Unraveling the Treatments Options for Sciatica: From Epidurals to Endoscopic Spine Surgery

Experience the intrigue of unraveling the complexities of sciatica with Dr. Paul Bagi and Dr. Steve Aydin as they take us on an insightful journey through the symptoms and risk factors of this common condition. Uncover the silent contributors to back pain, from our daily activities and habits to lumbar disc problems, and learn how they interplay with age and occupation to leave us vulnerable. Knowledge is power, and this episode equips you with an understanding of how posture and spinal alignment directly impact your comfort and health, setting the stage for an empowering discussion that could change the way you manage back pain.

Feel a wave of hope wash over you as our experts illuminate the transformative potential of physical therapy and proper muscle support for spinal health. Together with Dr. Bagi and Dr. Steven Aydin, we navigate the delicate intricacies of the spine's natural curvature and the pivotal role these structures play in our overall well-being. Their conversation moves beyond mere theory, offering real-world insights into the progression of treatments for sciatica, from trigger point injections to the cutting-edge advances in less invasive spine surgeries. Discover the evolving landscape of back pain management where individualized care promises better outcomes, less discomfort, and a quicker path to recovery.

Cap off this informative session with a deep dive into the latest breakthroughs in interventional pain management and endoscopic spine surgery techniques. As our esteemed guests articulate the careful balance between intervention and the body's innate healing processes, you will gain a fresh perspective on pain management that prioritizes patient safety and optimized recovery. By the end of our dialogue, you'll be motivated by the promise of current and emerging treatments that not only alleviate pain but transform lives. This is a must-listen episode for anyone touched by the shadow of back pain—patients and practitioners alike will find valuable takeaways to carry into their journey towards a pain-free existence.

Transcript

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

Hello and welcome to another edition of the Kale Ortho podcast. Today is March 14th, 2024 and we're so privileged to have with us today Dr Paul Boggy, our very own Orthopedic Spine Surgeon. Dr Boggy serves as the chief of spine at the Kale Orthopedic Center and Dr Steven Aiden. Steve is the chief of Interventional Pain Management at Kale Orthopedic Center. Welcome to the podcast, dr Boggy and Dr Aiden. We're so happy to have you here today. Today's featured presentation is on the ubiquitous condition we call sciatica. Dr Boggy, take a second and, if you don't mind, just refresh our viewing audience's memory About the condition of sciatica. Can you describe that condition for us?

Paul Bagi, MD, FAAOS: 1:04

Yeah, so sciatica is a very common problem that we see in our patients, and it's actually more of a Description of a symptom than an actual diagnosis, and what I mean by that is there are a few different things that can cause sciatic pain.

Paul Bagi, MD, FAAOS: 1:22

So sciatic pain is pain that runs along the sciatic nerve, which runs down from the lower back across the buttocks and down the back of the leg all the way down to the foot, and so people can have pain anywhere in that distribution.

Paul Bagi, MD, FAAOS: 1:37

It doesn't have to be along the entire path. The most common cause is a lumbar disc herniation, usually at l5s1, which is the lowest level in the back, and sometimes at l4 5, which is the second level, second lowest level in the back. A couple other things can also cause it any kind of degeneration in the lower back, maybe that causes bones burrs or disc bulges that hit the nerve on their way out, and then paraforma syndrome, which is a muscle that's in the buttocks underneath the gluteus, can also pinch the nerve and cause pain in the same area. So it's a very, very common condition that affects a lot of people. It causes a lot of issues with activity, going to work, sitting for long periods of time and you know, really Treating it and getting people back to doing all the things they want to is very, very important.

Robert A. Kayal, MD, FAAOS: 2:35

Yeah, thank you so much, Dr Aiden. Are there certain groups of Patients that are maybe predisposed to developing sciatica?

Dr. Steve Aydin: 2:44

Sure, you know in general sciatica is such a common thing but, as dr Boggy mentioned Both currently and in the previous podcast talking about sciatica, you know it most commonly. It's probably the most common thing we see in the practice from a pain perspective. But what are the things that are at risk for them in in different populations and especially younger individuals that have healthy discs? You know, a disc herniation that kind of protrudes out or touches the nerve and pinches the nerve can often be the main cause of a patient feeling sciatica or pain down the leg. The other thing that can cause it is degeneration. So there's a subset of patients.

Dr. Steve Aydin: 3:29

As we age, our discs kind of dehydrate and they go from being like a grape to a raisin and so where I mentioned earlier, you have that disc that leaks or pops or herniates and the Gellier, the part of the disc, kind of touches the nerve. Now you're kind of in the dehydrated disc that kind of gets smushed Like a raisin does and it starts pushing onto the nerves and hence touching the nerves and giving you that sensation Down that wire, that sciatic nerve or the nerve root that makes up the sciatic nerve, giving that pain into the leg or the back of the leg, and that's usually in the older population. So you have these two categories or these two groups of people the younger healthy disc versus the older degenerative disc. So those are mainly the two conditions that we'll often see Kind of present into the office.

Robert A. Kayal, MD, FAAOS: 4:20

That's what I was sort of getting at.

Robert A. Kayal, MD, FAAOS: 4:22

It's sort of the young, typically the younger active patient with a healthy disc that ultimately twist their back in some provocative position or perform some maneuver, lift something very heavy, sits on an airplane eight hour flight for a long period of time, goes to lift a box without proper body mechanics, coughs, knees vacuums, things like that.

Robert A. Kayal, MD, FAAOS: 4:47

These are the typical patients that will endure a lumbar disc herniation at a younger population, from probably age 20 to 40 or so, like that. Older patients, as we've alluded to in the past, typically suffer from less sciatica but more of degenerative conditions, and we and I know we did a podcast in the past about this condition called spinal stenosis. But today we're going to focus primarily on that younger age group population age 20 to 40 or 50 years of age where they have a pretty healthy looking back, except for some type of trauma of some sort. They twist, they lift, they cough, they sneeze, they sit for a prolonged period of time and and their spine is typically in an Abnormal posture which will then subject themselves to a lumbar disc herniation. Incidentally, I know we talked about the younger age population that is at risk for this, but also smokers, right, dr Boggian, that's correct, and why is that so?

