full

of people because everybody's going to say they can't go to the bathroom tomorrow and they have to see me. i've seen that a handful of times, none of you have it. i'm going to say that right now. those are the simple things. so i would say that to you in the office like i'm saying it toyou now and would say

which one do you have? if you can't say yesto any of those things, then you don't need an operation. that's simple stuff. and that way, we makethe decision together. - [man] so what do youdo, do you deal with the levels of pain for years? - so if you hit thatthree or four month mark and you're still, you're sick and tired

of being sick and tired,then we look and see if you say the right thing and we see the right thing on the mri. there's plenty of literature to suggest that patients who have operations earlier with their pain do betterthan those who have waited. and that's my experienceas well in the office. that doesn't mean we pushpeople to have operations after a week.

it means that patientswho have had chronic back pain for six years don't do as well as if you had back pain for aweek, it's that simple. and it makes sense. if you had a horribly pinched nerve that was flat and youwere writhing in pain and it went on for six months, looking back, it wouldhave been better to do that after a week.

the literature is quiteclear that those patients who have an acute disc herniation, assuming yours is acuteand looks horrible, and everything else isin line, that you will get better fastest with an operation. not four months of chiropractic care and injections and allthis other treatment. but no one wants a back operation, i mean who wants a back operation?

so i would do everything that you're doing unless you fall intoone of those categories. - [man] how long is an mri good for before you need another one? - i'm going to say it depends. standard, run-of-the-mill stenosis if we were considering an operation, so 65-year-old female, classic stenosis, seeing for the firsttime, if i'm not going

to operate and there'sno change in symptoms, there's no real reason to update it. if we were going to operate, i need that road map. i don't want the roadmap from five years ago. that's the best chance is that first time you're going in for a back operation. for a disc herniation, iusually say six months. if it's, but it depends,if it's a big extruded

fragment, if the characteror quality has changed, we have these wonderful tests, these mris, the quality of which is fantastic, generally, closed mri, not an open mri, those are not so good, but they can provide us awealth of information to help you get better. so somewhere, i'm going to say six months, but that may be...

- [man] (unable to hear) about the opening after you cut away bone? - it depends on wherethe disc herniation is. - [woman] i'm sorry,what was his question? - something about theopening when you take out the disc herniation. oh, so the hole itself, and the answer is no. there is a hole, forget about that,

if it's in a textbook,we can talk about it. but i told you the fairydust and the lasers, we're not talking about that. i put them in the same category. but, so there's a hole,for a disc to herniate it has to make a hole. so your body put a hole in it. there's nothing i can stuff in there. people have tried plugs,they've tried sewing it up,

in my mind, none of thathas conclusively shown that it decreases your pain, or that it decreasesthe risk of a recurrent disc herniation, but it has increased the operative time and the blood loss and the chance for a spinal fluid leak and all these other things. so i don't close the hole, no one does in this area.

i don't know anybody who'snot working on a study to try to prove something that does that. - [woman] i have never had an mri, but i've got two artificial knees and an artificial hip... - it's not a contraindication. sometimes they like towait three or four months. - [woman] the metal doesn't affect it? - it should be fine, i'mgoing to make a broad

statement, it should be fine. i don't know what's in your knee, but it should be fine. - [woman] my son is 38 andhe lives in new york city, he has been diagnosedwith a herniated disc and the surgeon, doctor/surgeon with whom he's been dealing has recommended surgery and the plan would be he would go through the front of...

- is it neck or back? - [woman] neck, yeah through the front of the neck, and the doctor has alsosaid that he thinks that if doug doesn't do it now, or waits it would get worse ina few years, etc. etc. with that limited bit of information, would you recommend,like would this doctor comment on minimally invasivesurgery do you think,

or should doug look into that separately before he does anything? - so i don't, i'm going to make, first of all, for a neck operation going through the front, standard of care. - [woman] that is standard? - absolutely, i love that operation. i'm going to do that operation tomorrow. if i didn't have to lookat another back pain

patient, all i could do was neck, i would do it all day long. - [woman] so that's a good thing? - oh, i love it. it's great. - [woman] and the fact that this doctor thinks that's workable is a good thing? - yeah, i mean that's the way it is. i mean i think that neckoperations work very well from the front.

it doesn't seem that wayto the average person, but they work quite well from the front. so that's the first thing. some people are candidates for a procedure that i can do on the back with the tube. i have my doubts with a 38-year-old, it generally works in younger people, generally with a soft disc herniation. - [woman] the front does (unclear)?

- i'm talking about the minimally invasive posterior procedure. but the front procedure, that sounds very reasonable. but i think you canapply what we've talked about when i gave the indications for the lumbar discectomyto this situation as well. but i don't have the opportunity

to look at the mri or anything like that. but failure of nonoperative treatment, incapacitating pain, progressive numbness tingling, or weakness, bowel or bladder dysfunction, and he mayhave other problems, spinal cord impingement and so forth, but at the end of the day you have to trust your doctor and hope that they're just doing the right thing and they

want to do the right operation, and if you have disagreement about it, and you're worried about it, a second opinion, whileit's time consuming, and annoying and stuff like that, i don't think there's, there's certainly no harm to that if it makesmom sleep better at night. - [woman] and i'm sorry,you were referring to the minimally invasive tube approach

is good for 38-year-olds,is that what you said? - it may not work, i don't know, i haven't looked at it,because you have to look, that's when it's a very specific diagnosis in my hands. again, the worst thing,one of the worst things you can do is, what ifyou have an operation and you sign the waiver to have this done and you didn't get therelief you were seeking

treatment for? that doesn't help anybody, so i'm not interested in performingthose kinds of operations, and so you have to see what the best one. but often times, it'svery common to go through the neck. - [woman] thank you. - that sounds right.