Latest advances in non operative and surgical therapies can help alleviate back pain and treat slipped discs.
Millions of adults suffer from back pain, but there are solutions. Drs. Aggarwal and Goldstein discuss the latest advances in non operative and surgical therapies that can help you find relief from slipped discs and other back pain issues.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Dr. Vinay Aggarwal: All right, welcome back to our NYU Langone Orthopedics podcast series with Doctor Radio, the Bone Whisperers. My name is Vinay Aggarwal, and I'm an orthopedic surgery attending at NYU Orthopedics. I'm glad to be joined by Jeff Goldstein, the clinical professor of orthopedics and neurosurgery at NYU. Doctor Goldstein also serves as the Director of Education for the spine division and as the fellowship program director for the Spine Fellowship here at NYU Langone. Jeff, thanks for joining us, we have a very important topic that I want to talk to you about today. It's about slipped discs and what patients should do about them. Very, very often, patients will have a complaint of back pain. But more often than we see in our practices is the complaint of the patient coming to our office with an MRI report or a doctor, primary care physician, telling them that they may have a slipped disc. This is obviously panic striking in some patients, causes a lot of anxiety. Tell me a little bit about the background of slipped discs, back pain - the overall debilitating nature of this, and, um, what you think about this when you establish it from your practice standpoint and expertise.
Dr. Jeff Goldstein: Vinay, first of all, thanks so much for inviting me to speak today. Slipped discs are probably one of the most common reasons that people go to see their doctor, whether it's an orthopedic surgeon, their primary care doctor, or somebody else. A slipped disc is not something that you necessarily need to be afraid of. Many people will have back pain. About 60% of Americans will have at some point in their life, have back pain. And it's usually, uh, very transient, it gets better and goes away. It's what we call mechanical back pain for patients who have what we commonly call a slipped disc. Now, you said it in the back. It could actually be in the neck or the back. And, uh, as orthopedic spine surgeons, we treat both. When patients come to us with, uh, what's called a slipped disc, we first will get a history from them, do a physical examination, and then obviously, look at their imaging and their MRI, Xrays and what other imaging that they brought with them. Many people will find that the symptoms for this will go away after a short course of rest, some, perhaps some over the counter medication, and potentially things like physical therapy. So it's not something to necessarily be afraid of, but it is good to get it evaluated, typically often by your primary physician.
Dr. Vinay Aggarwal: Yeah, absolutely. I think you mentioned something that's really interesting, and people should really understand this. 60% or more of patients are going to get back pain or neck pain at some point in their life, and I think most of our listeners are able to vouch for that. I know I can, certainly. So the broadness of this topic of having back pain or neck pain, it makes it one of the most difficult problems to treat. Is there a way in your mind, as an expert in this topic, that you conceptualize or categorize the different types of neck pain, back pain? It's such a broad thing. Is there a timing, acute versus chronic, neck, upper back, lower back. Is there a way that you conceptualize the different categories of back pain?
Dr. Jeff Goldstein: First of all, the most common pain that people get in their back or their neck is they maybe they did a little bit too much activity at the gym, or maybe they sat in their chair all day. You don't have to use a jackhammer to get back pain. When patient comes to me and they have a day or two of back pain, then usually I can give them some confidence after I examine them and take their history, that this will probably get better in a few days. Obviously, not everybody gets better, and sometimes we have to do further evaluations. Patients will often come and say, well, geez, do I need to get an MRI? Well, knowing the natural history, in most cases, uh, the answer is no, you probably don't need an MRI right away. There are certainly things that we look for. We call them red flags. A patient who has maybe a severe neurologic deficit or night pain, urinary or bowel problems, things like incontinence, fever, chills, weight loss. All of these things are things we take consideration of in the history, and that might make us somewhat more concerned. Certainly, we're concerned that our patients have pain, and we'd like to help them get some resolution of that. But most times we can manage this, uh, in a conservative, in a conservative manner. Patients ask, well, geez, don't I need to get an MRI?
Dr. Vinay Aggarwal: That was going to be my question, actually. Yeah.
Dr. Jeff Goldstein: If you take a group of young or middle aged patients, I won't put an age on that because people might disagree. But if you take patients without back pain, a third of those patients may have an abnormal MRI. So don't get too concerned about a diagnosis of, quote, unquote, a bulging disc or a slipped disc, because you may have had that even before you had back pain.
