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

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

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

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

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Episode Transcript

Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is March 14th, 2024 andwe're so privileged to have with
us today Dr Paul Boggy, ourvery own Orthopedic Spine
Surgeon.
Dr Boggy serves as the chief ofspine at the Kale Orthopedic
Center and Dr Steven Aiden.

(00:20):
Steve is the chief ofInterventional Pain Management
at Kale Orthopedic Center.
Welcome to the podcast, drBoggy and Dr Aiden.
We're so happy to have you heretoday.
Today's featured presentationis on the ubiquitous condition
we call sciatica.
Dr Boggy, take a second and, ifyou don't mind, just refresh

(00:41):
our viewing audience's memoryAbout the condition of sciatica.
Can you describe that conditionfor us?

Paul Bagi, MD, FAAOS (00:48):
Yeah, so sciatica is a very common
problem that we see in ourpatients, and it's actually more
of a Description of a symptomthan an actual diagnosis, and
what I mean by that is there area few different things that can
cause sciatic pain.
So sciatic pain is pain thatruns along the sciatic nerve,

(01:10):
which runs down from the lowerback across the buttocks and
down the back of the leg all theway down to the foot, and so
people can have pain anywhere inthat distribution.
It doesn't have to be along theentire path.
The most common cause is alumbar disc herniation, usually
at l5s1, which is the lowestlevel in the back, and sometimes

(01:33):
at l4 5, which is the secondlevel, second lowest level in
the back.
A couple other things can alsocause it any kind of
degeneration in the lower back,maybe that causes bones burrs or
disc bulges that hit the nerveon their way out, and then
paraforma syndrome, which is amuscle that's in the buttocks

(01:53):
underneath the gluteus, can alsopinch the nerve and cause pain
in the same area.
So it's a very, very commoncondition that affects a lot of
people.
It causes a lot of issues withactivity, going to work, sitting
for long periods of time andyou know, really Treating it and

(02:14):
getting people back to doingall the things they want to is
very, very important.

Robert A. Kayal, MD, FAAOS (02:18):
Yeah , thank you so much, Dr Aiden.
Are there certain groups ofPatients that are maybe
predisposed to developingsciatica?

Dr. Steve Aydin (02:28):
Sure, you know in general sciatica is such a
common thing but, as dr Boggymentioned Both currently and in
the previous podcast talkingabout sciatica, you know it most
commonly.
It's probably the most commonthing we see in the practice
from a pain perspective.
But what are the things thatare at risk for them in in

(02:50):
different populations andespecially younger individuals
that have healthy discs?
You know, a disc herniationthat kind of protrudes out or
touches the nerve and pinchesthe nerve can often be the main
cause of a patient feelingsciatica or pain down the leg.
The other thing that can causeit is degeneration.

(03:10):
So there's a subset of patients.
As we age, our discs kind ofdehydrate and they go from being
like a grape to a raisin and sowhere I mentioned earlier, you
have that disc that leaks orpops or herniates and the
Gellier, the part of the disc,kind of touches the nerve.
Now you're kind of in thedehydrated disc that kind of

(03:30):
gets smushed Like a raisin doesand it starts pushing onto the
nerves and hence touching thenerves and giving you that
sensation Down that wire, thatsciatic nerve or the nerve root
that makes up the sciatic nerve,giving that pain into the leg
or the back of the leg, andthat's usually in the older
population.
So you have these twocategories or these two groups

(03:52):
of people the younger healthydisc versus the older
degenerative disc.
So those are mainly the twoconditions that we'll often see
Kind of present into the office.

