good evening and welcome to doctors on call I'm Dr Peter nalen professor and head of the Department of Family Medicine and biobehavioral health an associate Dean for Rural medicine at the University of Minnesota Medical School Duluth campus I am your host for our program tonight on upper extremity neck and back problems the success of this program is very dependent on you the viewer so please call in your questions or email them to ask wdsc.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Chris Davies a pain management specialist with the pain clinic of Lake Superior Dr Matthew Davies a neurosurgeon with Orthopedic Associates of Duluth and Dr Sandy Stover a family medicine physician and faculty member at the University of Minnesota Medical School Duluth our medical students answering the phones tonight are Kayla Agnes from Alexandria Minnesota Caitlin henningsen from Hermantown Minnesota and Logan hooker of Sandstone Minnesota and now on to tonight's program on upper extremity neck and back problems and the first question is for Dr Stover how is a shoulder dislocation treated well I've shoulder dislocation needs a treatment right away to get the the ball of the of the joint back into its socket but the process of dislocation will often injure some of the ligaments and muscles around that area and so the first step is is letting it heal and then physical therapy to get get the tone back in sometimes surgery is needed if the tears in the soft tissue have been more disruptive and it needs to be rebalanced so it can take a while the shoulders are I could be slow to heal Dr Chris Davies how does a neck problem cause pain beyond the neck that's a really great question and we get that from a lot of our patients and the neck is composed of many important structures the the cervical spine which is a primary area of focus for me has a series of Bones and ligaments and most importantly nerves and it's those nerves that can cause pain to radiate beyond the neck itself and down into the arms predominantly okay thank you and Dr Matthew Davies what Imaging usually precedes your neck or back surgeries that's an excellent question it's very common for patients to have both X-rays and MRIs of their neck prior to surgery x-rays are good at looking at the Bony structures and MRIs they're good at looking at soft tissue such as discs or nerves thank you Dr Stover how would you initially evaluate a Tremor or shaking in one hand and that's kind of kind of like question because sometimes that shaking can come from nerves that are getting a sort of a mismessage to the hand for a number of different diseases Parkinson's disease being one sometimes Tremor is a natural sort of process of the Aging in the tissue that you can also have you know issues of the muscle weakness that can cause Tremor when you're trying to do something so the first step is just looking to see is it more muscle or nerve by testing both of them through a physical exam and things like a electromyelogram that looks at muscle innervation or how the nerves feed the muscles will make them strong so it's a little bit of a complex one and if people have a one-sided Tremor it's really a good well a Tremor on either side or both should be checked out by their doctor to make sure that what's going on is something that that can be helped or there's ways of sort of accommodating so that it doesn't bother terminals can sometimes cause problems when you want to write or bring in a cup of of tea to the to your mouth and so it's there's a number of things that can be done for them thank you and next a surgical question how do you safeguard that surgery is performed on the correct side of the body so prior to every surgery we Mark our patients whether it's on directly on their skin or on a marking sheet depending on where we're doing surgery this is double check throughout the pre-operative process by many people including the operative nurses myself and other staff that's in the room okay thank you Dr Chris Davies perhaps this one for you does cracking your neck or back cause further damage or pain or is it beneficial oh that's a really great question as well and it's it's an old wives tale where you crack your knuckles and it leads to further arthritis the same thing can happen in the neck where the actual cracking sound is typically just the fluid in the joint moving throughout the joint space itself and does not necessarily cause damage or further damage if there's underlying damage already okay thank you for that another question Dr Stover why does side sleeping cause neck pain um well that's actually kind of interesting if you think about the Dynamics of what happens when you lay down in bed whether it's on your side or your back it's the alignment of your neck in a in a more straight line which is sort of the neutral place for your body for your body to lay so it may be more related to the angle of the pillow or the angle of the softness or hardness of the bed that's changing and making things uneven and then stressors happen you get some muscle cramping and that can be problematic so uh actually get going to a get a bed that works well for your body type and making sure you have a pillow that keeps the head you know in an alignment with the spine is the most weight most likely way to to help keep neck pain from happening from from sleep positions unfortunately sometimes it's just stiffness from being in one position for a while too and that's a hard one is I think I'm the oldest on the group here it's a little harder as we get older because of some of our natural stiffness can wake us up in that night too just from not having moved for a while is it that some pillows are too large or too thin in the the angle of the the head to the shoulder and this very Body by Body um too often if we're at a at an angle when we're sleeping because the pillow is too too un um doesn't take up enough space or to bent over the other side because it's too big a pillow is is the problem so it's about the alignment of the neck if you think of me instead of being vertical if I was horizontal this alignment is the is the most neutral and best alignment for