This video appeared on local cable access TV in Long Island New York…
Larry Mikorenda: Hi. I’m Larry Mikorenda and welcome to Excelsior Forum, and with me today is Vedant Vaksha. He is a spinal surgeon and if we have heard that terminology, “Oh, my aching back,” and hopefully he’s going to tell us a little bit about what’s going on with that aching back.
Larry Mikorenda: If you would just tell the audience a little bit about your background and how you got to become a spinal surgeon.
Dr. Vaksha: Hi. I’m orthopedic surgeon and I did fellowships in spine surgery. I did two fellowships. Rochester, New York, and Cleveland Clinic, Ohio. And spine has always been my passion. So, with the background of fellowships, I have been practicing spine for the last few years now. Taking care of patients surgically, non-surgically, of their back, of their neck, and the lower back.
Larry Mikorenda: Now, how exactly is the back put together? We always hear disc and hernias and all these other things, and we’ll get into those later, but how is the back basically put together?
Dr. Vaksha: So, back is made up of vertebrae, which are multiple bones stacked over each other. Now, there are seven vertebrae which make up the cervical spine or the neck. There are 12 vertebrae which make up the thoracic spine, or the upper back, and there are five lumbar spine vertebrae, or the lower back.
Dr. Vaksha: Then, there are five sacral vertebrae, which are all fused together to make one bone called sacrum, and there are three to five coccyxial segments which fuse to become a coccyx. So, essentially there are three segments of the spine. The neck, or the cervical spine, the upper back, or the thoracic spine, and the lower back, which is lumbar, sacrum, and coccyx.
Dr. Vaksha: These are all stacked over each other to give a structure which holds the body together, helps in transmitting the weight of the upper body onto the lower body and the legs. At the same time, they protect all the nerves within the spinal canal, which go down the body to supply the muscles as well as bring the sensations back onto the brain.
Larry Mikorenda: Now, that was a mouthful. But the disc. We hear a lot of times, slipped disc, and everything. Where exactly are the discs in the back? Are they between the bones?
Dr. Vaksha: So, between each of these segments. These segments are mobile onto each other. So, there has to be something between the vertebrae to help them with the mobility. Essentially, every vertebrae with each other makes three joints. Two are the facet joints, which are the back, and the one is the intervertebral joint, which is essentially the disc. So the disc is a cartilaginous structure between two vertebral segments. It is made up of a fibrocartilaginous outer ring, and gelatinous inside, which is called a nucleus pulposus.
Dr. Vaksha: This disc is hydrated when we are born, and it gradually, as the aging process, loses some of this hydration, loses its water content, and that’s what happens when we call degenerative disc.
Larry Mikorenda: Now, you hear slipped disc a lot. “I slipped a disc in my back.” How does that occur? What’s happening with the body when you slip a disc?
Dr. Vaksha: So, essentially, when we talk about slipped disc, what it means is that there possibly is an annular tear in the disc or some of the material from inside what we call the nucleus pulposus, comes out from the disk pushes behind the disc, and maybe compress one of the nerve roots. This is essentially what is slipped disk, and this is closely related to what is called the degenerative disc disease, because with loss of hydration as we discussed the disc is prone to injury prone to tears, and this is gelatinous structure comes out pushing the nerves.
Larry Mikorenda: So if you have a slip disc, even if you fix it. It’s a good chance that you could re-injure it very easily.
Dr. Vaksha: Yes, as the disc is already in the aging process. So, the injury that has happened cause the slip disc or the disc herniation can again happen, can happen on the other side, can happen on the same side, but it is unusual. Though, not impossible to have the same thing at the same level on the same side.
Larry Mikorenda: Now we talked also about, we have pinched nerves or sciatica. So let’s take pinched nerves first of all. What happens with pinched nerves, is the disc is eroded… nerve gets in there? I really don’t know.