Robert A. Kayal, MD, FAA (04:04):
That's what I was sort of getting at.
It's sort of the young,typically the younger active
patient with a healthy disc thatultimately twist their back in
some provocative position orperform some maneuver, lift
something very heavy, sits on anairplane eight hour flight for
a long period of time, goes tolift a box without proper body

(04:27):
mechanics, coughs, knees vacuums, things like that.
These are the typical patientsthat will endure a lumbar disc
herniation at a youngerpopulation, from probably age 20
to 40 or so, like that.
Older patients, as we'vealluded to in the past,
typically suffer from lesssciatica but more of

(04:50):
degenerative conditions, and weand I know we did a podcast in
the past about this conditioncalled spinal stenosis.
But today we're going to focusprimarily on that younger age
group population age 20 to 40 or50 years of age where they have
a pretty healthy looking back,except for some type of trauma
of some sort.
They twist, they lift, theycough, they sneeze, they sit for

(05:14):
a prolonged period of time andand their spine is typically in
an Abnormal posture which willthen subject themselves to a
lumbar disc herniation.
Incidentally, I know we talkedabout the younger age population
that is at risk for this, butalso smokers, right, dr Boggian,
that's correct, and why is thatso?

Paul Bagi, MD, FAAOS (05:34):
what smoking does?
It's, as we know, there are alot of different things in
cigarettes.
One of the main ones that doesthis is nicotine, but also tar
and a couple of other productsthat are in there, but it
decreases the blood flow toevery part of the body, and here
specifically, the problem isthat the discs already have a

(05:55):
poor blood supply, so theyactually get all their nutrients
from the bone that's right nextto it, and so with smoking,
what happens is the blood flowis decreased to the bone and the
nutrition doesn't get to thedisc, and that causes the disc
to start to wear down, making itmuch more prone to injury.

Robert A. Kayal, MD, (06:14):
Absolutely .
And also the position of thespine and certain occupations
will certainly increase yourrisk and predispose you to
developing a disc herniation.
You know, I remember that we'vedone in the orthopedic field,
we've done Clinical studieswhere we've placed transducers
into discs and then we measuredthe pressure inside the discs in

(06:35):
different positions and theyconcluded that essentially,
sitting, coughing, sneezing, etc.
Will increase the andvibrational, constant
vibrational maneuvers like thiswhere the spine is going up and
down, for instance, if you're atruck driver or a bus driver and

(06:56):
your your spine is constantlyenduring it Axial load, that
will increase the pressureinside the disc and predispose
to disc herniations.
Furthermore, they concludedthat lying down flat, unstant
and standing has decreased thethe pressure inside the disc,
creating almost a negativepressure which is favorable for

(07:19):
a disc correct, yeah, and I mean, dr Kale, you hit it right on
the head.

Dr. Steve Aydin (07:22):
The disc is kind of like a shock absorber
and you know, as dr Boggiealluded, it'sa A item that
receives very little vascularsupply.
So it's turnover and it's itshealing process is very, very
slow and its inflammatoryprocess is very, very fast or
over exaggerated.
So you can't really mitigatethe inflammation in the disc

(07:47):
like that because there isn'tgood blood supply.
The disc is really prone tothose kinds of injuries because
of its, its architecture.
It's not a perfect circle, it'snot reinforced really well on
every part of itself.
It has very weak points,especially in the positions that
put pressure on it that youjust described.
So if leaning forward, leaningforward and twisting Increase

(08:11):
the pressure on the disc byalmost two to three fold, and
then if you're sitting Leaningforward and twisting, it almost
increases it to five, and that'susually the position that
Places the disc at the highestpressure, with a high risk for
herniation or that Kind of thatpop effect or leaking of the
disc that compress onto thenerve, which is unfortunate

(08:33):
because a lot of these patientsare young, active patients,
right, and a lot of thesepatients want to participate in
racket sports and golf inparticular, and that's always
difficult managing thesepatients.

Robert A. Kayal, MD, FAAOS (08:43):
What do you do with patients like
that, dr Boggi?
Yeah, so exactly what we'retalking about here.
Those are actually also thesymptoms to quickly review.

Paul Bagi, MD, FAAOS (08:55):
People will have increased pain when
they're in those positions.
So sitting in a car for anextended period of time is
usually very uncomfortable, andwhen you're sitting, the sciatic
nerve is very uncomfortable,and when you're sitting, the
sciatic nerve is also undertension.
So not only are you puttingmore pressure on the disc, but
the nerve that's alreadyirritated is getting put under

(09:17):
tension.
So that's usually how Patientspresent, as we've been talking
about, and then in terms of whatwe do about it.
But really the key is to getpeople back to everything they
want to do.
So activities, work, and thegreat news is that most people
do get better without needingany invasive treatment.

