This video recently appeared on local cable access TV here in Long Island New York…
Larry Mikorenda: Hi I’m Larry Mike [inaudible 00:01:01] and welcome to this edition of “Profiles” and with us today is Vedant Vaksha. He is a spinal surgeon, and he has been helping us talk about back problems. And today we discuss the pain in the neck. So the other episode was, “My aching back”. This is, “That pain in my neck. What’s going on?”
Larry Mikorenda: So Vedant, last program, we spoke a lot about the back. But the other part of the back is the neck. And how many times we hear the expression, “Pain in the neck”. Pain in the neck is really a very, very scary and heavy pain. So let’s get into a little bit about some of the causes.
Larry Mikorenda: Now you had referred in the last program as the upper spine is the cervical?
Dr. Vaksha: Cervical spine, yes.
Larry Mikorenda: Now, the same things that can happen to lower back, can they happen in the cervical back? The pinched nerves, the slipped discs, stuff like that. Can you tell us about that?
Dr. Vaksha: Yeah. So the neck is made up of seven vertebrae stacked over each other, and they’re very mobile. They carry the weight of the head connected to the trunk, and they allow us look here, up, down, on the sides. This mobility comes with a cost. The discs in the cervical spine between each vertebrae, they also degenerate as the lower back discs.
Dr. Vaksha: Now when they degenerate they can also again slip, that’s what disc herniation is. They can have degenerative changes, bone formation, that has calcification of the ligament. There’s formation of cysts, there’s pinching of the nerves, and also there can be pinching of the spinal cord here, contrary to what in lower back there are only nerve roots, here the spinal cord travels. And pinching of the spinal cord can be of grave consequences.
Larry Mikorenda: Now we hear a lot of people they have, the pain in the neck it also goes to the jaw. They think they’re having a heart attack. Well, also severe headaches too because some of these neck pains. What is going on with the nerves in the neck that are causing these pains?
Dr. Vaksha: So the neck has nerve roots which supply the upper part of the face, actually the upper part of the back of the neck, and also into the arms. Unusually if there is a pathology going on in the upper cervical spine that patient can have headaches, can have pain which goes down to the sort of jaw, face, upper neck, and maybe have going down to the hand, which may be confused with cardiac pain, especially if it’s going on the left side.
Dr. Vaksha: So these patients usually present into the ER or Urgent Care, and the physicians are usually in a good place to diagnose or say that this is a cardiac pain or the neck pain, or they can do certain investigations to confirm what type of pain it is.
Larry Mikorenda: Now, we spoke about degenerative disc disease in the back, which basically like you said, the lower half, the hips, the legs, the knees, the feet, now we’re dealing with the upper neck. This is going to be the shoulders, the chest plate here, this area … You have a pain in the neck, it’s not going to affect your foot, right?
Dr. Vaksha: It can actually.
Larry Mikorenda: It can?
Dr. Vaksha: Yes. So what happens is, the neck, the spinal cord in the neck is the same spinal cord which is going to supply the legs down there. But at the same time, as in the back, here also the nerve roots come out at all levels, and they go on to supply their respective areas, which in cervical spine is essentially the arm, the forearm, the hand.
Dr. Vaksha: So, when the nerve roots specific to a certain area get pinched, then it will usually present with pain, radiating pain, tingling, numbness, weakness into that part of the upper extremity, or the arm, the hand, the forearm. Patient may have a problem with writing, apart from having the pain.
Dr. Vaksha: But if the disc is compressing the spinal cord itself which it can compress if it is in the center, then patient will have problems in the leg. It usually does not go as a radiating pain, but these patients have electric shock-like sensations going down their body. They may have weakness, they may have gate problems, imbalance, they may be falling, they may have problems with their gall and bladder. They may have decreased sensation in the genital area or other areas of the body.
Larry Mikorenda: So you’re saying, neck pain could actually cause constipation?
Dr. Vaksha: Neck pain can cause constipation. But I think, the more important part that it can cause, which is like weakness, which is like tingling and numbness going down their body, which is dangerous. These patients have very advanced disease and they need treatment for that.
Larry Mikorenda: Now, we’ve located the area. Now why do these neck problems happen? Is it sports? Is it repetitive? Is it stress? There has to be some reasons why these neck pains keep coming out.