Dr. Vinay Aggarwal: Yeah. That was exactly the path I was leading down, is the patient comes in, they have back pain. They haven't really tried a bunch of things, but you're the specialist, they’re there to see you. Don't I need an MRI? Are you able to see everything you need to see? When are you getting that MRI? What is it that's concerning you enough to get that MRI? And then the second part of that question is, how do you get it through insurance authorization? Because I know that can be a pain.
Dr. Jeff Goldstein: Well, that can be painful. First of all, Vinay, we think about whether the patient has red flags. As I mentioned before, if somebody has a red flag, I'll be more apt to get an MRI earlier than later. Typically, if a patient comes in even with more than back pain, maybe what we call sciatica or radiculopathy, which can be pain that goes down their arms or their legs. Those patients, even if they have a normal neurologic examination, we’ll still most likely send those patients for some rehab, some physical therapy, some medications before we go thinking about getting an MRI. So if the pieces of the puzzle fit together, and it looks like they likely have a, what you're calling a slipped disc or a herniated disc, I feel very comfortable in my practice sending those patients for some non operative treatment. Certainly, if patients don't respond to non operative treatment or they have an MRI or there are some patients that present with incontinence, those kind of things can be surgical emergencies and require an MRI much earlier than later. But in most cases, that's not what we need to do as far as getting the MRI right away. And then you asked about dealing with insurance companies. Insurance companies don't want a patient who has routine mechanical back pain, necessarily, to get an MRI. And quite frankly, as their treating physician, I don't want them to either. So we can usually, uh, work along with the insurance companies and sometimes have to press a little harder than others if the insurance company throws up a lock.
Vinay Aggarwal: Got it. Yeah. That sounds very wise advice. I think we've all been in a situation where we think more imaging is better than less imaging. But as you mentioned, MRIs are very detailed, and a lot of times they can lead to false positives. I've had that in my hip and knee practice. I'm a hip and knee surgeon. A lot of people looking for advanced imaging, the imaging doesn't necessarily correlate with what they're feeling or what they're actually problem is. And so it can be some extra noise. Do you know about what percent you can give our listeners an idea, do you think of their pain? Out of 100% of patients, if they wait six weeks, twelve weeks, what percent of these patients is their pain going to go away?
Dr. Jeff Goldstein: I would say, in my experience, about 80% of patients who come up with mechanical back pain with no red flags will find that within six weeks or less that their pain is much better. The problem is, it's hard for a patient who has that kind of severe pain to understand that they could possibly get better. Because, quite frankly, it hurts.
Dr. Vinay Aggarwal: Right. Waiting with pain is the hardest thing to do. Yep, I completely agree with you, but that is quite a high number, and I would agree with that. You know, it's just, we learned that it's hard for our patients to realize that, but we are here for them, and it doesn't mean we're kind of just sending them away and never come back. But sometimes that pain does linger. In terms of the pain sources, we're talking a little about discs, but the back, the neck, overall the entire spine is such a complex structure. There's a lot of structures involved. There's a lot of, I guess, pain generators is the word I would say. Are there certain anatomic structures that we can break down, number one, two, and three, that you think of for the layperson, when you're trying to work up where their pain might be coming from? Could be the disc or something else?
Dr. Jeff Goldstein: Sure, Vinay, I think the most common source of pain in my patients with spine problems is probably from the muscles in the back. Now, the muscles in the back can be irritated by other components of the spine, meaning the, uh, discs and the nerves. As a spine surgeon, we most commonly will operate on patients who don't respond well to non operative treatments for things like pinched nerves or disc herniations that compress the nerves, sciatica, radiculopathy as I mentioned, in the neck or the back, there are different problems that present with different age groups. I mean, I have, uh, patients who come in their twenties who present with sciatica and slipped disc or a herniated disc and say, aren't I too young to have this? Well, you know, a herniated disc is a young person's problem. Older patients can get herniated disc, but they might also get other types of nerve compression, things like spinal stenosis.
Dr. Vinay Aggarwal: Got it. Got it. Yeah. I think that one of the things that I think I get a lot of questions about with patients getting access to their test results and their notes and their reports in real time is, what does this mumbo jumbo mean? What is this terrifying verbiage that the radiologist may use? The language, it sounds to me, you know, like all of my patients, they come in, they have these MRIs with degenerative meniscus or, you know, this and that with chondromalacia, et cetera. A lot of high falutin words. I'm sure you see it in the spine world as well. How do you counsel a patient through some of that language? What are the most common questions you get about your MRI reports in your office?