(09:39):
So 90% of people will getbetter, usually between four to
six weeks, and so initially webegin with things that can help
strengthen the musculature thatsupports the spine.
So working on the core, thelower back and the muscles that
are around the pelvis,especially the hips and down

(09:59):
into the legs as well, includingthe quads and the hamstrings,
is very important, so that cantake the pressure off the disc
that's injured.
Physical therapy is very, veryhelpful with that.
Other things we can do tomitigate the pain is
chiropractic treatments,acupuncture.
Both can work very, very well.
The key in the beginning is toget that acute pain down so that

(10:21):
people are able to do more ofthe things they want to, and of
course what the goal is is thatevery day and every week that
pain continues to decrease Alongwith those.
Medications can also help.
So anti-inflammatories can workvery well to decrease the
inflammation.
Sometimes the inflammationcauses muscle spasms, and so

(10:44):
muscle relaxants can work wellalso, and sometimes nerve
medications can be very helpfuland they help to decrease the
sensation or pain, numbness,tingling that's going into the
leg from the nerve compression.
So that's usually how we beginand usually it's very effective.
And of course we have all ofthose treatments at Kale

(11:04):
Orthopedic Center, so we're ableto provide patients with care
as soon as they come in and tryto get their pain down.

Robert A. Kayal, MD, FAAOS (11:13):
Dr Ian, what role does posture play
in the management of lower backdisorders, sciatica and the
spine in general?

Dr. Steve Aydin (11:21):
I mean posture is really important, poor
posture, whether you'reslouching or kind of just
putting a lot of pressure on thelower back, kind of losing that
normal curve.
So in your neck you have kindof this backwards or a C which
is called the lower or lowerdoses, and then it curves into
the mid back, called a kyphosis,and then back to a C for a

(11:44):
lower doses and then to akyphosis for the sacrum.
So there's supposed to be a Cin your neck and your lower back
and you're supposed to maintainthose positions, mainly because
that's where the least amountof energy or force is pulled
onto the spine from gravity.
So if you start losing that C,where you kind of bring your
shoulders forward and you bringyour head forward or you slouch

(12:04):
your back and you slouch forward, you're actually putting more
pressure on the disc because nowyou're putting flexion or
leaning forward position ontothe discs which are very, very
mobile, and that puts morestrain, shear wear and tear and
hence accelerates thatdegenerative process.
So, as Dr Boggi mentioned,physical therapy, core

(12:26):
strengthening, staying limber,those things are paramount in
trying to maintain properposition.
And then what it also does ismany times we talk about the
back as just the back.
We forget that the back or thespine is really a tube.
So with the abdominal muscles,the side muscles, the obliques,
all those components areactually recruiting and

(12:49):
activating to kind of maintainthis tube that is really your
spine, because if you just thinkof it as just the back and
where the vertebrae and thediscs are, you're missing three
other components of this cube orthis sphere as we talk about.
That's really maintaining theposition.

Robert A. Kayal, MD, FAA (13:06):
That's an excellent description.
In fact, you hit the nail onthe head.
That's exactly the point I wastrying to make, and actually I
think it's so important that Ithink it's worthy of
demonstration.
So we're going to take a minuteto demonstrate exactly what
we're talking about, because Ithink it is so critical to the
management of spinal disorders,and I know Dr Boggi and Dr Aiden
agree.
So we're going to pull out amodel and we're going to

(13:28):
demonstrate exactly what wasjust described.
So this is a model of exactlywhat Dr Aiden so eloquently
described, and I do want torefer you back to an older
podcast that I did with Dr PaulBoggi.
I think Dr Boggi did such amagnificent job in describing
this as well.
But essentially, this is what wewould describe as a side view

