This is the third part of Dr. Vaksha’s appearance on local cable access…
Larry Mikorenda: Hi, I’m Larry Mikorenda, welcome to this edition of Excelsior Forum & Profiles, and back with us for part three is Dr. Vaksha. Dr. Vaksha, thank you so much for coming back. So many viewer questions, I didn’t realize so many people had these back and neck problems. Hopefully you can explain a bit little more.
Last time we got into some of the diseases and problems. Now we’re going to get more into the cure, the surgeries, and what could be done with some of these things. We did get a couple of viewer questions, which we are going to answer during the program, but the first one is: can sciatica develop into stenosis?
Dr. Vaksha: Yeah. First of all, it’s my pleasure to be here with you Larry, and I will be answering all the questions that we have today. Sciatica is caused because on the pressure on the nerve roots in the lower back, and this may be isolated presentation of a disc herniation, or a cyst, but this can be also a part of stenosis, can be a presentation from the stenosis.
Though the stenosis may be mild to moderate to present with, but causing a compression on a specific nerve roots causes the sciatica pain. On the other hand, the stenosis if it gets severe, can compress on multiple levels, and can cause presentation of stenosis, along with the presentation of sciatica, maybe at one or two levels.
Larry Mikorenda: What exactly is stenosis? To reverify what we went over before.
Dr. Vaksha: Stenosis means that the canals size has decreased. Anywhere stenosis, it might be an artery or spinal canal, that means the size of the lumen has decreased. Stenosis in the spine means the canal size of the roots that they are going through has decreased, and that decrease in space causes pressure effect on the cord or the root where it is, causing the problems to come on.
Larry Mikorenda: Basically to explain it in more lay terms, it’s if you had a half-inch pipe that was running, which is the nerve now all of a sudden its down to quarter-inch.
Dr. Vaksha: Yes!
Larry Mikorenda: Because of compression, so what’s happening is that nerve is being squeezed and eventually like any electrical wire, if it’s broken or squeezed off then-
Dr. Vaksha: Yes, exactly. In this condition when they get squeezed the issue is that they don’t get good blood supply, and hen they don’t get good blood supply, the nerve tissue will induce ischemia and ischemia causes varied symptoms of pain, tingling, numbness, even weakness, involvement of bowel, bladder, involvement of gait and all these things.
Larry Mikorenda: Which gait, by the way is a way you walk.
Dr. Vaksha: Its the way you walk yes.
Larry Mikorenda: People are going to thing we are talking about their [crosstalk 00:03:45]
Dr. Vaksha: Imbalance, yeah.
Larry Mikorenda: Now, when is the time for people to visit their physicians office with these neck and back problems?
Dr. Vaksha: Patients may have a neck and back problem all the time, over their lifetime. Again, the incidents of spine pain, is 60 to 80 percent. Most of these people don’t need to visit a physician they can get treated by themselves, varied short periods of rest, taking some anti-inflammatory medications, using some ice and heat, and they can get back to their normal routine and work.
Over their life, I would always suggest that they should keep themselves fit, especially with regards to the muscles of the neck and back, doing core strengthening exercises as a part of their daily routine maybe at home, maybe at the gym.
Dr. Vaksha: Now, there will be a very small subset of people who will not get better with time. These people may need to visit a physician, their primary care physician, or a pain physician. There will be a very small subset of people who will also have pain radiating down their legs or arms, depending on the location of the problem and they may need to see a pain physician, maybe their primary care can help or a spine physician, spine surgeon can help these patients.
Larry Mikorenda: Now, when is it the time to visit the ER with a back problem? Is it you can’t walk? Total numbness? What are the symptoms, when should you go to the ER?
Dr. Vaksha: Exactly. Not every patient should be visiting the ER for a back problem, but, if they have very severe back pain, that they are incapacitated, at that point of time they may visit an ER and they will be helped with some pain medications. But, the patients who can be really helped in the E.R. are the patients who developed sudden onset, worsening of their neurological status, like weakness in their legs, or unable to control their bowel or bladder, they are either retaining urine or they are incontinence, they just can’t control their pee, or they have numbness around their genital areas.
These patients may have some very serious pathology in their spine, and these are on a timeline. They should immediately reach the hospital, they should be treated, possibly they may need a treatment immediately, may need a surgery to get better or at least stop the process, which is making their neurological status to worsen.