the pressures of the muscles and ligaments that makes sense yeah um Dr Matthew Davies what determines the approach to surgery from the front or the back so the approach is dependent on the type of problem that you're having and what location in the spine that problem comes from so surgically surgeries approach from the front are typically from the disc space as the disc itself is more in the front part of the spine surgeries approach from the back often have to do with the joints which are more in the back part of the spine or muscles or ligaments that are back there often related to trauma okay thank you Dr Chris Davies what are one or two new developments in the pain management procedures another great question and it's something I discussed with my patients on a regular basis that we're always looking for new and Innovative therapies there are some tried and true therapies for neck pain and when patients get to me it's typically because they need some sort of intervention as an Interventional pain specialist I focus predominantly on injections on injections but do a variety of other procedures as well one of the more novel approaches to treating neck pain specifically from arthritis is something called a radio frequency ablation where we use heat to essentially destroy the nerves that provide the sensation to the facet joints in the neck which can cause pain relief or alleviate pain for anywhere from 6 to 18 months if you look at at Mayo Clinic literature when you're speaking of injections what are one or two or three of the most frequently injected compounds or medications that you're actually injecting yeah absolutely so if you look at traditional pain management it's frequently a combination of a local anesthetic numbing medicine and a steroid such as cortisone or a similar compound there's newer developments coming out about this whole field of regenerative medicine where we're actually using our body's tissues to heal itself that would be something known as platelet-rich plasma or even stem cells where we Harvest them from the body process them and then inject them into damaged areas fascinating Dr Stover a caller wants to know can neck pain or neck injury cause vertigo um that's an interesting one so the our balance and what the perception of vertigo is having like the room spinning around you is the probably the most common designation and the place in our body where that kind of sensation comes from is really more in the inner ear area so in terms of neck issues you actually can have a small kind of stroke in the back of the head which is at the top of the neck that can cause vertigo but but that's really a vascular issue so the neck does not have as much role to play directly in how we sense balance although with bad balance in our back you know it can make it easier for us to feel unsteady does that make sense but vertical of spinning is really more of coming from the brain and from the inner ear and how it it's being interpreted by the brain Dr Matthew Davies how do you approach a patient who's already had a surgery in the part of the body where you're proposing to offer surgery again so there's a bunch of different ways to approach that problem first would be if possible to look at what their preoperative problem was prior to their original surgery helps to kind of gather the thought process that went into their original surgery and then updated Imaging is very important whether that be a new MRI X-ray or frequently we use CT scans to look at the bones in more detail in those situations especially if it was a prior fusion surgery that had taken place to make sure the original surgery had healed properly and how best to approach a new surgery to help patients understand how do you usually explain that you are a neurosurgeon and the group name has the word Orthopedics in it does that question come up yeah that that comes up quite frequently there's a lot of given play in Orthopedics and neurosurgery so there's two different approaches to becoming a spine surgeon one is traditionally through Neurosurgical training Neurosurgical training is both brain and spine surgery Orthopedic surgical training is joints and then a fellowship after graduation in spine surgery and so there's a little Nuance to it but we all kind of practice within the same Realm thank you for explaining that um here's one from a caller what could be causing a sharp pain that shoots up from the back of the neck to the occipital bone over the head and to the eye what could be causing such a sharp pain yeah there's a phenomenon known as occipital neuralgia there's a bundle of nerves that runs along the back of the head in what they call the occipital Ridge and then traverses over the the top of the skull and into the forehead actually causing a very similar constellation of symptoms that you were just describing so in occipital neuralgia and there's a variety of different treatments for that sometimes you would start off with medications and frequently you would see that in patients that have had a prior trauma to the back of the head again fascinating a caller is been diagnosed with a bone cancer and wondering how or what to expect for radiation to the neck I can do my best at explaining that so bone cancer is a pretty big term and so if they've been offered radiation already um I'm sorry to hear that first off and radiation is often an upfront treatment for that there's a lot of different approaches to radiate radiation therapy whether it's proton beam therapy for particular types if they're for particular types of bone tumors or more focused radiation called gamma knife radiation can be used as well but often it is a multidisciplinary approach so people that have cancer within the bone of the spine often are going to be managed with oncology team and often a surgical team in tandem in case surgery is needed as well great and this next caller wants to know can a stenosis of the vertebrae cause tremors from the brain specifically originating at the thalamus the artery that would be affected in the neck would more frequently be the vertebral artery it's an artery that supplies brain to the back part