Understanding Cervical Disc Herniations with Dr. Michael Dinizo: Diagnosis, Treatment and Surgery

Do you ever find yourself grappling with neck pain that just doesn't seem to go away, or perhaps, unexplained numbness or weakness in your arm? Let us embark on a journey to explore the intricate world of cervical disc herniations, guided by our expert guest, Dr. Michael Dinizo - a seasoned orthopaedic spine surgeon. Drawing on his deep knowledge, we unravel the complexities of the cervical spine and the varied symptoms that cervical disc herniations can present.

Take a deep dive into the realm of advanced cross-sectional medical imaging modalities as we explore how they play a pivotal role in diagnosing and understanding cervical disc herniations. We shed light on how MRI's, CAT scans, and nerve studies can be instrumental in the diagnostic process. Dr. Dinizo, with his wealth of experience, walks us through the process of discerning between a soft and hard disc and the implications this has on treatment plans. Plus, we underscore the importance of reducing inflammation and allowing the patient time to heal.

Finally, we navigate through the pros and cons of cervical spine surgery. We zoom in on the anterior cervical discectomy fusion surgery, discussing the materials used and their role in stabilizing the vertebral bodies. The conversation also covers the significance of maintaining good posture in mitigating neck and lower back pain. So, tune in for an enlightening ride through the nuanced landscape of cervical disc herniations and make informed decisions about managing this common condition. Trust us, your neck will thank you for it!

Transcript

Robert A. Kayal, MD, FAAOS: 0:16

Hello and welcome to another edition of the Kale Ortho Podcast. Today is July 18, 2023. And we're so happy to have with us today our very own spine surgeon, dr Michael Denizzo, orthopedic spine surgeon at the Kale Orthopedic Center, and today's topic is going to be cervical disc herniations. Welcome to the podcast, dr Denizzo.

Michael R. Dinizo, MD: 0:37

Thank you very much, dr Kale, really excited.

Robert A. Kayal, MD, FAAOS: 0:40

Before we get started, why don't you just tell us a little bit about yourself?

Michael R. Dinizo, MD: 0:43

Sure, my first time here in New Jersey went to undergrad at Johns Hopkins University and from there I actually did some spinal cord injury research, both at Johns Hopkins and the University of Maryland Shock Trauma Center. From there I went to Rutgers University for my medical school, followed by five years orthopedic surgery at NYU and then an additional one year spine surgery fellowship, also at NYU. Wow, impressive credentials. And how about your family? All from New Jersey? My dad is a small business owner, my brother works with him, my sister does marketing, and they're really excited to hear this podcast Awesome.

Robert A. Kayal, MD, FAAOS: 1:21

Well, we're so happy to have you with us today to discuss this very, very ubiquitous condition called the cervical disc herniation. Neck pain is such a common problem, isn't it?

Michael R. Dinizo, MD: 1:31

It's very common, especially in people between the 30s and 50s. It's a very common source of people missing work and also coming to see us to help treat them.

Robert A. Kayal, MD, FAAOS: 1:42

Yeah, and that's the anatomy. Okay, sure, our patients, so they get an idea of what we're talking about. So, dr Denizo, for the benefit of our viewing audience, can you please tell us what I'm holding in our hands right now? Sure.

Michael R. Dinizo, MD: 1:55

We're looking at a full model of the spine. You're getting down here. This is where your pelvis is. Lumbar spine is down here. Thoracic spine is in the middle.

Michael R. Dinizo, MD: 2:03

But for today's discussion we're going to be talking about the top seven vertebrae, the cervical vertebrae. You're getting up here at the base of the skull, down here to the seventh cervical vertebrae when we're looking at the front of the spine. So from this angle here we're looking at the front. These are the vertebral bodies, or the bony structures of the spine. In between each one of those vertebral bodies is the vertebral disc, which we're going to get to in a little bit, exiting out here these yellow lines. Those are the nerves that control the sensation as well as the strength to your upper extremities. Now, as we kind of rotate around the back here, you can see that there's additional structures. So in the back here, this is the lamina, the back covering of the spine. These are the spinous processes and in here is something called the pedicle. This forms the posterior vertebral arch, which protects the spinal cord during everyday activities and allows us to move and function.

Robert A. Kayal, MD, FAAOS: 2:54

So thank you for that demonstration of the spinal anatomy, Dr Dinizo. Let's talk specifically about a cervical disc herniation. What is actually happening when a cervical disc herniates?

Michael R. Dinizo, MD: 3:04

So what happens when a cervical disc herniates is part of the inner disc called the nucleus pulposus, which acts as a shock absorber for the spine, gets displaced posteriorly and compressed on some of the neural structures.

Robert A. Kayal, MD, FAAOS: 3:16

Okay. So as far as the intervertebral disc is concerned, we discussed that these are soft cushions between the vertebral bodies and we have them from the neck all the way down to the lower back right, correct, these discs are primarily made up of water right Water and collagen material. That's a soft material that serves as a shock absorber, a cushion between the hard bones of our spine, allowing for motion and load absorption, things like that. Within the disc itself, it's made up primarily of an outer ring of cartilage called the annulus fibrosis, made up of type 1 collagen. That material contains the softer inner gelatinous material called the nucleus pulposus, which is typically very hydrated, filled with a lot of water, and it allows for the disc to be soft and mobile and absorb a lot of load. When discs herniate, very often there's pathology to the outer ring of tissue called the annulus fibrosis right.

Michael R. Dinizo, MD: 4:20

So what can happen is there can be a tearing of that outer covering the annulus, fibrosis, and that can lead to the inner material, as you mentioned, the nucleus pulposus, displacing posteriorly and potentially causing pain and neurologic issues to the patients. That can happen either following acutely, like following a trauma or a car accident or a sports injury, or it can sometimes happen more chronically and it's more degenerative type of process.