(13:49):
or a lateral view of the entirespine.
Up here we're dealing with thecervical spine.
Up here, that's where the neckwould be, and this is that
C-shaped lardotic posture of thecervical spine, which is
appropriate.
And then in the upper spine, orthe thoracic spine, we're
appreciating this kyphoticposture and, again, that's

(14:11):
normal.
In the lower back, this is whatwe call the lumbar spine, or
the normal lumbar lardoticposture, that C-shape that Dr
Aiden was describing and again,that's a normal posture.
And then, finally, in thesacrum and coccyx, we again
appreciate this kyphotic spinalposition and again, that's

(14:33):
normal.
The body and, by the way, in thecoronal plane or in the AP
trajectory, we should not seeany curvatures.
It should for the most part bea straight line.
A curvature in this coronalplane would be described as
scoliosis and that's a conditionand topic that we will discuss

(14:56):
in a future podcast.
But for today's purposes, we dowant to appreciate that the
spine has this normal curvaturein the sagittal or lateral plane
.
Now, it's important that it'sin this position because this is
where the discs and the spineand the patient is most
comfortable and that is becausethere is something called center

(15:19):
of gravity.
Can you describe that for us,dr?

Paul Bagi, MD, FAAOS (15:23):
Paghi, yeah, so this is very important
to spine health and causes a lotof discomfort and pain and
disability when it's not in thenormal alignment.
So if you think of a coneextending from the pelvis up
towards the head, with the pointat the bottom and the wider

(15:45):
part of the cone at the top, thefurther away from the center
that the head is, towards thefront, towards the back or
either side, the more pressurethere is on the entire spine.
So in normal alignment the headis centered right over the
pelvis, so that gravity is doingmost of the work to keep it
there.
As soon as our head is nolonger positioned over our

(16:08):
pelvis, there is an extremeamount of force that's going on
the entire spine and then ourmuscles have to work to pull our
head back over our pelvis, andthese muscles get tired very
quickly when they're doingsomething they weren't designed
for and that can cause a lot ofpain, a lot of discomfort, and
people can barely do things theyneed to on an everyday basis.

(16:31):
They can get to the point wherepeople can't stand and cook, do
the dishes full laundry formore than a few minutes at a
time, and so that's anotherreason why this alignment is
very important Because whenwe're younger, a lot of times it
does have to do with posture,and sometimes it's pain that's
causing our posture to be offfrom where it's supposed to be,

(16:54):
and this is where our excellentphysical therapists come into
play.
So they are very focused onbringing back our normal posture
by strengthening the musclesthat have become weak over time
and so really focusing on thecore, the stabilizing muscles,
the lower back, mid back muscles, and bringing that strength

(17:15):
back, also working onflexibility and stretching, and
a lot of times when we'reyounger, that's really all we
need to fix our posture, bringthe spine back into alignment
and really decrease a lot of thediscomfort that people are
having from sciatica or discherniation.

Robert A. Kayal, MD, FAAOS (17:32):
Okay , that was great.
And just to further elaborateon that, dr Bagi and this will
be the last thing we'll talkabout until we get into the
treatment options for sciatic inparticular it's so important
that I just feel the need toelaborate a little bit.
If the head is up here, forinstance, and the head is
resting on the cervical spine,dr Bagi is describing that the

(17:52):
spine is and gravity issupporting that head, without
much pain or discomfort to themuscles surrounding the spine.
A lot of patients' neck go intospasm and it straightens out
and all of a sudden the head isleaning forward and so the
muscles in the back have tosupport that head that wants to
fall off and so that causes alot of neck pain.