Larry Mikorenda: Again, going back to what we said before about that nerve, with a vein or muscle or something like that they can maybe cut, restring, and everything. When a nerve is broke that’s it, until they can rewire the body and the majority of controls like we had said in the last program, are that lower T1, L1 whole area. Its kind of scary and a lot of people from other previous programs that we did, had wrote in and were panicking and stuff so hopefully we can relieve some of that from them.
Realizing that, som if you’re going to go to the ER it has to be, should bee real drastic problem, nerves, can’t walk, lost all feeling in legs, again this is that centralized area of the spine that we were talking to. Now, when people have this type of problem and they come to see you, what kind of surgery, procedures can you do to bring this back to them?
Dr. Vaksha: Yes, patients who have back problems who have sciatica, complaining of pain in their legs, tingling or numbness, these patients are initially treated without surgery. We treat them with medications, we treat them with physical therapy, sometimes they can get cortisone injections in their back depending on the location where it is, it can be en epidural or a nerve block and these patients get better, actually 90% of these patients will get better without surgery but there a 10% population subset and we don’t know which subset it is.
Which patient will develop that will need surgery or not but these people will not have any relief with these treatment modalities, and will need surgery to decrease their pain, to improve their life style functioning, and get back to their life.
Dr. Vaksha: So, we perform various types of surgeries on the these patients. They vary from a small surgery, like decompression or discectomy, to bigger surgery like fusion, depending on their presentation, depending on their findings on the imaging, depending on what other pathologies they have.
Larry Mikorenda: We had already spoken before about the new discs that are out there, disc replacement. One question we didn’t answer though, which came up was do genetics play a factor with these back problems? Like, grandpa had it, my dad had it, I have it. Is it really genetic?
Dr. Vaksha: Yes, recently studies have found that yes the genetics do affect our body composition and disease process especially on the spine degeneration and arthritis, and there has been found a positive correlation between families over time developing stenosis or over time developing degeneration of the spine, lumbar spine, and presenting with various pathologies.
Larry Mikorenda: So it’s a big yes on that one, right?
Dr. Vaksha: Yes it is.
Larry Mikorenda: Now, we had spoke before, you had said about injections into the back? What type of injections could you do for somebody who is having some of these issues?
Dr. Vaksha: When patients present with pain with especially going down their legs in the form what we call sciatica, we do try to treat them with the cortisone injection. It can be done by a spine surgeon, it’s usually done by pain physicians. There are essentially two types, epidural and nerve block, though we can do facet block, we can do trigger point injections, a side joint injections sometimes are needed for these patients, and these injections try to focus on a specific point, specific area, to reduce the inflammation, to reduce the pain.
Many of patients get good relief after this and those that get good relief may never need to get any other treatment done after that.
Larry Mikorenda: So it does work out. Some it can’t be a cure all, but then we have others where they’ve let the problem go like you had said before. You having the back problem take a couple of pills, now you’ve had the back problem six months, eight months, not realizing that compression of that nerve is getting worse and worse, now your sciatica could be stenosis and it could grow in to worse things. What other options after surgery, what are the good results that can come from surgeries for the back?
Dr. Vaksha: So surgeries done for these indications what we do is decrease the pressure from the nerve root, or nerve roots depending where the compression is by doing a discectomy or decompression surgery. We take care of the pressures, it gives good blood supply to the nerve roots that causes the relief in the symptoms and the patient can get back to their normal life activities and activities of daily living, so that’s what the surgeries help with.
Over time, even after the surgery they have to keep their back fit, because the degeneration process can still go on on that level, and on other levels to and so to keep them away from other treatment options like surgeries, they have to keep themselves fit.
Dr. Vaksha: Now there is a subset of patients who may also have some instability of their spine which we find out on imaging. These patients may just not need just decompression surgeries, but may need to have fusion surgery also on the back, in which we fuse the segments of the vertebrae which are unstable or have the problem by use of multiple modalities like cages, rods and screws, using bone grafts, we can go from the front, from the back, from the side, so there are multiple ways that we do that.
Larry Mikorenda: That was going to be my next question, because a bunch of you wrote in to find out. When we had mentioned on the program that not only can you operate on the spine from the back, but you can also operate on the spine from the front, kind of blew every bodies mind. Can you explain a little bit more, how that goes between the front and the back?