of the the brain specifically the brain stem and the cerebellum not so much the thalamus it's just a little bit further forward in the brain so in theory it could happen but there's also carotid arteries that live in the neck as well which is really outside of the spine but within the neck structures and the Carotid artery supplies broad blood to the front part of the brain so if there's narrowing in that region it could affect the thalamus thank you Dr Stover some patients wonder whether they have carpal tunnel how do you approach that evaluation well the carpal tunnel is is actually kind of at an area right in here where the the body has sort of protected all the tendons and ligaments and blood vessels and nerves that feed the center part of the hand and so that bundle of sort of it's almost like a little belt that holds it in place and protects it can be sometimes too restrictive so what is in that area which is usually the median part portion of the the nerves and blood vessels can get squished a little bit so that can cause numbness tingling Sometimes some shooting pain or something you know weakness in the hand so the evaluation is first a physical exam to see if there's signs of any trouble and a couple of signs of where those nerves can get stretched and tingle when you tap on the on the on the wrist right over that carpal tunnel and then using an electromyelogram or a way of checking to see if the nerves have a reduced signal going to them can say if the if the compression has been to the point where it's helpful to open that up and so that little belt that's in there can be snipped open and these days used to be I'm feeling old tonight used to be there was a big Z cut and that and for those of my age who remember that that doesn't happen very often anymore it's under under arthroscopy now so very minimal uh minimal incision and that opens it up to let the full use of the nerves and blood vessels that go through that area and so it's important to do that before there's any weak any significant weakness in the hand because you don't want to lose that ability to keep that strength going are there any conditions that might lead a patient to present with it on one side or both sides um anything that creates tightness in there so some people have a predilection if they have arthritis already or if they've had a previous injury that may have left some scar tissue in there repetitive issues can also cause the trouble so anyone who who has something where they're flipping the hand or doing a lot of of up and down sometimes people who do a lot of keyboarding will find that that repetitive constant thing can make it more likely to have swelling develop in that area Dr Chris Davies a caller is unable to lay down flat could this be due to an issue in the neck or the shoulders foreign absolutely yeah that that would require a full history and physical exam to sort out exactly what's going on but yeah there's a variety of different cervical spine neck issues that could prevent you from laying flat typically due to pain so it's more so the pain than than a structural issue but there is significant curvature that can happen of the spine that could also prevent you from laying flat and Dr Matthew Davies how has the post-operative recovery of patients with neck or back surgery improved or speeded up over the years yeah there's been some pretty remarkable changes recently in surgical techniques for the neck and very frequently patients can often expect to go home the same day after surgery these days whereas most surgery on the neck used to be thought to be an inpatient only problem you'd have to spend a day or two or more in the hospital a lot of that has come with the advancements in pain management postoperatively and thanks to people like my brother and being able to help manage the post-operative pain which was often the hardest thing to control and the the main requirement for staying in a hospital there are different types of injections that can be done either before or after surgery that help pain management considerably for the first 24 to 48 hours in which case people can recover in a place like a surgery center and then go home the same day okay good to know what to expect Dr Stover I think your answers have generated some questions about pillows so I'll I'll give you these there's about three questions I think they're related is a water pillow good for neck pain when sleeping on one side what kind of pillow would be recommended and perhaps what type of material would the pillow be made of those are all good questions it's hard to generalize to all body types because you know even if you see us sitting here we have three you know four different neck types here and so what what's what's ideal is to be in a position again where your body has as little strain as possible across that line from your low back all the way up into your neck and so for some people that's going to be something on the along lines of a foam you can kind of see the pillows are built so there's a wider part of the narrower part so your head fits in between those two curves for others that using something like some of the um the kernel pillows that are a little bit more rigid and this is a preference issue more than that anything what feels right to you I wish there was a a way we could give a prescription to people to say this pillow will work for you but I think it's to some extent it's trial and error thinking and with uh having someone else look at how you're laying down but try and again sometimes not it's not just the neck that needs to be supported but sometimes the pillow between the knees so that the pelvis is is light lined up a little more common in women to have that issue than men sometimes when you're laying on your back having a pillow on your knees to flatten the low back and also make it much more comfortable to sleep and again the sometimes this means that you have to try something I will say in our house we have a number of different pillow to shapes that have been tried over time and just when you feel like things are working well your neck or body may change position or your bed may