(18:15):
So, to extrapolate to the lowerback, the same principle
applies.
The lower back muscles are verycomfortable when the spine is
in lordosis.
The whole body weight is beingabsorbed by this beautiful
architecture.
The discs are happy, themuscles are happy, the patient
is happy.
No back pain.
The second the lumbar spinecollapses into either spasm or

(18:40):
straightening or loss of thatnormal lardotic posture or
potentially into kyphosis.
The lower back muscles arescreaming, they're writhing in
pain, the discs feel pressurethat they should not feel and
ultimately can hernia and causesomething like this lumbar disc
herniation that we're seeing.
So enough about thearchitecture and the design and

(19:04):
position and the importance ofposture.
Let's now focus our attention onsurgical and interventional
pain management options for thetreatment of sciatica.
So, dr Aiden, let's take thisopportunity and I'm going to ask
you to speak to our listeningand viewing audience from least

(19:24):
invasive to most invasivenon-surgical treatment options.
When I say non-surgical, I meanwithout the intervention of a
spine surgeon.
Dr Aiden is an interventionalpain management specialist.
He does surgical procedures ina very, very minimally invasive

(19:46):
manner and if and when those arenot enough, that is typically
when we employ the expertise ofour board certified fellowship
trained spine surgeon like DrPaul Bogge.
So in the beginning, I'd liketo focus our attention on
treatment alternatives that canbe offered by a technically
savvy, cutting edgeinterventional pain management

(20:09):
specialist like Dr Steve Aiden.
So, steve, take it from here.
What can you offer our patientsthat are suffering from back
pain?
But, in particular, today'spodcast is on sciatica.

Dr. Steve Aydin (20:22):
So in general there are a lot of different
options that can be offered forthings that are causing sciatica
.
The most important thing ineven starting a treatment is
kind of establishing what thecause of the sciatica is.
So imaging in your physicalexam whether it's an MRI, x-ray,
ct scan, electrodiagnosticstudies, all those things should
kind of be teed up with thepatient who's had this stubborn

(20:45):
symptom, where they may haveseen their primary doctor.
They got some medications, youknow.
They started some chiropracticcare which can help with the
alignment and adjustments of themuscle spasms, and I've really
gotten to a point where they'veplateaued.
They've tried physical therapyas well, or they're just in such
intense pain nothing is working.

(21:06):
So once we establish what thecause is and we talked a little
bit about the disc herniation inthe younger population, you
know once that disc herniates itcauses this inflammatory
cascade.
You'll often start with somesort of history where the
patient went to pick somethingup, felt a pop, intense back
pain.
They seek care, the intenseback pain gets better and then

(21:26):
all of a sudden they have legpain, and so that sciatica pain
is where we start to getinvolved as interventionalists.
Many times one of the firsttreatments that someone could
try is something called atrigger point injection, and
many times the orthopedist orthe PAs or the primary care
doctor has already gone downthis road.
They kind of palpate along thearea in the spine, they find

(21:50):
areas of muscle spasm whetherit's in the lower back muscles,
the gluteal muscles, thepiriformis muscle and they take
a needle and they sprinkle alittle bit of numbing medication
and some cortisone or some justnumbing medicine, no cortisone,
even saline or something elsewe call dry needling, and they
just try to agitate the musclewhile introducing a local

(22:13):
anesthetic and a little bit ofcortisone to help reduce the
inflammation.
So that's one of the simplestkind of bread and butter first
line treatments that we'll oftentry for someone with stubborn
sciatica.
If that works, great, thepatient improves, they don't
need anything from me, theydon't need to see Dr Baghi.
If that doesn't work, what'sthe next step?

(22:33):
If we establish that it workeda little bit or it didn't work
at all, we start thinking aboutthings along the lines of
getting to the area where theinflammation is coming from, and
once we've established the MRIand looked at the images and we
see a disc herniation that kindof matches the symptoms, we'll
talk about something called anepidural steroid injection.

(22:55):
Now, an epidural steroidinjection is a X-ray or live
fluoroscopy guided injectionthat we get a needle near the
nerve or the disc or both and weinject a combination of sterile
salt water, a numbingmedication like lidocaine and a
corticosteroid or just steroidinto the area.
The goal of that is to helpmitigate that inflammation

(23:18):
response that that disc hascaused.
That disc can cause the problemfrom a few different effects.
Sometimes it's purelymechanical the disc herniates,
it pushes onto the nerve, itpushes the nerve into the corner
of where it exits and itinflames, it swells and there's