Dr. Vaksha: Yeah. So, as you know, the nerves are present in the spinal canal which is protected by the vertebrae itself. The nerves at each level, get out of the spinal canal from every vertebrae. Now this is the place where the nerve route is surrounded by multiple structures, which is facet joint on the back, bones on the side and front but also a disc in the front. Now this disc if herniated it can push this nerve root and decrease the space for the nerve.
Dr. Vaksha: When the space for the nerve decreases, it gets irritated, its blood supply gets decreased, it gets inflamed and that’s when it becomes painful. It presents with pain in the area that’s going to supply and it may be associated with other symptoms like tingling, numbness, really weakness. There are nerve routes which supply the bowel and bladder function. If those are involved, then they may involve the bowel and bladder function and patient may have retention, or incontinence.
Larry Mikorenda: So you can actually from having something wrong with your back, it can actually affect your internal organs also.
Dr. Vaksha: Yes, essentially, the internal organs that usually get affected if there is a problem in the back and nerves getting compressed, or bowel and bladder. The other internal organs of the belly and all they are essentially supplied by the other nerves which are not contributory from the back.
Larry Mikorenda: Right so that whole lower back area that we will call it the lumbar?
Dr. Vaksha: Lumber sacral spine.
Larry Mikorenda: Sorry if I can’t pronounce.
Larry Mikorenda: But also, we talked about sciatica we hear that word is so much, and so many back injuries. What exactly is sciatica?
Dr. Vaksha: Sciatica word comes from the inflammation or pain along the sciatic nerve, the sciatic nerve is formed by multiple nerve roots that come up out of the spine and fuse to become a thick nerve called the sciatic nerve. This nerve travels from the back of the head into the back of the thigh to the back of the knee, making small branches and supplies, all the way along. When the nerve roots usually l five and s one are compressed because these are the most mobile segments of the lumbar spine patient starts having pain which goes along the back of the thigh and the leg or on the outer aspect of the thigh and the leg. And this pain, which goes from the back towards the toes is essentially described as sciatica.
Larry Mikorenda: Now, also can that sciatic nerve give you pain in your hip?
Dr. Vaksha: Yes, very good question. So, the sciatic nerve can occasionally present with pain in the hip. Now, it’s not usually because of the nerve itself, but the because of the pathology that is causing the sciatica because it is compressing the sciatic nerve at the same time, there is some pathology going on, which may present with a hip pain, also.
Larry Mikorenda: Now, the way to diagnostic all right there’s so many areas of the spine, the neck, like you were saying, how do you go about diagnosing some of these diseases?
Dr. Vaksha: So, first of all, as a clinician, a history and physical examination is of paramount importance for these patients. The physician by the history itself, supported by the examination can make a clinical diagnosis, as to what’s going on. Then we need relevant investigations to support our diagnosis, especially when we are trying to do something actively for the patient to relieve the patient of the pain.
Dr. Vaksha: So we do x rays and just to see if there is no fracture, no subluxation, dislocation as to the amount of arthritis that’s going on, or any other relevant finding. Then, if needed we do advanced imaging, like the MRI.
Dr. Vaksha: MRI helps very much in detailing all the soft tissue in the spine, it gives us how the disc is how the capsules, how the facet joint, if there is any cyst, fluid filled cyst, if there is any ligament which is buckling causing compression of the nerve roots, a lot of information that we get from the MRI.
Larry Mikorenda: Now, do they ever use like sonograms for the back or anything like that?
Dr. Vaksha: Sonogram is not usually used for the back, but we can still use investigations like CAT scan, we can use investigations like putting dye into the spinal canal and taking a CAT scan after that called the CT myelogram, and this is essentially done in patients who cannot undergo MRI, and this is a population who have MRI non compatible pacemakers usually some patients with individual clips or certain implants, which cannot undergo an MRI. They are helped by a CT myelogram.
