July 20, 2023 • 53 mins
Do you ever find yourself grappling with neck pain that just doesn't seem to go away, or perhaps, unexplained numbness or weakness in your arm? Let us embark on a journey to explore the intricate world of cervical disc herniations, guided by our expert guest, Dr. Michael Dinizo - a seasoned orthopaedic spine surgeon. Drawing on his deep knowledge, we unravel the complexities of the cervical spine and the varied symptoms that cervical disc herniations can present.
Take a deep dive into the realm of advanced cross-sectional medical imaging modalities as we explore how they play a pivotal role in diagnosing and understanding cervical disc herniations. We shed light on how MRI's, CAT scans, and nerve studies can be instrumental in the diagnostic process. Dr. Dinizo, with his wealth of experience, walks us through the process of discerning between a soft and hard disc and the implications this has on treatment plans. Plus, we underscore the importance of reducing inflammation and allowing the patient time to heal.
Finally, we navigate through the pros and cons of cervical spine surgery. We zoom in on the anterior cervical discectomy fusion surgery, discussing the materials used and their role in stabilizing the vertebral bodies. The conversation also covers the significance of maintaining good posture in mitigating neck and lower back pain. So, tune in for an enlightening ride through the nuanced landscape of cervical disc herniations and make informed decisions about managing this common condition. Trust us, your neck will thank you for it!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho Podcast.
Today is July 18, 2023.
And we're so happy to have withus today our very own spine
surgeon, dr Michael Denizzo,orthopedic spine surgeon at the
Kale Orthopedic Center, andtoday's topic is going to be
cervical disc herniations.
Welcome to the podcast, drDenizzo.
Michael R. Dinizo, MD (00:21):
Thank you very much, dr Kale, really
excited.
Robert A. Kayal, MD, FAA (00:23):
Before we get started, why don't you
just tell us a little bit aboutyourself?
Michael R. Dinizo, MD (00:26):
Sure, my first time here in New Jersey
went to undergrad at JohnsHopkins University and from
there I actually did some spinalcord injury research, both at
Johns Hopkins and the Universityof Maryland Shock Trauma Center
.
From there I went to RutgersUniversity for my medical school
, followed by five yearsorthopedic surgery at NYU and
then an additional one yearspine surgery fellowship, also
(00:49):
at NYU.
Wow, impressive credentials.
And how about your family?
All from New Jersey?
My dad is a small businessowner, my brother works with him
, my sister does marketing, andthey're really excited to hear
this podcast Awesome.
Robert A. Kayal, MD, FAAOS (01:04):
Well , we're so happy to have you
with us today to discuss thisvery, very ubiquitous condition
called the cervical discherniation.
Neck pain is such a commonproblem, isn't it?
Michael R. Dinizo, MD (01:14):
It's very common, especially in people
between the 30s and 50s.
It's a very common source ofpeople missing work and also
coming to see us to help treatthem.
Robert A. Kayal, MD, FAAOS (01:25):
Yeah , and that's the anatomy.
Okay, sure, our patients, sothey get an idea of what we're
talking about.
So, dr Denizo, for the benefitof our viewing audience, can you
please tell us what I'm holdingin our hands right now?
Sure.
Michael R. Dinizo, MD (01:39):
We're looking at a full model of the
spine.
You're getting down here.
This is where your pelvis is.
Lumbar spine is down here.
Thoracic spine is in the middle.
But for today's discussion we'regoing to be talking about the
top seven vertebrae, thecervical vertebrae.
You're getting up here at thebase of the skull, down here to
the seventh cervical vertebraewhen we're looking at the front
of the spine.
So from this angle here we'relooking at the front.
(02:00):
These are the vertebral bodies,or the bony structures of the
spine.
In between each one of thosevertebral bodies is the
vertebral disc, which we'regoing to get to in a little bit,
exiting out here these yellowlines.
Those are the nerves thatcontrol the sensation as well as
the strength to your upperextremities.
Now, as we kind of rotatearound the back here, you can
see that there's additionalstructures.
(02:20):
So in the back here, this isthe lamina, the back covering of
the spine.
These are the spinous processesand in here is something called
the pedicle.
This forms the posteriorvertebral arch, which protects
the spinal cord during everydayactivities and allows us to move
and function.
Robert A. Kayal, MD, FAAOS (02:37):
So thank you for that demonstration
of the spinal anatomy, DrDinizo.
Let's talk specifically about acervical disc herniation.
What is actually happening whena cervical disc herniates?
Michael R. Dinizo, MD (02:48):
So what happens when a cervical disc
herniates is part of the innerdisc called the nucleus pulposus
, which acts as a shock absorberfor the spine, gets displaced
posteriorly and compressed onsome of the neural structures.
Robert A. Kayal, MD, FAAOS (02:59):
Okay .
So as far as the intervertebraldisc is concerned, we discussed
that these are soft cushionsbetween the vertebral bodies and
we have them from the neck allthe way down to the lower back
right, correct, these discs areprimarily made up of water right
Water and collagen material.
That's a soft material thatserves as a shock absorber, a
(03:21):
cushion between the hard bonesof our spine, allowing for
motion and load absorption,things like that.
Within the disc itself, it'smade up primarily of an outer
ring of cartilage called theannulus fibrosis, made up of
type 1 collagen.
That material contains thesofter inner gelatinous material
(03:43):
called the nucleus pulposus,which is typically very hydrated
, filled with a lot of water,and it allows for the disc to be
soft and mobile and absorb alot of load.
When discs herniate, very oftenthere's pathology to the outer
ring of tissue called theannulus fibrosis right.
Michael R. Dinizo, MD (04:03):
So what can happen is there can be a
tearing of that outer coveringthe annulus, fibrosis, and that
can lead to the inner material,as you mentioned, the nucleus
pulposus, displacing posteriorlyand potentially causing pain
and neurologic issues to thepatients.
That can happen eitherfollowing acutely, like
following a trauma or a caraccident or a sports injury, or
(04:26):
it can sometimes happen morechronically and it's more
degenerative type of process.
Robert A. Kayal, MD, FAAOS (04:31):
So it's just very similar to what
actually happens in the lumbarspine right, and I'd like to
refer our viewing audience toanother podcast that we've done
with Dr Paul Baghe, when wediscussed lumbar disc
herniations in the lower back insciatica.
So, for the benefit of ourviewing audience, let's
demonstrate to them what acervical disc herniation can
(04:52):
look like now.
Michael R. Dinizo, MD (04:53):
Sure.
So this is a model again of thespine.
So this is first looking at theside here.
So these are the vertebralbodies here and in the middle
here is the disc Turning it overand looking straight down on
the spine here this is theannulus fibrosis that we
mentioned before.
In the middle here is where thenucleus pulposis is, and when
someone has a disc herniationthere's a tearing on the outside
(05:16):
ring of that annulus fibrosisand part of the inner structure.
It's normally a very softshock-absorbing material can
extrude out and press on some ofthe spine, the nervous
structures in the back of thespine.
Robert A. Kayal, MD, FAAOS (05:29):
Okay , great.
Thank you so much for thatdemonstration.
So typically, how will apatient present to the office
when they're complaining ofsymptoms consistent with a
cervical disc herniation?
Michael R. Dinizo, MD (05:40):
So the symptoms can vary.
It can vary anything from badneck pain to arm pain, and
sometimes they can have weaknessor even numbness going down
their arms.
Typically is there traumaassociated with this, so these
can happen in acutely after atrauma or a car accident or any
type of other accident that apatient may have.
(06:03):
So it's very important part ofthe history to figure out.
Is this something that beganvery quickly following an
accident or is it somethingthat's been more slowly
progressing over the lastseveral weeks or months?
Robert A. Kayal, MD, FAAOS (06:14):
And when you see patients with
discurneations, is the paintypically localized in the neck
or around the shoulder girdle inthe trapezius area, going down
the arm, all the above.
How does it typically present?
Michael R. Dinizo, MD (06:27):
So it definitely can be.
All of the above Usually isassociated with neck pain, with
neck pain a lot of times.
Reading towards their shoulderwas sometimes even getting
muscle spasms or pain aroundtheir shoulder Many times.
Often, too, it's associatedwith pain going down one of the
arms, sometimes even withtingling, and sometimes with
some weakness as well.
Robert A. Kayal, MD, FAAOS (06:48):
Yeah , what I found in my own
clinical experience is patientswith cervical disc bulges or
herniations very often will havepain in the area of their
trapezius over here, and it also, if you can turn your body a
little bit, very often they havepain in this area of the
trapezius that we're describing.
They often have a palpable knotthat we can appreciate right
(07:11):
here, and also the pain radiatesvery often to what we call the
periscapular region around theshoulder girdle in the back
there, and a lot of timesthey'll have spasm, tenderness
and what we call a myofascialtrigger point in these areas and
the pain will also very oftenradiate down the arm.
So what determines where thepain goes?
Michael R. Dinizo, MD (07:35):
So when we're looking at that model
before, we saw that there wasthose paired nerves that were
coming off of the spine andthose are numbered from C1 to C8
.
And each one of those differentnerves controls the sensation
in a different part of yourupper extremity, whether it's in
the upper arm or even down tothe hand, and each one of those
different nerves, they innervatea specific muscle.
(07:56):
So it's very important for usto get a very clear picture of
exactly where their pain is andif they're having weakness, what
muscle groups is that weaknessin?
Robert A. Kayal, MD, FAAOS (08:05):
So those nerves are both sensory
and motor nerves, right Correct,so they're mixed nerves.
Yeah, mixed nerves.
They're responsible for a lotof things.
They're responsible forsensation, to what we call the
different dermatomes of the body, so for instance, c3, c4, c5,
c6, c7, c8, they go to differentparts of a patient's upper
(08:27):
extremity, and so when that areais experiencing pain or
numbness and tingling, it givesthe doctor an idea of what nerve
root may be involved.
Those mixed nerves are alsoresponsible, some of them at
least, for reflexes, right, andso we can test patients' upper
extremity reflexes to identifywhether or not their reflexes
(08:48):
are intact or abnormal, and thatwill also give the physician
some feedback about what nervemight be involved.
And then, finally and mostimportantly, these nerve roots
are responsible for innervatingdifferent motor groups that Dr
Denizzo referred to, and whenpatients experience weakness in
those muscle groups, itcertainly is concerning for us
(09:12):
and it suggests that maybe thenerve is not working properly.
Correct, Correct.
Michael R. Dinizo, MD (09:16):
And the reasons that the nerve can be
not functioning correctly can beeither from actual compression,
from the disc herniation, or itcan be from a huge inflammatory
cascade that can happen whenthat nucleus pulpulosis comes
out to an area that it's notnormally supposed to be Right.
Robert A. Kayal, MD, FAAOS (09:32):
So also these patients.
Very often, besides the classicpains that I've demonstrated,
very often one of the telltalesigns that they're suffering
from a cervical disc herniationis when you ask the patients if
they find relief by puttingtheir arm over their head.
Right.
That's very classic.
I found in my years of practicethat when patients put their
(09:53):
arms over their head like thisto alleviate the symptoms, it's
almost pathodendomonic for acervical disc herniation.
Michael R. Dinizo, MD (10:00):
I 100% agree.
And so walk in the room andI'll see the patient sitting in
the chair basically holding thatposition, and they'll say that
that's really the only positionthat they can find any relief of
their pain.
And what the patient's actuallydoing by doing that is they're
taking some of that tension offof that nerve and then relieving
some of their symptoms, right.
Robert A. Kayal, MD, FAAO (10:18):
Right .
It is one of the mostuncomfortable conditions to have
to endure right Sure, first ofall, any nerve pain in general.
But in my experience, cervicaldisc herniations with an acute
cervical radiculopathy we callit is extremely, extremely
uncomfortable for the patients.
Michael R. Dinizo, M (10:37):
Definitely .
You know patients come inseeking help because they can't
sleep at night because of thepain.
It's kind of an unrelentingpain that they have had trouble
on their own trying to relieveand that's why they come to see
us, Right.
Robert A. Kayal, MD, FAAOS (10:50):
So, now that we've discussed the
classic presentation, what doyou do as a physician when
you're performing a physicalexamination to try to determine
if they are indeed sufferingfrom a cervical disc herniation
and, if so, the severity of thatdisc herniation, what disc
might be herniated, et cetera,on physical exam?
Michael R. Dinizo, MD (11:10):
So we first start with the range of
motion of their neck.
So they're having the spasms inthose muscles, like you were
discussing before.
A lot of times you will seelimited range of motion and
they'll actually have that veryspasmatic muscles in their neck.