Robert A. Kayal, MD, FAAOS: 4:48

So it's just very similar to what actually happens in the lumbar spine right, and I'd like to refer our viewing audience to another podcast that we've done with Dr Paul Baghe, when we discussed lumbar disc herniations in the lower back in sciatica. So, for the benefit of our viewing audience, let's demonstrate to them what a cervical disc herniation can look like now.

Michael R. Dinizo, MD: 5:09

Sure. So this is a model again of the spine. So this is first looking at the side here. So these are the vertebral bodies here and in the middle here is the disc Turning it over and looking straight down on the spine here this is the annulus fibrosis that we mentioned before. In the middle here is where the nucleus pulposis is, and when someone has a disc herniation there's a tearing on the outside ring of that annulus fibrosis and part of the inner structure. It's normally a very soft shock-absorbing material can extrude out and press on some of the spine, the nervous structures in the back of the spine.

Robert A. Kayal, MD, FAAOS: 5:46

Okay, great. Thank you so much for that demonstration. So typically, how will a patient present to the office when they're complaining of symptoms consistent with a cervical disc herniation?

Michael R. Dinizo, MD: 5:57

So the symptoms can vary. It can vary anything from bad neck pain to arm pain, and sometimes they can have weakness or even numbness going down their arms. Typically is there trauma associated with this, so these can happen in acutely after a trauma or a car accident or any type of other accident that a patient may have. So it's very important part of the history to figure out. Is this something that began very quickly following an accident or is it something that's been more slowly progressing over the last several weeks or months?

Robert A. Kayal, MD, FAAOS: 6:30

And when you see patients with discurneations, is the pain typically localized in the neck or around the shoulder girdle in the trapezius area, going down the arm, all the above. How does it typically present?

Michael R. Dinizo, MD: 6:44

So it definitely can be. All of the above Usually is associated with neck pain, with neck pain a lot of times. Reading towards their shoulder was sometimes even getting muscle spasms or pain around their shoulder Many times. Often, too, it's associated with pain going down one of the arms, sometimes even with tingling, and sometimes with some weakness as well.

Robert A. Kayal, MD, FAAOS: 7:05

Yeah, what I found in my own clinical experience is patients with cervical disc bulges or herniations very often will have pain in the area of their trapezius over here, and it also, if you can turn your body a little bit, very often they have pain in this area of the trapezius that we're describing. They often have a palpable knot that we can appreciate right here, and also the pain radiates very often to what we call the periscapular region around the shoulder girdle in the back there, and a lot of times they'll have spasm, tenderness and what we call a myofascial trigger point in these areas and the pain will also very often radiate down the arm. So what determines where the pain goes?

Michael R. Dinizo, MD: 7:52

So when we're looking at that model before, we saw that there was those paired nerves that were coming off of the spine and those are numbered from C1 to C8. And each one of those different nerves controls the sensation in a different part of your upper extremity, whether it's in the upper arm or even down to the hand, and each one of those different nerves, they innervate a specific muscle. So it's very important for us to get a very clear picture of exactly where their pain is and if they're having weakness, what muscle groups is that weakness in?

Robert A. Kayal, MD, FAAOS: 8:22

So those nerves are both sensory and motor nerves, right Correct, so they're mixed nerves.

Robert A. Kayal, MD, FAAOS: 8:26

Yeah, mixed nerves. They're responsible for a lot of things. They're responsible for sensation, to what we call the different dermatomes of the body, so for instance, c3, c4, c5, c6, c7, c8, they go to different parts of a patient's upper extremity, and so when that area is experiencing pain or numbness and tingling, it gives the doctor an idea of what nerve root may be involved. Those mixed nerves are also responsible, some of them at least, for reflexes, right, and so we can test patients' upper extremity reflexes to identify whether or not their reflexes are intact or abnormal, and that will also give the physician some feedback about what nerve might be involved. And then, finally and most importantly, these nerve roots are responsible for innervating different motor groups that Dr Denizzo referred to, and when patients experience weakness in those muscle groups, it certainly is concerning for us and it suggests that maybe the nerve is not working properly. Correct, Correct.

Michael R. Dinizo, MD: 9:33

And the reasons that the nerve can be not functioning correctly can be either from actual compression, from the disc herniation, or it can be from a huge inflammatory cascade that can happen when that nucleus pulpulosis comes out to an area that it's not normally supposed to be Right.

Robert A. Kayal, MD, FAAOS: 9:48

So also these patients. Very often, besides the classic pains that I've demonstrated, very often one of the telltale signs that they're suffering from a cervical disc herniation is when you ask the patients if they find relief by putting their arm over their head. Right. That's very classic. I found in my years of practice that when patients put their arms over their head like this to alleviate the symptoms, it's almost pathodendomonic for a cervical disc herniation.

Michael R. Dinizo, MD: 10:16

I 100% agree. And so walk in the room and I'll see the patient sitting in the chair basically holding that position, and they'll say that that's really the only position that they can find any relief of their pain. And what the patient's actually doing by doing that is they're taking some of that tension off of that nerve and then relieving some of their symptoms, right.

Robert A. Kayal, MD, FAAOS: 10:35

Right. It is one of the most uncomfortable conditions to have to endure right Sure, first of all, any nerve pain in general. But in my experience, cervical disc herniations with an acute cervical radiculopathy we call it is extremely, extremely uncomfortable for the patients.

Michael R. Dinizo, MD: 10:53

Definitely. You know patients come in seeking help because they can't sleep at night because of the pain. It's kind of an unrelenting pain that they have had trouble on their own trying to relieve and that's why they come to see us, Right.

Robert A. Kayal, MD, FAAOS: 11:07

So, now that we've discussed the classic presentation, what do you do as a physician when you're performing a physical examination to try to determine if they are indeed suffering from a cervical disc herniation and, if so, the severity of that disc herniation, what disc might be herniated, et cetera, on physical exam?