Paul Bagi, MD, FAAOS: 5:50

what smoking does? It's, as we know, there are a lot of different things in cigarettes. One of the main ones that does this is nicotine, but also tar and a couple of other products that are in there, but it decreases the blood flow to every part of the body, and here specifically, the problem is that the discs already have a poor blood supply, so they actually get all their nutrients from the bone that's right next to it, and so with smoking, what happens is the blood flow is decreased to the bone and the nutrition doesn't get to the disc, and that causes the disc to start to wear down, making it much more prone to injury.

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

Absolutely. And also the position of the spine and certain occupations will certainly increase your risk and predispose you to developing a disc herniation. You know, I remember that we've done in the orthopedic field, we've done Clinical studies where we've placed transducers into discs and then we measured the pressure inside the discs in different positions and they concluded that essentially, sitting, coughing, sneezing, etc. Will increase the and vibrational, constant vibrational maneuvers like this where the spine is going up and down, for instance, if you're a truck driver or a bus driver and your your spine is constantly enduring it Axial load, that will increase the pressure inside the disc and predispose to disc herniations. Furthermore, they concluded that lying down flat, unstant and standing has decreased the the pressure inside the disc, creating almost a negative pressure which is favorable for a disc correct, yeah, and I mean, dr Kale, you hit it right on the head.

Dr. Steve Aydin: 7:38

The disc is kind of like a shock absorber and you know, as dr Boggie alluded, it'sa A item that receives very little vascular supply.

Dr. Steve Aydin: 7:50

So it's turnover and it's its healing process is very, very slow and its inflammatory process is very, very fast or over exaggerated. So you can't really mitigate the inflammation in the disc like that because there isn't good blood supply. The disc is really prone to those kinds of injuries because of its, its architecture. It's not a perfect circle, it's not reinforced really well on every part of itself. It has very weak points, especially in the positions that put pressure on it that you just described. So if leaning forward, leaning forward and twisting Increase the pressure on the disc by almost two to three fold, and then if you're sitting Leaning forward and twisting, it almost increases it to five, and that's usually the position that Places the disc at the highest pressure, with a high risk for herniation or that Kind of that pop effect or leaking of the disc that compress onto the nerve, which is unfortunate because a lot of these patients are young, active patients, right, and a lot of these patients want to participate in racket sports and golf in particular, and that's always difficult managing these patients.

Robert A. Kayal, MD, FAAOS: 9:00

What do you do with patients like that, dr Boggi? Yeah, so exactly what we're talking about here. Those are actually also the symptoms to quickly review.

Paul Bagi, MD, FAAOS: 9:11

People will have increased pain when they're in those positions. So sitting in a car for an extended period of time is usually very uncomfortable, and when you're sitting, the sciatic nerve is very uncomfortable, and when you're sitting, the sciatic nerve is also under tension. So not only are you putting more pressure on the disc, but the nerve that's already irritated is getting put under tension. So that's usually how Patients present, as we've been talking about, and then in terms of what we do about it. But really the key is to get people back to everything they want to do. So activities, work, and the great news is that most people do get better without needing any invasive treatment. So 90% of people will get better, usually between four to six weeks, and so initially we begin with things that can help strengthen the musculature that supports the spine. So working on the core, the lower back and the muscles that are around the pelvis, especially the hips and down into the legs as well, including the quads and the hamstrings, is very important, so that can take the pressure off the disc that's injured. Physical therapy is very, very helpful with that. Other things we can do to mitigate the pain is chiropractic treatments, acupuncture. Both can work very, very well.

Paul Bagi, MD, FAAOS: 10:34

The key in the beginning is to get that acute pain down so that people are able to do more of the things they want to, and of course what the goal is is that every day and every week that pain continues to decrease Along with those. Medications can also help. So anti-inflammatories can work very well to decrease the inflammation. Sometimes the inflammation causes muscle spasms, and so muscle relaxants can work well also, and sometimes nerve medications can be very helpful and they help to decrease the sensation or pain, numbness, tingling that's going into the leg from the nerve compression. So that's usually how we begin and usually it's very effective. And of course we have all of those treatments at Kale Orthopedic Center, so we're able to provide patients with care as soon as they come in and try to get their pain down.

Robert A. Kayal, MD, FAAOS: 11:29

Dr Ian, what role does posture play in the management of lower back disorders, sciatica and the spine in general?

Dr. Steve Aydin: 11:38

I mean posture is really important, poor posture, whether you're slouching or kind of just putting a lot of pressure on the lower back, kind of losing that normal curve. So in your neck you have kind of this backwards or a C which is called the lower or lower doses, and then it curves into the mid back, called a kyphosis, and then back to a C for a lower doses and then to a kyphosis for the sacrum. So there's supposed to be a C in your neck and your lower back and you're supposed to maintain those positions, mainly because that's where the least amount of energy or force is pulled onto the spine from gravity. So if you start losing that C, where you kind of bring your shoulders forward and you bring your head forward or you slouch your back and you slouch forward, you're actually putting more pressure on the disc because now you're putting flexion or leaning forward position onto the discs which are very, very mobile, and that puts more strain, shear wear and tear and hence accelerates that degenerative process.

Dr. Steve Aydin: 12:40

So, as Dr Boggi mentioned, physical therapy, core strengthening, staying limber, those things are paramount in trying to maintain proper position. And then what it also does is many times we talk about the back as just the back. We forget that the back or the spine is really a tube. So with the abdominal muscles, the side muscles, the obliques, all those components are actually recruiting and activating to kind of maintain this tube that is really your spine, because if you just think of it as just the back and where the vertebrae and the discs are, you're missing three other components of this cube or this sphere as we talk about. That's really maintaining the position.

Robert A. Kayal, MD, FAAOS: 13:22

That's an excellent description. In fact, you hit the nail on the head. That's exactly the point I was trying to make, and actually I think it's so important that I think it's worthy of demonstration. So we're going to take a minute to demonstrate exactly what we're talking about, because I think it is so critical to the management of spinal disorders, and I know Dr Boggi and Dr Aiden agree. So we're going to pull out a model and we're going to demonstrate exactly what was just described. So this is a model of exactly what Dr Aiden so eloquently described, and I do want to refer you back to an older podcast that I did with Dr Paul Boggi. I think Dr Boggi did such a magnificent job in describing this as well.