That's usually the first thingwe start off with.
The most important part of theexam is to do a very thorough
neurological exam.
(11:31):
So what we do is we check allthe muscle groups, we check the
strength, we compare it fromside to side to see if there's
any weakness in any of thosemuscles.
We also do a very detailedsensory exam to see if there's
any areas of their arm wherethey're having any sort of
numbness or altered sensation.
And in addition to that there'sa couple of special tests that
we can do too to almost try toprovoke the symptoms that they
(11:54):
have.
So those are some of the otherthings that we'll do to try to
give us more of a hint exactlywhat's going on with the
patients.
Robert A. Kayal, MD, FAAOS (12:01):
All right, but this is typically a
very classic presentation.
So by the time you take thehistory for the most part even
made the diagnosis right, thephysical examination often just
confirms our suspicion.
So you will be assessing forsensation, you will be assessing
reflexes, you will be assessingmotor strength to make sure
that those physical examinationfindings corroborate with the
(12:23):
patient's subjective complaints.
Once you've identified in yourown mind that more than likely
the patient suffering from anacute cervical discurreation and
nerve compression, or whatpatients like to call a pinched
nerve in their neck, whatobjective findings besides the
physical exam can you doutilizing imaging modalities?
Michael R. Dinizo, MD (12:43):
So we'll normally start first with
getting x-rays.
The x-rays give us a good viewof the overall alignment of the
cervical spine.
First Things that we're lookingfor are the lordosis or the
backwards curvature of the spine.
Sometimes that can bestraightened.
In the case of cervical discherniation, because patients are
having severe muscle spasms.
We can change their alignmentof their spine.
(13:03):
Other things that we look at welook at the vertebral disc
heights, so that can give us anidea of how healthy those discs
are and how hydrated they are.
We can also see somethingcalled osteophytes, which are
like bone spurs that can form inthe spine.
It's something that gives us abetter idea of the overall
health and structure of thespine as well too.
We almost always get flexionextension x-rays, which is
(13:27):
special x-rays with the neck indifferent positions that can
look to see if there's anyabnormal motion or instability
in the spine, which can give usa better idea of exactly what's
the cause of the patient'ssymptoms.
Robert A. Kayal, MD, FAAOS (13:39):
Okay , so in addition to x-rays, are
there any other advancedcross-sectional medical imaging
modalities that we can employ tohelp hone in on the diagnosis?
Michael R. Dinizo, MD (13:49):
There definitely is.
So usually, when we'resuspicious that a patient has a
cervical disc herniation, thenext test that we'll get is an
MRI.
Mris are a special type ofimaging that allows us to see
the disc, allows us to see thenerves, allows us to see if
there is a disc herniation.
We get to see the health of thedisc, whether they're well
(14:09):
hydrated, and the height of thedisc, and allows us to see if
there's anything else going onas well, too, and we think it's
a disc herniation.
It can be something else weweren't necessarily expecting,
so it's a way to get a completepicture of the spine and exactly
what's going on, and certainlyyou're looking to evaluate for
compression on the spinal cord,as well, right, definitely so.
Cervical disc herniation theycan either press on the nerves
(14:31):
themselves or actually on thespinal cord, which is another
topic.
Cervical myelopathy, whichhopefully we get to talk about
in the future.
Robert A. Kayal, MD, FAAOS (14:40):
So the cervical spine is a very
delicate part of our body.
Obviously nerves do not like tobe touched right.
Nerves in general, especiallythe spinal cord, do not
appreciate any compression.
Well, in general, when we'reevaluating the cervical spine on
MRI, we don't really want tosee anything compressing the
spinal cord.
(15:00):
If there's any compression itcertainly can be concerning for
us and we'll evaluate thatfurther with the patient.
So are there any indicationsfor the usage of CAT scan in the
cervical spine?
Michael R. Dinizo, MD (15:11):
Yes, there are Sometimes.
We will do that because the CATscan gives us a much better
picture of the bony structure ofthe spine.
So when we're looking at, youknow, maybe there's not just a
disc but maybe there's some bonyimpingement on some of those
nerves as well.
That will definitely besomething that will help us.
So the CAT scan gives us a muchbetter picture of the bony
structures of the spine andsometimes it will show us things
(15:33):
that we don't necessarily seeon the MRI.
So it's definitely helpful togive us the full picture of
exactly what's going on.
Robert A. Kayal, MD, FAAOS (15:39):
I agree.
And what do you do when theradiologist comes back with a
report that says something likedisc, osteophyte, complex or
hard disk?
Can you define for our viewingaudience what a soft disk is,
what a hard disk is and why ithas some implications?
Michael R. Dinizo, MD (15:57):
Sure.
So a soft disk is usually in apatient younger patients because
they tend to have bigger,softer, healthier disks compared
to some of the older patientswho have a little bit more
degeneration.
So the soft disk will usuallyherniate posteriorly and press
on those nerves and it's usuallymore of a much more acute type
(16:17):
of process, whereas when we seedisk osteophyte complex, that
gives us an idea that it'ssomething potentially more
chronic, something that's beenthere for a while and start to
actually calcify and we'returned into a bony structure
rather than a soft diskstructure.
Robert A. Kayal, MD, FAAOS (16:34):
And it matters right, because soft
disks, at least theoretically,have the potential of maybe
going back in place withtreatment, physical therapy, or
the body will absorb some ofthat.
But a hard disk, what we call adisc osteophyte complex or a
hard disk, is something that isnot going anywhere.
It's a chronic degenerativeprocess that has developed over
(16:54):
years and we still willpotentially try to treat that
conservatively.
But the odds of that mechanicalcompression on the spinal cord
or the nerve improving withphysical therapy are not very
good right.
Michael R. Dinizo, MD (17:09):
So we can definitely do things that will
help the patient's symptoms inthose cases.
So we will do things likephysical therapy or maybe
trigger point injections orchiropractic treatment.
There's multiple things that wecan do to help those patients,
but it won't be changing theactual MRI or the structure, the
structural problem that's goingon the spine that time Because
it's a bony structure that'spressing on that nerve, and
(17:32):
sometimes those are the onesthat are more likely to require
some sort of intervention.
Robert A. Kayal, MD, FAAO (17:36):
Right , because the soft disk
potentially can get better withtime.
Do you ever consider getting anerve study if there's nerve
compression?
Michael R. Dinizo, M (17:43):
Definitely so.
When patients have neurologicsymptoms in their upper
extremities, with pain ratingdown their arm or tingling and
numbness in their arms,sometimes the physical exam and
the history is not enough topinpoint exactly what nerve is
the one that's affected.
In addition to that too, thenerves can be compressed in
other places of their arms, sothey can be in their elbow, in
(18:05):
their wrist.
So sometimes that will help us,especially those nerve tests to
help us figure out is it justthe neck or is there something
else, also something called adouble crush phenomenon, which I
think Dr Lane spoke about verywell the other week.
Robert A. Kayal, MD, FAAOS (18:17):
Okay .
So now that you have thediagnosis, you might even know
what level is involved One level, two levels, sometimes three
levels.
What are you going to do?
Michael R. Dinizo, MD (18:27):
So it depends a lot on the severity of
the patient's symptoms, howlong they've been going on and
any of the neurologic issuesthat we've been talking about.
So a patient this is an acutething that they just started
having pain very recently.
A lot of times we'll start withanti-inflammatory medications.
We'll start with physicaltherapy, chiropractic,
acupuncture, those sorts ofthings, and we'll give the
(18:49):
patient time because the studieshave shown that the majority of
patients in about six to 12weeks actually will get much
better.
In the cases of a soft discherniation, that's usually what
we'll start with if it's justpain and it just started.
But obviously we'll follow themvery closely.
The patients having moreneurologic symptoms, where
they're having especiallyweakness, then we tend to be a
(19:11):
little bit more aggressive withtheir treatment and we monitor
them a little bit more closely.
Robert A. Kayal, MD, FAAOS (19:16):
So just to further elaborate on
what you're saying, dr Dinizo,as I've said numerous times in
the past, inflammation isassociated with redness, warmth,
pain and swelling, and the samething happens around the
cervical spine.
Nurses do not like to getcompressed, they hurt like crazy
.
It causes a local reaction ofinflammation which often results
(19:36):
in that redness, warmth, painand swelling, and so sometimes
we'll call our interventionalpain management specialists,
like Dr Aiden, to get involvedto perform a cervical epidural,
and I'm going to have him backin the future to discuss with us
on a future podcast how we infact he treats cervical disc
herniations with hisinterventional pain management
(19:56):
procedures, but suffice it tosay he puts a little bit of
cortisone or corticosteroid witha local anesthetic around the
nerve root or around the spinalcord to decrease that
inflammation, thereby decreasingthe redness, warmth, pain and
swelling.
What else could we do to helpmanage patient's pain?
Michael R. Dinizo, MD (20:16):
So another thing we can do too is
someone's having a lot of painaround their neck area with
muscle spasms.
We can also do trigger pointinjections.
That's something we can do inthe office.
It's similar idea as theepidural we're using a
corticosteroid medication and ananesthetic, but we're targeting
it more for the muscles andsome of the muscle spasms and
pain that patients are having.
So that's another thing that wecan do as well to try to help
(20:38):
with their pain.
Robert A. Kayal, MD, FAAO (20:40):
Great , thank you.
So let's just assume now thatthe patients are still suffering
.
Nothing has worked.
We've done everything thatwe've discussed Physical therapy
, anti-inflammatories,chiropractic intervention,
acupuncture, massage, cervicalepidurals, trapezole trigger
point injections.
When do we finally indicatepatients for surgery to get them
(21:01):
out of their misery?
Michael R. Dinizo, MD (21:02):
So patients that are having
intractable pain, pain that'sbeen refractory to these other
interventions that you were justdiscussing, dr Kale.
Pain that's severe.
They're interfering with theirlife.
They're not able to do thethings that they want to do
every day.
It's diminishing their qualityof life.
That's one of the indicationsthat we can potentially have and
(21:22):
we start the surgicaldiscussion with patients.
Another thing is if someone'shaving weakness that's
progressive or it's in a musclegroup that they need for their
everyday function, we don't wantto let that go for too long
because then potentially thatstrength won't come back all the
way, if it's something that'sleft for too long.
That's why we closely followthe patients.
(21:43):
We do close neurological examsto see if their strength is
changing or if they're gettingworse weakness.
It's definitely something thatwe then we start the surgical
discussion with the patients.
Robert A. Kayal, MD, FAAOS (21:54):
Yeah , I agree with you.
I think nothing's cut in stone.
But for the most part, if thepatient presents with just pain,
we'll treat them veryconservatively because we can do
things to manage their painwith medications or
interventional pain managementprocedures.
Once you start talking aboutweakness, we tend to become a
little more aggressive.
So if the weakness is minor,we'll still treat them
(22:16):
conservatively.
People often give them a goodthree months of physical therapy
, but sometimes the weakness isquite severe.
On the first presentation, onthe first day we see this
patient, we examine this patient, there's almost a flaccid
paralysis.
There's profound weakness.
In those particular cases doyou become a little more
aggressive.
Michael R. Dinizo, MD (22:36):
I do.
It's very concerning to me as aspine surgeon.
The patient comes in withprofound weakness.
Anytime they have profoundweakness, we are worried that
that's going to be somethingthat potentially would not
recover without some sort ofintervention.
Depending on the imaging thatthey have at that time, we might
discuss surgery from the veryfirst time we meet them that
(22:57):
they're having severe weakness,because it's something that we
do take very, very seriously.
I mean.
Robert A. Kayal, MD, FAAOS (23:02):
when I talk to patients about this,
I very often give them theanalogy of when our legs go numb
.
Sometimes, when we cross ourlegs, it's intuitive to just
uncross your legs when your legstarts getting numb.
That's the same concept with apinched nerve in the neck or in
the lower back, it's intuitivefor us to want to take that
mechanical compression off thenerve because we don't want any
(23:25):
of our patients to havepermanent nerve damage.
Okay, I think we've beatenconservative management to death
.
Now for the conservativemanagement of cervical disc
herniations.
Let's now focus in ourattention on the treatment
alternatives for cervical discherniations as they pertain to
surgical options.
What options are available nowin managing these cervical disc
(23:49):
herniations?
Michael R. Dinizo, MD (23:51):
Based on the location of the disc
herniation.
Some of those disc herniationsare more amenable to surgery
from the front part of the neck.
Others are more amenable tosurgery from the back part of
the neck.
