good evening and welcome to doctors on call i'm dr peter nalen professor and department head of family medicine and biobehavioral health associate dean for rural medicine and co-leader of the duluth campus of the university of minnesota medical school 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 at wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include dr matthew davies a neurosurgeon with orthopedic associates of duluth and dr christina reed a pain medicine specialist with essentia's newly developed spine care program our medical students answering the phones tonight are bailey gifford of big lake minnesota and holly olsen from cameron wisconsin and now on to tonight's program on upper extremity neck and back problems dr reed welcome to duluth we'd like to hear a little about your practice and the range of ages that you care for i'm new to essentia and our practice includes ages really probably seven or eight years old on up i think my oldest patient is 102. and we focus on pain management with a multi-disciplinary and multi-factor approach starting with conservative management when possible but making sure that patients get an adequate workup and diagnosis to get the appropriate level of care as soon as possible thank you and dr davies welcome back to duluth you're from here man thank you terrific tell us about your practice and the age of patients that you care for first off thank you for the opportunity to be here it's a pleasure being on the stage with both of you so thank you again my practice is spine focused at the orthopedic associates clinic here in duluth the age range is somewhere between 15 and 99 so pretty much all ages similar to dr reed's practice and it's all encompassing with spine care from cervical thoracic and lumbar spine terrific well let's get on with our questions dr reed what are the top two or three referral paths into your practice i think most of my patients right now are coming from primary care which is is great because a lot of good quality primary care and management has done prior to seeing me so that we can get patients who are really appropriate for the next level the new spine care program has also opened up the door to direct referrals directly from patients and a lot of physical therapists are referring as well we're trying to do that to improve access a little bit and the second would definitely be the more urgent care and emergency room physicians thank you and dr davies how about for you similarly referrals from primary care physicians are probably number one close second to that would be self-patient referrals directly to our office and then sub-specialty referrals such as from dr reed and other physicians in town would be the third and in your practice what might a patient expect for evaluation at a first visit so with the first visit with me what they should expect beforehand is that i spend a pretty lengthy amount of time going over their medical history and their imaging prior to their consultation so we typically get a chance to launch in right into the reason that they're with me and so it usually starts predominantly with listening to their story their their problem that led them to seeking my care to begin with followed by a physical exam and then some discussion about surgical treatment and other modalities that would be useful to helping their pain very good and dr reed how about for you describe a first visit evaluation of a typical patient for you very similar that a really thorough look has been done through their chart sometimes even discussions with other people who've been in contact with them their physical therapist is often a good source for me because they've had a lot of one-on-one time but going through their previous imaging also modalities that maybe have tried and failed things that they've really worked on and and have gotten them to the point where they're seeking a higher level of care then history is really important listening to what the patient is telling you um doing not just an evaluation of where their pain is but how they're how they're functioning sometimes a good barometer of how someone's really doing has more to do with what they're able to do and not able to do really than where they're rating their pain on a level of 10 but then doing a good physical exam and then making a plan together with the patient one that they're comfortable with and outlying all the options letting them choose what's most comfortable but making my recommendations you know so that they know where i think the priorities are wonderful dr davies what are symptoms in the arm that would lead you to evaluate the patient's neck that's a very good question there's a lot of overlay between neck problems and arm problems so radiating pain that starts in the neck and goes down into the arm would be a classic sign for some sort of nerve impingement in the neck and the other one that's more acute and something to think about is if you're losing what we say function in the hand so your hands are becoming numb tingling and classically we like to talk about function like dr reed spoke about specifically are you able to do those fine motor tasks that you used to be able to do so easily such as buttoning buttons opening jars those are the type of symptoms that we kind of look for and doctor a patient is working more from home during covid and notices an overall increase in neck and back pain what could be some recommendations to help such a patient well after screening initially quickly to make sure there's nothing that's a red flag or that's worrisome we're getting a lot of this lately people are spending a lot more time at their desk a lot more time in their computers