Dr. Vaksha: Yes. So the discs. Usually it’s the degeneration of the disc which happens with age, which happens with every person. But only few people will have neck pain. Only very few people will have some herniation of the disc enough to cause compression of the nerve root. Enough to cause pain, and enough to get a medication attention.
Dr. Vaksha: Most of the patients, despite getting the degeneration do not complain of things and they do not go to a doctor. Definitely, injuries to the neck which can be an accident, which can be a repetitive injury because of sports, or the type of work they do can accelerate the degeneration of this disc, and cause early problems.
Dr. Vaksha: Occasionally patients who are in like road traffic accident, motor vehicle accidents, can have fractures, can have disc herniations, traumatic disc herniations, which can cause certain onset of these symptoms.
Larry Mikorenda: Now, again, with the neck, repetitive injury, they were talking about … And I believe, cause you do a lot of therapy work also in your practice, that people who sit at desks all day staring at the computer day after day, year after year, what is this doing to their neck?
Dr. Vaksha: Yeah, so our body is made to sit. It is made to be active. It’s made to be used. Now when we sit on the desk, we’re just not using those muscles, may be neck muscle, back muscle, even legs. And sitting all day long without taking breaks, without doing stretching, without doing other exercises which can be done at the end of the day, or early part of the day, we are just disusing the muscles, we are atrophying them. And once the muscles start atrophying, they do not support the neck, the back, and they start to degenerate and start to have pain.
Dr. Vaksha: And for these patients, it’s more important that they should get out of the desk, nowadays there are standing desks, people should stand while they’re working, sitting causes a lot of problems.
Larry Mikorenda: Or even if they had one of those treadmills where you can actually [crosstalk 00:07:55]
Dr. Vaksha: Yes!
Larry Mikorenda: But now, the necks therapies that are involved. Now you do a great deal of these therapies and stuff like that. Are there some ways that without surgery that you can help your neck and prevent some of these really horrible diseases.
Dr. Vaksha: Yes. Most of the patients don’t need surgery. Most of the patients can be treated with physical therapy. Especially those who have neck pain only. Patients who have ventricular pain, tingling, numbness, weakness, these patients are initially treated with some medications so that the inflammation can be taken care of. And you know what? 90% of these patients don’t need surgery. But then there is a certain amount of people who don’t get better with anything, and if they have symptoms which are worsening, weakness, if that’s happening, we need to operate to take care of that compression, so as the disease process does not go further, and the problems don’t exemplify from there.
Larry Mikorenda: Now some of the people may be watching the program, may be terrified about, “Oh! I’m going to get my neck operated”. The surgeries, again like we have said on the last program, pretty astounding, it’s almost like sci-fi, some of these things. We’ve seen some of these pictures now and these devices that you guys can look at the spine, you can actually see the nerve, you can see it in color, 3D, it’s really incredible.
Larry Mikorenda: So what would you tell people who are considering spinal or neck surgery to ease their fears?
Dr. Vaksha: First of all they should be meeting a good surgeon who does a good history examination and come to a good diagnosis. They should be probably getting good investigations, X-rays, MRI to confirm what the findings are.
Dr. Vaksha: Most of the time they will be treated without surgery, conservative means. Physical therapy, medications, and over time most of them will get better. It’s only if the patient is not getting better, or the symptoms are worsening, or very rarely if they start developing acute neurological deficit in the form of weakness, involvement of gallbladder, gate problems, electric shock-like sensations down the body, then these patients may need urgent surgery, but most of the times they can be treated without surgery.
Larry Mikorenda: And we’ve mentioned that terminology before, and just for clarification for the audience or the people that are watching. When we say gate, we’re not talking about the fence gate and stuff like that [crosstalk 00:10:21]
Dr. Vaksha: No.
Larry Mikorenda: We are talking about, it has to do with the way, I believe you walk, you can have a negative gate or a positive gate.
Dr. Vaksha: It’s the usual gate, usual walking stance, the way we walk. These patients will have involvement of their spinal cord, compression on the spinal cord, maybe in the neck or the upper back, or maybe involvement of the nerve roots in the lower back. These patients are not able to walk straight as normal do. They may walk with a wide stance just to balance themselves, they may use a walker to balance so that they don’t fall. And these patients have advanced disease process going on which needs to be taken care of.