It's all based on the locationof that disc herniation.
Just to refresh your memory,looking at this model here, this
is us looking at the spine fromthe side, the front being here,
the back being here.
This is us looking directlydown right on the disc here,
(24:15):
with the nerves coming out fromthe side and in the middle.
Here is where the spinal cordis.
The location of this discherniation helps to dictate how
we're going to do the surgery.
Unlike with a lot of lumbarsurgery where we almost always
will do it from the back part ofthe spine, the spinal cord is
in the middle here.
If we do surgery from the backpart of the spine, we can't move
(24:37):
that spinal cord because it'san extremely sensitive structure
that could lead to severeneurologic issues.
We actually approach it fromthe front part of the spine
through a small incision on theside of the neck which allows us
to access the disc here.
Then we can use specialinstruments and a microscope,
basically, so we can then get tothe back here and remove that
(24:58):
disc herniation that is pressingon those nerves and causing
those symptoms.
Robert A. Kayal, MD, FAAO (25:02):
Thank you for that explanation, Dr
Denizzo.
It's certainly intuitive thatif the problem is in the back of
the disc, we should approachthe disc herniation from the
back.
The caveat is that in the areaof the neck we have spinal cord.
The spinal cord is in our way.
More often than not, thelocation of the spinal cord
(25:24):
forces our hands to operate fromthe front of the spine as
opposed to from the back of thespine.
Thank you, Dr Denizzo.
We've discussed the essentiallytwo options.
We can approach the cervicaldisc herniation from the front
or the back, the front being amuch, much more common exposure
and approach.
Why don't we talk about whatyou actually do when you
(25:49):
approach a cervical discherniation from the front?
You have options, right, youcould take the disc out, but
then there's a void there whenthe disc is gone.
What are the options and whatexactly are you doing when you
approach a cervical disc fromthe front?
Michael R. Dinizo, MD (26:05):
We approach from the front part of
the spine, as you mentioned, wedo have to remove the entire
disc in order to get to the backpart of the spine, where the
pathology is and where the nerveis getting compressed.
Because we have to remove thatdisc in order to get to that
area that's compressing thenerves, we have to replace that
area with something that caneither be a spacer or a cage,
(26:27):
that's filled with the materialthat will allow for fusion and
that's supplemented often witheither plates or screws to hold
everything in place until yourbody is able to heal it on its
own.
More recently, they havecervical disc replacements,
which is another implant thatgoes into the disc space that
allows them to preserve themotion of their neck rather than
(26:47):
doing a fusion surgery.
That's something that's beenout for about the past 20 years
and is a great option forpatients as well, too.
This is looking at the front ofthe spine.
This is the front of the spinehere.
Back of the spine is here.
We're looking at the front partof the spine here.
That shows a plate that hadbeen placed following an
(27:09):
anterior cervical fusion surgery.
This is where the discpreviously was, which was then
removed during the surgery toallow those nerves to be
decompressed.
This is showing it after it hasfused already.
This is actually bone that's inbetween each one of those
vertebral bodies where that discused to be the plate again that
(27:30):
we see at the front here.
That acts as an internal splint, basically to allow those
vertebral body to not move untilthey can heal on their own.
Ultimately, the patient's ownbone basically grows in between
those vertebral bodies and thencreates the fusion.
Robert A. Kayal, MD, FAAO (27:47):
Right .
When you approached this spinefrom the front and took out the
two discs that were compressingthe nerves of the spinal cord,
it left a void.
You have to put something inthere, whether it's a cadaver
bone, a cage bone graft,something to replace the disc
that were removed.
Because the discs are removed,the spine would be rendered
(28:10):
inherently unstable.
You have to do something tostabilize that area as well.
In this particular case, youchose to use a plate.
You did what's called ananterior cervical dyskectomy
infusion utilizing a plate.
The plates are holding thevertebral bodies together,
(28:30):
stabilizing the spine andputting bone graft in between to
allow those levels to fuse andalleviate the compression on the
nerve roots as well.
What other options can youemploy when you address the
cervical spine from the front?
Michael R. Dinizo, MD (28:47):
This other model that we have here.
This shows the plate that's inthe front part of the spine.
This shows some of the othertypes of materials that we
sometimes may put in that spaceafter we take the disc out.
Looking at it here from theside a little bit closer, you
can see at this top level herethere's some bone graft that's
placed in between thosevertebral bodies.
(29:09):
Another option that's verycommon is a cage.
It's usually either plastic ora metal type of cage that is
filled with different biologicsubstances that help to promote
a fusion between the twodifferent levels.
Then when we do that, we havethe plate again on the front
there.
That's going to hold everythingstable until your body is
(29:31):
allowed to heal on its own.
Robert A. Kayal, MD, FAAO (29:33):
Right , you had mentioned earlier that
sometimes on an X-ray you'llfind that the patient has lost
the normal, what we callcervical lardotic posture of the
spine, the normal curve of thecervical spine.
Are there advantages ofapproaching the spine from the
front in order to restore thenormal anatomical curvatures of
(29:53):
the spine?
What is the problem when thecervical spine collapses into
kyphosis?
Michael R. Dinizo, MD (29:59):
Yeah, that's a thing that we look at
before every single one of oursurgeries.
We look at the lardosis withthe curvature of the spine.
Based on that usually becausein the front part of the spine,
here, because those discs havecollapsed, the spine itself
starts to lose some of thatcurvature.
When we approach the spine fromthe front part, there we can
(30:21):
place these implants or thosecages in the front part of the
spine to restore that discheight that that patient has
lost from their injury or fromwear and tear.
When comparing the X-rays frombefore the surgery to afterwards
, we can see that we can restoretheir normal alignment based on
how it was prior to theirinjury.
Robert A. Kayal, MD, FAAOS (30:44):
I think that's so important.
I always tell patients thatkyphosis equals pain In the neck
and in the lower back.
The spine is supposed to havewhat we call a lardotic posture,
a normal cervical posture andlardotic lower back posture that
is curved.
When patients lose thatlardotic posture from muscle
(31:07):
spasm, degenerative disc disease, whatever it may be, that
equates to pain.
Very often we see thesepatients with cervical disc
herniations and lumbar discherniations where they lose the
proper curvature because of aherniated disc or a degenerative
disc.
One of the advantages,especially in the cervical spine
(31:28):
, of approaching the spine fromthe front is that Dr Denizo and
other of our spine surgeons areable to restore the cervical
lardotic posture by sort ofjacking up that degenerative
disc level.
Michael R. Dinizo, MD (31:41):
So this is another model of just the
cervical spine.
So the rest of the spine isdown here.
This is the top of the skull,just for the orientation here.
This is the front of the spine.
This is the back of the spine.
Normally the curvature of thespine should be curving gently
backwards, like this.
When people have muscle spasmsor in the case of disc
degeneration or disc herniation,they can lose the height of
(32:03):
those discs in the front, whichleads to straightening of the
spine or sometimes even aforward posturing of the spine.
Like that During thesesurgeries, when we come in
through the front, we're able toopen up that space again and
restore it to the normalalignment and get them back into
a more natural position, whichleads to less muscle pain, less
neck pain and better function.
Robert A. Kayal, MD, FAA (32:24):
That's the concept behind the cervical
pillow right, the cervicalpillow in the cervical spine and
the lumbar support that'susually offered to help restore
the proper posture of thepatient's lower back and also
cervical spine, where you'resupporting that normal lardotic
posture.
I always tell patients that,for instance, when they're
(32:47):
sitting and standing, to makesure that they're maintaining
good posture, the ear shouldalways line up with the shoulder
, which should always line upwith the elbow, which should
always line up with your hip.
So it helps to maintain a goodposture.
When your ear is lined up withyour shoulder, which is lined up
with your elbow and lined upwith your hip, you can for the
(33:10):
most part, ensure that you'remaintaining a good posture of
your upper back and lower backand neck and that just by
restoring that proper posture itshould alleviate a lot of your
neck and lower back pain.
Michael R. Dinizo, M (33:24):
Definitely agree.
It's much more energy efficientto be well balanced when it
comes to your spinal balance,and that's something that we
take into account.
As we were just talking about,we're trying to restore that
normal alignment which allowsthose muscles to not work so
hard, you know, even throughoutthe day, which leads to less
neck pain and less other issuesas well, too.
(33:46):
I 100% agree with that, forsure.
Robert A. Kayal, MD, FAAOS (33:48):
So let's say the patient doesn't
want a cervical fusion from thefront.
Are there any otherpossibilities to offer certain
patients Sure?
Michael R. Dinizo, MD (33:59):
so something that we do here at the
Kaila Orthopedic Center iscervical disc replacements.
So when we were talking beforeabout replacing that space where
we took the disc out with acage or bone graft, we can
actually put an implant in therethat continues to move, so that
way that patient does not loseemotion at that level.
(34:19):
So that's something that we dohere as well.
We do it for cervical discherniations as well as for other
cervical pathology and patientsdo great.
Robert A. Kayal, MD, FAAOS (34:30):
You know there are certain
circumstances where you canapproach the patient from the
back of the spine, in the neck,and when do you?
When you appreciate thoseopportunities.
Michael R. Dinizo, MD (34:41):
We approach from the back part of
the neck for a disc herniationin just a couple specific cases.
This is usually when somethingis very lateral, lateral,
meaning further from the outsidepart of the spine, away from
the spinal cord.
In that case we can sometimesapproach it from the back and
remove that disc herniation andtake that pressure off of the
nerve.
But it's only in special caseswhere that is a surgical option.
(35:05):
Most often we do have to do itfrom the front, as you said
before, dr Kaila, because thatspinal cord is in the back and
it's something we have to stayaway from.
We can't put any extra pressureon it.
Robert A. Kayal, MD, FAAOS (35:14):
So yes, I agree with that.
It is a rare instance when wecan indicate someone for a
posterior cervical decompression.
But when we find that patient,we're happy, right, because we
can.
We can essentially do thatprocedure in a relatively
minimally invasive manner, takethe pressure off the nerve and
not have to even discuss fusionat that time right.
Michael R. Dinizo, MD (35:38):
Correct.
So in those cases it is a verysmall incision.
We usually use a microscope andtubes to basically allow us to
see that area and that way wecan safely remove that disc
herniation without disruptingsome of the other structures
that would require us to eitherdo a fusion or use some sort of
other implant in order tostabilize the spine afterwards.
(36:00):
So in those cases it is a greatoption for patients because
it's usually a same dayprocedure, it's very quick and
the patients can recover veryquickly.
Robert A. Kayal, MD, FAAOS (36:09):
So we've covered the surgical
approaches for cervical discherniations both from the front
and from the back.
Well, if there are multipleoptions, there must be some pros
and cons of each right, forsure like we were kind of
talking about before.
Michael R. Dinizo, MD (36:25):
With the posterior approach it's a small
incision just on one side.
There's no fusion involved withat that level and the disc in
the front part of the spineactually stays there and stays
intact.
We just removed that small discherniation.
So that's one of the pros withthe posterior approach to the
spine.
From the anterior approach wecan remove the entire disc.
(36:49):
We can decompress the spinalcord and both nerves.
From the the anterior approach,from the front part of the
spine, we can also restore thealignment, as we were talking
about previously.
So we can jack up that discspace after we remove that disc
to help to restore thatalignment.
So that's another greatadvantage of the anterior
(37:10):
approach.
Robert A. Kayal, MD, FAAOS (37:11):
So, when it comes to deciding
whether to approach thesepatients from the front or the
back, you had mentioned thattypically, when we address them
from the front, a surgicalfusion is involved.
How does that affect thepatients?
Acute post-operative course.
Michael R. Dinizo, MD (37:30):
So when we do a fusion the patient very
often is immobilized for acertain amount of time, whereas
with those posterior basedsurgeries there is in the period
of immobilization they can getback to their activities very,
very quickly.
A lot of times in youngerpatients or more active patients
, and sometimes even in athletes, we can get them back to doing
what they wanted to very quicklybecause we don't have to wait
(37:53):
for that fusion in the front orsome of the morbidities
associated with putting animplant in.
Rather than we just take thatdisc out from the back, people
can recover quicker and get backto their activities much faster
.
Robert A. Kayal, MD, FAAOS (38:06):
Yeah , I mean certainly in this area
there are indications to go infrom the, from the back, but
those indications are very, veryrare and although it's
tremendously advantageous to beable to go in from the back and
not have to contemplate fusion,unfortunately those instances
are rare and so so many times inour practice we have
(38:31):
conversations with patientsabout the pros and cons, the
advantages and disadvantages ofcertain things, and sometimes we
will ask the patient toparticipate in that
decision-making process andsometimes it's not so
straightforward.
