Low Back Pain - Ty Thaiyananthan, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Ty Thaiyananthan. Dr. Thaiyananthan finished his medical school training at the University of California San Francisco. From there he complete a neurosurgical residency at Yale. He completed a complex, minimally invasive spine fellowship at Cedar Sinai in Los Angeles. Today, Dr. Thaiyananthan is the Director of the Neurosurgical Spine Center at University of California Irvine. Good morning, Dr. Thaiyananthan.

Dr. Ty Thaiyananthan: Good morning, Randy. Thanks for having me.

Dr. Sechrest: Today what I'd like to discuss is your approach to low back pain. Low back pain is as common a disease as the common cold, and I'm certain that, like me, you see this disease process on a daily basis.

Dr. Ty Thaiyananthan: Yes. So low back pain is actually the second most common admitting complaint in the emergency room. It accounts for about 15% of sick leaves in the United States and about 90% of us, by the time we're 85, will have some complaint of low back pain. It's a very ubiquitous problem.

Dr. Sechrest: Well that brings up the point - what's causing this low back pain? What's hurting in the low back?

Dr. Ty Thaiyananthan: It's actually a very complicated anatomical portion of the body. There are a lot of different things down there that can cause low back pain. It can be from the joints. It can be from the bones and the wear and tear that normal life brings about. It can be from the discs associated with it. There could be compression of the nerve roots. There could actually be compression of the lower part of the spinal cord, and the cluster of roots that start from there.

Dr. Sechrest: Now a lot of folks who present to the emergency room, or present to a primary care physician's office, they present with low back pain, they leave that office with a diagnosis of lumbar strain. What's a lumbar strain?

Dr. Ty Thaiyananthan: It's an umbrella term, basically, in my head when somebody says lumbar strain that means you need to see a specialist for further workup.

Dr. Sechrest: It means you've got low back pain and we don't know what's causing the pain?

Dr. Ty Thaiyananthan: Right. It's an umbrella term that a lot of physicians use, but it really is a flag that something may be going on that needs to be evaluated and treated.

Dr. Sechrest: Now you said that 90% of us are going to have some problem with low back pain, and my understanding is that the vast majority of those, especially if this is the first or second episode, are going to get better no matter what happens.

Dr. Ty Thaiyananthan: Yeah, that's correct. Most of us from personal experience know that you may get an ache or pain in your back, and over the span of a month or even shorter, the pain goes away. In fact, the data out there suggests that patients that initially present with low back pain or radiculopathy, a nerve pain that shoots down the legs, about 60% will get better in about 3 months.

Dr. Sechrest: So what you're saying is that even if you've got a pinched nerve or a herniated disc or something that is significant and it's not just run-of-the-mill back pain that's restricted to the back; that even those, a lot of them are going to get better without any treatment.

Dr. Ty Thaiyananthan: That's correct. That doesn't mean you don't need to see a specialist. I think if you are having a symptom of low back pain or pain shooting down your legs, you need to be seen by a doctor. But I think that one of the take-home points is that a lot of people that do come into the office saying, "I have low back pain", may be able to be effectively and completely managed with conservative therapy.

Dr. Sechrest: Now it's interesting, I think that as we talk about 90% of us are going to have low back pain at some point in our life. Why do you think that is? Why do you think that this is such a prevalent disease process in humans?

Dr. Ty Thaiyananthan: It's actually a bioengineering issue. Our spine really wasn't made for erect posture. We were creatures that initially were probably meant to use all four limbs for ambulation. As we walk, as we go about our daily activities, it places a lot of strain on the spine; the lumbar spine, in particular, because it sort of supports the entire weight of the body and there is a factor of 10 forces that is greater in the lumbar spine compared to neck. All this sort of adds to the wear and tear that happens in your lower spine. The bones are constantly undergoing a regenerative process. The joints tend to wear out a little bit. The discs, because of the amount of pressure and strain that they're under, may give out, and this is all registered by the body as pain.

Dr. Sechrest: Now people are always wondering, they come in and they say, "What caused my back pain?" or they relate it to an injury, and there's this great tendency amongst patients to identify, "I was doing this and this caused an injury to my spine", "I ruptured a disc", "I injured something", "I pulled a muscle"; this injury concept is just so prevalent among patients and physicians. What are your thoughts on that? Is back pain something that just occurs, or is it always an injury?