Michael R. Dinizo, MD: 11:27

So we first start with the range of motion of their neck. So they're having the spasms in those muscles, like you were discussing before. A lot of times you will see limited range of motion and they'll actually have that very spasmatic muscles in their neck. That's usually the first thing we start off with. The most important part of the exam is to do a very thorough neurological exam. So what we do is we check all the muscle groups, we check the strength, we compare it from side to side to see if there's any weakness in any of those muscles. We also do a very detailed sensory exam to see if there's any areas of their arm where they're having any sort of numbness or altered sensation. And in addition to that there's a couple of special tests that we can do too to almost try to provoke the symptoms that they have. So those are some of the other things that we'll do to try to give us more of a hint exactly what's going on with the patients.

Robert A. Kayal, MD, FAAOS: 12:18

All right, but this is typically a very classic presentation. So by the time you take the history for the most part even made the diagnosis right, the physical examination often just confirms our suspicion. So you will be assessing for sensation, you will be assessing reflexes, you will be assessing motor strength to make sure that those physical examination findings corroborate with the patient's subjective complaints. Once you've identified in your own mind that more than likely the patient suffering from an acute cervical discurreation and nerve compression, or what patients like to call a pinched nerve in their neck, what objective findings besides the physical exam can you do utilizing imaging modalities?

Michael R. Dinizo, MD: 12:59

So we'll normally start first with getting x-rays. The x-rays give us a good view of the overall alignment of the cervical spine. First Things that we're looking for are the lordosis or the backwards curvature of the spine. Sometimes that can be straightened. In the case of cervical disc herniation, because patients are having severe muscle spasms. We can change their alignment of their spine. Other things that we look at we look at the vertebral disc heights, so that can give us an idea of how healthy those discs are and how hydrated they are. We can also see something called osteophytes, which are like bone spurs that can form in the spine. It's something that gives us a better idea of the overall health and structure of the spine as well too. We almost always get flexion extension x-rays, which is special x-rays with the neck in different positions that can look to see if there's any abnormal motion or instability in the spine, which can give us a better idea of exactly what's the cause of the patient's symptoms.

Robert A. Kayal, MD, FAAOS: 13:55

Okay, so in addition to x-rays, are there any other advanced cross-sectional medical imaging modalities that we can employ to help hone in on the diagnosis?

Michael R. Dinizo, MD: 14:06

There definitely is. So usually, when we're suspicious that a patient has a cervical disc herniation, the next test that we'll get is an MRI. Mris are a special type of imaging that allows us to see the disc, allows us to see the nerves, allows us to see if there is a disc herniation. We get to see the health of the disc, whether they're well hydrated, and the height of the disc, and allows us to see if there's anything else going on as well, too, and we think it's a disc herniation. It can be something else we weren't necessarily expecting, so it's a way to get a complete picture of the spine and exactly what's going on, and certainly you're looking to evaluate for compression on the spinal cord, as well, right, definitely so.

Michael R. Dinizo, MD: 14:45

Cervical disc herniation they can either press on the nerves themselves or actually on the spinal cord, which is another topic. Cervical myelopathy, which hopefully we get to talk about in the future.

Robert A. Kayal, MD, FAAOS: 14:56

So the cervical spine is a very delicate part of our body. Obviously nerves do not like to be touched right. Nerves in general, especially the spinal cord, do not appreciate any compression. Well, in general, when we're evaluating the cervical spine on MRI, we don't really want to see anything compressing the spinal cord. If there's any compression it certainly can be concerning for us and we'll evaluate that further with the patient. So are there any indications for the usage of CAT scan in the cervical spine?

Michael R. Dinizo, MD: 15:28

Yes, there are Sometimes. We will do that because the CAT scan gives us a much better picture of the bony structure of the spine. So when we're looking at, you know, maybe there's not just a disc but maybe there's some bony impingement on some of those nerves as well. That will definitely be something that will help us. So the CAT scan gives us a much better picture of the bony structures of the spine and sometimes it will show us things that we don't necessarily see on the MRI. So it's definitely helpful to give us the full picture of exactly what's going on.

Robert A. Kayal, MD, FAAOS: 15:55

I agree. And what do you do when the radiologist comes back with a report that says something like disc, osteophyte, complex or hard disk? Can you define for our viewing audience what a soft disk is, what a hard disk is and why it has some implications?

Michael R. Dinizo, MD: 16:13

Sure. So a soft disk is usually in a patient younger patients because they tend to have bigger, softer, healthier disks compared to some of the older patients who have a little bit more degeneration. So the soft disk will usually herniate posteriorly and press on those nerves and it's usually more of a much more acute type of process, whereas when we see disk osteophyte complex, that gives us an idea that it's something potentially more chronic, something that's been there for a while and start to actually calcify and we're turned into a bony structure rather than a soft disk structure.

Robert A. Kayal, MD, FAAOS: 16:50

And it matters right, because soft disks, at least theoretically, have the potential of maybe going back in place with treatment, physical therapy, or the body will absorb some of that. But a hard disk, what we call a disc osteophyte complex or a hard disk, is something that is not going anywhere. It's a chronic degenerative process that has developed over years and we still will potentially try to treat that conservatively. But the odds of that mechanical compression on the spinal cord or the nerve improving with physical therapy are not very good right.

Michael R. Dinizo, MD: 17:25

So we can definitely do things that will help the patient's symptoms in those cases. So we will do things like physical therapy or maybe trigger point injections or chiropractic treatment. There's multiple things that we can do to help those patients, but it won't be changing the actual MRI or the structure, the structural problem that's going on the spine that time Because it's a bony structure that's pressing on that nerve, and sometimes those are the ones that are more likely to require some sort of intervention.