Robert A. Kayal, MD, FAAOS: 14:02

But essentially, this is what we would describe as a side view or a lateral view of the entire spine. Up here we're dealing with the cervical spine. Up here, that's where the neck would be, and this is that C-shaped lardotic posture of the cervical spine, which is appropriate. And then in the upper spine, or the thoracic spine, we're appreciating this kyphotic posture and, again, that's normal. In the lower back, this is what we call the lumbar spine, or the normal lumbar lardotic posture, that C-shape that Dr Aiden was describing and again, that's a normal posture. And then, finally, in the sacrum and coccyx, we again appreciate this kyphotic spinal position and again, that's normal.

Robert A. Kayal, MD, FAAOS: 14:50

The body and, by the way, in the coronal plane or in the AP trajectory, we should not see any curvatures. It should for the most part be a straight line. A curvature in this coronal plane would be described as scoliosis and that's a condition and topic that we will discuss in a future podcast. But for today's purposes, we do want to appreciate that the spine has this normal curvature in the sagittal or lateral plane. Now, it's important that it's in this position because this is where the discs and the spine and the patient is most comfortable and that is because there is something called center of gravity. Can you describe that for us, dr?

Paul Bagi, MD, FAAOS: 15:39

Paghi, yeah, so this is very important to spine health and causes a lot of discomfort and pain and disability when it's not in the normal alignment. So if you think of a cone extending from the pelvis up towards the head, with the point at the bottom and the wider part of the cone at the top, the further away from the center that the head is, towards the front, towards the back or either side, the more pressure there is on the entire spine. So in normal alignment the head is centered right over the pelvis, so that gravity is doing most of the work to keep it there. As soon as our head is no longer positioned over our pelvis, there is an extreme amount of force that's going on the entire spine and then our muscles have to work to pull our head back over our pelvis, and these muscles get tired very quickly when they're doing something they weren't designed for and that can cause a lot of pain, a lot of discomfort, and people can barely do things they need to on an everyday basis. They can get to the point where people can't stand and cook, do the dishes full laundry for more than a few minutes at a time, and so that's another reason why this alignment is very important Because when we're younger, a lot of times it does have to do with posture, and sometimes it's pain that's causing our posture to be off from where it's supposed to be, and this is where our excellent physical therapists come into play.

Paul Bagi, MD, FAAOS: 17:15

So they are very focused on bringing back our normal posture by strengthening the muscles that have become weak over time and so really focusing on the core, the stabilizing muscles, the lower back, mid back muscles, and bringing that strength back, also working on flexibility and stretching, and a lot of times when we're younger, that's really all we need to fix our posture, bring the spine back into alignment and really decrease a lot of the discomfort that people are having from sciatica or disc herniation.

Robert A. Kayal, MD, FAAOS: 17:48

Okay, that was great. And just to further elaborate on that, dr Bagi and this will be the last thing we'll talk about until we get into the treatment options for sciatic in particular it's so important that I just feel the need to elaborate a little bit. If the head is up here, for instance, and the head is resting on the cervical spine, dr Bagi is describing that the spine is and gravity is supporting that head, without much pain or discomfort to the muscles surrounding the spine. A lot of patients' neck go into spasm and it straightens out and all of a sudden the head is leaning forward and so the muscles in the back have to support that head that wants to fall off and so that causes a lot of neck pain. So, to extrapolate to the lower back, the same principle applies. The lower back muscles are very comfortable when the spine is in lordosis. The whole body weight is being absorbed by this beautiful architecture. The discs are happy, the muscles are happy, the patient is happy. No back pain. The second the lumbar spine collapses into either spasm or straightening or loss of that normal lardotic posture or potentially into kyphosis. The lower back muscles are screaming, they're writhing in pain, the discs feel pressure that they should not feel and ultimately can hernia and cause something like this lumbar disc herniation that we're seeing. So enough about the architecture and the design and position and the importance of posture.

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

Let's now focus our attention on surgical and interventional pain management options for the treatment of sciatica. So, dr Aiden, let's take this opportunity and I'm going to ask you to speak to our listening and viewing audience from least invasive to most invasive non-surgical treatment options. When I say non-surgical, I mean without the intervention of a spine surgeon. Dr Aiden is an interventional pain management specialist. He does surgical procedures in a very, very minimally invasive manner and if and when those are not enough, that is typically when we employ the expertise of our board certified fellowship trained spine surgeon like Dr Paul Bogge. So in the beginning, I'd like to focus our attention on treatment alternatives that can be offered by a technically savvy, cutting edge interventional pain management specialist like Dr Steve Aiden. So, steve, take it from here. What can you offer our patients that are suffering from back pain? But, in particular, today's podcast is on sciatica.

Dr. Steve Aydin: 20:39

So in general there are a lot of different options that can be offered for things that are causing sciatica. The most important thing in even starting a treatment is kind of establishing what the cause of the sciatica is. So imaging in your physical exam whether it's an MRI, x-ray, ct scan, electrodiagnostic studies, all those things should kind of be teed up with the patient who's had this stubborn symptom, where they may have seen their primary doctor. They got some medications, you know. They started some chiropractic care which can help with the alignment and adjustments of the muscle spasms, and I've really gotten to a point where they've plateaued. They've tried physical therapy as well, or they're just in such intense pain nothing is working.

Dr. Steve Aydin: 21:22

So once we establish what the cause is and we talked a little bit about the disc herniation in the younger population, you know once that disc herniates it causes this inflammatory cascade. You'll often start with some sort of history where the patient went to pick something up, felt a pop, intense back pain. They seek care, the intense back pain gets better and then all of a sudden they have leg pain, and so that sciatica pain is where we start to get involved as interventionalists. Many times one of the first treatments that someone could try is something called a trigger point injection, and many times the orthopedist or the PAs or the primary care doctor has already gone down this road. They kind of palpate along the area in the spine, they find areas of muscle spasm whether it's in the lower back muscles, the gluteal muscles, the piriformis muscle and they take a needle and they sprinkle a little bit of numbing medication and some cortisone or some just numbing medicine, no cortisone, even saline or something else we call dry needling, and they just try to agitate the muscle while introducing a local anesthetic and a little bit of cortisone to help reduce the inflammation. So that's one of the simplest kind of bread and butter first line treatments that we'll often try for someone with stubborn sciatica. If that works, great, the patient improves, they don't need anything from me, they don't need to see Dr Baghi. If that doesn't work, what's the next step? If we establish that it worked a little bit or it didn't work at all, we start thinking about things along the lines of getting to the area where the inflammation is coming from, and once we've established the MRI and looked at the images and we see a disc herniation that kind of matches the symptoms, we'll talk about something called an epidural steroid injection. Now, an epidural steroid injection is a X-ray or live fluoroscopy guided injection that we get a needle near the nerve or the disc or both and we inject a combination of sterile salt water, a numbing medication like lidocaine and a corticosteroid or just steroid into the area. The goal of that is to help mitigate that inflammation response that that disc has caused.