There are advantages anddisadvantages of both techniques
.
Clearly we get the most bangfor our buck going from the
(38:52):
front, because from the front wecompletely decompress
everything the spinal cord, thenerve roots, we take the entire
disc out and that patient isguaranteed to get better for the
most part.
The downside of that is theyhave to fuse and it can take
months to fuse that cervicalspine.
So the post-op course issomewhat restricted as you
(39:14):
encourage them to protect thefusion and allow it to heal.
The advantage of going from theback is there's no fusion but
there's less bang for the buck.
So sometimes you cannotadequately decompress the nerve
fully from the back because thespinal cord is in the way.
So it's only really those verylateral disc herniations or the
(39:35):
spinal foramen that's gettingencroached upon by a bone spur
or something, a disc herniationthat we can satisfactorily
address from the back.
And sometimes it's borderline,where the disc herniation is a
little bit close to the spinalcord but largely lateral, and
you may have a conversation witha patient, say, look, we're
going to try to go from the backas much as we can and see what
(39:57):
pain goes away.
If you continue to have painand discomfort, we may have to
do a second procedure down theroad.
Do you find that you'resometimes in those situations
with patients?
Michael R. Dinizo, MD (40:08):
Yeah, I do.
And I think the biggest, youknow, the most important part of
that is to talk with thepatient, have that conversation
about the risks and the benefitsand the pros and cons of the
different approaches that wehave.
You know, I think having ashared decision with the patient
and, just you know, discussingthe different likely outcomes of
their surgery and allowing thepatient to have input on that
(40:30):
decision is extremely, extremelyimportant.
Like you were saying, with theposterior cervical decompression
we're just removing thatcompression that's right around
the nerve root.
There the whole rest of thedisc is still there and this
disc has had a herniation onetime.
There's a potential that itcould herniate again.
Work in the herniating on theother side, whereas with the
(40:50):
anterior approach that disc iscompletely removed and both
nerves on both sides of thespine are completely
decompressed.
So that way in the future thatpatient doesn't necessarily have
to worry about having arecurrence of the symptoms at
that level compared to what ifthey did it from the posterior
aspect.
And those are the decisions inthe discussions that we have
(41:11):
with patients, so that way theycan help to make the decision
themselves along with us.
Robert A. Kayal, MD, FAAOS (41:16):
Yeah , but just to be clear, probably
more than likely, over 95% ofyour cervical disc herniations,
when approached surgically orapproached from the front,
correct, correct, yeah, it'svery, very rare to approach
these cervical disc herniationsfrom the back, because we want
to make sure that these patientsare completely satisfied with
their outcomes and that thatnerve is completely decompressed
(41:40):
and really the best way to dothat is from the front.
But again, there are those veryrare circumstances where we may
be able to get away with theposterior cervical decompression
and I just wanted to bring thatto your attention.
As far as disc replacementsurgery, how often are you able
to do a disc replacement andwhat are the indications for a
disc replacement?
Michael R. Dinizo, MD (42:00):
The indications for a disc
replacement are a little bitmore restrictive than they would
be for a fusion type of surgery.
If a patient has discdegeneration and they have
degeneration of other parts ofthe spine there's something
called the facet joints, whichis in the back part of the neck
If they have arthritis oranything there, they might be
better off with a fusion type ofsurgery, so that way those
(42:21):
arthritic joints aren't movinganymore.
If there's no arthritis inthose joints, by maintaining
motion there that patient couldpotentially have increased range
of motion and reduce the riskof what we call adjacent segment
disease.
That happens from having afusion in one area of the spine.
Robert A. Kayal, MD, FAAOS (42:39):
Yeah you can imagine that if you
fuse one level, the area belowand above that level is going to
have to pick up the brunt ofthe load right and work harder
than they're used to working andultimately maybe become
degenerative and wear out andrequire a fusion above and below
.
And that's where the concept ofa disc replacement really
became popular.
(42:59):
If we can preserve motion atthat level and decompress the
nerve at the same time by takingout the disc and instead of
fusing it, get away with a discreplacement to preserve motion,
that should hopefully preservemotion throughout the entire
cervical spine and avoid thecomplication of having an
associated adjacent disc diseasein the future, requiring a
(43:24):
fusion in those levels.
Michael R. Dinizo, MD (43:26):
Correct.
Yeah, so that's been the ideabehind the cervical disc
replacement, and both surgeriesare extremely successful at
decreasing the patient's pain intheir neurologic symptoms.
Most of the studies show thatthey're very close to equivocal,
with the disc replacementshowing a slight decreased risk
(43:46):
of that adjacent segment disease, meaning the disc above and
below the area that has surgerypotentially degenerate slightly
faster with the fusion comparedto the disc replacement.
Both are extremely successful.
Robert A. Kayal, MD, FAAOS (44:00):
Yeah , but just to be clear, the gold
standard of care is what'scalled the anterior cervical
discectomy and fusion.
For the most part correct.
Michael R. Dinizo, MD (44:06):
Correct.
Yeah, the disc replacement isgreat in the times when we can
use it, but definitely the goldstandard is still the fusion,
the anterior cervical discectomyand fusion.
Robert A. Kayal, MD, FAAOS (44:17):
Yeah , for that acute cervical disc
herniation that's going toundergo a cervical disc
replacement.
That patient really needs tohave a very clean spine, right.
Michael R. Dinizo, MD (44:26):
Yeah, it's usually younger patients
that have normal alignment oftheir spine.
They don't have other issueswithin their spine.
As far as degeneration in bonespurs forming or arthritis in
their neck, the indications forthat are a little bit more
restrictive compared to thefusion, but in the cases where
it is indicated, patients dogreat.
Robert A. Kayal, MD, FAAOS (44:47):
Yeah , so if you don't mind, just
comparing contrast for ouraudience, the post op protocol
for the different varioussurgical procedures you
mentioned the anterior cervicaldiscectomy and fusion with
plates or cages or however youwant to proceed, versus the
anterior cervical discreplacement, versus the
(45:07):
posterior cervical decompression.
Michael R. Dinizo, MD (45:10):
Sure.
So with the anterior cervicaldiscectomy and fusion a big part
of the post op restrictions intheir care depends on whether
this is done at one level of thespine or multiple levels.
I think, kind of just tocompare apples to apples, if
we're comparing a one levelcervical disc replacement versus
(45:31):
a one level anterior cervicaldiscectomy and fusion, the
patients that have the discreplacement they're able to get
back to activities a little bitearlier than the fusion patients
.
The fusion patients usuallythey have about six weeks of
restrictions, the restrictionsbeing they can continue all
their regular everydayactivities but we don't want
(45:51):
them doing anything to shreners,one for avoiding lifting
anything heavy bending, twistingthose sorts of things.
Those are the restrictions thatwe have for the fusion patients
, whereas with the disreplacement patients they can
get back to their activitiesusually within two to four weeks
.
When we're talking about theposterior cervical decompression
patients, the recovery ispretty quick.
(46:12):
We give them a soft collar asneeded, basically just to help
them with the comfort they'reable to get back to their
activities as soon as we get tosee them for their post
operative visit and their woundis healed and everything.
Then we can start to gentlybring them back to all their
normal activities.
It can be pretty quick recoveryfor the posterior cervical
(46:33):
decompression.
Robert A. Kayal, MD, FAAOS (46:34):
Yeah , as far as the surgical
outcomes, I would venture toguess and say that cervical disc
surgery for you is probably themost rewarding procedure you do
.
Michael R. Dinizo, MD (46:49):
It's my favorite surgery, whether the
disc replacement or the fusion.
The studies that are publishedshow anywhere from 90 to 95%
complete relief of arm pain.
Patients are very happyafterwards.
It's a surgery that I reallylike to do because I can have
the discussion with the patientsthat we have a very high chance
(47:11):
of decreasing their symptomsand their pain and getting them
back to enjoying their life more.
So it's a great surgery andit's an honor to help patients.
Robert A. Kayal, MD, FAAOS (47:22):
It's certainly a very gratifying
procedure and that's for themost part why most of us have
chosen the field of orthopedicsurgery.
We all appreciate that instantgratification, and nothing gives
a spine surgeon more instantgratification than doing a disc
surgery on the cervical spine.
I think Because, again, whenthat spinal cord and when those
(47:42):
cervical nerve roots arecompressed, the patients are
miserable.
They're suffering, they're inso much pain and for the most
part they wake upinstantaneously without pain and
they continue to improve dayafter day after day.
It's a very minimally invasivesurgery, very often done almost
exclusively as an outpatient,for the most part through a very
(48:04):
small incision.
Patients have little to no painafter surgery, experience
immediate pain relief from thenerve compression, and that's
what we're all about here at theKaila Orthopedic Center to
provide patients with cuttingedge orthopedic technologies and
pain relief.
So that's what we're in thebusiness of doing.
So, dr Denizl, let me ask you aquestion now.
(48:26):
That's, I'm sure, on all of ourpatients' minds, and that is if
I'm about to undergo a fusionof my cervical spine, aren't I
going to lose motion in my neck?
Michael R. Dinizo, MD (48:36):
Yeah, so that's a very common question
that I get anytime.
We're talking about fusionsurgery for the cervical spine,
so a big thing that goes intothis is where in the cervical
spine that that fusion is goingto happen.
The top three, the C1, the C2and the C3 vertebrae, are the
ones that are responsible forthe majority of your everyday
(48:58):
motion, looking side to side andup and down.
When people have cervical discherniations, it's most common to
happen at some of those lowerlevels of C5, c6, c7, sometimes
at the C4 or C5.
Those levels are notresponsible for a lot of the
everyday motion that we that weneed to drive our car or to do
any of the activities that wenormally want to do.
So those lower levels, from theC4 down to the C7, those are
(49:21):
mostly with bending your neckside to side, which is not
normally a motion that people doa lot during their their
everyday activities.
And even with a multi-levelfusion, their motion for the
most part in every everydayactivities is completely
preserved and that there's norestrictions on what they want
to do.
Robert A. Kayal, MD, FAAO (49:38):
Great .
Thank you for that, dr Diniz.
So another question that theyoften have is well, what about
activities of daily living?
What will I still be able toparticipate in after I undergo a
fusion of my neck?
Michael R. Dinizo, MD (49:51):
So more early on, within the first six
weeks or so after surgery, we'retrying to let the patient
recover and avoid most strenuousactivities.
But once they're healed theycan reach almost all normal
activities.
Even there's been professionalfootball players who have gone
back to playing in the NFL afterhaving cervical fusions.
Patients are able to playsports once they're healed and
(50:16):
they can get back to almost alltheir regular normal activities
without any restrictions onceeverything is healed up.
When we're talking about thecervical disc replacements,
patients can get back a littlebit quicker because we don't
need to monitor for that fusionthat needs to happen in between
those vertebrae.
So with the cervical discreplacements, patients can get
back to almost all unlimitedactivities within the first six
(50:39):
to eight weeks after theirsurgery.
Robert A. Kayal, MD, FAAOS (50:41):
One thing I think is very important
for our patients to understandis that when surgeons perform a
fusion of the cervical spine anduse implants like plates and
cages and bone grafts the platesand cages they're designed to
keep the bones together to allowthe biological fusion to take
(51:02):
place, and once that biologicalfusion takes place between the
vertebral bodies, the plates andthe cage really serve no
function at all.
So it's really really importantduring that post-operative
period that patients are takingsupplements like calcium and
vitamin D and avoiding certainthings like smoking and alcohol
(51:24):
consumption and even the usageof over-the-counter
anti-inflammatory medications,all of which have been shown to
significantly deleteriouslyaffect outcomes after this type
of procedure.
Is that something that youcounsel your patients on?
Michael R. Dinizo, M (51:39):
Definitely .
It's all part of the historybefore talking about smoking and
risk factors that we can modifybefore the surgery so that way
the patient can have asuccessful outcome.
So if there's smokers, we talkto them about that.
We discuss avoidinganti-inflammatory medications
afterwards and also talkingabout their bone health too, so
they have a history ofosteoporosis or other things.
(51:59):
That will be something we wantto keep in mind when we're
talking about the differenttypes of surgery, because we
want them to heal, we want themto do well, absolutely.
Robert A. Kayal, MD, FAAOS (52:08):
I know we've even canceled
patients proposed surgicalfusions when they would not stop
smoking.
That significantly increasesthe risk of what we call
non-union, where the bones willnot fuse.