Larry Mikorenda: Now we’ve, we’ve mentioned and spoke before about osteoporosis on this program and one of the things is, is that these back injuries are not just limited to people who are over 50 or over 45, you also deal a lot with athletes and sports medicine, because it gets to the rigorous bending and jumping and everything else that they do.
Larry Mikorenda: How do you go about treating patients who are younger was going to have the spinal problems because they may lead to much worse problems later on in life?
Dr. Vaksha: Yes, younger population is prone to spine problems, more often like disc herniation, rather than the older population who are more prone to conditions like spinal stenosis, younger patients are a tricky population, because we don’t want to do too much because they have a lot of life in front but at the same time we don’t want to leave them in pain, which will make their life, very difficult to go on. Spine surgery as almost any other orthopedic surgery or today’s medicine is more about quality of life. So we try to do optimum, so that they can regain their quality of life, and live better.
Larry Mikorenda: And a lot of times, and I know from the other doctors who founded the program. They don’t want to be pill doctors they don’t want to keep filling people with painkillers and stuff like that, of course, you know there are some cases that may be different, but the majority is to treat and to get out get rid of this this problem not to just keep throwing drugs and stuff like that. So you will also specialize in certain therapies also for the back?
Dr. Vaksha: As a surgeon. I do prefer that I keep the patient, off especially the narcotic medications, but I need to give them, I will give them, but I try to keep them off that so I try to do the therapies, or surgeries so that they get better off all the problems that they’re having, and they get off the medication soon, as soon as possible for them.
Larry Mikorenda: Now we were talking about athletes before spondylitis, I believe it is, and the spinal stenosis, what are they?
Dr. Vaksha: So spondylitis is another technical term for degenerative disc disease and this actually starts early in the age, 30 or 40 years age but usually it’s asymptomatic and patients do not present in the age of 50, 60, depending on their symptoms.
Dr. Vaksha: Now in patients who are athletes, who are sportsman, they may have had rough reason they’re back in the past, which can accelerate the process of spondylitis, and they may present early. These are the patients who represent with disc degeneration, disc herniation, and they made a treatment for that. Contrary to that older population presents with more of spinal stenosis, in this, they may have disc herniation but they may also have bottling or calcification of the ligament which is on the back of the spinal canal called the ligament inflame and multiple disc bulges and they usually present at multiple levels.
Dr. Vaksha: These are the patients who contrary to the disc herniation patient who presented with a regular pain, or the sciatica. These will present with pain or nagging sensation in both their calves, both their legs, after walking a certain distance, and they will tell you, I walk a block, and then I cannot walk, I want to sit down, I need to bend forwards. These patients when they go to a grocery store, they will take a grocery cart and lean on it, and then they go to shopping. If they don’t have a grocery cart, they won’t be able to shop, because they’re not able to lean. So these are the patients who are spinal stenosis.
Larry Mikorenda: Now, we hear the term subluxation used a lot. Now, subluxation sounds like a some sort of building block or something like that. Can you tell us really what that is?
Dr. Vaksha: Yes, subluxation is what it means is partial dislocation.
Dr. Vaksha: That means that bodies, the vertebral bodies are in contact with each other, but they have not, they have separated slightly, or slightly more but not completely. In spine the word that we use is spodnylosis for the same thing. That means that the patient has a movement of upper body. Over the lower body, and these spondylosis are divided into grades. Grade one, two three, four and even five depending on how far it has gone. Most of the patients and these patients usually have a degenerative disc disease, present with a grade one spondylosis. And these patients, again, do not need treatment, till they have symptoms, which may be just back pain or which may be already clipping going down the legs. They may also have tingling, numbness, weakness, gait problems, walking problems because of the weakness in their muscles. Very rarely they will have a bowel or bladder problems.
Larry Mikorenda: Now, sometimes people think it’s restless leg syndrome. When it can actually be the back and the, I believe you said the lumbar part of the spine, because the spine is broken up into three sections right?
Dr. Vaksha: Yes.