Robert A. Kayal, MD, FAAOS: 17:52

Right, because the soft disk potentially can get better with time. Do you ever consider getting a nerve study if there's nerve compression?

Michael R. Dinizo, MD: 17:59

Definitely so. When patients have neurologic symptoms in their upper extremities, with pain rating down their arm or tingling and numbness in their arms, sometimes the physical exam and the history is not enough to pinpoint exactly what nerve is the one that's affected. In addition to that too, the nerves can be compressed in other places of their arms, so they can be in their elbow, in their wrist. So sometimes that will help us, especially those nerve tests to help us figure out is it just the neck or is there something else, also something called a double crush phenomenon, which I think Dr Lane spoke about very well the other week.

Robert A. Kayal, MD, FAAOS: 18:33

Okay. So now that you have the diagnosis, you might even know what level is involved One level, two levels, sometimes three levels. What are you going to do?

Michael R. Dinizo, MD: 18:43

So it depends a lot on the severity of the patient's symptoms, how long they've been going on and any of the neurologic issues that we've been talking about. So a patient this is an acute thing that they just started having pain very recently. A lot of times we'll start with anti-inflammatory medications. We'll start with physical therapy, chiropractic, acupuncture, those sorts of things, and we'll give the patient time because the studies have shown that the majority of patients in about six to 12 weeks actually will get much better. In the cases of a soft disc herniation, that's usually what we'll start with if it's just pain and it just started. But obviously we'll follow them very closely. The patients having more neurologic symptoms, where they're having especially weakness, then we tend to be a little bit more aggressive with their treatment and we monitor them a little bit more closely.

Robert A. Kayal, MD, FAAOS: 19:32

So just to further elaborate on what you're saying, dr Dinizo, as I've said numerous times in the past, inflammation is associated with redness, warmth, pain and swelling, and the same thing happens around the cervical spine. Nurses do not like to get compressed, they hurt like crazy. It causes a local reaction of inflammation which often results in that redness, warmth, pain and swelling, and so sometimes we'll call our interventional pain management specialists, like Dr Aiden, to get involved to perform a cervical epidural, and I'm going to have him back in the future to discuss with us on a future podcast how we in fact he treats cervical disc herniations with his interventional pain management procedures, but suffice it to say he puts a little bit of cortisone or corticosteroid with a local anesthetic around the nerve root or around the spinal cord to decrease that inflammation, thereby decreasing the redness, warmth, pain and swelling. What else could we do to help manage patient's pain?

Michael R. Dinizo, MD: 20:33

So another thing we can do too is someone's having a lot of pain around their neck area with muscle spasms. We can also do trigger point injections. That's something we can do in the office. It's similar idea as the epidural we're using a corticosteroid medication and an anesthetic, but we're targeting it more for the muscles and some of the muscle spasms and pain that patients are having. So that's another thing that we can do as well to try to help with their pain.

Robert A. Kayal, MD, FAAOS: 20:56

Great, thank you. So let's just assume now that the patients are still suffering. Nothing has worked. We've done everything that we've discussed Physical therapy, anti-inflammatories, chiropractic intervention, acupuncture, massage, cervical epidurals, trapezole trigger point injections. When do we finally indicate patients for surgery to get them out of their misery?

Michael R. Dinizo, MD: 21:19

So patients that are having intractable pain, pain that's been refractory to these other interventions that you were just discussing, dr Kale. Pain that's severe. They're interfering with their life. They're not able to do the things that they want to do every day. It's diminishing their quality of life. That's one of the indications that we can potentially have and we start the surgical discussion with patients. Another thing is if someone's having weakness that's progressive or it's in a muscle group that they need for their everyday function, we don't want to let that go for too long because then potentially that strength won't come back all the way, if it's something that's left for too long. That's why we closely follow the patients. We do close neurological exams to see if their strength is changing or if they're getting worse weakness. It's definitely something that we then we start the surgical discussion with the patients.

Robert A. Kayal, MD, FAAOS: 22:11

Yeah, I agree with you. I think nothing's cut in stone. But for the most part, if the patient presents with just pain, we'll treat them very conservatively because we can do things to manage their pain with medications or interventional pain management procedures. Once you start talking about weakness, we tend to become a little more aggressive. So if the weakness is minor, we'll still treat them conservatively. People often give them a good three months of physical therapy, but sometimes the weakness is quite severe. On the first presentation, on the first day we see this patient, we examine this patient, there's almost a flaccid paralysis. There's profound weakness. In those particular cases do you become a little more aggressive.

Michael R. Dinizo, MD: 22:53

I do. It's very concerning to me as a spine surgeon. The patient comes in with profound weakness. Anytime they have profound weakness, we are worried that that's going to be something that potentially would not recover without some sort of intervention. Depending on the imaging that they have at that time, we might discuss surgery from the very first time we meet them that they're having severe weakness, because it's something that we do take very, very seriously. I mean.

Robert A. Kayal, MD, FAAOS: 23:19

when I talk to patients about this, I very often give them the analogy of when our legs go numb. Sometimes, when we cross our legs, it's intuitive to just uncross your legs when your leg starts getting numb. That's the same concept with a pinched nerve in the neck or in the lower back, it's intuitive for us to want to take that mechanical compression off the nerve because we don't want any of our patients to have permanent nerve damage. Okay, I think we've beaten conservative management to death. Now for the conservative management of cervical disc herniations. Let's now focus in our attention on the treatment alternatives for cervical disc herniations as they pertain to surgical options. What options are available now in managing these cervical disc herniations?

Michael R. Dinizo, MD: 24:07

Based on the location of the disc herniation. Some of those disc herniations are more amenable to surgery from the front part of the neck. Others are more amenable to surgery from the back part of the neck. It's all based on the location of that disc herniation. Just to refresh your memory, looking at this model here, this is us looking at the spine from the side, the front being here, the back being here. This is us looking directly down right on the disc here, with the nerves coming out from the side and in the middle. Here is where the spinal cord is.