Well, this has been a veryinformative and very
enlightening podcast.
Have you here with us, drDenizzo.
(52:30):
I've really enjoyed our timetogether.
We hope that you have foundthis podcast informative and
helpful in your assessment andunderstanding of a cervical disc
herniation and a pinched nervein the neck.
So I just really want tosincerely thank you for your
time and your expertise.
It's a privilege and honor tohave you with us at the Kaila
(52:51):
Orthopedic Center caring for ourpatients.
Thank you so much for your time.
Michael R. Dinizo, MD (52:54):
Thank you , dr Kail, we appreciate it.
Robert A. Kayal, MD, FAAO (52:57):
Thank you.
Hello and welcome to another edition
of the Kale Ortho Podcast.
Today is July 18, 2023.
And we're so happy to have withus today our very own spine
surgeon, dr Michael Denizzo,orthopedic spine surgeon at the
Kale Orthopedic Center, andtoday's topic is going to be
cervical disc herniations.
Welcome to the podcast, drDenizzo.
Michael R. Dinizo, MD (00:21):
Thank you very much, dr Kale, really
excited.
Robert A. Kayal, MD, FAA (00:23):
Before we get started, why don't you
just tell us a little bit aboutyourself?
Michael R. Dinizo, MD (00:26):
Sure, my first time here in New Jersey
went to undergrad at JohnsHopkins University and from
there I actually did some spinalcord injury research, both at
Johns Hopkins and the Universityof Maryland Shock Trauma Center
.
From there I went to RutgersUniversity for my medical school
, followed by five yearsorthopedic surgery at NYU and
then an additional one yearspine surgery fellowship, also
(00:49):
at NYU.
Wow, impressive credentials.
And how about your family?
All from New Jersey?
My dad is a small businessowner, my brother works with him
, my sister does marketing, andthey're really excited to hear
this podcast Awesome.
Robert A. Kayal, MD, FAAOS (01:04):
Well , we're so happy to have you
with us today to discuss thisvery, very ubiquitous condition
called the cervical discherniation.
Neck pain is such a commonproblem, isn't it?
Michael R. Dinizo, MD (01:14):
It's very common, especially in people
between the 30s and 50s.
It's a very common source ofpeople missing work and also
coming to see us to help treatthem.
Robert A. Kayal, MD, FAAOS (01:25):
Yeah , and that's the anatomy.
Okay, sure, our patients, sothey get an idea of what we're
talking about.
So, dr Denizo, for the benefitof our viewing audience, can you
please tell us what I'm holdingin our hands right now?
Sure.
Michael R. Dinizo, MD (01:39):
We're looking at a full model of the
spine.
You're getting down here.
This is where your pelvis is.
Lumbar spine is down here.
Thoracic spine is in the middle.
But for today's discussion we'regoing to be talking about the
top seven vertebrae, thecervical vertebrae.
You're getting up here at thebase of the skull, down here to
the seventh cervical vertebraewhen we're looking at the front
of the spine.
So from this angle here we'relooking at the front.
(02:00):
These are the vertebral bodies,or the bony structures of the
spine.
In between each one of thosevertebral bodies is the
vertebral disc, which we'regoing to get to in a little bit,
exiting out here these yellowlines.
Those are the nerves thatcontrol the sensation as well as
the strength to your upperextremities.
Now, as we kind of rotatearound the back here, you can
see that there's additionalstructures.
(02:20):
So in the back here, this isthe lamina, the back covering of
the spine.
These are the spinous processesand in here is something called
the pedicle.
This forms the posteriorvertebral arch, which protects
the spinal cord during everydayactivities and allows us to move
and function.
Robert A. Kayal, MD, FAAOS (02:37):
So thank you for that demonstration
of the spinal anatomy, DrDinizo.
Let's talk specifically about acervical disc herniation.
What is actually happening whena cervical disc herniates?
Michael R. Dinizo, MD (02:48):
So what happens when a cervical disc
herniates is part of the innerdisc called the nucleus pulposus
, which acts as a shock absorberfor the spine, gets displaced
posteriorly and compressed onsome of the neural structures.
Robert A. Kayal, MD, FAAOS (02:59):
Okay .
So as far as the intervertebraldisc is concerned, we discussed
that these are soft cushionsbetween the vertebral bodies and
we have them from the neck allthe way down to the lower back
right, correct, these discs areprimarily made up of water right
Water and collagen material.
That's a soft material thatserves as a shock absorber, a
(03:21):
cushion between the hard bonesof our spine, allowing for
motion and load absorption,things like that.
Within the disc itself, it'smade up primarily of an outer
ring of cartilage called theannulus fibrosis, made up of
type 1 collagen.
That material contains thesofter inner gelatinous material
(03:43):
called the nucleus pulposus,which is typically very hydrated
, filled with a lot of water,and it allows for the disc to be
soft and mobile and absorb alot of load.
When discs herniate, very oftenthere's pathology to the outer
ring of tissue called theannulus fibrosis right.
Michael R. Dinizo, MD (04:03):
So what can happen is there can be a
tearing of that outer coveringthe annulus, fibrosis, and that
can lead to the inner material,as you mentioned, the nucleus
pulposus, displacing posteriorlyand potentially causing pain
and neurologic issues to thepatients.
That can happen eitherfollowing acutely, like
following a trauma or a caraccident or a sports injury, or
(04:26):
it can sometimes happen morechronically and it's more
degenerative type of process.
Robert A. Kayal, MD, FAAOS (04:31):
So it's just very similar to what
actually happens in the lumbarspine right, and I'd like to
refer our viewing audience toanother podcast that we've done
with Dr Paul Baghe, when wediscussed lumbar disc
herniations in the lower back insciatica.
So, for the benefit of ourviewing audience, let's
demonstrate to them what acervical disc herniation can
(04:52):
look like now.
Michael R. Dinizo, MD (04:53):
Sure.
So this is a model again of thespine.
So this is first looking at theside here.
So these are the vertebralbodies here and in the middle
here is the disc Turning it overand looking straight down on
the spine here this is theannulus fibrosis that we
mentioned before.
In the middle here is where thenucleus pulposis is, and when
someone has a disc herniationthere's a tearing on the outside
(05:16):
ring of that annulus fibrosisand part of the inner structure.
It's normally a very softshock-absorbing material can
extrude out and press on some ofthe spine, the nervous
structures in the back of thespine.
Robert A. Kayal, MD, FAAOS (05:29):
Okay , great.
Thank you so much for thatdemonstration.
So typically, how will apatient present to the office
when they're complaining ofsymptoms consistent with a
cervical disc herniation?
Michael R. Dinizo, MD (05:40):
So the symptoms can vary.
It can vary anything from badneck pain to arm pain, and
sometimes they can have weaknessor even numbness going down
their arms.
Typically is there traumaassociated with this, so these
can happen in acutely after atrauma or a car accident or any
type of other accident that apatient may have.
(06:03):
So it's very important part ofthe history to figure out.
Is this something that beganvery quickly following an
accident or is it somethingthat's been more slowly
progressing over the lastseveral weeks or months?
Robert A. Kayal, MD, FAAOS (06:14):
And when you see patients with
discurneations, is the paintypically localized in the neck
or around the shoulder girdle inthe trapezius area, going down
the arm, all the above.
How does it typically present?
Michael R. Dinizo, MD (06:27):
So it definitely can be.
All of the above Usually isassociated with neck pain, with
neck pain a lot of times.
Reading towards their shoulderwas sometimes even getting
muscle spasms or pain aroundtheir shoulder Many times.
Often, too, it's associatedwith pain going down one of the
arms, sometimes even withtingling, and sometimes with
some weakness as well.
Robert A. Kayal, MD, FAAOS (06:48):
Yeah , what I found in my own
clinical experience is patientswith cervical disc bulges or
herniations very often will havepain in the area of their
trapezius over here, and it also, if you can turn your body a
little bit, very often they havepain in this area of the
trapezius that we're describing.
They often have a palpable knotthat we can appreciate right
(07:11):
here, and also the pain radiatesvery often to what we call the
periscapular region around theshoulder girdle in the back
there, and a lot of timesthey'll have spasm, tenderness
and what we call a myofascialtrigger point in these areas and
the pain will also very oftenradiate down the arm.
So what determines where thepain goes?
Michael R. Dinizo, MD (07:35):
So when we're looking at that model
before, we saw that there wasthose paired nerves that were
coming off of the spine andthose are numbered from C1 to C8
.
And each one of those differentnerves controls the sensation
in a different part of yourupper extremity, whether it's in
the upper arm or even down tothe hand, and each one of those
different nerves, they innervatea specific muscle.
(07:56):
So it's very important for usto get a very clear picture of
exactly where their pain is andif they're having weakness, what
muscle groups is that weaknessin?
Robert A. Kayal, MD, FAAOS (08:05):
So those nerves are both sensory
and motor nerves, right Correct,so they're mixed nerves.
Yeah, mixed nerves.
They're responsible for a lotof things.
They're responsible forsensation, to what we call the
different dermatomes of the body, so for instance, c3, c4, c5,
c6, c7, c8, they go to differentparts of a patient's upper
(08:27):
extremity, and so when that areais experiencing pain or
numbness and tingling, it givesthe doctor an idea of what nerve
root may be involved.
Those mixed nerves are alsoresponsible, some of them at
least, for reflexes, right, andso we can test patients' upper
extremity reflexes to identifywhether or not their reflexes
(08:48):
are intact or abnormal, and thatwill also give the physician
some feedback about what nervemight be involved.
And then, finally and mostimportantly, these nerve roots
are responsible for innervatingdifferent motor groups that Dr
Denizzo referred to, and whenpatients experience weakness in
those muscle groups, itcertainly is concerning for us
(09:12):
and it suggests that maybe thenerve is not working properly.
Correct, Correct.
Michael R. Dinizo, MD (09:16):
And the reasons that the nerve can be
not functioning correctly can beeither from actual compression,
from the disc herniation, or itcan be from a huge inflammatory
cascade that can happen whenthat nucleus pulpulosis comes
out to an area that it's notnormally supposed to be Right.
Robert A. Kayal, MD, FAAOS (09:32):
So also these patients.
Very often, besides the classicpains that I've demonstrated,
very often one of the telltalesigns that they're suffering
from a cervical disc herniationis when you ask the patients if
they find relief by puttingtheir arm over their head.
Right.
That's very classic.
I found in my years of practicethat when patients put their
(09:53):
arms over their head like thisto alleviate the symptoms, it's
almost pathodendomonic for acervical disc herniation.
Michael R. Dinizo, MD (10:00):
I 100% agree.
And so walk in the room andI'll see the patient sitting in
the chair basically holding thatposition, and they'll say that
that's really the only positionthat they can find any relief of
their pain.
And what the patient's actuallydoing by doing that is they're
taking some of that tension offof that nerve and then relieving
some of their symptoms, right.
Robert A. Kayal, MD, FAAO (10:18):
Right .
It is one of the mostuncomfortable conditions to have
to endure right Sure, first ofall, any nerve pain in general.
But in my experience, cervicaldisc herniations with an acute
cervical radiculopathy we callit is extremely, extremely
uncomfortable for the patients.
Michael R. Dinizo, M (10:37):
Definitely .
You know patients come inseeking help because they can't
sleep at night because of thepain.
It's kind of an unrelentingpain that they have had trouble
on their own trying to relieveand that's why they come to see
us, Right.
Robert A. Kayal, MD, FAAOS (10:50):
So, now that we've discussed the
classic presentation, what doyou do as a physician when
you're performing a physicalexamination to try to determine
if they are indeed sufferingfrom a cervical disc herniation
and, if so, the severity of thatdisc herniation, what disc
might be herniated, et cetera,on physical exam?
Michael R. Dinizo, MD (11:10):
So we first start with the range of
motion of their neck.
So they're having the spasms inthose muscles, like you were
discussing before.
A lot of times you will seelimited range of motion and
they'll actually have that veryspasmatic muscles in their neck.
That's usually the first thingwe start off with.
The most important part of theexam is to do a very thorough
neurological exam.
(11:31):
So what we do is we check allthe muscle groups, we check the
strength, we compare it fromside to side to see if there's
any weakness in any of thosemuscles.
We also do a very detailedsensory exam to see if there's
any areas of their arm wherethey're having any sort of
numbness or altered sensation.
And in addition to that there'sa couple of special tests that
we can do too to almost try toprovoke the symptoms that they
(11:54):
have.
So those are some of the otherthings that we'll do to try to
give us more of a hint exactlywhat's going on with the
patients.