Dr. Vaksha: Yes, exactly. Most of the spine surgeries on the lumbar spine on the lower back are done from the back, but there are occasions in patients who are [inaudible 00:12:07], we need to go from the front and do what is called an anterior interbody fusion in which we clean the disc up, going from the belly clean the disc up and put a big cage or a bone graft there.
Many of these patients we have to go back also still to put the screws and rods, which we can do with minimal invasive surgery, and these patients do really great. Some of the patients who do not need to go from the front, we can do a similar procedures from the back also, and sometimes from the side.
Larry Mikorenda: Some of these surgeries that you had mentioned, I want to get a little bit more into this. You mentioned spinal fusion, so the first thing people are thinking about it’s like welding two pipes together, tell us a little bit about that.
Dr. Vaksha: Spinal fusion is something like welding two pipes, but in this case we are just welding the two segments of a mobile spine, we leave mobile segments above and below. We can do a spine fusion on one segment level or multiple, depending on the pathology, depending on the need for that procedure there.
In this, fusion is essentially a type of creating a fracture there, so that the body mimics in healing the fracture and recreates the biology around it by fixing it with using rods and screws and cages so that it does not move, at the same time putting down bone graft so that the body stimulates more union there.
Larry Mikorenda: Beside from the fusion, what other back surgeries are there?
Dr. Vaksha: The patients can also be candidate for a non fusion, like a disc placement. Now lumbar disc replacement is not as common as a cervical disc replacement but still can be done. The patients who are a good candidate for lumbar disc replacements are patients who essentially have just back pain and have failed all treatment modalities for at least six months.
That means they have tried physical therapy, medications and everything, and then we have an unequivocal imaging saying that the disc, one single disc or two are a problem. In such cases we can do a disc replacement also. There are certain other surgeries that can be done which are non fusion surgeries, for patients who are really old, like we put into spinal spaces in patients to take care of their stenosis, and at the same time doing minimal damage to them.
Dr. Vaksha: But in most of the non fusion surgeries that we do is essentially decompression, in which we take the back part of the vertebrae that’s called the laminectomy, clean up all the nerve roots so there is no bad tissue around them which is compression on the nerve roots, allowing them good blood supply and good environment to heal to recover from the pain, from the tingling, the numbness, balance problems, and others.
Larry Mikorenda: You can do, replacement on the lumbar spine as far as the discs are concerned?
Dr. Vaksha: Yes. It can be done. The selection process is a rigorous process for a lumbar spine disc replacement, but it is done and it is a successful surgery.
Larry Mikorenda: Again, that goes back to what you were saying about people think discs like Frisbees or something like that, these are like gels actually, right? They are not like the hard pieces of bone, their like gels, things that bend and move right?
Dr. Vaksha: They are cushions between the two vertebrae, they allow movement to a certain degree at the same time they act as shock absorbers. That’s the reason that a spine is mobile, that we can turn our heads, turn our body, bend it forwards and backwards because of the discs.
Larry Mikorenda: Now spinal problems like from car accidents have to be the worst, because the body is.. it’s thrown forward and it’s thrust back and that… it’s so much pressure on the spine, and a lot of people who are in these bad accidents really get some serious problems. Have there been any new technologies to help these people that their spines are almost dislocated or broken or? Can it be mended?
Dr. Vaksha: Yeah. So many of the patients who have these car accidents have injuries to their muscles or ligaments and they can be treated without surgery by physical therapy, medications but those who have a fracture, who have a dislocation or subluxation, they may need surgical treatment in the form of again fixation of the spine fusion.
There will be patients who injured their disk or the facet joints and ligaments during these accidents and who don’t get better with the conservative treatment, these patients may also need some surgery in the form of discectomy, decompression, foraminotomy or fusion surgeries. We also have recently come up with laminoplasty of the lumbar spine, which we also do on the cervical spine also in which we tried to do decompression without causing minimal damage to the back muscles and the bone there.
Larry Mikorenda: Now when you had referred to minimally invasive surgeries, what’s minimally invasive? Is like a two or three hospital day stay, is in and out, is it outpatient, what is it?