Michael R. Dinizo, MD: 24:37

The location of this disc herniation helps to dictate how we're going to do the surgery. Unlike with a lot of lumbar surgery where we almost always will do it from the back part of the spine, the spinal cord is in the middle here. If we do surgery from the back part of the spine, we can't move that spinal cord because it's an extremely sensitive structure that could lead to severe neurologic issues. We actually approach it from the front part of the spine through a small incision on the side of the neck which allows us to access the disc here. Then we can use special instruments and a microscope, basically, so we can then get to the back here and remove that disc herniation that is pressing on those nerves and causing those symptoms.

Robert A. Kayal, MD, FAAOS: 25:18

Thank you for that explanation, Dr Denizzo. It's certainly intuitive that if the problem is in the back of the disc, we should approach the disc herniation from the back. The caveat is that in the area of the neck we have spinal cord. The spinal cord is in our way. More often than not, the location of the spinal cord forces our hands to operate from the front of the spine as opposed to from the back of the spine. Thank you, Dr Denizzo. We've discussed the essentially two options. We can approach the cervical disc herniation from the front or the back, the front being a much, much more common exposure and approach. Why don't we talk about what you actually do when you approach a cervical disc herniation from the front? You have options, right, you could take the disc out, but then there's a void there when the disc is gone. What are the options and what exactly are you doing when you approach a cervical disc from the front?

Michael R. Dinizo, MD: 26:21

We approach from the front part of the spine, as you mentioned, we do have to remove the entire disc in order to get to the back part of the spine, where the pathology is and where the nerve is getting compressed. Because we have to remove that disc in order to get to that area that's compressing the nerves, we have to replace that area with something that can either be a spacer or a cage, that's filled with the material that will allow for fusion and that's supplemented often with either plates or screws to hold everything in place until your body is able to heal it on its own. More recently, they have cervical disc replacements, which is another implant that goes into the disc space that allows them to preserve the motion of their neck rather than doing a fusion surgery. That's something that's been out for about the past 20 years and is a great option for patients as well, too.

Michael R. Dinizo, MD: 27:12

This is looking at the front of the spine. This is the front of the spine here. Back of the spine is here. We're looking at the front part of the spine here. That shows a plate that had been placed following an anterior cervical fusion surgery. This is where the disc previously was, which was then removed during the surgery to allow those nerves to be decompressed. This is showing it after it has fused already. This is actually bone that's in between each one of those vertebral bodies where that disc used to be the plate again that we see at the front here. That acts as an internal splint, basically to allow those vertebral body to not move until they can heal on their own. Ultimately, the patient's own bone basically grows in between those vertebral bodies and then creates the fusion.

Robert A. Kayal, MD, FAAOS: 28:04

Right. When you approached this spine from the front and took out the two discs that were compressing the nerves of the spinal cord, it left a void. You have to put something in there, whether it's a cadaver bone, a cage bone graft, something to replace the disc that were removed. Because the discs are removed, the spine would be rendered inherently unstable. You have to do something to stabilize that area as well. In this particular case, you chose to use a plate. You did what's called an anterior cervical dyskectomy infusion utilizing a plate. The plates are holding the vertebral bodies together, stabilizing the spine and putting bone graft in between to allow those levels to fuse and alleviate the compression on the nerve roots as well. What other options can you employ when you address the cervical spine from the front?

Michael R. Dinizo, MD: 29:04

This other model that we have here. This shows the plate that's in the front part of the spine. This shows some of the other types of materials that we sometimes may put in that space after we take the disc out. Looking at it here from the side a little bit closer, you can see at this top level here there's some bone graft that's placed in between those vertebral bodies. Another option that's very common is a cage. It's usually either plastic or a metal type of cage that is filled with different biologic substances that help to promote a fusion between the two different levels. Then when we do that, we have the plate again on the front there. That's going to hold everything stable until your body is allowed to heal on its own.

Robert A. Kayal, MD, FAAOS: 29:49

Right, you had mentioned earlier that sometimes on an X-ray you'll find that the patient has lost the normal, what we call cervical lardotic posture of the spine, the normal curve of the cervical spine. Are there advantages of approaching the spine from the front in order to restore the normal anatomical curvatures of the spine? What is the problem when the cervical spine collapses into kyphosis?

Michael R. Dinizo, MD: 30:15

Yeah, that's a thing that we look at before every single one of our surgeries. We look at the lardosis with the curvature of the spine. Based on that usually because in the front part of the spine, here, because those discs have collapsed, the spine itself starts to lose some of that curvature. When we approach the spine from the front part, there we can place these implants or those cages in the front part of the spine to restore that disc height that that patient has lost from their injury or from wear and tear. When comparing the X-rays from before the surgery to afterwards, we can see that we can restore their normal alignment based on how it was prior to their injury.

Robert A. Kayal, MD, FAAOS: 31:00

I think that's so important. I always tell patients that kyphosis equals pain In the neck and in the lower back. The spine is supposed to have what we call a lardotic posture, a normal cervical posture and lardotic lower back posture that is curved. When patients lose that lardotic posture from muscle spasm, degenerative disc disease, whatever it may be, that equates to pain. Very often we see these patients with cervical disc herniations and lumbar disc herniations where they lose the proper curvature because of a herniated disc or a degenerative disc. One of the advantages, especially in the cervical spine, of approaching the spine from the front is that Dr Denizo and other of our spine surgeons are able to restore the cervical lardotic posture by sort of jacking up that degenerative disc level.