and common things being common postural issues are really bothering people at least in a lot of work situations there's proper ergonomic worksite evaluation big companies look at that in order to try to decrease you know injuries in the workplace but when somebody's home and they're sitting on the floor and they've got kids running around that stuff goes right out the window so we're really trying to encourage people to set up a proper workstation think about posture do the lifestyle stuff not spend too much time sitting alternate between sitting and standing and seeing if those kind of things can solve their problem great thank you dr davies what about a crick in the neck how do we explain that to patients who complain about that so it's pretty common to hear sounds or feel cricks in your neck most likely and in general that's usually from some form of arthritis in the neck arthritis like other joints if you can remember popping your fingers or cricking in your fingers is just fluid moving around inside of a joint which is pretty common to have happen in the neck which is made up of a series of joints okay and dr reed a patient asks should they use ice or heat for lower back pain it's a really good question when we get a lot there there's no real solid evidence-based answer for that but my rule of thumb for patients is kind of this if you are if you can use the word pain i'm in pain this is hurting me i say start with ice um you know that's a good pain reliever if you're using words like i'm sore i'm stiff i'm uncomfortable heat is probably a good place to start very good and doctor what would be an indication for fusing two vertebrae and what are some materials that are used so the classic reason for fusing is something called instability or abnormal motion within the spine there are several different ways to go about doing fusions there's surgeries that can be done from both the front the back of the neck or a combination of the two the most commonly used substance and fusion surgery would be made out of titanium or some variant of that and then there are different bone products that are used that are often from cadavers and can you elaborate just a little on the approach from the front or the back of the neck what did you mean by that so fusion surgeries can be done again as either from the front or the back going from the front allows direct access to the front part of the spine or the bone the vertebral body and the disc space that's in there that allows access and ability to have removal of the disk space and to cause a fusion from the front an approach from the back involves moving the muscles away from the spine and then if it's a fusion would involve screws and rods to fixate things in place dr reed another question about referred pain what is an example of referred pain that you evaluate and how do you approach it so referred pain just generally means any pain that starts in one location and then can spread and there can be lots of reasons for that that can come from strictly a nerve or that can come from a joint that has a referral pattern we look at those referral patterns to help us make diagnoses but it is really common in our fields both of ours that the where the patient feels the pain is often not at all where it's originating and that can be a source of frustration for patients one of the most common things i think we both hear is my hip hurts um and often times patients are worked up by say orthopedics for hip pain when in reality that pain is stemming from the lower spine um or from the s.i joint or some other location so uh it can be difficult to find the source and that can take up a lot of time and a lot of energy but it's worthwhile if you can get to what the originator is thank you dr a patient asks about heavy lifting and what about after surgery how do you advise patients about lifting and for what period of time my lifting restrictions for after surgery typically are limited to 10 pounds which i say is about a gallon of milk and then in terms of bending and twisting we try to eliminate or limit those motions as much as possible for a minimum of two weeks after surgery this is specific to the type of surgery the patient had done but in general two weeks is the building block where we start increasing lifting twisting and the weight back into their movements again thank you dr reed a patient asks about dry needling and how that might be used what is that dry needling is a technique oftentimes used by physical therapists in order to you actually insert a needle into a muscle um repeatedly it can dry needling you don't inject anything that can actually cause a little bit of bleeding and a little bit of inflammation the theory behind that is that it can then sort of draw the body to a sort of healing process to a chronically inflamed or a chronically sore muscle group and can aid in other modalities of care for for softening up muscle tissue thank you and doctor what about cortisone injections for previous vertebral breaks or pelvic brakes any role for that cortisone injections are typically assigned for helping pain control there are different elements that can be injected into fractures such as a vertebral body or pelvic fractures there's procedures called kyphoplasties or vertebroplasties where a type of bone cement is actually used to help fixate a fracture okay dr reed how has the role of muscle relaxants changed in the treatment of pain that's a complex question oftentimes muscle pain or muscle guarding can be a good thing the body's own way of splinting and underlying problems say a patient gets a herniated disc one of the things that will often drive them to the emergency room or to seek