Dr. Steve Aydin: 23:39

That disc can cause the problem from a few different effects. Sometimes it's purely mechanical the disc herniates, it pushes onto the nerve, it pushes the nerve into the corner of where it exits and it inflames, it swells and there's no relief. The other way it can cause pain is where the disc leaks or the disc gets a tear in it and an inflammatory fire forms and that agitates the nerves around the disc, the big nerve that goes down the leg and causes this pain pattern. The ones that I think respond the best to an epidural are probably the latter, the one where it's an inflammatory cascade, and those are the patients that will usually respond to the steroid pack or anti-inflammatories or the trigger points. But it will only last for a short time and then it returns after a week or a few weeks and I get in there and I do an epidural. Now the epidural can be done down the middle into the center of the spine, which is called an interlaminar approach, or from the side, which is called a transferaminal approach, and one is done for another reason or another. Sometimes we switch, sometimes we try one, thinking it's more for the leg if we do a transferaminal approach, or for the back pain If there's more back pain than leg pain we'll do an interlaminar approach. But I've been doing this long enough to know that there's no real great algorithm for that.

Dr. Steve Aydin: 25:04

The former condition, where it's actually the disc, is pushing onto the nerve, or a goop of jelly has popped out of the disc and pushing on the nerve and no matter what I do, no matter how much I inject, I can cool it off for a couple days and then the pain just returns. And that's kind of the situation that I'm trying to get better and prevent from sending to Dr Boggi. But that's where I get stuck. The epidural one works for a couple weeks. I see the patient back. We talk about a second, maybe a different approach. Same thing happens again. They get better, but they're still uncomfortable, they're still functionally not where they need to be and that's where I kind of say, well, now we need to talk about surgical options.

Robert A. Kayal, MD, FAAOS: 25:49

Before you get there. Steve, what are your thoughts about the epidural? Do you feel that the epidural is actually treating the condition or masking the condition? Because these are some of the questions that the patients ask in the office. They're concerned why are we doing the epidural? Are we just masking it? A lot of times patients want to know their body, how it feels, and if it's still there and they're still having pain, then it's not really getting better. What are your thoughts about the epidural? What are we looking to?

Dr. Steve Aydin: 26:19

achieve. That is one of the hardest questions I get in the office Because in the population that we're talking about, where it is a younger, more active individual, healthy individual, the first question they'll ask me is, like you said, is this just going to mask my pain? Or two, is this going to fix the problem? So let's attack the first one no, it's not going to mask the pain. The pain is purely a result of inflammation. So if I do an epidural and I reduce the inflammation from the event that caused the inflammation, then the patient should get better.

Dr. Steve Aydin: 26:57

We don't often treat pictures. So many times we'll see an MRI and we'll see herniations all over the place, you'll see degeneration at one level or there's just a multitude of things on the report or the image that we don't treat. So it's very hard for me to tell a patient we're going to change your spine. No, the epidural is not going to change the way the spine looks the day before or the day after the epidural. But we also don't treat pictures. We treat symptoms. So if the symptoms are generated by an inflammatory process, then they should get better. Many times when the patient asks, well, am I just masking the pain with this? I'll tell them well, no, you're not, because the difference between a symptom and no symptom is nanometers of swelling or irritation. So if I can reduce the inflammation where the nerve is no longer glued to that jelly from the inflammatory goop that's happened there and the nerve is now free to slide and glide, as we talked about earlier, with the core strengthening and the physical therapy, then the patient should be better. Nothing I'm giving the patient is going to numb the nerve for a period of time be around an hour or two where they won't feel pain if it comes back. So it's very hard to kind of convince the patient that we're not just masking it, we're trying to reduce the inflammation from it.

Dr. Steve Aydin: 28:19

The second part of the question that you asked me is why don't I just jump to fixing this and listen? My job here as much as I love Dr Boggi and the other surgeons in the practice I've always looked at this interventional spine as kind of preventing. My job is really to prevent you from needing surgery in a reasonable manner. So if I do this injection and it necessarily doesn't change your spine, it doesn't mean that the problem places you at risk for more problems. The goal is to get the patient back to functioning. The herniation can still be there and the patient may still be functional and not have pain.

Dr. Steve Aydin: 29:01

It's the stubborn cases where the epidural doesn't work or it doesn't respond that we need to have that conversation or sit down Now. In general, most times we start with conservative and we escalate to surgical. I'm not saying that interventional options must be done in every situation. Someone who's neurologically compromised, they're weak or they're just incapacitated, no matter what I do, even if they have one epidural, it does zero. Or they're just neurologically compromised, with weakness or bowel bladder issues. I'm not even talking about an epidural. I'm saying listen, you need to see the surgeons because, no matter what I do, you're at a point where I don't think it's going to return.

Robert A. Kayal, MD, FAAOS: 29:43

Before you even continue any further, I'm just interested, I'm curious on your perspective of what we're looking to achieve with the epidural.

Paul Bagi, MD, FAAOS: 29:52

Yeah, great question. So, just like Dr Aiden said, the epidural can be very effective at decreasing inflammation. So I think everything goes back to getting people back to full activities I think that's the key and, of course, to eliminate their pain. And, just as Dr Aiden said, often we're looking at the imaging and we see issues elsewhere in the spine that aren't causing any problems, so we don't need to treat those and that's why, if we can get people feeling better, back to full activities with an epidural, it's a great treatment. And there have been times when I've seen imaging where I didn't think the patient would feel better with an epidural. And they've got an epidural with Dr Aiden and they've been great and back to work in activities without any issues. Often symptoms won't return, and so that's the key.