Robert A. Kayal, MD, FAAOS (12:01):
All right, but this is typically a
very classic presentation.
So by the time you take thehistory for the most part even
made the diagnosis right, thephysical examination often just
confirms our suspicion.
So you will be assessing forsensation, you will be assessing
reflexes, you will be assessingmotor strength to make sure
that those physical examinationfindings corroborate with the
(12:23):
patient's subjective complaints.
Once you've identified in yourown mind that more than likely
the patient suffering from anacute cervical discurreation and
nerve compression, or whatpatients like to call a pinched
nerve in their neck, whatobjective findings besides the
physical exam can you doutilizing imaging modalities?
Michael R. Dinizo, MD (12:43):
So we'll normally start first with
getting x-rays.
The x-rays give us a good viewof the overall alignment of the
cervical spine.
First Things that we're lookingfor are the lordosis or the
backwards curvature of the spine.
Sometimes that can bestraightened.
In the case of cervical discherniation, because patients are
having severe muscle spasms.
We can change their alignmentof their spine.
(13:03):
Other things that we look at welook at the vertebral disc
heights, so that can give us anidea of how healthy those discs
are and how hydrated they are.
We can also see somethingcalled osteophytes, which are
like bone spurs that can form inthe spine.
It's something that gives us abetter idea of the overall
health and structure of thespine as well too.
We almost always get flexionextension x-rays, which is
(13:27):
special x-rays with the neck indifferent positions that can
look to see if there's anyabnormal motion or instability
in the spine, which can give usa better idea of exactly what's
the cause of the patient'ssymptoms.
Robert A. Kayal, MD, FAAOS (13:39):
Okay , so in addition to x-rays, are
there any other advancedcross-sectional medical imaging
modalities that we can employ tohelp hone in on the diagnosis?
Michael R. Dinizo, MD (13:49):
There definitely is.
So usually, when we'resuspicious that a patient has a
cervical disc herniation, thenext test that we'll get is an
MRI.
Mris are a special type ofimaging that allows us to see
the disc, allows us to see thenerves, allows us to see if
there is a disc herniation.
We get to see the health of thedisc, whether they're well
(14:09):
hydrated, and the height of thedisc, and allows us to see if
there's anything else going onas well, too, and we think it's
a disc herniation.
It can be something else weweren't necessarily expecting,
so it's a way to get a completepicture of the spine and exactly
what's going on, and certainlyyou're looking to evaluate for
compression on the spinal cord,as well, right, definitely so.
Cervical disc herniation theycan either press on the nerves
(14:31):
themselves or actually on thespinal cord, which is another
topic.
Cervical myelopathy, whichhopefully we get to talk about
in the future.
Robert A. Kayal, MD, FAAOS (14:40):
So the cervical spine is a very
delicate part of our body.
Obviously nerves do not like tobe touched right.
Nerves in general, especiallythe spinal cord, do not
appreciate any compression.
Well, in general, when we'reevaluating the cervical spine on
MRI, we don't really want tosee anything compressing the
spinal cord.
(15:00):
If there's any compression itcertainly can be concerning for
us and we'll evaluate thatfurther with the patient.
So are there any indicationsfor the usage of CAT scan in the
cervical spine?
Michael R. Dinizo, MD (15:11):
Yes, there are Sometimes.
We will do that because the CATscan gives us a much better
picture of the bony structure ofthe spine.
So when we're looking at, youknow, maybe there's not just a
disc but maybe there's some bonyimpingement on some of those
nerves as well.
That will definitely besomething that will help us.
So the CAT scan gives us a muchbetter picture of the bony
structures of the spine andsometimes it will show us things
(15:33):
that we don't necessarily seeon the MRI.
So it's definitely helpful togive us the full picture of
exactly what's going on.
Robert A. Kayal, MD, FAAOS (15:39):
I agree.
And what do you do when theradiologist comes back with a
report that says something likedisc, osteophyte, complex or
hard disk?
Can you define for our viewingaudience what a soft disk is,
what a hard disk is and why ithas some implications?
Michael R. Dinizo, MD (15:57):
Sure.
So a soft disk is usually in apatient younger patients because
they tend to have bigger,softer, healthier disks compared
to some of the older patientswho have a little bit more
degeneration.
So the soft disk will usuallyherniate posteriorly and press
on those nerves and it's usuallymore of a much more acute type
(16:17):
of process, whereas when we seedisk osteophyte complex, that
gives us an idea that it'ssomething potentially more
chronic, something that's beenthere for a while and start to
actually calcify and we'returned into a bony structure
rather than a soft diskstructure.
Robert A. Kayal, MD, FAAOS (16:34):
And it matters right, because soft
disks, at least theoretically,have the potential of maybe
going back in place withtreatment, physical therapy, or
the body will absorb some ofthat.
But a hard disk, what we call adisc osteophyte complex or a
hard disk, is something that isnot going anywhere.
It's a chronic degenerativeprocess that has developed over
(16:54):
years and we still willpotentially try to treat that
conservatively.
But the odds of that mechanicalcompression on the spinal cord
or the nerve improving withphysical therapy are not very
good right.
Michael R. Dinizo, MD (17:09):
So we can definitely do things that will
help the patient's symptoms inthose cases.
So we will do things likephysical therapy or maybe
trigger point injections orchiropractic treatment.
There's multiple things that wecan do to help those patients,
but it won't be changing theactual MRI or the structure, the
structural problem that's goingon the spine that time Because
it's a bony structure that'spressing on that nerve, and
(17:32):
sometimes those are the onesthat are more likely to require
some sort of intervention.
Robert A. Kayal, MD, FAAO (17:36):
Right , because the soft disk
potentially can get better withtime.
Do you ever consider getting anerve study if there's nerve
compression?
Michael R. Dinizo, M (17:43):
Definitely so.
When patients have neurologicsymptoms in their upper
extremities, with pain ratingdown their arm or tingling and
numbness in their arms,sometimes the physical exam and
the history is not enough topinpoint exactly what nerve is
the one that's affected.
In addition to that too, thenerves can be compressed in
other places of their arms, sothey can be in their elbow, in
(18:05):
their wrist.
So sometimes that will help us,especially those nerve tests to
help us figure out is it justthe neck or is there something
else, also something called adouble crush phenomenon, which I
think Dr Lane spoke about verywell the other week.
Robert A. Kayal, MD, FAAOS (18:17):
Okay .
So now that you have thediagnosis, you might even know
what level is involved One level, two levels, sometimes three
levels.
What are you going to do?
Michael R. Dinizo, MD (18:27):
So it depends a lot on the severity of
the patient's symptoms, howlong they've been going on and
any of the neurologic issuesthat we've been talking about.
So a patient this is an acutething that they just started
having pain very recently.
A lot of times we'll start withanti-inflammatory medications.
We'll start with physicaltherapy, chiropractic,
acupuncture, those sorts ofthings, and we'll give the
(18:49):
patient time because the studieshave shown that the majority of
patients in about six to 12weeks actually will get much
better.
In the cases of a soft discherniation, that's usually what
we'll start with if it's justpain and it just started.
But obviously we'll follow themvery closely.
The patients having moreneurologic symptoms, where
they're having especiallyweakness, then we tend to be a
(19:11):
little bit more aggressive withtheir treatment and we monitor
them a little bit more closely.
Robert A. Kayal, MD, FAAOS (19:16):
So just to further elaborate on
what you're saying, dr Dinizo,as I've said numerous times in
the past, inflammation isassociated with redness, warmth,
pain and swelling, and the samething happens around the
cervical spine.
Nurses do not like to getcompressed, they hurt like crazy
.
It causes a local reaction ofinflammation which often results
(19:36):
in that redness, warmth, painand swelling, and so sometimes
we'll call our interventionalpain management specialists,
like Dr Aiden, to get involvedto perform a cervical epidural,
and I'm going to have him backin the future to discuss with us
on a future podcast how we infact he treats cervical disc
herniations with hisinterventional pain management
(19:56):
procedures, but suffice it tosay he puts a little bit of
cortisone or corticosteroid witha local anesthetic around the
nerve root or around the spinalcord to decrease that
inflammation, thereby decreasingthe redness, warmth, pain and
swelling.
What else could we do to helpmanage patient's pain?
Michael R. Dinizo, MD (20:16):
So another thing we can do too is
someone's having a lot of painaround their neck area with
muscle spasms.
We can also do trigger pointinjections.
That's something we can do inthe office.
It's similar idea as theepidural we're using a
corticosteroid medication and ananesthetic, but we're targeting
it more for the muscles andsome of the muscle spasms and
pain that patients are having.
So that's another thing that wecan do as well to try to help
(20:38):
with their pain.
Robert A. Kayal, MD, FAAO (20:40):
Great , thank you.
So let's just assume now thatthe patients are still suffering
.
Nothing has worked.
We've done everything thatwe've discussed Physical therapy
, anti-inflammatories,chiropractic intervention,
acupuncture, massage, cervicalepidurals, trapezole trigger
point injections.
When do we finally indicatepatients for surgery to get them
(21:01):
out of their misery?
Michael R. Dinizo, MD (21:02):
So patients that are having
intractable pain, pain that'sbeen refractory to these other
interventions that you were justdiscussing, dr Kale.
Pain that's severe.
They're interfering with theirlife.
They're not able to do thethings that they want to do
every day.
It's diminishing their qualityof life.
That's one of the indicationsthat we can potentially have and
(21:22):
we start the surgicaldiscussion with patients.
Another thing is if someone'shaving weakness that's
progressive or it's in a musclegroup that they need for their
everyday function, we don't wantto let that go for too long
because then potentially thatstrength won't come back all the
way, if it's something that'sleft for too long.
That's why we closely followthe patients.
(21:43):
We do close neurological examsto see if their strength is
changing or if they're gettingworse weakness.
It's definitely something thatwe then we start the surgical
discussion with the patients.
Robert A. Kayal, MD, FAAOS (21:54):
Yeah , I agree with you.
I think nothing's cut in stone.
But for the most part, if thepatient presents with just pain,
we'll treat them veryconservatively because we can do
things to manage their painwith medications or
interventional pain managementprocedures.
Once you start talking aboutweakness, we tend to become a
little more aggressive.
So if the weakness is minor,we'll still treat them
(22:16):
conservatively.
People often give them a goodthree months of physical therapy
, but sometimes the weakness isquite severe.
On the first presentation, onthe first day we see this
patient, we examine this patient, there's almost a flaccid
paralysis.
There's profound weakness.
In those particular cases doyou become a little more
aggressive.
Michael R. Dinizo, MD (22:36):
I do.
It's very concerning to me as aspine surgeon.
The patient comes in withprofound weakness.
Anytime they have profoundweakness, we are worried that
that's going to be somethingthat potentially would not
recover without some sort ofintervention.
Depending on the imaging thatthey have at that time, we might
discuss surgery from the veryfirst time we meet them that
(22:57):
they're having severe weakness,because it's something that we
do take very, very seriously.
I mean.
Robert A. Kayal, MD, FAAOS (23:02):
when I talk to patients about this,
I very often give them theanalogy of when our legs go numb
.
Sometimes, when we cross ourlegs, it's intuitive to just
uncross your legs when your legstarts getting numb.
That's the same concept with apinched nerve in the neck or in
the lower back, it's intuitivefor us to want to take that
mechanical compression off thenerve because we don't want any
(23:25):
of our patients to havepermanent nerve damage.
Okay, I think we've beatenconservative management to death
.
Now for the conservativemanagement of cervical disc
herniations.
Let's now focus in ourattention on the treatment
alternatives for cervical discherniations as they pertain to
surgical options.
What options are available nowin managing these cervical disc
(23:49):
herniations?
Michael R. Dinizo, MD (23:51):
Based on the location of the disc
herniation.
Some of those disc herniationsare more amenable to surgery
from the front part of the neck.
Others are more amenable tosurgery from the back part of
the neck.
It's all based on the locationof that disc herniation.
Just to refresh your memory,looking at this model here, this
is us looking at the spine fromthe side, the front being here,
the back being here.
This is us looking directlydown right on the disc here,
(24:15):
with the nerves coming out fromthe side and in the middle.
Here is where the spinal cordis.
The location of this discherniation helps to dictate how
we're going to do the surgery.
Unlike with a lot of lumbarsurgery where we almost always
will do it from the back part ofthe spine, the spinal cord is
in the middle here.
If we do surgery from the backpart of the spine, we can't move
(24:37):
that spinal cord because it'san extremely sensitive structure
that could lead to severeneurologic issues.