Larry Mikorenda: Now, we also hear the word spinal tap a lot, which is scary to hear the word of it but basically what is that procedure that the spine fills up with fluid, it has to be drained or?
Dr. Vaksha: Spinal tap essentially it’s a procedure in which we put a needle into the spinal canal to pull the fluid out, and this is more often, a diagnostic procedure in which this fluid is taken out and sent to the lab for some testing and these are done if we’re suspecting a patient to have some brain infection on some spinal cord problem, which may be causing inflammation and.
Larry Mikorenda: So, when is it the time to see a doctor? When you are having, you know these problems in the back. I mean, should you just say oh I’m going to take a pill or you know ibuprofen or something like that and I’ll be okay in a day or two. When is the time to come and see you or see a doctor?
Dr. Vaksha: 80% of human population will suffer back pain, once in their life. That does not mean that all 80% have to see a doctor. Most of these back pain are self controlled, self restraining. So this treating of just treating them with a short period of rest, taking some medications, over the counter, using some ice, maybe heat. It can help elevate the pain and that’s it, but if the pain is not getting better with all these podalities in three to five days, then they should try to see their primary care to know as to what’s going on, and they may actually start some physical therapy for them or educate them how to use their back more efficiently.
Dr. Vaksha: But there are times when you start, especially when you start having been going down your legs, which again does not get relieved with the usual medication, then you may have to see a spine surgeon. Pain physician, someone who specializes in taking care of back pain, which is associated with radiculopathy or sciatica. And this is the time when you see us.
Larry Mikorenda: Now, also the term has been used spinal fusion. Now that’s something that sounds scary too but basically, can you tell us a little bit about what that is in case maybe somebody out there who’s going to have this procedure done?
Dr. Vaksha: Yes, so most of the times that procedure that we try to do is like a pain we are doing a procedure is decreasing the pressure from the spinal roots and this can be done in the form of this discectomy or laminectomy. Occasionally patient may have what we discuss about like sublimation or instability of the spine. These patients, if they just undergo a laminectomy or discectomy will further aggravate the instability and have problems. So these patients usually need to undergo a fusion surgeries. Also, if patients have more of back pain, then the leg pain, then fusion surgery is a better surgery for them to take care of everything which has been going on and elevate all the symptoms.
Larry Mikorenda: Now can some of these spinal problems also cause like twitching in the legs pain that constantly comes and goes? Recurrent pain? Some of the other things are like, total numbness I know some people like what the pains is it back but they can’t feel anything in the bottom of their feet, is that well because of the sciatic nerve or is it something else going on?
Dr. Vaksha: Yes. So, so there are certain patients who may have really severe form of this disease, and they need to, people need to understand when there is an urgency to go to see maybe a doctor, maybe urgent care, maybe emergency room. These are the patients who start developing worsening tingling, numbness pain, weakness of muscles, they start slapping their foot on the ground when they’re walking, which is called a foot drop. Patients may have numbness around their genitalia patient, may lose control of their bowel, bladder. And these are emergency conditions. They should seek urgent care. So as the process, which is causing this may be diagnosed and stop as soon as possible.
Dr. Vaksha: The diagnosis word that we use for here is accorded Aquinas syndrome, which is an emergent diagnosis and need, usually need surgical treatment to take care of it.
Larry Mikorenda: Now you had just mentioned before about a discectomy and I think it’s lumbar domain..
Dr. Vaksha: Laminectomy, yes.
Larry Mikorenda: What are those two procedures?
Dr. Vaksha: So these procedures are done in patients who have compression of the nerve roots, because of a disc herniation, then what we do is we go inside through a small incision minimally invasive surgeries. We use microscopes, we use tools, we use visual enhances, and we go in clean little amount of bone, go on to the disc. The disc which is causing the pressure on the nerve, results are great these patients do really well. This is a very small surgery minimally invasive surgery and this surgery do not contribute to the instability of the spine for the future and patient gets relieved. Laminectomy are usually done if the patients have symptoms on both sides, or in patients who we discussed as spinal stenosis because there is more of stenosis in the center, there’s a thickened ligament in which we talked about, maybe calcified, we need to remove that and then laminectomy is done. Again, a very successful surgery, very good results.