Paul Bagi, MD, FAAOS: 30:53

I do want to emphasize, as Dr Aiden said, that there are a few situations where we want to go with surgery sooner rather than later. The two main ones are weakness, and we can see which nerve is being compressed or compromised by where that weakness is. Each nerve goes to a different muscle and so we can see that weakness in ankle motion, knee motion, hip motion. The other one is when something called catechina happens and that's when the disc herniation is so big that it compresses all of the nerves that are running up and down the canal. That can lead to issues such as loss of bowel and bladder control, and that's something that's actually a surgical emergency. We want to do that as quickly as possible. The studies show that if we can do it within two days, people do the best and have the most recovery function.

Robert A. Kayal, MD, FAAOS: 31:50

The reason I was asking was and thank you for that is because the fact of the matter is I'm not really sure we know and that's why I was interested in your perspective, each of you. I can tell you this from a practitioner, an orthopedic surgeon, who's been practicing for 25 years now. I've written prescriptions for thousands and thousands of epidurals, but part of me has always wondered why. I know that I'm trying to manage the patient's pain clearly and decrease the inflammation, because the pain we're describing is 10 out of 10 pain. This is quite severe pain. Typically it's very significant pain, often intractable pain. Patients cannot function, carry out their activities of daily living, they can't sit and their leg is numb. They have so much severe pain in their lower extremities. I often order the epidurals so that they can be comfortable, get comfortable and be able to participate in physical therapy. I was interested in your perspective because inflammation is also sometimes part of the healing response.

Robert A. Kayal, MD, FAAOS: 33:03

A disc herniates. Sometimes the body interprets that as a foreign body, a mountain inflammatory cascade to resolve that disc and that inflammation, that inflammatory response, is associated with the severe pain we're describing. It causes significant compression and swelling around that nerve. It's a conundrum we're in. It's a catch-22. We want to get the patient comfortable to tolerate therapy and put an anti-inflammatory around there. I don't know if we really know fully if it's interfering or delaying the resorption of that disc or the effects of healing, but we all do it and it works. It works.

Robert A. Kayal, MD, FAAOS: 33:50

For that reason I was questioning your perspective, because we all know I've reiterated this over and over and over again the inflammation is often associated with redness, warmth, pain and swelling. All of those conditions are occurring after a disc herniation. What do we do? We give anti-inflammatory. Sometimes we'll do prednisone, the medril dose pack or a local anti-inflammatory around the nerve. It works. To me it's always been somewhat counterintuitive in that we need inflammation to promote healing. That being said, I raised this area of controversy, but it's not really controversial because we all do it and it works. But intuitively it doesn't make sense. A little bit right.

Dr. Steve Aydin: 34:36

No, as Dr Boggi mentioned earlier, it's a very avascular environment. You need blood for healing when the response happens. There's nothing to pull away. The response, the epidural or the injection therapies in general is to mitigate the inflammatory response. I'm not saying that we need to get rid of it, but I'm a big believer that many times and if you think about an epidural and what it's supposed to accomplish I'm supposed to introduce steroid into an environment. That doesn't happen immediately, that takes a few days for it to metabolize and whatnot.

Dr. Steve Aydin: 35:14

There is a subset of patients where I do an epidural and the moment they get off the table, or in the day or two, they're so much better, like significantly improved. I think there is an element of adherence. That happens Just like you would get a cut on your skin. There's a time where it bleeds, the bleeding stops and then you get that yellowish plasma layer on top of it. That's a very sticky, goopy product. That's when you do that flush. When I do the epidural, there's a flush component from the medium of the—and that's why I mentioned Preserve, refrease, saltwater and normal saline as a big component of it. Because there are a subset of clinicians that believe that you don't even need to inject steroid. You just do a saline with lidocaine or just the saline block.

Dr. Steve Aydin: 36:05

I think there's inflammation that's over-exaggerated, there's inflammation that's needed to heal, but then there's also this wash effect, this almost cleansing of the nerve or freeing up the nerve. That's why I think it's very important, from an imaging standpoint, that every interventionist knows exactly what and where they're injecting, because if you know where to put the product of injectate, I think you have much better outcomes.

Robert A. Kayal, MD, FAAOS: 36:30

Then, finally, the patients have to be comfortable to participate in chiropractics, acupuncture and physical therapy. We all know that we employ those modalities to try to fix the problem. Even if the epidural is not fixing the problem, it's making them comfortable to allow them to do physical therapy, to restore that proper lumbar lardotic posture, create that negative pressure in the disc, hopefully allow that disc to go back in place, like Robin McKenzie describes in his book Treat your Own Back with McKenzie therapy. We have to get the patients comfortable to live their lives, have some quality of life, go back to work and certainly participate in chiropractic, physical therapy and acupuncture Absolutely. I'm sorry that was a long-winded digression of what you were describing. Why don't you continue, Dr Aiden, and just talk more about your options that you offer our patients with respect to interventional pain management?

Dr. Steve Aydin: 37:31

We covered the epidural, so the approaches to the epidural. There's a third epidural that you can consider, which is a caudal epidural, which is where you go from the very base of the spine. It's almost as if we were godly designed with this access point to your spine from the sacrum and you can enter an access into there. Then sometimes there are patients who've had surgery that Dr Boggi and I will coordinate with, where I need to get in there with a catheter or a wire to get up to an area where there's scar tissue After surgery. Sometimes patients, their anatomy is a little bit variable and I can't access the spine the same way that I should be able to. So I run a wire or a catheter to get to those areas to break up adhesions or scar tissue.

Dr. Steve Aydin: 38:13

That's really the epidural. The epidural is my first step in a lot of the approach to sciatic pain, because I'm a big believer that the spine is a tube. Even the canal is a tube and there are components that make it up. The front of it is the disc, the back of it is the joints and the side of it is the nerves. The epidural can introduce medication or a block into those areas to cover all three.

Robert A. Kayal, MD, FAAOS: 38:37

Thank you for that, dr Aiden. By the way, dr Boggi, at this stage of patient care, are you typically involved? When the patient was seen by, say, myself or a physician assistant or another doctor, patients having sciatica, we ordered the MRI. Clearly the patient needs an epidural or some type of interventional pain management. Were you involved at this stage of the?

Paul Bagi, MD, FAAOS: 39:01

patient care? That's a great question, Dr Kale. The answer is definitely yes. As I said before, most people are not going to need surgery, but it's very important for patients to have every specialist involved in their care, because we each look at the issues from a different perspective. We can each help quarterback their care with other modalities that can help them feel better. So even very early on, I like to see patients who are coming in with sciatic pain and disc herniations and this way I can also explain to them maybe what the process would be if they did end up needing surgery, and then they're much more comfortable knowing that they're trying different modalities and they're still not feeling better. Or maybe they're developing weakness and now we need to move forward with surgery. So I think that's very, very important.