We actually approach it fromthe front part of the spine
through a small incision on theside of the neck which allows us
to access the disc here.
Then we can use specialinstruments and a microscope,
basically, so we can then get tothe back here and remove that
(24:58):
disc herniation that is pressingon those nerves and causing
those symptoms.
Robert A. Kayal, MD, FAAO (25:02):
Thank you for that explanation, Dr
Denizzo.
It's certainly intuitive thatif the problem is in the back of
the disc, we should approachthe disc herniation from the
back.
The caveat is that in the areaof the neck we have spinal cord.
The spinal cord is in our way.
More often than not, thelocation of the spinal cord
(25:24):
forces our hands to operate fromthe front of the spine as
opposed to from the back of thespine.
Thank you, Dr Denizzo.
We've discussed the essentiallytwo options.
We can approach the cervicaldisc herniation from the front
or the back, the front being amuch, much more common exposure
and approach.
Why don't we talk about whatyou actually do when you
(25:49):
approach a cervical discherniation from the front?
You have options, right, youcould take the disc out, but
then there's a void there whenthe disc is gone.
What are the options and whatexactly are you doing when you
approach a cervical disc fromthe front?
Michael R. Dinizo, MD (26:05):
We approach from the front part of
the spine, as you mentioned, wedo have to remove the entire
disc in order to get to the backpart of the spine, where the
pathology is and where the nerveis getting compressed.
Because we have to remove thatdisc in order to get to that
area that's compressing thenerves, we have to replace that
area with something that caneither be a spacer or a cage,
(26:27):
that's filled with the materialthat will allow for fusion and
that's supplemented often witheither plates or screws to hold
everything in place until yourbody is able to heal it on its
own.
More recently, they havecervical disc replacements,
which is another implant thatgoes into the disc space that
allows them to preserve themotion of their neck rather than
(26:47):
doing a fusion surgery.
That's something that's beenout for about the past 20 years
and is a great option forpatients as well, too.
This is looking at the front ofthe spine.
This is the front of the spinehere.
Back of the spine is here.
We're looking at the front partof the spine here.
That shows a plate that hadbeen placed following an
(27:09):
anterior cervical fusion surgery.
This is where the discpreviously was, which was then
removed during the surgery toallow those nerves to be
decompressed.
This is showing it after it hasfused already.
This is actually bone that's inbetween each one of those
vertebral bodies where that discused to be the plate again that
(27:30):
we see at the front here.
That acts as an internal splint, basically to allow those
vertebral body to not move untilthey can heal on their own.
Ultimately, the patient's ownbone basically grows in between
those vertebral bodies and thencreates the fusion.
Robert A. Kayal, MD, FAAO (27:47):
Right .
When you approached this spinefrom the front and took out the
two discs that were compressingthe nerves of the spinal cord,
it left a void.
You have to put something inthere, whether it's a cadaver
bone, a cage bone graft,something to replace the disc
that were removed.
Because the discs are removed,the spine would be rendered
(28:10):
inherently unstable.
You have to do something tostabilize that area as well.
In this particular case, youchose to use a plate.
You did what's called ananterior cervical dyskectomy
infusion utilizing a plate.
The plates are holding thevertebral bodies together,
(28:30):
stabilizing the spine andputting bone graft in between to
allow those levels to fuse andalleviate the compression on the
nerve roots as well.
What other options can youemploy when you address the
cervical spine from the front?
Michael R. Dinizo, MD (28:47):
This other model that we have here.
This shows the plate that's inthe front part of the spine.
This shows some of the othertypes of materials that we
sometimes may put in that spaceafter we take the disc out.
Looking at it here from theside a little bit closer, you
can see at this top level herethere's some bone graft that's
placed in between thosevertebral bodies.
(29:09):
Another option that's verycommon is a cage.
It's usually either plastic ora metal type of cage that is
filled with different biologicsubstances that help to promote
a fusion between the twodifferent levels.
Then when we do that, we havethe plate again on the front
there.
That's going to hold everythingstable until your body is
(29:31):
allowed to heal on its own.
Robert A. Kayal, MD, FAAO (29:33):
Right , you had mentioned earlier that
sometimes on an X-ray you'llfind that the patient has lost
the normal, what we callcervical lardotic posture of the
spine, the normal curve of thecervical spine.
Are there advantages ofapproaching the spine from the
front in order to restore thenormal anatomical curvatures of
(29:53):
the spine?
What is the problem when thecervical spine collapses into
kyphosis?
Michael R. Dinizo, MD (29:59):
Yeah, that's a thing that we look at
before every single one of oursurgeries.
We look at the lardosis withthe curvature of the spine.
Based on that usually becausein the front part of the spine,
here, because those discs havecollapsed, the spine itself
starts to lose some of thatcurvature.
When we approach the spine fromthe front part, there we can
(30:21):
place these implants or thosecages in the front part of the
spine to restore that discheight that that patient has
lost from their injury or fromwear and tear.
When comparing the X-rays frombefore the surgery to afterwards
, we can see that we can restoretheir normal alignment based on
how it was prior to theirinjury.
Robert A. Kayal, MD, FAAOS (30:44):
I think that's so important.
I always tell patients thatkyphosis equals pain In the neck
and in the lower back.
The spine is supposed to havewhat we call a lardotic posture,
a normal cervical posture andlardotic lower back posture that
is curved.
When patients lose thatlardotic posture from muscle
(31:07):
spasm, degenerative disc disease, whatever it may be, that
equates to pain.
Very often we see thesepatients with cervical disc
herniations and lumbar discherniations where they lose the
proper curvature because of aherniated disc or a degenerative
disc.
One of the advantages,especially in the cervical spine
(31:28):
, of approaching the spine fromthe front is that Dr Denizo and
other of our spine surgeons areable to restore the cervical
lardotic posture by sort ofjacking up that degenerative
disc level.
Michael R. Dinizo, MD (31:41):
So this is another model of just the
cervical spine.
So the rest of the spine isdown here.
This is the top of the skull,just for the orientation here.
This is the front of the spine.
This is the back of the spine.
Normally the curvature of thespine should be curving gently
backwards, like this.
When people have muscle spasmsor in the case of disc
degeneration or disc herniation,they can lose the height of
(32:03):
those discs in the front, whichleads to straightening of the
spine or sometimes even aforward posturing of the spine.
Like that During thesesurgeries, when we come in
through the front, we're able toopen up that space again and
restore it to the normalalignment and get them back into
a more natural position, whichleads to less muscle pain, less
neck pain and better function.
Robert A. Kayal, MD, FAA (32:24):
That's the concept behind the cervical
pillow right, the cervicalpillow in the cervical spine and
the lumbar support that'susually offered to help restore
the proper posture of thepatient's lower back and also
cervical spine, where you'resupporting that normal lardotic
posture.
I always tell patients that,for instance, when they're
(32:47):
sitting and standing, to makesure that they're maintaining
good posture, the ear shouldalways line up with the shoulder
, which should always line upwith the elbow, which should
always line up with your hip.
So it helps to maintain a goodposture.
When your ear is lined up withyour shoulder, which is lined up
with your elbow and lined upwith your hip, you can for the
(33:10):
most part, ensure that you'remaintaining a good posture of
your upper back and lower backand neck and that just by
restoring that proper posture itshould alleviate a lot of your
neck and lower back pain.
Michael R. Dinizo, M (33:24):
Definitely agree.
It's much more energy efficientto be well balanced when it
comes to your spinal balance,and that's something that we
take into account.
As we were just talking about,we're trying to restore that
normal alignment which allowsthose muscles to not work so
hard, you know, even throughoutthe day, which leads to less
neck pain and less other issuesas well, too.
(33:46):
I 100% agree with that, forsure.
Robert A. Kayal, MD, FAAOS (33:48):
So let's say the patient doesn't
want a cervical fusion from thefront.
Are there any otherpossibilities to offer certain
patients Sure?
Michael R. Dinizo, MD (33:59):
so something that we do here at the
Kaila Orthopedic Center iscervical disc replacements.
So when we were talking beforeabout replacing that space where
we took the disc out with acage or bone graft, we can
actually put an implant in therethat continues to move, so that
way that patient does not loseemotion at that level.
(34:19):
So that's something that we dohere as well.
We do it for cervical discherniations as well as for other
cervical pathology and patientsdo great.
Robert A. Kayal, MD, FAAOS (34:30):
You know there are certain
circumstances where you canapproach the patient from the
back of the spine, in the neck,and when do you?
When you appreciate thoseopportunities.
Michael R. Dinizo, MD (34:41):
We approach from the back part of
the neck for a disc herniationin just a couple specific cases.
This is usually when somethingis very lateral, lateral,
meaning further from the outsidepart of the spine, away from
the spinal cord.
In that case we can sometimesapproach it from the back and
remove that disc herniation andtake that pressure off of the
nerve.
But it's only in special caseswhere that is a surgical option.
(35:05):
Most often we do have to do itfrom the front, as you said
before, dr Kaila, because thatspinal cord is in the back and
it's something we have to stayaway from.
We can't put any extra pressureon it.
Robert A. Kayal, MD, FAAOS (35:14):
So yes, I agree with that.
It is a rare instance when wecan indicate someone for a
posterior cervical decompression.
But when we find that patient,we're happy, right, because we
can.
We can essentially do thatprocedure in a relatively
minimally invasive manner, takethe pressure off the nerve and
not have to even discuss fusionat that time right.
Michael R. Dinizo, MD (35:38):
Correct.
So in those cases it is a verysmall incision.
We usually use a microscope andtubes to basically allow us to
see that area and that way wecan safely remove that disc
herniation without disruptingsome of the other structures
that would require us to eitherdo a fusion or use some sort of
other implant in order tostabilize the spine afterwards.
(36:00):
So in those cases it is a greatoption for patients because
it's usually a same dayprocedure, it's very quick and
the patients can recover veryquickly.
Robert A. Kayal, MD, FAAOS (36:09):
So we've covered the surgical
approaches for cervical discherniations both from the front
and from the back.
Well, if there are multipleoptions, there must be some pros
and cons of each right, forsure like we were kind of
talking about before.
Michael R. Dinizo, MD (36:25):
With the posterior approach it's a small
incision just on one side.
There's no fusion involved withat that level and the disc in
the front part of the spineactually stays there and stays
intact.
We just removed that small discherniation.
So that's one of the pros withthe posterior approach to the
spine.
From the anterior approach wecan remove the entire disc.
(36:49):
We can decompress the spinalcord and both nerves.
From the the anterior approach,from the front part of the
spine, we can also restore thealignment, as we were talking
about previously.
So we can jack up that discspace after we remove that disc
to help to restore thatalignment.
So that's another greatadvantage of the anterior
(37:10):
approach.
Robert A. Kayal, MD, FAAOS (37:11):
So, when it comes to deciding
whether to approach thesepatients from the front or the
back, you had mentioned thattypically, when we address them
from the front, a surgicalfusion is involved.
How does that affect thepatients?
Acute post-operative course.
Michael R. Dinizo, MD (37:30):
So when we do a fusion the patient very
often is immobilized for acertain amount of time, whereas
with those posterior basedsurgeries there is in the period
of immobilization they can getback to their activities very,
very quickly.
A lot of times in youngerpatients or more active patients
, and sometimes even in athletes, we can get them back to doing
what they wanted to very quicklybecause we don't have to wait
(37:53):
for that fusion in the front orsome of the morbidities
associated with putting animplant in.
Rather than we just take thatdisc out from the back, people
can recover quicker and get backto their activities much faster
.
Robert A. Kayal, MD, FAAOS (38:06):
Yeah , I mean certainly in this area
there are indications to go infrom the, from the back, but
those indications are very, veryrare and although it's
tremendously advantageous to beable to go in from the back and
not have to contemplate fusion,unfortunately those instances
are rare and so so many times inour practice we have
(38:31):
conversations with patientsabout the pros and cons, the
advantages and disadvantages ofcertain things, and sometimes we
will ask the patient toparticipate in that
decision-making process andsometimes it's not so
straightforward.
There are advantages anddisadvantages of both techniques
.
Clearly we get the most bangfor our buck going from the
(38:52):
front, because from the front wecompletely decompress
everything the spinal cord, thenerve roots, we take the entire
disc out and that patient isguaranteed to get better for the
most part.
The downside of that is theyhave to fuse and it can take
months to fuse that cervicalspine.
So the post-op course issomewhat restricted as you
(39:14):
encourage them to protect thefusion and allow it to heal.
The advantage of going from theback is there's no fusion but
there's less bang for the buck.