treatment is the unrelenting muscle spasm that they feel if that can can actually aid in in the process to a certain extent but if it becomes overwhelming muscle relaxants can be used to treat some of that muscle spasm but that's a delicate balance but muscle relaxants will only treat muscle-based pain so oftentimes if say somebody has nerve pain or fracture pain or other types of pain they're not as useful and a follow-up question for you for patients with severe back pain who are told they are no longer surgical candidates what are some other treatments that could be considered that's a common situation sometimes surgery is just not an option for a variety of reasons there are many many options um starting on the conservative end even such things as you know meditation biofeedback pain relieving yoga pilates physical therapy topical agents moving up the ladder to medication management and all the types of medication management we can use for those patients then there are interventional procedures or spine procedures where we can do a variety of things they're not just cortisone injections anymore there are ways that we can treat the nerves that innervate joints or we can target discs directly or parts of the spine directly we we talked about kyphoplasty and vertebroplasty for patients who who are not surgical candidates that's often an answer for vertebral fractures so there there is a litany of things that can be done for chronic pain um and that's that's a role for my specialty and one when surgery just is not an option sounds like there's there are options to be concerned for sure yeah yeah dr davies a patient asks about leg tingling and numbness in the feet could there be a spine explanation yes definitely that could be from the spine similar to the similar symptoms we discussed up in the upper extremity or the arm the leg follows a similar pattern when there's nerve impingement and so tingling weakness numbness those sensations could be generating from the spine as well thank you dr reed a patient has felt a pinched nerve in the neck with tingling painfully for weeks how might this be evaluated and treated well you know we follow a pretty similar pattern when patients come in we want to review what's what's been done if there's imaging review that listen to the patient's story examine them neurologically especially and once we determine what we think the root cause of that is and then determine a treatment plan but the key is really is doing that history the physical exam and looking at what what's been done so far so important to look at all of those things not one is more important than the other what are some examples of some same-day treatments that patients might undergo that don't involve perhaps staying overnight for observation well there are there are things we can do right away in the office such as provide medication management um there are same-day type cortisone injection treatments that can be done right in the office there are procedures that take a special procedure room where we have a camera that helps guide us and sometimes those are done the same day depending on how acute the patient is so those are some of the initial things thank you dr davies a patient has a question about cis in this case tarlov cis can they always be asymptomatic a patient has some symptoms what might be going on so tarlov cysts they're called neuroenteric cysts they're thought to be enlargements of a nerve root sleeve very commonly seen down in the sacrum or the lower part of the lumbar spine these cysts are often thought to be congenital in nature meaning you were born with them and frequently thought to be asymptomatic like the caller has said they can cause symptoms predominantly if they get large enough to cause erosion or irritation of the bone the outer covering of the bone has sensory fibers in it and can be painful and that would be one example as to how they can cause symptoms thank you dr reed a viewer in cloquet asks for patients who sleep in a recliner due to back pain should they be trying to lie flat at night or not lots of people sleep in recliners so don't feel like you're alone listener and the answer is that people should try to maintain a position of comfort so that they can get good sleep ideally if we can do things to try to get them back into their bed that's perfect but there are conditions where the spine is no longer going to assume a flat position and trying to force it there is not good there are some better options than recliners sometimes if certain beds can be utilized but a lot of patients use recliners because they work thank you dr davies can you compare and contrast orthopedic surgery with neurosurgery and how the approaches might be different a viewer asks it's a very interesting question i think this comes up very frequently so i can speak mostly to my training because of neurosurgery but orthopedic spine surgery is very similar the approaches can be there's a lot of crossover between the two of them it's hard to really pinpoint an ortho versus neuro it's more of a practitioner's kind of development over time the way that we were trained where we were trained makes a big influence as to the approaches that we take to different surgeries there has thankfully been a lot more collaboration between neurosurgery and orthopedic surgery as seen in my practice being a neurosurgeon in a predominantly orthopedic group which has been great it allows for us to have conversations back and forth about the best way of taking care of patients very interesting thank you dr reed what about the role of acupuncture and is it offered in the duluth area acupuncture is interesting because there is really good medical