Dr. Ty Thaiyananthan: I think both happen. I think there are some injuries that can result in some damage at that point that cause pain. A lot of times I think it's just sort of the process of having a degenerative spine that then, eventually, having something that sort of tips you over the edge a little bit that then is registered as pain.
Dr. Sechrest: So you have all these aging things that are occurring; as we age our spine begins to collapse, the discs begin to collapse, it's not as resilient, it's not as good a shock absorber. But that doesn't cause pain. So you go on for years and years and although these changes are occurring, just like your skin's wrinkling, my hair's getting gray, those sorts of things; it's not causing pain. Then you do something crazy or not so crazy. You lift a 40 lb. bag of fertilizer and all of the sudden, boom, you're back's hurting and you're down, first episode of back pain.

Dr. Ty Thaiyananthan: Or it may even be something as simple as sitting in a chair, and then all of sudden noticing the pain. The tipping point for every person is different. But a lot of patients will come in saying, "It happened on Thursday when I was doing this", and it really may not be that event specifically, it's just at that point your spine may have just tipped over.

Dr. Sechrest: Now, obviously, back pain is a big huge issue amongst the working class person, and when I say working class I mean anybody that's working a job, so that the worker's compensation system is always dealing with low back pain and work. There is a big controversy, as I understand it, whether you're at higher risk if you're a person, for example, a heavy laborer who works concrete, construction, whatever - lifting, twisting, bending - those sorts of things. Do you think that really puts people at more risk for developing low back pain over, for example, a sedentary office worker, who is not doing that type of activity?

Dr. Ty Thaiyananthan: I think there's a little bit more wear and tear on the spine. It's a little controversial to say that maybe people who are doing more labor-oriented tasks are more susceptible to developing back pain. The data suggests that at least there's a higher incidence of complaints of back pain in patients have more physical activity associated with the jobs, and to a certain extent it makes sense. You're using your spine a little bit more. There's a little bit more motion. There's a little bit more wear and tear on your back, and you would think that that should lead to more back pain. The irony of it is, is that in people that have desk jobs that are seated for most of the day, actually have a higher complaint of pain from herniated discs.

Dr. Sechrest: Really.

Dr. Ty Thaiyananthan: Yeah. So being in a seated position actually places a lot of pressure in your lower back, so I think the take-home message is that just because you have a sedentary job doesn't mean that you're not at risk for developing lower back pain, and certain jobs may actually place you at higher risk.

Dr. Sechrest: It's an interesting point that you make and I think that you probably had the same experience that I did growing up where your mother always said, "Sit up straight", and even people who deal with ergonomics, the normal way of sitting in an office chair is sitting at 90° with your feet flat on the floor. I think that recent studies have shown that that's probably not good for your spine. You're actually better in a slouched position, and so those folks who are always sitting in a slouched position at their desks are probably better off in terms of their spine.

Dr. Ty Thaiyananthan: That's correct. I think ergonomics has really made its way into the working environment and it has a basis in sound philosophy. I think companies and people are becoming a little bit more aware of the fact that there are certain positions that can aggravate back pain and there are things that you can do to alleviate it or prevent it from occurring. You see these ergonomically designed chairs. I think those have a great benefit. I think having a workspace that's ergonomically designed may cut down on the incidence of certain back problems that people will develop over time. So I think there's a definite utility, too, and I think people are beginning to really address the importance of being conscious of posture and ergonomics when it comes to dealing with your back.

Dr. Sechrest: Two other things that we probably ought to bring up because I think they play an incredible role in low back pain. One is genetics. It's becoming more and more obvious to us that different are at higher risk for developing, for example, degenerative disc disease. The twin studies have shown us that genetics probably matter more than what you do. So, if you take a twin, one who is a heavy laborer and one who's a desk person, it's so amazing how, if you look at those people at age 50, their spines look pretty much the same, and it really is about the genetics.

Dr. Ty Thaiyananthan: Right.

Dr. Sechrest: The other thing is smoking. Genetics we can't stop. Genetics we're born with, we're going to have to just manage that. But smoking is one of those things that, I think, folks know about heart disease, they know about lung cancer, they know about all the bad things about smoking, but very few people know the huge impact smoking has on your spine.

Dr. Ty Thaiyananthan: Right. Smoking is actually one of the worst things you can do for your spine. There's a higher incidence of degenerative disc disease, problems with the cushions in-between the vertebral bodies. In the spine, in smokers, there's a higher incidence of just degeneration spine disease throughout. There's a higher incidence of radiculopathy, there's even a higher incidence of stenosis in patients that smoke. In addition to causing these problems, it makes treating these problems a little bit more difficult as well in patients that are candidates for a surgical intervention for their spine problems. Smoking is one of the issues that we have to address before we take the patient to the operating room. We need to get them into a smoking cessation program because it really works against what we do in the operating room to fix these problems. So it's a very complicated, it's a very important issue, in spine disease and something that really needs to be addressed. Patients that come in complaining of back pain that are smokers, I think a very reasonable and holistic approach is you also need to address the smoking factor as part of the treatment for back pain.