Larry Mikorenda: Now, with the way surgery is gone now you’ve been around for a while, and how would you say that the way modern medicine, just during the past six years in your field has changed? It’s pretty incredible isn’t it?
Dr. Vaksha: Yes, the best things that we have got our visual enhancers, the optics, the microscopes, the loops that we use, the lights that we get, apart from instrumentation. Also we have developed very new surgical techniques, over the last, I would say 10 years, 15 years. And these surgical techniques and enhance in plant material has specially helped us in developing the fusion surgeries, initially fusion surgery was only done from the back. Now, we can do the fusion surgery is from the back from the front from the sides and is done in the right patient can give great results.
Larry Mikorenda: Now, another thing I heard about which is really blew my mind is these synthetic disc, where surgeons can actually go in there, remove the deteriorated disc, slide in this synthetic disc which is probably even better than the regular disc that it’s replacing because of the content and cushion and everything else is made of. Now, what exactly is involved with that?
Dr. Vaksha: So there are very small percentage, but there are patients who can be a great candidate for a disc replacement surgery. In this, these patients usually present with low back pain, and they have when we do an investigation find a very degenerative dark disc. Usually a single level disc and for this we have to go from the front from the belly we go in clean up the disc and put this artificial disc.
Dr. Vaksha: What’s advantage of artificial disc? Well, we are able to keep the movement of the disc level intact because rocking a movement causes increased stresses on the segments above and below, causing them to degenerate. So keeping this movement intact, we are not bio mechanically harming the spine. So we are not doing fusion, these are non fusion surgeries and patient do great with.
Larry Mikorenda: And the synthetic material gets along fine with the body where there’s no major rejection and all these other problems that you get with these other things because it is the spinal column right?
Dr. Vaksha: Yes, good question. So again, this is very unlikely that the patient will have any rejection on these, these implants are very biocompatible, they have been tested, have been researched on and have been used in a number of patients before even get an FDA approval. So these things are researched very well on it.
Larry Mikorenda: And just before we get ready to wrap up here. I had a couple other questions for you. As far as the surgeries are concerned. Now, someone goes in for, you know, back repair lumber ectomy I can go on and on about some of the ones. Now, a lot of these people think that because they had back surgery… I’m going to be out of it for two or three months, I’m going to be you know a half a year and that’s no longer the case for these surgeries is it?
Dr. Vaksha: We try that our patients get out of bed, the same day or the next day, so that they are mobile. Definitely the fusion surgery or bigger surgeries, they are a little more painful, we control pain for the patient we keep them in the hospital for a few days and then send them out. But these patients are mobile right from the day one, and we keep them active, so that they can get back to their normal life as soon as possible.
Larry Mikorenda: So compared to like to say, even six or seven years ago, the turnaround time with the spinal surgeries has decreased majorly compared to where they used to be five or six years ago so people who maybe need the surgeries, they should not have to worry about recovery time?
Dr. Vaksha: I think we have come a long distance over the, I would say, last two decades, with all the improvements in the surgeries in the way we do it the approach we do it, and how we treat them, even after the surgery. We have a team, which works with the patient, the physical therapists, the hospital and everything to make them keep them mobile to make them out of bed, as soon as possible to keep the complications down, and to keep their quality of life high.
Larry Mikorenda: Well, we’re basically at a time here but if you stay tuned for part two, you’ll catch part Two on this program, later Vident W.on this week and we’ll have more. This time we’ll be talking about the neck. Until next time, I’m Larry Mikorenda. I’ll see you right here on this channel
Dr. Vaksha: I’m 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, 631 9812663.