(23:40):
no relief.
The other way it can cause painis where the disc leaks or the
disc gets a tear in it and aninflammatory fire forms and that
agitates the nerves around thedisc, the big nerve that goes
down the leg and causes thispain pattern.
The ones that I think respondthe best to an epidural are
probably the latter, the onewhere it's an inflammatory

(24:04):
cascade, and those are thepatients that will usually
respond to the steroid pack oranti-inflammatories or the
trigger points.
But it will only last for ashort time and then it returns
after a week or a few weeks andI get in there and I do an
epidural.
Now the epidural can be donedown the middle into the center
of the spine, which is called aninterlaminar approach, or from

(24:24):
the side, which is called atransferaminal approach, and one
is done for another reason oranother.
Sometimes we switch, sometimeswe try one, thinking it's more
for the leg if we do atransferaminal approach, or for
the back pain If there's moreback pain than leg pain we'll do
an interlaminar approach.
But I've been doing this longenough to know that there's no
real great algorithm for that.

(24:47):
The former condition, where it'sactually the disc, is pushing
onto the nerve, or a goop ofjelly has popped out of the disc
and pushing on the nerve and nomatter what I do, no matter how
much I inject, I can cool itoff for a couple days and then
the pain just returns.
And that's kind of thesituation that I'm trying to get
better and prevent from sendingto Dr Boggi.

(25:07):
But that's where I get stuck.
The epidural one works for acouple weeks.
I see the patient back.
We talk about a second, maybe adifferent approach.
Same thing happens again.
They get better, but they'restill uncomfortable, they're
still functionally not wherethey need to be and that's where
I kind of say, well, now weneed to talk about surgical

(25:31):
options.

Robert A. Kayal, MD, FAA (25:32):
Before you get there.
Steve, what are your thoughtsabout the epidural?
Do you feel that the epiduralis actually treating the
condition or masking thecondition?
Because these are some of thequestions that the patients ask
in the office.
They're concerned why are wedoing the epidural?
Are we just masking it?
A lot of times patients want toknow their body, how it feels,

(25:54):
and if it's still there andthey're still having pain, then
it's not really getting better.
What are your thoughts aboutthe epidural?
What are we looking to?

Dr. Steve Aydin (26:02):
achieve.
That is one of the hardestquestions I get in the office
Because in the population thatwe're talking about, where it is
a younger, more activeindividual, healthy individual,
the first question they'll askme is, like you said, is this
just going to mask my pain?
Or two, is this going to fixthe problem?
So let's attack the first oneno, it's not going to mask the

(26:25):
pain.
The pain is purely a result ofinflammation.
So if I do an epidural and Ireduce the inflammation from the
event that caused theinflammation, then the patient
should get better.
We don't often treat pictures.
So many times we'll see an MRIand we'll see herniations all

(26:45):
over the place, you'll seedegeneration at one level or
there's just a multitude ofthings on the report or the
image that we don't treat.
So it's very hard for me totell a patient we're going to
change your spine.
No, the epidural is not goingto change the way the spine
looks the day before or the dayafter the epidural.
But we also don't treatpictures.

(27:07):
We treat symptoms.
So if the symptoms aregenerated by an inflammatory
process, then they should getbetter.
Many times when the patientasks, well, am I just masking
the pain with this?
I'll tell them well, no, you'renot, because the difference
between a symptom and no symptomis nanometers of swelling or
irritation.

(27:27):
So if I can reduce theinflammation where the nerve is
no longer glued to that jellyfrom the inflammatory goop
that's happened there and thenerve is now free to slide and
glide, as we talked aboutearlier, with the core
strengthening and the physicaltherapy, then the patient should
be better.
Nothing I'm giving the patientis going to numb the nerve for a

(27:49):
period of time be around anhour or two where they won't
feel pain if it comes back.
So it's very hard to kind ofconvince the patient that we're
not just masking it, we'retrying to reduce the
inflammation from it.
The second part of the questionthat you asked me is why don't I
just jump to fixing this andlisten?