need to be readjusted to have the right Contours to support that position too so it's kind of complicated but I know that we're lucky in time we have some good places that sell bedding that can help allow you to try out a bed and see and help see if that alignment is is a little bit more in that nice horizontal plane sounds like that alignment is yep yep and and again uh visit you about every eight minutes we make a major body motion when we're sleeping and so you can get just right and then fall asleep and your body will have to will you're not even awake as it happens but moving around so sometimes you wake up feeling more stiff because your position has changed into one that may not be a little less um you know ideal Dr Matthew Davies would patients present to you with trigeminal neuralgia and is that a condition that you would treat that is a condition that is treated by neurosurgeons at this point in my career I'm not treating that condition but that condition is often from irritation to a nerve in the face or the side of the face called the trigeminal nerve there are a variety of different reasons that you can have pain related to that one of the most common mechanisms is a blood vessel that irritates the nerve there are a variety of different approaches that can be taken to treating that from medication management to actually going through a needle incision that goes through the side of the mouth and damaging the nerve itself to trade pain more for numbness and then there are more invasive approaches there's a technique called microvascular decompression which goes through an incision in the back of the head a little window is made in the bone and that blood vessel is actually padded away from the nerve which has quite remarkable results most oftenly Pat it away what is that small little piece of foam or a variation of that is placed between the blood vessel and the nerve to keep that pressure and irritation off of the nerve and often can instantaneously relieve the trigeminal pain is it unusual for patients to wonder how they how you actually get through that bone they often ask that question and we won't get into the graphic detail this evening because I don't think most people want to hear it but there are plenty of videos online if people want to look all right Dr Matthew Davies what treatment would be best or recommended for a fracture in the vertebrate due to osteoporosis so that that again kind of comes to one of the original questions we had as to approaches to surgery so fracture in the in the spine can be in the body of the bone itself which is again near the disc in the front or you can fracture the spine in the back which either is called the lamina or the spinous process area and the back part which can be fractured as well and so the the treatment approach is based off of where that fracture is located okay thank you the next question is about suspicious nodes in the neck and someone getting an MRI what are potential diagnoses anyone want to take that one um and that's a good question so when we use the word nodes we're usually referring to lymph nodes and if there can the word node can sometimes refer to other swellings that are coming from other tissue that's growing where it probably shouldn't be growing and so the the you had mentioned earlier with MRIs they look great at soft tissue and using an MRI can help differentiate the kind of density of tissue you might have in a regular normal healthy lymph node one that's a little inflamed because you've got an infection or one where there's something growing in it which could be more along a concerned of a cancer they even are fatty nodes that show up in our neck sometimes called lipomas so the nice part about having an MRI is it can really help differentiate and also localize it so it can have a biopsy done of that area making sure it's an easily accessed kind of an area in the neck there's a what's that when I was in anatomy we called it the high rent district in the neck because the there's a little bit of close Neighbors in there in terms of important structures of nerves some of the major blood vessels and and so important breathing apparatus in there so you want to know the anatomy really well before you enter in in a biopsy or obviously in surgery you guys have a well mapped before you you go anywhere near anything there I'm sure thank you and briefly are there new or developing treatments for migraine there are yeah they're migraines are predominantly managed with medications and typically managed by a neurologist I do have a little bit of exposure to patients with headaches and it's really important to narrow down the specific type of headaches there's there's three or four basic types of headaches but if you really dig a Little Deeper there's 50 to 100 different types of headaches if not more in terms of migraine specifically some people start with over-the-counter anti-inflammatories there's a two different classes of medications for migraines as well there's either a preventative or what they call an abortive where the migraine has already come on and we need to nip this in the bud okay and quite briefly I think we have time for one more question color and counter scoliosis for 14 years with the spine continue to move out of alignment or will it stop at a certain point so similar to the headache question there are a variety of different types of scoliosis whether it's adolescent or as one category in another category we call degenerative the Adolescent scoliosis often arrests and once they're skeletal maturity or if it's been treated prior to that whereas the degenerative type is something that unfortunately is a lifelong process as the elements of the spine change the scoliosis change over time thank you well I want to thank our panelists Dr Chris Davies Dr Matthew Davies and Dr Sandy Stover and our medical student volunteers Kayla Agnes Caitlin henningsen and Logan hooker please join Dr Mary Owen next week for a program on heart problems and high blood pressure when her panelists will be Dr Catherine benziger Dr Mark Earhart and Dr Addie Vittorio thank you for watching good night thank you