Dr. Jeff Goldstein: Well, I think in most patients, the first thing they become concerned about is, oh, my God, I have a spine problem, I'm going to be paralyzed. And certainly, as a spine surgeon, we are concerned about things like that. But the number of times that that happens in a patient that walks into my office, that they're going to have those sort of symptoms or MRI findings that are going to lead to paralysis, is much less common than treating somebody who comes in with pain.
Dr. Vinay Aggarwal: Got it. And when it says disc herniation or degenerative disc disease or something involving the disc, what does that actually mean? What should our patients know that is actually happening to them?
Dr. Jeff Goldstein: Well, most commonly, when patients come in with a disc herniation, the things that concern me are whether they have a compressed nerve. So if you picture a disc herniation as a cushion between the two bones, or we call the vertebral bodies, sometimes that disc can come out like jelly out of a jelly donut, and push against the nerve. And that can cause pain in the arms or the legs. Or you can just have some degeneration of the disc that can cause some back pain. There are many patients that come into my office have some back pain, they have a severely degenerative disc, and quite frankly, you're surprised their pain is not worse. That's why when it comes to the MRIs, I tell patients, you know, we don't treat MRIs, we treat patients. And, uh, you may or may not have symptoms related to the findings that we see on the MRI.
Dr. Vinay Aggarwal: Mhm. Yeah, yeah. I think that's really sound advice. Just like I said earlier, you treat the patient in front of you, not just the words on the paper or the imaging on the screen. As far as what is happening with the disc bulge, you mentioned the arm pain or the leg pain. That's just to clarify so that our listeners know - radiculopathy, right? Sciatica. Uh, that's what you're talking about, correct?
Dr. Jeff Goldstein: Right. I essentially just tell patients this is a pinched nerve. You have a pinched nerve, and if your pinched nerve goes down the arm or the leg, you'll have pain that corresponds to that.
Dr. Vinay Aggarwal: Got it. Is there any situation now with this, as you call it, radicular symptoms, pinched nerve symptoms, shooting down the leg or the arm, where a patient may not need surgery? Does it heal itself? That's the question I always get. How is this going to heal itself?
Dr. Jeff Goldstein: So that's a great question I see commonly also in my spine patients. The disc may not heal. The disc may always have some herniation. Patients with a, uh, slipped disc or a herniated disc who have arm or leg pain, we're not looking for the MRI to be normal. We're looking for their symptoms to go away. So a patient who has pain that goes down their arm or leg, most of them will get better. For patients who get better, we don't get follow up MRIs. Patients get better, likely for one of two reasons: Either that the disc dries up, maybe pulls away from the nerve, or the nerve just accommodates to the pressure on it. As long as the pain goes away, then that's good. If it doesn't go away, then we might consider some other non operative treatments, things like commonly physical therapy, sometimes cortisone or epidural shots. And some patients go on to require surgery. And surgery with a good indication can have very, uh, very positive results, and patients are generally very happy with that.
Dr. Vinay Aggarwal: Got it. Yeah. We're going to talk about the surgical aspects of this in a second, but one thing I do want to highlight was the physical therapy. Because I think many people feel, okay, he's sending me, or she's sending me to a physical therapist - What's that going to do for me? They just kind of, I don't really know how that's going to help if this disc is pushing on my nerve. How is that going to heal the disc? I get that in the hip and knee as well. Physical therapy - How is that going to help my knee arthritis or my hip arthritis or my hip bursitis or tendonitis? What's the idea behind physical therapy with the spine?
Dr. Jeff Goldstein: Physical therapy, in my experience, is an opportunity to hasten a patient's recovery, to help you get better faster by taking care of the inflammation that's causing the pain in your back or your arms or your legs, giving you pain relief with modality treatments, things like heat, ultrasound, massage. Doing some stretching and conditioning exercises just to help you feel better while the back or the neck is healing.
Dr. Vinay Aggarwal: Got it. Yeah. That's a great way of looking at it. There's a lot of modalities - People don't realize physical therapy isn't just walking around your apartment. I get that a lot, but I walk around my apartment. Well, physical therapy has a lot of modalities. As you mentioned, there's a lot of muscle strengthening and stretching that takes place and can offload some of these problems. And as you said, I didn't even think about it that way. It also just helps do something that feels good while the body takes care of itself in the meantime. I think that's a great way to look at it. Let's talk about the surgery now. So you have a slipped disc, you've tried non operative things, or maybe you have some red flag symptoms. It's time for surgery. Um, can you describe the journey of disc surgery for the neck and back that's taken place over the last, um, 20, 30 years that you've noticed?