Dr. Sechrest: Yeah, it's interesting. I think you mentioned surgery and the risk around surgery of smoking, and a lot of patients get the piece of, "Well, if you're going to put me to sleep and do a general anesthetic that affects my lungs". What they don't understand is that the smoking affects the healing of the wound. It affects the fusion rate. That bone doesn't grow very well in people who continue to smoke.

Dr. Ty Thaiyananthan: That's correct.

Dr. Sechrest: So it's a much broader problem that just we're trying to get you through the general anesthetic with less risk. So it's really about whole overall healing process of your spine surgery.

Dr. Ty Thaiyananthan: Even with some of the newer technologies that we have, with some of the proteins that we can actually implant that help bone grow at the time of surgery, and smoking is the single greatest factor that can cause an adverse outcome from a surgical procedure - just not healing, that the bone's not growing, to an appropriate point that you need to treat the problem. So it's definitely a very important issue that needs to be addressed.

Dr. Sechrest: This may be an unfair question for a neurosurgeon, but what about nutrition? Do you have any information that you can share with patients about what changes in nutrition are important in people who have low back pain or are contemplating surgery for a fusion? Anything you tell patients?

Dr. Ty Thaiyananthan: Nutrition is very important. One of the most important things that I think a patient can do is to be hydrated. Hydration is directly correlated with the condition of discs. It may help slow down the disease process in degenerative discs. I think the sources of nutrition that help supply the body with collagen and vitamin C are important for maintaining discs and also vitamin D as well for bone healing and for the bones to be stable in patients that have back pain. Nutrition is a critical, critical component in those patients and I think it's really something that needs to be addressed in a holistic manner when patients come in. Their activity, nutrition, and smoking, and medications that they may be on, all need to be reviewed in a detailed manner by a physician.

Dr. Sechrest: Now let's move on a little bit to your evaluation as a neurosurgeon for a patient with low back pain. When you see that patient in the office, what's the first thing you're going to do?

Dr. Ty Thaiyananthan: The first thing really involves a detailed history and physical exam. I think you need to figure out when the pain started, what caused it, what aggravates it, what alleviates it, what medications they might have taken over the counter that help, what physical activities they've done that might have helped it or aggravated it. Those are all very critical key components that help in forming a diagnosis about what may be going on. The physical exam - we'll take the history and hone it down to a specific region of the spine or specific nerve, or specific anatomic point that may then help guide you in picking an appropriate imaging study to take a closer look at what may be going on.

Dr. Sechrest: So you're going to start, and the age-old adage in medicine is that 85% of the diagnosis is made on the history and even in low back pain it's still very important. So you're going to start with that history, then you're going to move on to physical exam and then decide what to do in terms of imaging tests, MRI scan, CT scan, those sorts of things, x-rays. What questions are you focusing in on in with a patient with low back pain? What do you want to know as a neurosurgeon? What are the key points you're trying to get from that history?

Dr. Ty Thaiyananthan: As a physician I look for how long this pain been going on. How severe is it? Are the symptoms the patient is telling me consistent with compression of the nerve root? Are there symptoms that are consistent with what we call stenosis, or narrowing of the spinal canal? Is this patient having problems walking? Is this patient complaining of any bowel/bladder problems, which may be an indication of compression of some of the neural elements, that surround the spinal canal? How severely is this affecting the patient's quality of life? These are all issues that, when a patient comes in with an initial complaint, that I'm considering to help formulate the next step in diagnosing and treating a particular problem.

Dr. Sechrest: When you go on to that next step, when you begin doing your physical exam, what are looking for in the physical exam in a patient with low back pain? What sort of things are you trying to get from that information?

Dr. Ty Thaiyananthan: You look for what kind of motions cause the pain and that can help you pinpoint what parts of the spine may be the culprit. Is there pain when the patient extends his back backwards? Is there pain when he leans forward or turns to the side? Those are all clues that help you decide where the pain may be coming from. Is there a motor or sensory weakness, and if there is, what distribution is it. Those are all other clues that tell you what nerve roots may be involved. Those nerve roots then help guide you to a specific point in the spine. What we try to do as physicians is what we call a clinical pathologic correlation. You take the patient, their story, and then correlate it with the imaging studies and the tests that you have, and those two things really need to mesh together to pinpoint what may be causing it. A lot of times patients will come in and say, "I have back pain", and they have multiple issues going up and down their spine, but the really important question is which one of those issues is causing the patient's symptoms and addressing that. I think that really gives you the highest probability of success in treating the patient.