Larry Mikorenda: Now what can we do to help prevent some of these neck problems that we’re going to have? A lot of people now … And this is the great debate, and I wanted to ask this question in the last show, we ran out of time. Was that, some half people say, “Don’t exercise when you have neck and back pain.” The other people say, “Yes, do exercise when you have neck and back pain.” So let’s hear it directly from you. What should we do?
Dr. Vaksha: So when you have neck or back pain, you can do is rest for a couple of days, not a longer period. Start medications for pain, and after that you have to start some stretching and strengthening exercises. Exercises have to be a part of your life to prevent the pain also, you should be regularly doing the exercises. Even when the pain is there, the exercise regiment should start in early, though it will be gentle and gradually increasing.
Larry Mikorenda: Right. So it goes back to like what the weightlifters say, “No pain, no gain.” Or, “Suffer a little pain now or suffer major pain later.”
Dr. Vaksha: Yes, exactly.
Larry Mikorenda: So exercise, thumbs up, it’s a good thing to do.
Dr. Vaksha: Yes.
Larry Mikorenda: Now, some of these people also you see, with these necks, they have like bulges, like a little ball on the back of the neck. What is it? Is that water on the spine or? What is that?
Dr. Vaksha: The bulge usually is the bony prominence. Now these patients we have muscle atrophy of their back because of the disuse as we were discussing, and the bulge may become more prominent. The bulge is a normal anatomic structure, but it’s just saying that the muscles are weak, you have to strengthen those muscles.
Larry Mikorenda: Now we know from the last program also, that you can do lumbar fusions. When it comes to the cervical do you still do fusions with the vertebrae on the neck?
Dr. Vaksha: Yes. So depending on the type of problem patient is having, there are many procedures that can be done on the neck. If they have neck pain along with the pain going down their arm, then fusion is usually the correct answer, which is usually done from the front of the neck, we’re going clean up the disc, put a spacer there and I put a plate and screws there. Very good surgery and with a very good successful results.
Dr. Vaksha: Occasionally there may be patient who just have reticular pain going down their one arm, or both arms. These patients can actually be treated with minimal invasive procedure called microdiscectomy, which is done from the back.
Larry Mikorenda: Now we also had mentioned about the synthetic discs, now we know you can do that in the lower lumbar as we had said, but do they still do that in the neck? Isn’t that a tricky area to be getting a disc in there?
Dr. Vaksha: No, actually, doing the disc replacement on the neck is a very successful procedure, and it can be done on one or two levels depending on the requirement. The replacing the disc helps us keep the functions, not to put excessive pressure on the adjacent segments and prevent their degeneration. This procedure is usually done in patients who have reticular pain going down their arms.
Dr. Vaksha: If they have neck pain also, then this procedure may not be the correct procedure for them. But it’s up to the surgeon, when they meet the patient, examine the patient, discuss their problems, discuss their expectations, and the treatment options that they come to a mutual decision as to what is best for the patient.
Larry Mikorenda: Now are there like non-fusion treatments for the neck that can be done for this to alleviate these pains?
Dr. Vaksha: Yes, so doing the disc replacement surgery is a non-fusion method. The other method is microdiscectomy, which is, as we discussed, doing from the back, removing the disc fragment which is compressing the nerve root and alleviating the pain. In this we’re not doing fusion, so we’re not restricting the movement of the vertebrae.
Larry Mikorenda: Well, which is better? Would it be better to get spinal fusion or non-spinal fusion? Or is it a case-by-case basis?
Dr. Vaksha: Exactly. So doing a non-spinal fusion is definitely better, but, it cannot work with every patient. Every patient is different, so it is case by case, depending on the presentation, depending on the location of the pain, depending on the symptoms. And there’s a spine profile that we decide as to what is the best treatment for them.
Larry Mikorenda: And so I guess the degree of deterioration of the discs, okay, as well as spacing would basically decide that [that way 00:15:12].
Dr. Vaksha: Yes. As well as the symptoms if they have neck pain, if they have arm pain. How many levels are involved? How bad is it involved? All these things come into determinating the factors as to the patient will get better with a fusion, how many levels of fusion with a disc replacement even if the fusion is needed from the back, or from the front.
Larry Mikorenda: Now, can the organs of the head be affected by these pinched nerves? Like do you get blurry vision, problems with your hearing, stuff. Or some of these nerve pains or no?