Dr. Vaksha: So minimal invasive surgery essentially means doing the same surgery that we want to, to get the same result or better, but going through a channel or an opening in the skin with minimal damage to the nearby soft tissues like muscles. So it may be not a smaller incision, but it may be a little small incision, but we tried to give less damage to the tissue around.
Now minimally invasive surgery can be done using microscope, using tubes or tubular surgeries or using endoscopes and we tried to do minimal damage as the surgery itself says and go onto the site where the pathologies and take care of the pathology, the problem, cleaning up the nerve root, cleaning up the stenosis so that the patient get good relief but at the same time less modality.
Dr. Vaksha: This allows us to send the patient home early, maybe the same day sometimes, maybe the next day and at the same time it allows early recovery for the patient, shorter physical therapy period, shorter recovery period, and coming back to their normal living.
Larry Mikorenda: That was my next question, it was about to recovery time with these minimally invasive surgeries. Recovery time is like in at eight out by five some of the stuff, right?
Dr. Vaksha: Yes, exactly. Some of these strategies can be done on a day basis, that they can be operated in the morning and sent back home the same day. After that also, the recovery period is cut by half to one third in many of the surgeries and patients can jump back to their life.
Larry Mikorenda: Now we already spoke about fusion surgeries, what are non fusion surgeries?
Dr. Vaksha: Non Fusion surgeries are some surgeries in which we tried to keep the mobility of the spine and at same time not compromising the correction of the pathology. Non Fusion surgeries include total disc replacement because it allows mobility, it also includes surgery like discectomy and decompression surgeries, laminectomy, foraminotomy, laminoplasty and also the interspinous spaces. So any surgery in which we are not doing any fusion, we are not putting bone graph, we are not putting in screws and rods and any cages.
Larry Mikorenda: So what are the benefits of having some of these surgeries? We’d be cured once and for all or does the pain come back? What’s the benefits of it?
Dr. Vaksha: So again, the surgery is not for everyone but patients who are not getting relief with any other treatment modalities, who need treatment, who need to work, who need to get back to their life, they need a cure to the pathology, surgery helps taking that cure in sort of a permanent way. That does not mean that they will not have any spine problems in the future, the surgery in itself may cause some degeneration, but at the same time body is still aging, the degeneration will still happen at the segments above and below and if we have not done a fusion which has been successful then at the same level also.
So these patients can have problems in the future, but we are talking about taking care of the problem right now at this time as they are not able to continue with any other treatment modality actually.
Larry Mikorenda: That was going to be my next question would be, what are the risks of… we’ve spoken of the benefits of back surgery, what are the risks for back surgery?
Dr. Vaksha: Like any other surgery, every surgery has its risks lumbar spine surgery has its risk. The common risk with any of the surgery is infection, bleeding, injury to the edges and nerves and vessels. But again, we are working right on the nerves so we can cause deterioration of some of the neurological problems, we can cause some tingling, some short term pain, which may need some treatment.
We work very near to the sac where the nerve roots are so we may sometimes injure that cause leakage of the CSF, in which case we actually repaired them and most of the patients don’t have any problem, don’t need any secondary procedures, but there’s always a chance that we may need a second surgery.
Occasionally there is a chance that we have injury to the adjoining facets, they get degeneration and they may need future surgeries, but all in all back surgery are a very successful surgery, people do get better and they get back to the normal living as soon as they are healing there.
Larry Mikorenda: Again, to put people at ease. This is not the surgeries that were even performed 10 years ago, the new technology that’s out there we had spoken about previously with the MRI, now they’re working on this thing with the sonogram where they do this and they placed the needle, you can feel it… it’s actually really incredible and it’s much safer than surgeries that were done 10 years ago and most of the surgeries now, like we were saying are outpatient surgeries where people are thinking, oh well I’m going in Monday, I’m not coming back for a month or something, that’s no longer the fact right?
Dr. Vaksha: Yes, exactly. With the enhancements in our visual optics we use magnifications loops, we use sometimes microscope, at the same time we use intraoperative fluoroscopy which are like x rays we take inside the operating room to see where we are, what are we doing, where are we putting the screws and rods.
Also, we can now we have the capability of doing intraoperative CT scans, so we can do a CT scan especially if the patient has a crooked spine we try to do a CT scan, we can put screws according to what it shows on the monitor which is called a navigation. Also, in the recent advances, robotics have come into the spine in which we template everything into the software preoperatively, before the surgery, and then we use the robots in the surgery, which guides us as to where to put the screw, where to put the rods, which gives a very optimal result.