Dr. Sechrest: So you're really trying to localize what we've termed before the "pain generator". You want to know what's causing the pain. We see lots of abnormalities on the MRI scan all the time. Some of them are clearly just aging artifacts or things that are not causing any problems. They're abnormal, yes, but that doesn't mean that they're pathologic or they're causing significant problems that need to be addressed. I think you're point is that you don't want to see something on the MRI scan and focus on that and that's different than what the patient is there for, and you're ignoring what the patient actually telling you.
Dr. Ty Thaiyananthan: That's correct. You know, a lot of times patients will come in with a report from a radiologist saying everything that is abnormal with the spine, and rightfully so, a lot of patients get worried about that. But the critical question to ask is whatever is listed as an abnormality; is that really causing any of the symptoms that you're having. All of us, I think any one of us if we had an MRI of our back, would have some sort of abnormality with it. That's a normal process of life, and I think the clinical acumen is to identify what's causing the patient's problem, and I think that really gives you the highest probability of treating a patient's problem.

Dr. Sechrest: As you move on to those tests and you start to do your own tests, after you've done your history, done your physical, what test do you find most useful in the diagnosis of a patient with low back pain? Where do you start?

Dr. Ty Thaiyananthan: Generally, the first test is plain x-rays. I think give you a very bird's eye view of what's going on with the spine. The next step may involve getting a CT scan. It's a little bit more detailed view of the bony anatomy of the spine. It gives you a better view of the joints, what we call facets. It gives you a little better view of the space in-between the discs. If there's suspicion for soft tissue problems in the spine, an MRI would probably be warranted, in fact, a lot of patients automatically just get an MRI prior to even seeing a spine specialist. It's sort of a knee-jerk diagnostic test. The MRI is useful because it tells you a little bit about the discs, the nerve roots, about whether the spinal column itself is being compressed, and I think all three of those put together give you a very good picture of the spine. Often times it's not one or other, it's a combination of a couple or all of those modalities in getting a very accurate picture of what's going on.

Dr. Sechrest: Any other tests that you find useful in the lumbar spine? We've got multiple tests that we can do. Two tests that I would like some specific information on are: 1) the electrical studies or the EMGs in the lumbar spine - whether you think that is a useful tool in the lumbar spine.

Dr. Ty Thaiyananthan: It definitely is a useful tool, and I think when used in the right patient it really provides valuable information. The premise of that test is that it is an electrical study that helps identify a specific nerve and muscle group that may be having a problem, and it's valuable in confirming what a physical exam may show you on a patient may show you on a patient is a problem origin for the pain or numbness. I think it helps collaborate a clinical suspicion of what the pathology may be, and it's also a very useful tool for monitoring progress of certain treatment modalities. I think it's a very critical tool and something that is being used on a more frequent basis.

Dr. Sechrest: So explain that to me when you say, "use it as a tool to monitor treatment". A lot of people don't understand that the body and the nervous system are like a wiring diagram on any other piece of machinery to some degree. The nerves go to specific places and the muscles that those nerves go to are almost rigid from the standpoint that they're always the same. There's a little bit of variation, but not much. So you test the muscle and you take that information and you can then make decisions about where the nerves are going and whether they're working well so you can trace out what nerves are working and what aren't. If I hear you saying that, what you're saying is that if you have an abnormal EMG, you do an operation to relieve pressure, for example. So you've identified one or two nerve roots that are not functioning well, and you do something to change that, that you can come back with an EMG and see that nerve repair itself or function better.

Dr. Ty Thaiyananthan: That's correct. It's a really a snapshot view of well the nerve and muscles are working. When a nerve's compressed, the muscle downstream is affected. When a patient undergoes an intervention that may alleviate the pressure on that nerve, we may be able to pick up improvement in the nerve function and also improvement in the muscle that's downstream to the nerve; and I think it gives the physician a very good picture of whether what's been done was actually beneficial to the patient. So I think it's a very useful tool in monitoring patients after a procedure that may still have some persistent pain or numbness.

Dr. Sechrest: The other test, two other tests let's talk about, two other radiological imaging tests. One is a myelogram. In the old days, the myelogram was all we had to see or make some estimation of whether the spinal nerves were being compressed and that test basically involves putting dye into the spinal fluid, through a spinal tap, and then taking x-rays. The dye actually showed up on x-rays so you could sort of look and say, "Well, here are where the nerves are going because that's where the dye is going". Do you still use that test in your practice?