evidence for pain good pain control with acupuncture the interesting thing is we don't know exactly how it works so we can't we can't ignore 3000 years of evidence and it's something that i utilize in my practice we do have some excellent acupuncture practice practitioners in duluth right now you'd have to use google but um but there are some really great people who provide adjunctive care for us all the time great dr davies does your evaluation and treatments include pregnant women for example with lower back pain so i would be willing to evaluate pregnant women i have not in my practice thus to this point but the most common symptom that women who are pregnant experience is s-i joint pain it's very common for when the fetus is enlarging or the baby's getting bigger and the pelvis everything moves a little bit and one of the joints that typically gets the brunt of that stress is called the si joint or the sacroiliac joint thankfully most of which will improve on its own with time after delivery dr reed can you tell us about your practices and perhaps pregnant women with low back pain and that's something i could speak about for a long time but i will keep it brief i just moved from utah and there are a lot of pregnant people there we had a specialty clinic specifically for pregnant spine patients dr davies was right a lot of si joint dysfunction but the other the flip side of that coin is that pregnant people also get organic spine disease they get disc herniations they get other things that they would normally get if they were not pregnant um and we have to be careful because we do have to change how we treat them medication management is different how treating the fetus in concert with the mother is is important things like therapy are more successful when we can unweight the pelvis such as pool therapy and water walking there are our physical therapists who are trained specifically to treat pregnant or women in pregnancy an additional problem that we see especially after having more than one baby is the front side of the pelvis called the pubic symphysis where that comes together can certainly cause a lot of discomfort if it's moving around and we can do cortisone injections both into the si joints and the pubic symphysis while people are pregnant safely we can use ultrasound guidance and even fluoroscopic guidance depending on how how far along they are but there are lots of good modalities of care for pregnant women you know with the help and guidance of their ob gyns it's a good collaborative effort in our practice terrific and dr davies can you give our viewers an example of an operation that would usually be less than an hour and one that would normally take more than an hour okay in terms of the neck or the cervical spine one that would take under an hour would be what we would say single level one disc space either a disc replacement or a single level fusion takes roughly under an hour in the low back that would be similar to a laminectomy or a decompression surgery in the low back in terms of beyond an hour the more complex the problem is the longer the surgery is going to take there are some quite lofty undertakings that can be had in both the neck and the low back a lot of which involve collaborative effort with general surgeons if you're accessing the front of the low back or the lumbar spine those surgeries can take quite some time great and dr reed in terms of follow-up care what are you usually recommending to patients in terms of return visits for common conditions our common practice is if there is mostly conservative management medication management physical therapy something that's not invasive folks usually come back and see us about four to six weeks later so we can assess how things have been going functionally and pain wise is the patient doing better if there's been some sort of intervention injections or procedures that we've done two weeks we have them come back with you know post-procedure calls and follow-ups but in person in a couple of weeks so that we can assess what we've done and what the next steps need to be thank you dr davies uh a maybe a brief question what are some simple advice for patients for keeping their operative sites clean and dry after surgery in the days and weeks that follow so every surgeon closes their wound in a different way i use a waterproof dressing that essentially is sterile super glue and that gives patients the benefit of being able to shower immediately the day after surgery and so simple washing with soap and water and patting dry and not putting dressings on top of it is my standard great and dr reed how about in your practice what do you recommend in terms of symptom monitoring or keeping track of how patients are doing well there we have a couple different methods for that um if we're concerned about someone's neurologic progression you know if we've intervened in some way we have to measure are they getting worse are they getting better um you know is their numbness getting worse is their weakness getting worse you know those types of things then we have a fairly tight schedule for when they're going to be followed up by myself or one of our spine care coordinators um and we have nurses that that help me do that but we keep a pretty tight eye especially on patients with neurologic issues wonderful well i thank you both and with that i want to thank our panelists dr matthew davies and dr christina reed and our medical student volunteers bailey gifford and holly olsen please join dr mary owen next week for a program on lung problems copd and asthma when her panelists will be dr andrew keenan and dr paul sanford thank you for watching good night [Music] you