So sometimes you cannotadequately decompress the nerve
fully from the back because thespinal cord is in the way.
So it's only really those verylateral disc herniations or the
(39:35):
spinal foramen that's gettingencroached upon by a bone spur
or something, a disc herniationthat we can satisfactorily
address from the back.
And sometimes it's borderline,where the disc herniation is a
little bit close to the spinalcord but largely lateral, and
you may have a conversation witha patient, say, look, we're
going to try to go from the backas much as we can and see what
(39:57):
pain goes away.
If you continue to have painand discomfort, we may have to
do a second procedure down theroad.
Do you find that you'resometimes in those situations
with patients?
Michael R. Dinizo, MD (40:08):
Yeah, I do.
And I think the biggest, youknow, the most important part of
that is to talk with thepatient, have that conversation
about the risks and the benefitsand the pros and cons of the
different approaches that wehave.
You know, I think having ashared decision with the patient
and, just you know, discussingthe different likely outcomes of
their surgery and allowing thepatient to have input on that
(40:30):
decision is extremely, extremelyimportant.
Like you were saying, with theposterior cervical decompression
we're just removing thatcompression that's right around
the nerve root.
There the whole rest of thedisc is still there and this
disc has had a herniation onetime.
There's a potential that itcould herniate again.
Work in the herniating on theother side, whereas with the
(40:50):
anterior approach that disc iscompletely removed and both
nerves on both sides of thespine are completely
decompressed.
So that way in the future thatpatient doesn't necessarily have
to worry about having arecurrence of the symptoms at
that level compared to what ifthey did it from the posterior
aspect.
And those are the decisions inthe discussions that we have
(41:11):
with patients, so that way theycan help to make the decision
themselves along with us.
Robert A. Kayal, MD, FAAOS (41:16):
Yeah , but just to be clear, probably
more than likely, over 95% ofyour cervical disc herniations,
when approached surgically orapproached from the front,
correct, correct, yeah, it'svery, very rare to approach
these cervical disc herniationsfrom the back, because we want
to make sure that these patientsare completely satisfied with
their outcomes and that thatnerve is completely decompressed
(41:40):
and really the best way to dothat is from the front.
But again, there are those veryrare circumstances where we may
be able to get away with theposterior cervical decompression
and I just wanted to bring thatto your attention.
As far as disc replacementsurgery, how often are you able
to do a disc replacement andwhat are the indications for a
disc replacement?
Michael R. Dinizo, MD (42:00):
The indications for a disc
replacement are a little bitmore restrictive than they would
be for a fusion type of surgery.
If a patient has discdegeneration and they have
degeneration of other parts ofthe spine there's something
called the facet joints, whichis in the back part of the neck
If they have arthritis oranything there, they might be
better off with a fusion type ofsurgery, so that way those
(42:21):
arthritic joints aren't movinganymore.
If there's no arthritis inthose joints, by maintaining
motion there that patient couldpotentially have increased range
of motion and reduce the riskof what we call adjacent segment
disease.
That happens from having afusion in one area of the spine.
Robert A. Kayal, MD, FAAOS (42:39):
Yeah you can imagine that if you
fuse one level, the area belowand above that level is going to
have to pick up the brunt ofthe load right and work harder
than they're used to working andultimately maybe become
degenerative and wear out andrequire a fusion above and below
.
And that's where the concept ofa disc replacement really
became popular.
(42:59):
If we can preserve motion atthat level and decompress the
nerve at the same time by takingout the disc and instead of
fusing it, get away with a discreplacement to preserve motion,
that should hopefully preservemotion throughout the entire
cervical spine and avoid thecomplication of having an
associated adjacent disc diseasein the future, requiring a
(43:24):
fusion in those levels.
Michael R. Dinizo, MD (43:26):
Correct.
Yeah, so that's been the ideabehind the cervical disc
replacement, and both surgeriesare extremely successful at
decreasing the patient's pain intheir neurologic symptoms.
Most of the studies show thatthey're very close to equivocal,
with the disc replacementshowing a slight decreased risk
(43:46):
of that adjacent segment disease, meaning the disc above and
below the area that has surgerypotentially degenerate slightly
faster with the fusion comparedto the disc replacement.
Both are extremely successful.
Robert A. Kayal, MD, FAAOS (44:00):
Yeah , but just to be clear, the gold
standard of care is what'scalled the anterior cervical
discectomy and fusion.
For the most part correct.
Michael R. Dinizo, MD (44:06):
Correct.
Yeah, the disc replacement isgreat in the times when we can
use it, but definitely the goldstandard is still the fusion,
the anterior cervical discectomyand fusion.
Robert A. Kayal, MD, FAAOS (44:17):
Yeah , for that acute cervical disc
herniation that's going toundergo a cervical disc
replacement.
That patient really needs tohave a very clean spine, right.
Michael R. Dinizo, MD (44:26):
Yeah, it's usually younger patients
that have normal alignment oftheir spine.
They don't have other issueswithin their spine.
As far as degeneration in bonespurs forming or arthritis in
their neck, the indications forthat are a little bit more
restrictive compared to thefusion, but in the cases where
it is indicated, patients dogreat.
Robert A. Kayal, MD, FAAOS (44:47):
Yeah , so if you don't mind, just
comparing contrast for ouraudience, the post op protocol
for the different varioussurgical procedures you
mentioned the anterior cervicaldiscectomy and fusion with
plates or cages or however youwant to proceed, versus the
anterior cervical discreplacement, versus the
(45:07):
posterior cervical decompression.
Michael R. Dinizo, MD (45:10):
Sure.
So with the anterior cervicaldiscectomy and fusion a big part
of the post op restrictions intheir care depends on whether
this is done at one level of thespine or multiple levels.
I think, kind of just tocompare apples to apples, if
we're comparing a one levelcervical disc replacement versus
(45:31):
a one level anterior cervicaldiscectomy and fusion, the
patients that have the discreplacement they're able to get
back to activities a little bitearlier than the fusion patients
.
The fusion patients usuallythey have about six weeks of
restrictions, the restrictionsbeing they can continue all
their regular everydayactivities but we don't want
(45:51):
them doing anything to shreners,one for avoiding lifting
anything heavy bending, twistingthose sorts of things.
Those are the restrictions thatwe have for the fusion patients
, whereas with the disreplacement patients they can
get back to their activitiesusually within two to four weeks
.
When we're talking about theposterior cervical decompression
patients, the recovery ispretty quick.
(46:12):
We give them a soft collar asneeded, basically just to help
them with the comfort they'reable to get back to their
activities as soon as we get tosee them for their post
operative visit and their woundis healed and everything.
Then we can start to gentlybring them back to all their
normal activities.
It can be pretty quick recoveryfor the posterior cervical
(46:33):
decompression.
Robert A. Kayal, MD, FAAOS (46:34):
Yeah , as far as the surgical
outcomes, I would venture toguess and say that cervical disc
surgery for you is probably themost rewarding procedure you do
.
Michael R. Dinizo, MD (46:49):
It's my favorite surgery, whether the
disc replacement or the fusion.
The studies that are publishedshow anywhere from 90 to 95%
complete relief of arm pain.
Patients are very happyafterwards.
It's a surgery that I reallylike to do because I can have
the discussion with the patientsthat we have a very high chance
(47:11):
of decreasing their symptomsand their pain and getting them
back to enjoying their life more.
So it's a great surgery andit's an honor to help patients.
Robert A. Kayal, MD, FAAOS (47:22):
It's certainly a very gratifying
procedure and that's for themost part why most of us have
chosen the field of orthopedicsurgery.
We all appreciate that instantgratification, and nothing gives
a spine surgeon more instantgratification than doing a disc
surgery on the cervical spine.
I think Because, again, whenthat spinal cord and when those
(47:42):
cervical nerve roots arecompressed, the patients are
miserable.
They're suffering, they're inso much pain and for the most
part they wake upinstantaneously without pain and
they continue to improve dayafter day after day.
It's a very minimally invasivesurgery, very often done almost
exclusively as an outpatient,for the most part through a very
(48:04):
small incision.
Patients have little to no painafter surgery, experience
immediate pain relief from thenerve compression, and that's
what we're all about here at theKaila Orthopedic Center to
provide patients with cuttingedge orthopedic technologies and
pain relief.
So that's what we're in thebusiness of doing.
So, dr Denizl, let me ask you aquestion now.
(48:26):
That's, I'm sure, on all of ourpatients' minds, and that is if
I'm about to undergo a fusionof my cervical spine, aren't I
going to lose motion in my neck?
Michael R. Dinizo, MD (48:36):
Yeah, so that's a very common question
that I get anytime.
We're talking about fusionsurgery for the cervical spine,
so a big thing that goes intothis is where in the cervical
spine that that fusion is goingto happen.
The top three, the C1, the C2and the C3 vertebrae, are the
ones that are responsible forthe majority of your everyday
(48:58):
motion, looking side to side andup and down.
When people have cervical discherniations, it's most common to
happen at some of those lowerlevels of C5, c6, c7, sometimes
at the C4 or C5.
Those levels are notresponsible for a lot of the
everyday motion that we that weneed to drive our car or to do
any of the activities that wenormally want to do.
So those lower levels, from theC4 down to the C7, those are
(49:21):
mostly with bending your neckside to side, which is not
normally a motion that people doa lot during their their
everyday activities.
And even with a multi-levelfusion, their motion for the
most part in every everydayactivities is completely
preserved and that there's norestrictions on what they want
to do.
Robert A. Kayal, MD, FAAO (49:38):
Great .
Thank you for that, dr Diniz.
So another question that theyoften have is well, what about
activities of daily living?
What will I still be able toparticipate in after I undergo a
fusion of my neck?
Michael R. Dinizo, MD (49:51):
So more early on, within the first six
weeks or so after surgery, we'retrying to let the patient
recover and avoid most strenuousactivities.
But once they're healed theycan reach almost all normal
activities.
Even there's been professionalfootball players who have gone
back to playing in the NFL afterhaving cervical fusions.
Patients are able to playsports once they're healed and
(50:16):
they can get back to almost alltheir regular normal activities
without any restrictions onceeverything is healed up.
When we're talking about thecervical disc replacements,
patients can get back a littlebit quicker because we don't
need to monitor for that fusionthat needs to happen in between
those vertebrae.
So with the cervical discreplacements, patients can get
back to almost all unlimitedactivities within the first six
(50:39):
to eight weeks after theirsurgery.
Robert A. Kayal, MD, FAAOS (50:41):
One thing I think is very important
for our patients to understandis that when surgeons perform a
fusion of the cervical spine anduse implants like plates and
cages and bone grafts the platesand cages they're designed to
keep the bones together to allowthe biological fusion to take
(51:02):
place, and once that biologicalfusion takes place between the
vertebral bodies, the plates andthe cage really serve no
function at all.
So it's really really importantduring that post-operative
period that patients are takingsupplements like calcium and
vitamin D and avoiding certainthings like smoking and alcohol
(51:24):
consumption and even the usageof over-the-counter
anti-inflammatory medications,all of which have been shown to
significantly deleteriouslyaffect outcomes after this type
of procedure.
Is that something that youcounsel your patients on?
Michael R. Dinizo, M (51:39):
Definitely .
It's all part of the historybefore talking about smoking and
risk factors that we can modifybefore the surgery so that way
the patient can have asuccessful outcome.
So if there's smokers, we talkto them about that.
We discuss avoidinganti-inflammatory medications
afterwards and also talkingabout their bone health too, so
they have a history ofosteoporosis or other things.
(51:59):
That will be something we wantto keep in mind when we're
talking about the differenttypes of surgery, because we
want them to heal, we want themto do well, absolutely.
Robert A. Kayal, MD, FAAOS (52:08):
I know we've even canceled
patients proposed surgicalfusions when they would not stop
smoking.
That significantly increasesthe risk of what we call
non-union, where the bones willnot fuse.
Well, this has been a veryinformative and very
enlightening podcast.
Have you here with us, drDenizzo.
(52:30):
I've really enjoyed our timetogether.
We hope that you have foundthis podcast informative and
helpful in your assessment andunderstanding of a cervical disc
herniation and a pinched nervein the neck.
So I just really want tosincerely thank you for your
time and your expertise.
It's a privilege and honor tohave you with us at the Kaila
(52:51):
Orthopedic Center caring for ourpatients.
Thank you so much for your time.
Michael R. Dinizo, MD (52:54):
Thank you , dr Kail, we appreciate it.
Robert A. Kayal, MD, FAAO (52:57):
Thank you.
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