Dr. Ty Thaiyananthan: Yes, absolutely. The CT myelogram actually was a predecessor to the MRI, and it gave physicians ability, in the days before an MRI, to look at the spinal cord and whether it may be compressed at certain points. To a certain extent the MRI has kind of replaced looking at those sections of the spine, but to a certain extent CT myelograms have a re-emergence because it really provides a very detailed anatomy of the nerves and the spinal cord as it relates to the bones around the nerves and the spinal cord. A lot of physicians find a lot of utility in using that. It's especially in patients that may be going to a physician after they've had spine surgery in which instrumentation - metal - has been placed for a fusion or what have you, and traditionally, if you get an MRI in those patients, you get a very distorted image. A CT myelogram gives you a very clear image of what's going on and how the nerves relate to the bone and some of the instrumentation that might have been placed. So it's a very useful diagnostic tool in the right patient.

Dr. Sechrest: What about bone scans? Bone scans are used for lots of purposes, but I've noticed an increased utilization of bone scans to try to determine what's going on with the skeleton in the low back. I usually tell patients what I'm really looking for is what parts of your skeleton and your spine are under stress. What is that bone reacting against? How do you use a bone scans?

Dr. Ty Thaiyananthan: A bone scan essentially lights up hot spots, metabolic hot spots, in a patient's spine. It can be an indication, it can help pinpoint, where the body itself is identifying that there may be problems. In the air of spine fusion, it's been used increasingly to assess the efficacy of spinal fusions to see at a certain point out from the surgery is the body still lighting that up as a hot spot. Is there a spot where there's a lot of activity going on, which is then an indication that there is some sort of inflammatory process going on, that there may be something abnormal going on. It has a very good utility in identifying patients that may be having pain from tumors that are involving the vertebral bodies or the bones of the spine. It, again, is a very useful tool in the right patient, but I think it needs to be put in conjunction with the physical exam and the history and other imaging modalities to get a very accurate picture of what's going on.

Dr. Sechrest: Are there any other tests, either radiological tests or anything that you do that you think is critical to the evaluation of a patient who comes to your office presenting with low back pain?

Dr. Ty Thaiyananthan: Yes, absolutely. There's a new technology that we use - dynamic MRIs - which are an imaging modality that actually images the patient in the position that causes the pain. That gives us a better view of the pathology. Say if a patient comes into your clinic saying, "The pain's really aggravated when I sit". Traditional MRIs, you lie on your back, you get an image. We have the ability now to actually get MRIs with the patient in a seated position. That may show the disc that's being pushed out, or nerve root being compressed in that position. That's a new treatment, a new imaging modality that we have recently available. I think some of the other things that we employ are diagnostic nerve root blocks. It's a very useful tool if you suspect a patient with radiculopathy, a pain that's radiating down their leg. We may be able to numb that specific nerve root and it provides us with two benefits: 1) if it truly is the nerve root that is causing the pain, patient usually experience some relief of the pain from that therapeutic block; 2) it helps us confirm that that is the nerve root that is actually the cause of the pain. In patients that have symptoms from compression of their spinal canal, a condition we call stenosis, we're able to do epidural blocks and that also helps as both a diagnostic and a therapeutic modality for us. It gives us information but we're also able to help the patient at the same time. Those are some of the other commonly used tools that we use.

Dr. Sechrest: One thing that we ought to probably point to patients, and that is, not all low back pain is coming from the back. So there's always this thing in the back of our minds that we're always thinking, "Gosh, does this patient have something going on in their belly such as an aortic aneurysm or something?

Dr. Ty Thaiyananthan: That's correct.

Dr. Sechrest: I think that all people who deal with spine conditions, especially low back conditions, always have that in the back of our minds. So sometimes we may ask patients to do something crazy that they say, "Well, wait a minute. I've got back pain. Why are you asking me to get an ultrasound of my belly? Or a CT scan of my belly?"; because we're worried about that. The other thing that is commonly forgotten, I think, is that there are other reasons that people's backs hurt like infection, or even some type of inflammatory arthritis like ankylosing spondylitis, a rheumatoid arthritis variant. So, pretty early in the process, you and I are probably going to order some lab tests to make sure that there is no inflammation, things like a blood count, a CBC, a sedimentation rate, and some of the newer tests that look for arthritis of an inflammatory nature, and I'm assuming that you do that as well in your practice.