Dr. Vaksha: It’s unusual. So, vision is usually not involved with the nerve roots in the neck. The hearing can sometimes get involved. It’s rare. Especially it happens when the vertebral artery which is going from the back into the head, on the back of the head gets compressed, which is an unusual process, and it can be caused by many other things rather than disc, like with tumors.
Larry Mikorenda: Now, another question I had, and when I had told [inaudible 00:16:15] to share with you, asked me this, and it may sound like it’s a bit of ridiculous question, but there’s that one bone that sticks out between your neck and your back, what is that thing? People think that it’s getting bigger, or … What is it?
Dr. Vaksha: So that’s what is technically called the spinal stenosis of the C7 and T1 vertebrae. They are especially big, so they are prominences onto the back. And as we discussed, in the muscle of the side atrophies they get prominent. So they are normal bones there. It’s just, if your muscles are strong and bulging, you will never see them. But if the muscles are down, you will see them and feel them.
Larry Mikorenda: That’s all for now. And also, we talk about hunchback people. Now this is a severe curvature of the spine, I believe. And that happens to some people as they age. What causes this?
Dr. Vaksha: So hunchback can be seen in two different population: One is adolescent young kids, and the other is the older age. The older age is the more common variety, and it’s usually because of osteoporosis or the weakening of the bones causing multiple compression fractures or wedge compression fractures of the vertebrae so that the wedge and over a period of time the curvature increases and they get a hunchback.
Dr. Vaksha: The younger population is a different disease process which can cause hunchback, and they are treated in a different way, usually by the pediatric spine surgeons.
Larry Mikorenda: So the curvature again of your spine and of your neck. Is there any little things that people can do besides stretching, exercises, stuff like that from being in front of a computer screen? Or you get some construction workers who are constantly lifting heavy and the neck goes back. What can they possibly do, you know, alleviate, or stop from having these major pains later on?
Dr. Vaksha: That is as you said, exercise is one of the key thing in keeping your musculature, keeping your structure straight, definitely when you are using a desktop computer, a computer or on a desktop, you should try to keep the computer at your eye level so that you’re not seeing down all the time. And stretching your muscles, strengthening your muscles is the way to keep them straight. You can try using posture [charts 00:18:39] and there are many new gadgets they try to remind you that you are hunching, but that ultimately they lead you to exercising your spine so that you keep them straight.
Larry Mikorenda: Okay. So now I’m going to put you on the hot seat. Now I’m going to play patient for you. So now I come in to see you, and I’ve been having these recurrent neck pains back and forth. I have a constant pain if I move forward with my neck. Now, what therapies would you recommend for me? What could be done to help me with this problem?
Dr. Vaksha: There are a wide modalities of treatment therapies that can be done for neck pain, which include not only exercises, but there are pain modalities, there are tense units that can be used to decrease your pain. There are stimulation techniques, and these help great with you. These are usually done with a physical therapist. They teach you, and I would definitely advice you to do almost as much as you can at home, multiple times in a day. So as to recover early and optimally.
Larry Mikorenda: So, it’s not a quick fix, it’s over time, it’s taking care of yourself, and basically nurturing your spine and your neck. We hear so much about all the other, you know, lungs, heart, liver, all the … You never hear too much about what’s going on with the spine and the neck, even though the majority of people have pain in the neck, pain in the back, and all these other problems and pains. But sometimes they don’t know when it’s a time to see a doctor. And I’ll again ask that question to you, when do you really think it’s time to see a doctor when you’re having these problems with your neck?
Dr. Vaksha: So whenever there is a pain in the neck, or pain going down your arms, if it’s not getting better in three to five days, seven days, taking over the count of medications, then these patients should consult their primary care physician or us plain surgeon, and they should ask for advice for treatment for this pain.
Dr. Vaksha: Most of these patients do not need surgery. They can be treated conservatively with medications, with physical therapy, maybe a short rest using some ice, taking a break from the work, and they do well after that. Very small percentage of patient who don’t get better with all these things may need surgery.
Dr. Vaksha: Now there’s a sub-population who may need to go to Urgent Care or ER immediately. These are the patients who have pain, which is worsening, especially associated with worsening, tingling, numbness and radiating pain. And [inaudible 00:21:13] or sudden onset of neurological deficits. They’re not able to lift their arm, lift their elbow, not able to write or they suddenly start having foot weakness, they start having current-like sensation going down their body, involvement of bowel, bladder in the form of incontinence, these patients should immediately seek medical attention.