Robert A. Kayal, MD, FAAOS: 39:55

That's exactly my point, and we make it of a policy, the modus operandi at the Kailor Orthopedic Center. When a patient is being seen for back pain or sciatica, we get all our specialists involved because we all add a certain, a different element of care to that patient. Different level of expertise. Our training is different and what we can offer our patients is going to be different from each specialty. And the fact of the matter is everybody helps the patient get better, whether it's the chiropractor, the acupuncturist, the massage therapist, the physical therapist, the orthopedic surgeon, the PA, the interventional pain management or, as a last resort, the spine surgeon. But we always employ the expertise of our spine surgeons because they're the experts in the spine. So it is incumbent upon us to employ their expertise to evaluate the MRI and, god forbid, the patient makes a turn for the worse and all of a sudden the pain is intractable or worse.

Robert A. Kayal, MD, FAAOS: 41:01

Yet there's that cortoquina syndrome that develops, that Dr Boggi alluded to, or a significant area of motor weakness. The patient doesn't need to have an emergent introduction to the spine surgeon and then get scheduled immediately for surgery. That patient already has enjoyed a doctor-patient relationship with our spine surgeons and feels comfortable. So they're highly trained and specialized. They did additional fellowship training in the area of spine and we certainly will employ that to offer our patients the best medical care in the area of their spinal disorder. What else can you offer, dr Aydin, to our patients If, for instance, epidurals fail? You've tried different types of epidurals. You've done an intralaminar epidural transferaminal, maybe even a caudal. What's next? Does the patient go right for surgery, or is there anything else in your armamentarium that you can offer our patients?

Dr. Steve Aydin: 42:02

So I mean in general, if we've established the diagnosis as really being that disc and we've tried a round of one or two or three epidurals and they've really not turned the corner, at some point you have to say, well, how much more cortisone or how many more injections can I do for someone?

Robert A. Kayal, MD, FAAOS: 42:20

What about regenerative medicine? Are there any regenerative medical therapies that you can offer our patients?

Dr. Steve Aydin: 42:24

I mean certainly. Those are options that can be considered. We can always consider doing regenerative options like PRP.

Robert A. Kayal, MD, FAAOS: 42:31

What are some examples?

Dr. Steve Aydin: 42:32

Yeah, so some of them are PRP. And then there's bone marrow aspirate which can be injected in or around the disc or into the disc. Those are kind of a little bit different than outside the box Insurance companies and the research is not really robust. What?

Robert A. Kayal, MD, FAAOS: 42:50

is PRP, just for those that don't understand.

Dr. Steve Aydin: 42:53

So PRP is Platonel rich plasma and it's basically removal of your own blood, processing it, removing the red blood cells and the heavy products and leaving the upper layer of the plasma. And the plasma is where we think a lot of the growth factors and the healing factors are. And many times we'll introduce that into, say, a tendon, ligament, disc or around an area of inflammation to help promote a healing cascade. And there is a fair amount of research out there that does show, it does have promise, but it hasn't really achieved the standard of care that we've kind of had in medicine with a lot of our other treatments.

Robert A. Kayal, MD, FAAOS: 43:32

That was my point, I think. For the patient that is inoperable, for instance, and you've exhausted other interventional treatment alternatives, you can't keep giving steroids, steroids, steroids, but the patient is not medically clearable to undergo a spinal procedure. And as a last resort, we do offer regenerative medical therapies where, like Dr Aiden said, we do harvest a certain amount of blood from patients veins. We take that whole blood, we place it in a centrifugation system that we have in our office or at the hospital or surgical center, we spin that blood from anywhere from five to 17 minutes and separate the whole blood into red blood cells, white blood cells and platelets and then we take the portion of their whole blood which is enriched with proteins and activated growth factors. It's called the autologous condition plasma or platelet-rich plasma, which is then subsequently injected in and around the area of disease and inflammation and a lot of people feel that it has profound healing potential, anti-inflammatory properties. But again, it is considered experimental cutting edge, not often approved by insurance companies, but for patients that are desperate or can't have more injection therapy or can't have surgery or can be ultimately opposed to having surgery, just refuse to have surgery. It is something that we can offer our patients. We just want you to be aware of that. So now it sounds like we've failed.

Robert A. Kayal, MD, FAAOS: 45:12

Non-traditional spinal surgical interventions. We've tried everything. We've tried physical therapy, anti-inflammatories, steroids, chiropractic acupuncture, trigger point injections, you name it everything we've described. This is where you often will come into play, right, Dr Bogg? You've already met the patient. You've prepared the patient that we're going to try conservative management. We're going to try to put that disk back in place, we're going to try to reduce your pain and inflammation, but for whatever reason, the pain persists. The patient has developed weakness, possibly bowel or bladder dysfunction, numbness around the perineal region, leg weakness in both legs, issues that are now causing surgery to become now imminent. Where do you?

Paul Bagi, MD, FAAOS: 46:05

start. So at this point the situation is usually due to a few things. It can either be a mechanical issue, as Dr Aiden mentioned earlier. The nerve is actually getting compressed by the disc herniation and all the modalities that we've used thus far haven't been enough to take the pressure off the nerve. The other issue could be that it's now turning into more chronic inflammation. We've done everything we can to decrease that inflammation, but it persists and that continues to put pressure on and irritate the nerve. So now is when we started thinking about actually using surgical options to go into the spine and remove that mechanical compression or to remove the piece of disc that is causing the inflammation. So spine surgery has evolved quite a bit over time and in the past even this surgery was pretty invasive. So a large incision, a lot of muscle dissection to get down to the spine, removing quite a bit of bone to actually be able to see the disc herniation and then take it out. Over the past few decades that has changed quite a bit and we don't need to do that anymore.

Robert A. Kayal, MD, FAAOS: 47:21

So the traditional way to and, by the way, this is the purpose of today's podcast.