Dr. Ty Thaiyananthan: That's correct. I really thing that what you're alluding to is that when a patient comes in, that you really can't view them solely as a spine. It really is a reflection of what may be going on with other organ systems. Lab tests are critical. I think there are certain labs that we can use to assess for rheumatoid arthritis, as you stated, certain labs that we use to assess for an infection. Those are all very important. In addition, a lot of patients come in, especially with their lower back, complaining of pain in their legs, may have conditions with the vasculature in their legs, and an important thing to distinguish is the difference between a neurogenic or a spine cause for the pain and a vascular cause for that. I think it's really important to order the appropriate tests and rule those other possibilities out.

Dr. Sechrest: Yeah, I would totally agree. Let's move on to talking a little bit about how you then begin treatment with a patient. If you've evaluated a patient, and you don't see anything that you think is necessary to have surgery for, that it's clear that this is a problem and we need to proceed on and do something invasive. How do you begin to manage that patient as a neurosurgeon? What do you tell that patient and what's the first treatment modality that you'll try?

Dr. Ty Thaiyananthan: The way that I view it is surgery is a modality that we have but there are also several other things in our armamentarium that we can use to treat patients. There are very focused exercises, physical therapy that a lot of patients will benefit from. There are pain management treatments that we could explore; injections, epidural injections, facet blocks, nerve root injections, that patients also may benefit from. There is a whole family of medications that we can use to treat patients - non-steroidals, antispasmodics - that may provide certain patients with relief. There are external stimulators, non-implantable external stimulators, which may help electrically massage both the muscles and nerves that certain patients have some relief from. In certain patients with mechanical lower back pain, we may even be able to use specific braces to help at least alleviate some of their pain while we allow some of the medications and physical therapy to sort of help out. There are a lot of treatment modalities and I think it's an area of medicine that's evolved significantly over the last few years, and I think patients with back pain really have a lot of options available to them to help alleviate the pain.

Dr. Sechrest: So in your practice, you mentioned the pain management and the physical therapy. If you've got a patient who has an episode of low back pain that's just not getting better to the point to they've come in to see a neurosurgeon. You've decided they don't have a surgical lesion. Pretty much, in your experience and your practice, those patients are referred to a physical therapist and a pain management physician to sort of manage this early treatment phase?
Dr. Ty Thaiyananthan: The philosophy that we have is when a patient comes in to us with back pain; they usually stay with us until we figure out a solution for the pain. They're not ‘turfed out' to a pain specialist, but we work in conjunction with the pain specialist who then is in direct communication with us and we formulate a plan for treatment. I think a lot of patients are afraid of getting bumped from physician to physician, but, in our practice, we work in conjunction with physicians, we hold clinic in the same area at the same time that helps a little bit more of a collaborative approach; and even though a patient may go out for a pain management referral, they come back to our clinic and we review the progress that's been made, or hasn't been made, and then sort of revise a treatment strategy.

Dr. Sechrest: So you guys have put together a pretty optimized team environment that everybody is working on the same basic plan for this patient in a more, as you said, collaborative approach.

Dr. Ty Thaiyananthan: In our comprehensive spine center, we have an orthopaedic spine surgeon, a neurosurgical spine surgeon, and a pain management physician, all working in conjunction with each other. We review the films together and we formulate a treatment plan from three different perspectives on how to appropriately treat these patients and I think that works out remarkably well.

Dr. Sechrest: Now when you start this process, how long do you think it takes, or how long should a patient expect to be in this treatment process before they see some results? Is this immediate? Is this something they should stick out for 6-8 weeks? What's the norm?

Dr. Ty Thaiyananthan: It really varies. I think on average you would expect a patient to be in some sort of treatment plan for about 6-8 weeks, and I say that on average because some patients that don't see immediate relief, they may find some relief a few weeks down. It takes a little bit of time for some of these treatment modalities to work. Physical therapy may take a month and a half to several months in order for a patient to adequately strengthen the muscles that support their spine to a point that they may get some relief from that. Some of the more invasive treatments, such as pain injections, tend to have a more immediate relief and some patients may see relief at the time of the session or a few days immediately afterwards. So it varies a little bit, but I think on average, patients probably need to be prepared to go through at least a 6 week course of treatment before they may notice some result.

Dr. Sechrest: So if they're not seeing immediate relief from these programs, they need to have a little patience.

Dr. Ty Thaiyananthan: That's right. It doesn't mean it's not going to work. In fact a lot of patients in about a month out will start to notice some relief. It's just sort of a waiting game to let some of those treatments take effect.