Michael R. Dinizo, MD: 31:58

So this is another model of just the cervical spine. So the rest of the spine is down here. This is the top of the skull, just for the orientation here. This is the front of the spine. This is the back of the spine. Normally the curvature of the spine should be curving gently backwards, like this. When people have muscle spasms or in the case of disc degeneration or disc herniation, they can lose the height of those discs in the front, which leads to straightening of the spine or sometimes even a forward posturing of the spine. Like that During these surgeries, when we come in through the front, we're able to open up that space again and restore it to the normal alignment and get them back into a more natural position, which leads to less muscle pain, less neck pain and better function.

Robert A. Kayal, MD, FAAOS: 32:41

That's the concept behind the cervical pillow right, the cervical pillow in the cervical spine and the lumbar support that's usually offered to help restore the proper posture of the patient's lower back and also cervical spine, where you're supporting that normal lardotic posture. I always tell patients that, for instance, when they're sitting and standing, to make sure that they're maintaining good posture, the ear should always line up with the shoulder, which should always line up with the elbow, which should always line up with your hip. So it helps to maintain a good posture. When your ear is lined up with your shoulder, which is lined up with your elbow and lined up with your hip, you can for the most part, ensure that you're maintaining a good posture of your upper back and lower back and neck and that just by restoring that proper posture it should alleviate a lot of your neck and lower back pain.

Michael R. Dinizo, MD: 33:41

Definitely agree. It's much more energy efficient to be well balanced when it comes to your spinal balance, and that's something that we take into account. As we were just talking about, we're trying to restore that normal alignment which allows those muscles to not work so hard, you know, even throughout the day, which leads to less neck pain and less other issues as well, too. I 100% agree with that, for sure.

Robert A. Kayal, MD, FAAOS: 34:05

So let's say the patient doesn't want a cervical fusion from the front. Are there any other possibilities to offer certain patients Sure?

Michael R. Dinizo, MD: 34:15

so something that we do here at the Kaila Orthopedic Center is cervical disc replacements. So when we were talking before about replacing that space where we took the disc out with a cage or bone graft, we can actually put an implant in there that continues to move, so that way that patient does not lose emotion at that level. So that's something that we do here as well. We do it for cervical disc herniations as well as for other cervical pathology and patients do great.

Robert A. Kayal, MD, FAAOS: 34:47

You know there are certain circumstances where you can approach the patient from the back of the spine, in the neck, and when do you? When you appreciate those opportunities.

Michael R. Dinizo, MD: 34:58

We approach from the back part of the neck for a disc herniation in just a couple specific cases. This is usually when something is very lateral, lateral, meaning further from the outside part of the spine, away from the spinal cord. In that case we can sometimes approach it from the back and remove that disc herniation and take that pressure off of the nerve. But it's only in special cases where that is a surgical option. Most often we do have to do it from the front, as you said before, dr Kaila, because that spinal cord is in the back and it's something we have to stay away from. We can't put any extra pressure on it.

Robert A. Kayal, MD, FAAOS: 35:31

So yes, I agree with that. It is a rare instance when we can indicate someone for a posterior cervical decompression. But when we find that patient, we're happy, right, because we can. We can essentially do that procedure in a relatively minimally invasive manner, take the pressure off the nerve and not have to even discuss fusion at that time right.

Michael R. Dinizo, MD: 35:54

Correct. So in those cases it is a very small incision. We usually use a microscope and tubes to basically allow us to see that area and that way we can safely remove that disc herniation without disrupting some of the other structures that would require us to either do a fusion or use some sort of other implant in order to stabilize the spine afterwards. So in those cases it is a great option for patients because it's usually a same day procedure, it's very quick and the patients can recover very quickly.

Robert A. Kayal, MD, FAAOS: 36:26

So we've covered the surgical approaches for cervical disc herniations both from the front and from the back. Well, if there are multiple options, there must be some pros and cons of each right, for sure like we were kind of talking about before.

Michael R. Dinizo, MD: 36:42

With the posterior approach it's a small incision just on one side. There's no fusion involved with at that level and the disc in the front part of the spine actually stays there and stays intact. We just removed that small disc herniation. So that's one of the pros with the posterior approach to the spine. From the anterior approach we can remove the entire disc. We can decompress the spinal cord and both nerves. From the the anterior approach, from the front part of the spine, we can also restore the alignment, as we were talking about previously. So we can jack up that disc space after we remove that disc to help to restore that alignment. So that's another great advantage of the anterior approach.

Robert A. Kayal, MD, FAAOS: 37:27

So, when it comes to deciding whether to approach these patients from the front or the back, you had mentioned that typically, when we address them from the front, a surgical fusion is involved. How does that affect the patients? Acute post-operative course.

Michael R. Dinizo, MD: 37:46

So when we do a fusion the patient very often is immobilized for a certain amount of time, whereas with those posterior based surgeries there is in the period of immobilization they can get back to their activities very, very quickly. A lot of times in younger patients or more active patients, and sometimes even in athletes, we can get them back to doing what they wanted to very quickly because we don't have to wait for that fusion in the front or some of the morbidities associated with putting an implant in. Rather than we just take that disc out from the back, people can recover quicker and get back to their activities much faster.

Robert A. Kayal, MD, FAAOS: 38:23

Yeah, I mean certainly in this area there are indications to go in from the, from the back, but those indications are very, very rare and although it's tremendously advantageous to be able to go in from the back and not have to contemplate fusion, unfortunately those instances are rare and so so many times in our practice we have conversations with patients about the pros and cons, the advantages and disadvantages of certain things, and sometimes we will ask the patient to participate in that decision-making process and sometimes it's not so straightforward. There are advantages and disadvantages of both techniques. Clearly we get the most bang for our buck going from the front, because from the front we completely decompress everything the spinal cord, the nerve roots, we take the entire disc out and that patient is guaranteed to get better for the most part. The downside of that is they have to fuse and it can take months to fuse that cervical spine. So the post-op course is somewhat restricted as you encourage them to protect the fusion and allow it to heal.