Larry Mikorenda: And a lot of people are afraid and just to clarify again that if they get spinal or neck surgery and right away they write now the will and you know, they are all worried. But it’s a whole new world out there with medicine and technology. People should not fear these surgeries if they need it.
Dr. Vaksha: No. With advancement with all the way we do the anesthesia, with the way we do the surgery, the visual enhance, the microscopes, instrumentation, the things have advanced so much it’s a very safe surgery now with very good results. And we go from the front of the neck, and we go from the back, as is needed, and the results are great for them.
Larry Mikorenda: Now, are there any tests, I don’t know if this technology is out yet, but are there any tests that they actually do on the nerves to see if like there’s like … Is like electrical wire where there’s a short, or maybe a pinch or something like that.
Dr. Vaksha: Yes. So we occasionally do EMGs and nerve conduction studies on patients if they don’t have a clear picture of what we’re looking for. These tests help us confirm a diagnosis if the patient is having a problem from the neck, the nerve roots in the neck. Or it maybe some nerves are getting involved in their arm, or in their forearm. And these are the patients who may have other problems also which may confirm our results.
Larry Mikorenda: And I have to say, about that nerve test, it’s highly accurate, I mean, it pinpoints right on the scale where your problem is. Helps you majorly, right?
Dr. Vaksha: Yes. It helps us to know specifically which nerve or which nerve root is involved, and we can make a better diagnosis, especially in patients who have confusing presentations.
Larry Mikorenda: Yeah, because a lot of times you’re not sure. And like you said, but these nerves all over the body, and I’m picturing it like electrical wiring. If you have a short somewhere in the building, and you have 500 floors in the building, with 5000 rooms, your diagnostic could be very hard to do. But with these new tools that you have, and the other sources that you work with, you’re able to pretty much pinpoint these things, plus your experience of coming in there. You know, this is not, you’re walking in there as your first surgery, you know, you have done thousands of these I’m pretty sure.
Dr. Vaksha: Yes, and this is important, because you don’t want to operate a patient on a wrong label, or a wrong diagnosis because those symptoms are not going to be alleviated and they will still have problems. So getting a correct diagnosis before what we’re trying to do surgically or non-surgically is important.
Larry Mikorenda: And the days of the fears where they were going to be stuck with needles or like Frankenstein, have electrodes put in their neck or something like that, that’s totally gone, that way. Most of these tests are painless, they’re harmless. I know a lot of people worry about, x-rays and radiations and stuff like that. But the new tech, not like that at all now.
Dr. Vaksha: Yes. The studies done for EMG and nerve condition do involve needles, but they’re very thin needles, they have negligible pain on it, and regarding the MRI. MRI does not have any radiation which cause harm to the body. Occasionally patients may need a CT-scan which is needed for surgical purposes, or sometimes these patients are not compatible to get MRI because maybe they have pacemaker, they have an aneurysmal clip or something, or implants. Then we may have to do a CT-scan. CT-scan does give some radiation, but MRI does not.
Larry Mikorenda: And like you said, again they’re working on these new MRIs that you can actually wear, you know … I know they’re working on them for the wrist, they’re working on one for the back right now. That will only be the next stage and maybe even the next show that we’ll be doing on some of these medicine marvels that have been coming up.
Larry Mikorenda: But it’s good to know, just to give a recap to everybody before we wrap up. That there are therapies out there. You don’t always need a pill or medication, okay? If you do need surgery, the surgeries can be minimally invasive. You can be up and walking around within a day or two.
Larry Mikorenda: The old way of doing medicine with the spine and the neck has basically gone the way of the dodo. So would you agree with all these statements?
Dr. Vaksha: Yes, the treatment today is very advanced, and we are able to give patients quality of life back as soon as possible. With surgical or non-surgical means.
Larry Mikorenda: Well, with that, I wanted to thank you for coming on the program. You have given us a whole … new ideas on knowledge and medicine on the spine and neck, and we’re hoping to have you back very soon. Until next time, I’m Larry Mike [inaudible 00:26:17]. This has been an edition of Profiles, and we’ll see you soon back on this channel.
Dr. Vaksha: I’m Dr. Vedant Vaksha. I work with Complete Orthopedics. We have offices in Stony Brook, in Little Neck and in Babylon. And I can be reached through our website cortho.org, or through our phone number (681) 981-2663.