Dr. Sechrest: Now let's talk about some of these treatments specifically. A couple of things that I want to address is: 1) chiropractic - a lot of patients in this country really look to their chiropractor as the primary care physician for their spine. Some folks are being treated by an osteopath, which are similar, they're different than chiropractors, but the similarities are that both use manipulation; and now physical therapists have sort of gotten their own brand, so to speak, of manipulation; and there's a whole raft of physical therapists who really have focused in on manipulative therapy for acute and subacute low back pain. What's your take on manipulation in the low back?

Dr. Ty Thaiyananthan: My philosophy on it if patients are getting some benefit that it's probably worth trying. There is a caveat, though, to that. I think that, in some patients that have signs and symptoms of severe compression of either their spinal cord or their nerves, are probably at greater risk of injury from manipulations that they may undergo. I think, for the most part, chiropractors and osteopathic physicians that do manipulations, or physical therapists that do manipulations, are aware of those signs and symptoms. I think the safest plan for a patient would be to undergo these manipulations in conjunction with the supervision of the physician. I think it's a very useful modality if it's working in certain patients, but it needs to be done under a very supervised condition to prevent any inadvertent injury.

Dr. Sechrest: What about some of the other, what we would consider some of the alternative medicine modalities such as acupuncture? Acupuncture, massage, there are different types of, sometimes referred to under the rubric as "body work"; which acupuncture is a little different animal, but there are a lot of massage modalities, different types of massage, then there's Rolfing, there are these things. What's your take on those? Are these useful with patients who are suffering from low back pain?

Dr. Ty Thaiyananthan: One of the symptoms of low back pain may be spasms or muscle knots, and a lot of patients will say that they get some relief, at least from the pain that's being caused by the spasms or knots from massage therapy. I think it's a very useful modality. It really boils down to - is the patient getting some relief from that? If they are, it's a worthwhile endeavor. Acupuncture, really I view it the same way; if patients are stating that they are getting some relief, and some will, I think it's a worthwhile modality to pursue. The key thing for patients to realize, people who decide to undergo those modalities, is that if it's not getting better or getting worse, it may be time to see a specialist.

Dr. Sechrest: Now when do you, as a specialist, advise a patient that, we've tried this, it's not working. When do you make the decision to move on and maybe recommend to a patient that it's time to consider a more invasive option, for example, surgery. What leads you to that decision?

Dr. Ty Thaiyananthan: It's actually a big picture view. We go through the exam, some of the diagnostic studies, we will probably try a course of conservative treatment. The funny thing is usually it's the patients that tells me, "This isn't working", that, "We need to do something a little bit more definitive", and I think it really depends on the type of condition that a patient has. Understanding what the patients problems are, taking a look at their images, and seeing if there is something that we can effectively treat; those all sort of factor into deciding if we're going to proceed ahead with treatment. Other important factors are: How badly is it affecting their quality of life? Is it impeding their ability to complete their job? To work, to perform some of their tasks at home? All of those factor into a decision-making process that may ultimately lead to surgery.

Dr. Sechrest: It's interesting. I think most spine practitioners have finally come to the realization that, low back pain especially, is what we would term, the new term is ‘biopsychosocial' disease. I'm curious and interested to understand your take on when you actually get the mind-body piece plugged into patients with low back pain, and when I say ‘mind-body piece' I'm talking about what triggers you to consider having a patient see a pain psychologist and begin to work on the element of that biopsychosocial, the ‘psycho' element, of the process. I'm not saying, as a lot of patients mistake, that we think somehow it's a psychogenic disease process, or it's all in their head - that's not what we're saying. I think what we're saying is that it has, the chronic back pain has profound implications for their psychological well being, and we need to address that as well. In your practice are you fairly aggressive with engaging psychological care providers as well?

Dr. Ty Thaiyananthan: I think one of the most common long-term consequences to people that suffer from pain is depression. It's really the psychological aspects of dealing and living with pain that kind of will plaque patients and I think it's really important to identify anything, it's very important to address because any sort of treatment modality really needs to be a holistic approach. You treat what's wrong and all the other symptoms associated with it. I think that a lot of patients recently have benefited from talking to counselors that have a special expertise in treating patients with issues that may result from living with long-standing pain. I think a lot of patients also benefit from biofeedback as a modality, that a lot of physical therapists that we refer to will use, to help register what kind of activities that may be doing them some good and also to more completely understand their pain and the conditions associated with their pain. I think that biopsychological aspect of pain is a very important part that can't be ignored and it needs to also be addressed.