Robert A. Kayal, MD, FAAOS: 39:35

The advantage of going from the back is there's no fusion but there's less bang for the buck. So sometimes you cannot adequately decompress the nerve fully from the back because the spinal cord is in the way. So it's only really those very lateral disc herniations or the spinal foramen that's getting encroached upon by a bone spur or something, a disc herniation that we can satisfactorily address from the back. And sometimes it's borderline, where the disc herniation is a little bit close to the spinal cord but largely lateral, and you may have a conversation with a patient, say, look, we're going to try to go from the back as much as we can and see what pain goes away. If you continue to have pain and discomfort, we may have to do a second procedure down the road. Do you find that you're sometimes in those situations with patients?

Michael R. Dinizo, MD: 40:24

Yeah, I do.

Michael R. Dinizo, MD: 40:25

And I think the biggest, you know, the most important part of that is to talk with the patient, have that conversation about the risks and the benefits and the pros and cons of the different approaches that we have.

Michael R. Dinizo, MD: 40:36

You know, I think having a shared decision with the patient and, just you know, discussing the different likely outcomes of their surgery and allowing the patient to have input on that decision is extremely, extremely important. Like you were saying, with the posterior cervical decompression we're just removing that compression that's right around the nerve root. There the whole rest of the disc is still there and this disc has had a herniation one time. There's a potential that it could herniate again. Work in the herniating on the other side, whereas with the anterior approach that disc is completely removed and both nerves on both sides of the spine are completely decompressed. So that way in the future that patient doesn't necessarily have to worry about having a recurrence of the symptoms at that level compared to what if they did it from the posterior aspect. And those are the decisions in the discussions that we have with patients, so that way they can help to make the decision themselves along with us.

Robert A. Kayal, MD, FAAOS: 41:33

Yeah, but just to be clear, probably more than likely, over 95% of your cervical disc herniations, when approached surgically or approached from the front, correct, correct, yeah, it's very, very rare to approach these cervical disc herniations from the back, because we want to make sure that these patients are completely satisfied with their outcomes and that that nerve is completely decompressed and really the best way to do that is from the front. But again, there are those very rare circumstances where we may be able to get away with the posterior cervical decompression and I just wanted to bring that to your attention. As far as disc replacement surgery, how often are you able to do a disc replacement and what are the indications for a disc replacement?

Michael R. Dinizo, MD: 42:16

The indications for a disc replacement are a little bit more restrictive than they would be for a fusion type of surgery. If a patient has disc degeneration and they have degeneration of other parts of the spine there's something called the facet joints, which is in the back part of the neck If they have arthritis or anything there, they might be better off with a fusion type of surgery, so that way those arthritic joints aren't moving anymore. If there's no arthritis in those joints, by maintaining motion there that patient could potentially have increased range of motion and reduce the risk of what we call adjacent segment disease. That happens from having a fusion in one area of the spine.

Robert A. Kayal, MD, FAAOS: 42:55

Yeah you can imagine that if you fuse one level, the area below and above that level is going to have to pick up the brunt of the load right and work harder than they're used to working and ultimately maybe become degenerative and wear out and require a fusion above and below. And that's where the concept of a disc replacement really became popular. If we can preserve motion at that level and decompress the nerve at the same time by taking out the disc and instead of fusing it, get away with a disc replacement to preserve motion, that should hopefully preserve motion throughout the entire cervical spine and avoid the complication of having an associated adjacent disc disease in the future, requiring a fusion in those levels.

Michael R. Dinizo, MD: 43:42

Correct. Yeah, so that's been the idea behind the cervical disc replacement, and both surgeries are extremely successful at decreasing the patient's pain in their neurologic symptoms. Most of the studies show that they're very close to equivocal, with the disc replacement showing a slight decreased risk of that adjacent segment disease, meaning the disc above and below the area that has surgery potentially degenerate slightly faster with the fusion compared to the disc replacement. Both are extremely successful.

Robert A. Kayal, MD, FAAOS: 44:16

Yeah, but just to be clear, the gold standard of care is what's called the anterior cervical discectomy and fusion. For the most part correct.

Michael R. Dinizo, MD: 44:22

Correct. Yeah, the disc replacement is great in the times when we can use it, but definitely the gold standard is still the fusion, the anterior cervical discectomy and fusion.

Robert A. Kayal, MD, FAAOS: 44:33

Yeah, for that acute cervical disc herniation that's going to undergo a cervical disc replacement. That patient really needs to have a very clean spine, right.

Michael R. Dinizo, MD: 44:42

Yeah, it's usually younger patients that have normal alignment of their spine. They don't have other issues within their spine. As far as degeneration in bone spurs forming or arthritis in their neck, the indications for that are a little bit more restrictive compared to the fusion, but in the cases where it is indicated, patients do great.

Robert A. Kayal, MD, FAAOS: 45:03

Yeah, so if you don't mind, just comparing contrast for our audience, the post op protocol for the different various surgical procedures you mentioned the anterior cervical discectomy and fusion with plates or cages or however you want to proceed, versus the anterior cervical disc replacement, versus the posterior cervical decompression.

Michael R. Dinizo, MD: 45:26

Sure. So with the anterior cervical discectomy and fusion a big part of the post op restrictions in their care depends on whether this is done at one level of the spine or multiple levels. I think, kind of just to compare apples to apples, if we're comparing a one level cervical disc replacement versus a one level anterior cervical discectomy and fusion, the patients that have the disc replacement they're able to get back to activities a little bit earlier than the fusion patients. The fusion patients usually they have about six weeks of restrictions, the restrictions being they can continue all their regular everyday activities but we don't want them doing anything to shreners, one for avoiding lifting anything heavy bending, twisting those sorts of things. Those are the restrictions that we have for the fusion patients, whereas with the dis replacement patients they can get back to their activities usually within two to four weeks.