Dr. Jeff Goldstein: The most common reason that we take patients to the operating room for disc surgery in the neck or back are typically for pain. There are some patients that have neurologic deficits, meaning they have weakness in their arms or legs. So first we identify a patient who hasn't responded well to non operative treatment. There are some times when this is an emergency operation, like I said, when patients have bowel or bladder issues, meaning incontinence, and that becomes a surgical emergency where a patient needs to go to an emergency department or see their physician right away. Most of the time, we take patients what we call electively. That doesn't mean cosmetically - it's a quality of life decision. And I tell my patients, when you have pain that you don't want to live with, not that I don't want to live with. So when I take the patient, uh, for example, with a slipped disc or herniated disc of their low back, at this point, I've decided, or we've decided together that they failed non operative treatment. They have pain they don't want to live with. I have my imaging studies. The pieces of the puzzle fit, meaning their pain matches the MRI, their neurologic exam matches the MRI. And I can tell those patients many times, not all the time, that I think your pain will go away after an operation. So typically these days we do, uh, minimally invasive or microdiscectomies. Essentially it involves, in one way or another, a small incision on your low back, and we'll go in with some sort of imaging, find the disc fragment. We don't make the disc normal. We take out the herniated disc fragment that's compressing the nerve in any free fragments, and typically the pain goes away. I tell patients it's kind of like getting your finger stuck in a door. You take the door off the finger, that gives the finger or the nerve the opportunity to heal. And generally patients do very well. The results are usually very predictable.
Dr. Vinay Aggarwal: Yeah, that's exactly what I wanted to hear, is kind of what is actually being done. It's taking out the diseased fragments or taking the pressure off the nerve. Has there been an evolution or advancement in spine surgery with regards to discs? You talk a little bit about minimally invasive. Is there anything else being done with technology, with implants themselves?
Dr. Jeff Goldstein: So typically for a patient who has just a, a slipped disc without any instability in their spine, we’ll do a microdiscectomy. It can be, uh, through a tube, it can be used with a microscope, it can be endoscopic. You know, there's a lot of ways to do it. Ultimately, you just want to get the pressure off the nerve. You ask about implants. Implants are often used for patients that may have some instability, and when we're doing a spinal fusion. And, uh, the implants have changed. Typically for many patients in the past, we've done primarily spinal fusions, um, whether it be a spinal fusion in the neck or the low back. Now, I would say over the last 20 years that, uh, we've developed motion preservation surgeries, meaning we can take the pressure off the nerve, take the pressure off the spinal cord, and put in an implant that doesn't limit the motion of that disc That helps you maintain motion of that disc, and also limits the degeneration that may go on to adjacent discs. Oftentimes when we do decide that a patient needs fusion, we can do our fusions now through less invasive or minimally invasive approaches. We often will use instrumentation, things like cages or screws in the spine. And today we can do those with robotic assist in many patients. And that allows us to do surgery, often with greater accuracy and precision, ah, through less invasive approaches.
Dr. Vinay Aggarwal: Have you noticed any change in the recovery? Are patients walking the same day or the next day? Is this doable nowadays with minimally invasive surgery, first thing?
Dr. Jeff Goldstein: You need to understand is every patient's different. Some patients will go home earlier than later. Some patients have different, uh, requirements at home. They have stairs to go up to, they have different living situations. But there are many times in select patients where we can do a spinal fusion and have a patient go home, potentially the same day or the next day. So the patients are going home, uh, faster and going back to work faster with less pain and a quicker recovery. Once again, depends on the patient - that's not true in all patients.
Dr. Vinay Aggarwal: Right, right. Look, I mean, I think it sounds phenomenal. Obviously, nobody wants surgery necessarily as the first step of their treatment course, but it definitely sounds promising and appealing that we've come such a long way, even in the last 15-20 years. But overall, the treatment has been tried and true. Taking the pressure off of the pain generators, the nerves. Taking that disc, and getting it to function in a less painful manner, it sounds like it's very, very rewarding. Maybe some of your happiest patients, would you agree?