Dr. Sechrest: Yes, I think you are accurate that the physical therapists do a better job at that sometimes than we do. I think they spend more time with the patient. I think they get to know the patient a little better, and I think they really tune in to some of those psychological implications of dealing with chronic pain. I think they also have a much broader understanding of the importance of that relaxation response and the biofeedback, or meditation, or yoga, any way that you can tap into that really benefits the patients who are having to deal with chronic pain, and can be a huge help to them.

Dr. Ty Thaiyananthan: Absolutely. You know, another important aspect of that is that a lot of patients that we see will be on a lot of pain medications, just to help treat them with the pain; and if we are considering some sort of procedure, a very important part is cutting down some of those pain medications or tailoring it to a point that after the surgery we're able to have it in a monitored way, with the pain medications weaned off, and cut down to a point that we can actually see if the surgery is working, and monitor the progress. I think it's very important to get those patients connected with a pain management specialist as well, so it's very important to address those issues before thinking about doing something invasive.

Dr. Sechrest: Are there any real key points that you would drive home to patients that you use to switch from a conservative approach to treating pain to when you would tell the patient, "It's in your best interest to have surgery, and this is not really an option necessarily, it really would be in your benefit to consider this".

Dr. Ty Thaiyananthan: Yes, there are. That's a great question. If the patient's have symptoms of weakness, any motor or sensory problems, those are indications that there may be something going on that's at a point where there's severe compression of the nerve. If the patient's have any bowel-bladder problems, we consider those urgent issues that we need to probably address. If the patient's having walking difficulty, if the patient has gone from walking to unstably walking, an unstable gait, to now in a wheelchair, those are issues that I think we need to address on a more urgent basis. They may not warrant going the traditional route or conservative therapy. There are certain conditions, based on imaging and the physical exam, that if the patient has severe stenosis; those are things we can effectively and easily treat with a high success rate, and I think those are things that we could talk to a patient about and direct him more to a surgical intervention. I think with a large disc herniation that's compressing a nerve root that can be treated effectively in a not so complicated manner, that's another condition that may warrant a more rapid surgical treatment. There are a whole host of conditions that patients may benefit more from an invasive procedure than pursuing a conservative route.

Dr. Sechrest: It sounds like to me, from most of those conditions that you just laid out if I could paraphrase, is that anything that's putting the neurological system at risk you probably feel as a neurosurgeon, you should seriously consider surgical intervention. Anything that's not is probably elective, but there are a lot of things this day and age that, even though it's not damaging or threatening the nervous system, there are a lot of things that can be treated effectively with surgery that 20 years ago we couldn't treat very effectively or the results weren't as good as they are now.

Dr. Ty Thaiyananthan: That's correct. I think that's why it's important when patients are having symptoms to see a specialist early on and not wait until their symptoms get worse. I think it's important to at least have an opinion from a specialist at the very early stages. It doesn't mean you need to get something done, but at least have someone that's versed in looking at those conditions, render an opinion, and guide the treatment that may eventually happen.

Dr. Sechrest: It sounds like the situation that you're currently in at the University of California Irvine with this multidisciplinary approach to spine disease, it really looks like the Holy Grail that practitioners have been looking for. Patients who come in with a specific disease process have everything under one roof that really they can access and get that information that they need and not be bounced from physician to physician.

Dr. Ty Thaiyananthan: I think it's useful for us as physicians to have those resources readily available and I think it's also useful for patients because they really are approached from a very holistic manner.

Dr. Sechrest: As we close on this topic of low back pain, especially your approach as a neurosurgeon how you go about understanding and evaluating patients with low back pain, do you have any advice for patients, and it's probably 90% of the population because we all have this problem, do you have any advice for patients that you think they should know - key points that a patient with low back pain should know about making decisions about how to have their low back pain evaluated and treated?

Dr. Ty Thaiyananthan: I think that the most important point is that if you are suffering from low back pain, we have a lot of treatment modalities that can probably help. So the most important point it is if you are having it seek help. Go see a physician, go see you primary care physician, ask for a specialist, and have the appropriate workup done and talk to someone about what's available. It's something that most people don't have to live with or it can effectively treated, and I think that it's very important for patients that are having low back pain to look for help. There are a lot new technologies available, a lot of treatment modalities that may not involve surgery that patients can benefit from.

Dr. Sechrest: Well, thanks. It's been useful information for patients and I think I've learned a few things. Thanks for coming by.

Dr. Ty Thaiyananthan: Thanks, Randy. Thanks for having me.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.