Robert A. Kayal, MD, FAAOS: 47:25

I know we've spent a lot of time leading up to this, but really the focus of today's podcast is to really focus our attention on describing the evolution of spine surgery with respect to our Dr Boggs and Dr Denizo's approach to surgical management of disc herniations and sciatic in particular. And I'm going to ask Dr Boggs to start from least invasive, from most invasive rather to the least invasive, most cutting edge techniques, from open incisions to tubes, and then something he's going to communicate to you which I'm sure you'll all be excited about as much as we are.

Paul Bagi, MD, FAAOS: 48:08

Yeah, thank you, dr Kale. So we were talking about the large, open approaches. So the key is to be able to see the disc and remove it safely without injuring the nerves or any of the other important structures in the area. And in the past the only way to see it was to really have a large incision and look into it, usually with loops, and that magnifies it while we're looking into the incision. But now what we're able to do is.

Paul Bagi, MD, FAAOS: 48:36

So the two main ways to do this is one you can make a small incision and usually, as we talked about earlier, the disc herniation is on one side. So what we can do is, once we make the small incision, we will only dissect the muscle slightly to be able to get down to the bone. Then what we do is we use a microscope to be able to see through that small incision and remove a tiny little window of bone. And this does not change the mechanics or the structure of the spine at all. We only make enough so we can see in there and we move the nerve over and we take out the piece of disc, and usually people will feel better very, very quickly, sometimes immediately afterwards, sometimes if the compression has been there for some time. It can take a few days for the inflammation and the nerve to calm down, but usually people will have 95 up to close to 100% improvement just in a matter of a few weeks.

Paul Bagi, MD, FAAOS: 49:34

So then what we started doing was using tubular, minimally invasive approaches. So what this does is we can use larger and larger tubes to dilate the muscle rather than cutting through it. So what this does is it moves the muscle away so we can see, and through the tube we look in with a microscope. Then the procedure is the same from there, remove a tiny little bit of bone, find the disc and take it out.

Robert A. Kayal, MD, FAAOS: 50:03

So instead of making a big incision, you make a small incision, dilate with larger and larger tubes, which then stretches the soft tissues in the skin, but the incision is tiny, typically. How big is that incision for a one level microdiscectomy?

Paul Bagi, MD, FAAOS: 50:17

So it could be a centimeter and a half. It's incredible. So half an inch and recovery is very, very quick after this. So people usually have some back discomfort, of course for a couple of days, usually don't even need pain medication to treat it, anti-inflammatories, muscle relaxers for a few days and then people are feeling a lot better. Actually, the bigger issue with these is not so much how big the incision is we just talked about with the tubular approach you can get that pretty small it's actually the restrictions. So the reason for the restrictions is that the disc is injured.

Paul Bagi, MD, FAAOS: 50:56

So Usually there's a tear in the back of the disc and the piece of disc is a little bit like an iceberg. Most of it is out in the canal hitting the nerve, but a little bit of it is in the disc space. It's a great description. So when we take the piece out there's going to be a tear in the back of the disc. And the back of the disc is pretty flimsy and that's why it tends to have an issue especially in this area. So we can't put stitches into it to close the area because they'll tear out. So we need to wait for the back of the disc to scar down and, just like when somebody has a pretty bad soft tissue injury, it takes a while for it to scar and heal. Usually that timeline is six weeks. So in six weeks, just as with a scar, it's healed and the body is done with the healing process and it's not going to make it any stronger. So we usually have restrictions in place for that six weeks to prevent another piece of disc coming out while the disc is healing. And the restrictions are no heavy lifting and usually we use gallon of milk as a guide, which is around eight pounds no bending, no twisting, which, as we talked about earlier, are the movements that are putting the most pressure on the disc. And more often than not people will tell me I'm having trouble keeping these restrictions because I feel so much better. So it's not really the recovery process, it's us putting the restrictions on them to keep another disc from herniating.

Paul Bagi, MD, FAAOS: 52:27

So now the technique that we're using, which really solves both of these issues how invasive is this, and the restrictions is endoscopic spine surgery. So what is endoscopic spine surgery? It's a little bit like arthroscopic for different joints, like the shoulder, the hip, the ankle, the knee, or like laparoscopic for abdominal and pelvic procedures. So we can make an even smaller incision, in this case usually seven millimeters, because that's the size of the camera. We could put the camera down into the spine and the camera lets us see everything we need to see without making a larger incision. Then, using that, we can take out the piece of disc through the same cannula that the camera is in, and so the incision stays seven millimeters.

Paul Bagi, MD, FAAOS: 53:18

We're able to remove the disc very minimal disruption of tissue. We don't have to dilate anything because the camera is what we're using to see. And more often than not the restrictions are only for a few days while someone's recovering, and then they can go back to full activities, back to work, back to sports, back to recreational activities, without having those six weeks of restrictions. And the reason for that is even when we're working on the disc space to get out the piece, we usually have to make the disc tear a little bit bigger with traditional approaches to get the piece out. But with the camera we can actually put that, sometimes even into the disc space and then use small micro instruments to tease out the piece of disc without making the tear in the back any bigger. So that's where the advantages come in. Now, in some patients, the tear can be huge already, and so they may need restrictions, no matter what we do. So of course, those are a case by case basis, but more often than not we can do this.

Robert A. Kayal, MD, FAAOS: 54:29

That's incredible. I mean. Well, I'm a little upset because we were supposed to start talking about that section of this podcast. Dr Aiden was going to give us a drum roll before we started talking about endoscopic surgery.

Robert A. Kayal, MD, FAAOS: 54:43

Anyway, you beat me to it. But yeah, we are so excited, so excited to pioneer endoscopic spine surgery at the Cato Orthopedic Center with both Dr Boggy and Dr Denizo. The analogy I can give, I guess, is very much akin to the evolution of meniscus surgery in the knee Years ago. Before I started, 25 years ago, and even before that, the common condition called the medial meniscus tear, for instance, or the lateral meniscus tear, would be treated through an open incision. An incision would be made about this long in the front of the knee. It would be an open procedure. We'd work our way down into the knee and then subsequently take a smiley knife and essentially enucleate the entire meniscus out of the knee through an open procedure.