Larry Mikorenda: And so you talked about this, a cyber knife and robo knife and stuff like that, is that what these are?
Dr. Vaksha: Yes, exactly. We use the robotics and these on the spine which have been traditionally used on the brain.
Larry Mikorenda: And again to put people’s fears at ease, there’s not going to be some robot that’s standing there with a couple of scalpels, the doctor is there, everybody’s around. The computer really and the robots do the cutting through the assistance of the doctor and everything like right?
Dr. Vaksha: Exactly. The surgeon is still scrubbed with the surgery, the robot is only there to help the surgeon. The drilling part, the putting the screw part is all done by the surgeon himself, but the robot helps to guide and there is a fail safe on it, we do check it at that time also live in the OR as to we are not doing anything wrong. And these things have been tested and research over time to find that their accuracy rates are far above 99% before they are even implemented into the operating room.
Larry Mikorenda: So people can rest assured that if they’re going through something like that, it’s because also the precision of these robots, cyber knife, stuff like that. I believe that they use sometimes laser scalpels or something? It sounds like something from Star Trek.
Dr. Vaksha: We do use ultrasonics scalpels actually, which is what we do when we have to cut the bone, we do use ultrasonic scalpels, they make sharp cuts, they make a surgery easier and quicker that helps us taking the patient in and out of the OR very quickly and they tend not to injure the adjoining soft tissues and the dura from where the CSF can leak and they help a lot.
Larry Mikorenda: What advice would you give to somebody who’s about to have a back surgery? It can it be anything to calm them down or anything or… you must get this all the time with patients, what do you usually tell them?
Dr. Vaksha: As a preparation first of all, they should have usually taking a course of conservative management in the form of medications, physical therapy, sometimes injections and if they’ve failed everything then we talk about the risks, the benefits, the complications of a surgery, what are the treatment options other than surgery and how they can come they can fold out to them if we dig one path or the other. There is also regarding optimization of a patient before the surgery, they should have a good nutrition,
They shouldn’t have a good hemoglobin in their body, their albumin should be good so that means that they will heal well. We preferred they should not be smoking even if they’re using nicotine in any form like a vapes, cigarettes, cigars, patches, we discontinue them before the surgery especially if we are doing a fusion surgery, it is imperative that they should not be using nicotine in any form.
Larry Mikorenda: And why is that?
Dr. Vaksha: Because nicotine hampers healing, bony fusion and the chances that someone using nicotine failing a fusion are very high. So unless it’s an emergency and we cannot we will do a fusion, but otherwise electively we would try not to do a fusion surgery on a patient who is using nicotine.
Larry Mikorenda: Wow, that’s really something else. You find out all these things about smoking and we’re finding this out today.
Dr. Vaksha: Yeah, and smoking also enhances a degeneration of the spine so it is one of the causes of back pain now. Apart from that, we would also see that if the patient is overweight or obese we would like them to have some weight control in the meantime when they’re doing physical therapy and also that helps optimize their recovery after the surgery.
Larry Mikorenda: Exactly, and just to repeat what we said in the last program about weight was that your spine is designed just like, let’s say a truck can hold 250 pounds, you’re throwing 500 pounds on this thing sooner or later something’s going to break, a shock absorber or something’s going to go down on that thing.
Dr. Vaksha: Yeah, increased weight is a major cause of advancing arthritis not only in the back, but also in the hip and the knees and the foot and control of it, decreasing the weight is one of the very good treatment modalities to actually control your pain in musculoskeletal that’s the spine and the hips and the knees.
Larry Mikorenda: Well Dr. Vaksha we’re at a time for this episode, but will you come back and tell us about the neck and the neck problem? You’ve pretty much covered the back on this one.
Dr. Vaksha: Sure, it was nice being here.
Larry Mikorenda: Okay, until next time we’ll be back again with Dr. Vaksha on this channel. Stay tuned and take care.
Dr. Vaksha: I’m Dr. Vedant Vaksha I work with Complete Orthopedics, we have offices in Stony Brook, in Little Neck and Babylon and I can be reached through our website cortho.org or through our phone number (631) 981-2663.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
Please take a look at my profile page and don't hesitate to come in and talk.