Dr. Jeff Goldstein: You know, the best feedback we get from patients when they say, listen, I can spend more time with my family, I was able to go enjoy my vacation, I can go back to work without the pain I had before. And I see patients for follow up in the office, and you can just see the pain relief in their face. It's very rewarding.
Dr. Vinay Aggarwal: Yeah. I mean, another testament to why doing orthopedic surgery and musculoskeletal complaints is so rewarding for us as surgeons, doctors, and giving hope to our patients. That's really what it's all about. All right, Doctor Goldstein, so you spoke about artificial disc replacement, minimally invasive, and I think one of the words that our listeners are really going to catch on to is robotic surgery. So obviously, the artificial disc replacement, that sounds great. You know, you're not taking out disc necessarily, and just leaving it, you're putting in a new, potentially disc, correct? Maybe the function is as good potentially as a normal disc, maybe not. But robotic surgery, what's going on there? Who's doing the surgery? How does it work? Why do you use it? What does it help you do?
Dr. Jeff Goldstein: So there are different kinds of robots. Everybody is aware of the robots they see on television that are building your cars. It's similar to that in the sense that you have a robotic arm. You have what it's called an end effector, which is the end of the robotic arm that actually holds an instrument. But this is a robot different than other robots in medicine, where the robot actually doesn't touch the patient. The robot provides, essentially, a path for us to do our surgery. It gives us the opportunity to put our instruments in the right place and then subsequently put our implants in the right place, whether it be a cage or a screw. But the robot never touches the patient.
Dr. Vinay Aggarwal: Yeah.
Dr. Jeff Goldstein: At least not the robots we have today.
Dr. Vinay Aggarwal: Right. I think there's a difference between something like the da Vinci robot from urology and a lot of our orthopedic robots. Similarly, in hip and knee replacement, I think it's probably the same as in neck and back surgery. A lot of the manufacturers are the same. The robot is an assisted tool, so it's a tool for the surgeon to do the job, but the robot can't do the job alone, right? And that's pretty similar in spine, correct?
Dr. Jeff Goldstein: It's very similar. In anything we do in orthopedics, we have tools or instruments, and this provides us the opportunity to use our tools and instruments in a more safe and effective manner.
Dr. Vinay Aggarwal: And would it be more precise, basically, than measuring things or deciding location wise, because the robot is assessing things with imaging and things like that, we've gotten.
Dr. Jeff Goldstein: Pretty good over time without using robots. So I think using a free hand use of instruments, I think, in many surgeons hands, works very well in most surgeons hands. But this is an opportunity, I think, to bring it to the next level with even greater precision and greater accuracy.
Dr. Vinay Aggarwal: Got it. Yeah. Like, with any technology, time will tell from a clinical impact how much it's going to help the patient. But you're right, we have gotten so good at what we do over decades and decades of experience of master surgery that experienced surgeons and experienced institutions like NYU Langone are probably what matters more. But just know that these technologies being on the forefront is really exciting and potentially really helpful.
Dr. Jeff Goldstein: At NYU Langone we have five robots, we have intraoperative CAT scan, we use navigation. And these are all things which enhance the skills of the surgeon and, uh, have benefit to the patient.
Dr. Vinay Aggarwal: Perfect. As always, I do want to end on a take home message for our patients. Any words of wisdom, Doctor Goldstein, that you might have for people with back pain and slipped discs? How would you summarize our conversation or advice to them going forward here?
Dr. Jeff Goldstein: I would say, uh, Vinay, that in most patients, the back pain is transient. Um, take good care of your back. What happens to patients is they go, they take care of their back, they do their physical therapy, they get back to their activities, and maybe they get back into some bad habits. So they need to, you know, it's a lifelong, if your back is bothering you, it requires lifelong care, keeping your core strong, exercising. You know, if you have a sedentary job, try to get up and move around. If you don't get better or if you're not responding to the, uh, non operative treatment that perhaps your primary care physician gave you, then it's time to see a potentially see an orthopedic spine surgeon. And, you know, there may be an opportunity to provide other treatments.
Dr. Vinay Aggarwal: Wonderful. Well, thank you so much for joining us. Again, I've been joined by Jeff Goldstein, clinical professor of orthopedics and neurosurgery at NYU Langone and the director of education of the spine division, as well as the fellowship program director for Spine Surgery at NYU Langone Orthopedics. My name is Vinay Aggarwal. Thank you for joining us on Bone Whisperers, brought to you by NYU Langone and SiriusXM radio. Thank you.
Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.