Robert A. Kayal, MD, FAAOS: 55:41

Over the years there has been an evolution of meniscus surgery with the advent of arthroscopic surgery, where we now make puncture sites very much akin to what Dr Boggy is describing in the spine. Now it's essentially sports medicine of the spine. We're doing arthroscopic surgery of the spine. We call that endoscopic because we're not going into a joint, we're going into a space. Essentially it's a sports medicine procedure on the spine, just like arthroscopic surgery is so, so common now and so successful in the area of shoulder, ankle, elbow, hip, knee. They have now pioneered endoscopic surgery of the spine, which is actually incredible. It's unbelievable what can be done now through the endoscope. We're just so proud to have Dr Boggy and Dr Denizo at the Kale Orthopedic Center to help pioneer this unbelievably successful cutting edge advancement in the area of spine surgery.

Robert A. Kayal, MD, FAAOS: 56:50

Thank you for bringing that expertise and offering those minimally invasive techniques to our patients. At the Kale Orthopedic Center we're always working in earnest, year after year to try to train ourselves in the latest and greatest technologies. We never practice on patients. We always go to labs and spend hours and hours and hours first operating on the cadavers that have been so generous, giving back to society, allowing us to operate on them and their bodies, to learn these techniques and technologies. We're very thankful to the vendors that offer these technologies and allow us to train on the cadavers at their labs. We're just so appreciative of that because it allows us to offer our patients the latest and greatest cutting edge techniques. That's what we've always been proud of at the Kale Orthopedic Center. That's what we feel our patients deserve. Is there anything else you'd like to add, dr Aiden, to this? I know you're very familiar with these endoscopic approaches because you've always done things in a minimally invasive manner. Where do you see the endoscope potentially working in your area of expertise as an interventional pain management specialist?

Dr. Steve Aydin: 58:13

There's a lot of crossover between the specialties. Now, as aggressive as you want to be as an interventionalist, you can get into a very similar approach to doing treatments that Dr Boggi and Dr Denizo or other spine surgeons are doing For me. I think interventional pain really has its own space to stay in. We're not true surgeons in the sense that I can go in there and operate, god forbid something goes wrong. As an interventionalist, I have to know my limitations. I have to know how to manage complications for things that I do, whereas if I do something and the complication occurs within the spinal cord, I need to call Dr Boggi or have Dr Boggi as the second backup for a complication that could happen. Where I'm cavalier in the sense that I want to learn everything and be able to do everything, I also know there are limitations on what I can do within my expertise to providing optimal care for patients. It's sort of a great doctor. I've certainly pushed the envelope with many procedures like minimally invasive lumbar decompressions are a mild or interspinous space or implants, but again, I'm never really entering the spinal canal, not getting to the nerve where Dr Boggi and Dr Denizo are actually inside, near the nerve, near the vascular supply of the nerve where you could potentially compromise or even interrupt and cause an infection inside the spinal canal. Those are things that we all need to think about when we're approaching these things.

Dr. Steve Aydin: 59:55

I did have some questions for Dr Boggi about the endoscopic. You mentioned the microdyskectomies and there is such a high rate of reherniation with that. Has there been a lot of literature that looks at the difference between endoscopic and microdisc for reherniation? Because, like we talked about earlier, patients just want to be fixed. They don't want to worry about. Can this happen to me again? But I know with microdisc that's a conversation that we often have you got to really watch it for six weeks because there's still a hole in the back of your disc. No matter how much glue we put there, it can still leak out.

Paul Bagi, MD, FAAOS: 1:00:35

That's a great question. So there's two timelines to look at here. So there's the short timeline of reherniation and then a longer timeline of months to years. So the research actually shows that the immediate or short-term reherniation rates are lower with endoscopic A little bit of the reason is what we talked about before not having to extend the tear in the back of the disc to get out the piece, less disruption of the structures around the spine that help support it and protect the disc.

Paul Bagi, MD, FAAOS: 1:01:10

But when you look at long-term rates of reherniation they're more similar, and the reason for that is once there's a herniation there's injury to the disc and, as we talked about, with the blood supply to the disc, the blood supply is poor and so the disc is not great at healing itself. And disc is made up of collagen and once that collagen is injured it's not able to provide that same support or that cushion that a normal disc does, and so over time additional pieces can break off and reherniate. Notice that back of the disc is always a weak point and even if the scar is small versus large, over time that becomes less of a differentiating factor. But still, the fact that there are less reherniations in the beginning is very important, Because that's actually when it can be the most limiting, Because now someone has just gone through this episode of being in extreme pain, missing work, missing activities, and they are finally getting back to it and it happens again, and that's something we definitely want to avoid.

Robert A. Kayal, MD, FAAOS: 1:02:18

Right. Well, I think this has been an awesome podcast. I appreciate having both of you. It's been a great panel. I think it's important to take home really here is if our patients are suffering from back pain, don't ignore it. We want you to come in, get assessed, because it's certainly much easier for us as healthcare providers to take care of you and avoid potentially surgery or even interventional pain management procedures the sooner we see you. It can be a lifestyle modification. It could be abnormal posture, it could be excessive weight, it could be that you need some strengthening exercises and physical therapy to restore that lumbar lordotic posture that we described, and we can certainly potentially prevent further injury or herniation of your disc and nerve compression. So would you all agree that that's probably the take home here that they should see us sooner than later so we can assess them, find out the etiology of their problem, get appropriate imaging, find out the severity of the problem and maybe be able to prevent even having to see you guys for any type of surgical or interventional management.

Paul Bagi, MD, FAAOS: 1:03:30

Anyway, if there's any question in anyone's mind about what's going on, are my symptoms not bad enough that I need to be seen? That's never the case. Come and see us and we can help you make that determination and point you in the right direction.

Dr. Steve Aydin: 1:03:49

Yeah, totally agree. I think the longer something hangs around, it becomes harder for us to treat and at the end of the day, our goal is to treat and get you better with the easiest things. And I tell patients all the time I'm not here to do the procedure, I'm just here to recommend it and if you need it, we will offer it to you. But, as we mentioned earlier, there's a gamut of conservative options that can be offered that can get you to a place of significant recovery where, if you're not pursuing those things, you don't know. And then you may get to a point where you get to a head and you're like now I'm stuck and now we have to be much more aggressive where we may have been much more preventative.

Paul Bagi, MD, FAAOS: 1:04:34

Amen Well, dr Aiden it was a pleasure having you back.

Robert A. Kayal, MD, FAAOS: 1:04:39

Dr Boggi, thank you so much. Viewing audience, listening audience. We appreciate your time. We hope that you find this helpful and again, if you have any issues, we're happy to see you Take care.