Michael R. Dinizo, MD: 46:23

When we're talking about the posterior cervical decompression patients, the recovery is pretty quick. We give them a soft collar as needed, basically just to help them with the comfort they're able to get back to their activities as soon as we get to see them for their post operative visit and their wound is healed and everything. Then we can start to gently bring them back to all their normal activities. It can be pretty quick recovery for the posterior cervical decompression.

Robert A. Kayal, MD, FAAOS: 46:51

Yeah, as far as the surgical outcomes, I would venture to guess and say that cervical disc surgery for you is probably the most rewarding procedure you do.

Michael R. Dinizo, MD: 47:05

It's my favorite surgery, whether the disc replacement or the fusion. The studies that are published show anywhere from 90 to 95% complete relief of arm pain. Patients are very happy afterwards. It's a surgery that I really like to do because I can have the discussion with the patients that we have a very high chance of decreasing their symptoms and their pain and getting them back to enjoying their life more. So it's a great surgery and it's an honor to help patients.

Robert A. Kayal, MD, FAAOS: 47:38

It's certainly a very gratifying procedure and that's for the most part why most of us have chosen the field of orthopedic surgery.

Robert A. Kayal, MD, FAAOS: 47:46

We all appreciate that instant gratification, and nothing gives a spine surgeon more instant gratification than doing a disc surgery on the cervical spine. I think Because, again, when that spinal cord and when those cervical nerve roots are compressed, the patients are miserable. They're suffering, they're in so much pain and for the most part they wake up instantaneously without pain and they continue to improve day after day after day. It's a very minimally invasive surgery, very often done almost exclusively as an outpatient, for the most part through a very small incision. Patients have little to no pain after surgery, experience immediate pain relief from the nerve compression, and that's what we're all about here at the Kaila Orthopedic Center to provide patients with cutting edge orthopedic technologies and pain relief. So that's what we're in the business of doing. So, dr Denizl, let me ask you a question now. That's, I'm sure, on all of our patients' minds, and that is if I'm about to undergo a fusion of my cervical spine, aren't I going to lose motion in my neck?

Michael R. Dinizo, MD: 48:53

Yeah, so that's a very common question that I get anytime.

Michael R. Dinizo, MD: 48:56

We're talking about fusion surgery for the cervical spine, so a big thing that goes into this is where in the cervical spine that that fusion is going to happen. The top three, the C1, the C2 and the C3 vertebrae, are the ones that are responsible for the majority of your everyday motion, looking side to side and up and down. When people have cervical disc herniations, it's most common to happen at some of those lower levels of C5, c6, c7, sometimes at the C4 or C5. Those levels are not responsible for a lot of the everyday motion that we that we need to drive our car or to do any of the activities that we normally want to do. So those lower levels, from the C4 down to the C7, those are mostly with bending your neck side to side, which is not normally a motion that people do a lot during their their everyday activities. And even with a multi-level fusion, their motion for the most part in every everyday activities is completely preserved and that there's no restrictions on what they want to do.

Robert A. Kayal, MD, FAAOS: 49:54

Great. Thank you for that, dr Diniz. So another question that they often have is well, what about activities of daily living? What will I still be able to participate in after I undergo a fusion of my neck?

Michael R. Dinizo, MD: 50:07

So more early on, within the first six weeks or so after surgery, we're trying to let the patient recover and avoid most strenuous activities. But once they're healed they can reach almost all normal activities. Even there's been professional football players who have gone back to playing in the NFL after having cervical fusions. Patients are able to play sports once they're healed and they can get back to almost all their regular normal activities without any restrictions once everything is healed up. When we're talking about the cervical disc replacements, patients can get back a little bit quicker because we don't need to monitor for that fusion that needs to happen in between those vertebrae. So with the cervical disc replacements, patients can get back to almost all unlimited activities within the first six to eight weeks after their surgery.

Robert A. Kayal, MD, FAAOS: 50:58

One thing I think is very important for our patients to understand is that when surgeons perform a fusion of the cervical spine and use implants like plates and cages and bone grafts the plates and cages they're designed to keep the bones together to allow the biological fusion to take place, and once that biological fusion takes place between the vertebral bodies, the plates and the cage really serve no function at all. So it's really really important during that post-operative period that patients are taking supplements like calcium and vitamin D and avoiding certain things like smoking and alcohol consumption and even the usage of over-the-counter anti-inflammatory medications, all of which have been shown to significantly deleteriously affect outcomes after this type of procedure. Is that something that you counsel your patients on?

Michael R. Dinizo, MD: 51:56

Definitely. It's all part of the history before talking about smoking and risk factors that we can modify before the surgery so that way the patient can have a successful outcome. So if there's smokers, we talk to them about that. We discuss avoiding anti-inflammatory medications afterwards and also talking about their bone health too, so they have a history of osteoporosis or other things. That will be something we want to keep in mind when we're talking about the different types of surgery, because we want them to heal, we want them to do well, absolutely.

Robert A. Kayal, MD, FAAOS: 52:24

I know we've even canceled patients proposed surgical fusions when they would not stop smoking. That significantly increases the risk of what we call non-union, where the bones will not fuse. Well, this has been a very informative and very enlightening podcast. Have you here with us, dr Denizzo. I've really enjoyed our time together. We hope that you have found this podcast informative and helpful in your assessment and understanding of a cervical disc herniation and a pinched nerve in the neck. So I just really want to sincerely thank you for your time and your expertise. It's a privilege and honor to have you with us at the Kaila Orthopedic Center caring for our patients. Thank you so much for your time.

Michael R. Dinizo, MD: 53:11

Thank you, dr Kail, we appreciate it.

Robert A. Kayal, MD, FAAOS: 53:13

Thank you.