(28:09):
My job here as much as I loveDr Boggi and the other surgeons
in the practice I've alwayslooked at this interventional
spine as kind of preventing.
My job is really to prevent youfrom needing surgery in a
reasonable manner.
So if I do this injection andit necessarily doesn't change
your spine, it doesn't mean thatthe problem places you at risk

(28:32):
for more problems.
The goal is to get the patientback to functioning.
The herniation can still bethere and the patient may still
be functional and not have pain.
It's the stubborn cases wherethe epidural doesn't work or it
doesn't respond that we need tohave that conversation or sit
down Now.

(28:53):
In general, most times we startwith conservative and we
escalate to surgical.
I'm not saying thatinterventional options must be
done in every situation.
Someone who's neurologicallycompromised, they're weak or
they're just incapacitated, nomatter what I do, even if they
have one epidural, it does zero.
Or they're just neurologicallycompromised, with weakness or

(29:16):
bowel bladder issues.
I'm not even talking about anepidural.
I'm saying listen, you need tosee the surgeons because, no
matter what I do, you're at apoint where I don't think it's
going to return.

Robert A. Kayal, MD, FAA (29:26):
Before you even continue any further,
I'm just interested, I'm curiouson your perspective of what
we're looking to achieve withthe epidural.

Paul Bagi, MD, FAAOS (29:35):
Yeah, great question.
So, just like Dr Aiden said,the epidural can be very
effective at decreasinginflammation.
So I think everything goes backto getting people back to full
activities I think that's thekey and, of course, to eliminate
their pain.
And, just as Dr Aiden said,often we're looking at the

(30:00):
imaging and we see issueselsewhere in the spine that
aren't causing any problems, sowe don't need to treat those and
that's why, if we can getpeople feeling better, back to
full activities with an epidural, it's a great treatment.
And there have been times whenI've seen imaging where I didn't

(30:21):
think the patient would feelbetter with an epidural.
And they've got an epiduralwith Dr Aiden and they've been
great and back to work inactivities without any issues.
Often symptoms won't return,and so that's the key.
I do want to emphasize, as DrAiden said, that there are a few
situations where we want to gowith surgery sooner rather than

(30:45):
later.
The two main ones are weakness,and we can see which nerve is
being compressed or compromisedby where that weakness is.
Each nerve goes to a differentmuscle and so we can see that
weakness in ankle motion, kneemotion, hip motion.
The other one is when somethingcalled catechina happens and

(31:08):
that's when the disc herniationis so big that it compresses all
of the nerves that are runningup and down the canal.
That can lead to issues such asloss of bowel and bladder
control, and that's somethingthat's actually a surgical
emergency.
We want to do that as quicklyas possible.
The studies show that if we cando it within two days, people

(31:30):
do the best and have the mostrecovery function.

Robert A. Kayal, MD, FAAOS (31:33):
The reason I was asking was and
thank you for that is becausethe fact of the matter is I'm
not really sure we know andthat's why I was interested in
your perspective, each of you.
I can tell you this from apractitioner, an orthopedic
surgeon, who's been practicingfor 25 years now.
I've written prescriptions forthousands and thousands of

(31:53):
epidurals, but part of me hasalways wondered why.
I know that I'm trying tomanage the patient's pain
clearly and decrease theinflammation, because the pain
we're describing is 10 out of 10pain.
This is quite severe pain.

(32:14):
Typically it's very significantpain, often intractable pain.
Patients cannot function, carryout their activities of daily
living, they can't sit and theirleg is numb.
They have so much severe painin their lower extremities.
I often order the epidurals sothat they can be comfortable,

(32:35):
get comfortable and be able toparticipate in physical therapy.
I was interested in yourperspective because inflammation
is also sometimes part of thehealing response.
A disc herniates.
Sometimes the body interpretsthat as a foreign body, a
mountain inflammatory cascade toresolve that disc and that

(32:58):
inflammation, that inflammatoryresponse, is associated with the
severe pain we're describing.
It causes significantcompression and swelling around
that nerve.
It's a conundrum we're in.
It's a catch-22.
We want to get the patientcomfortable to tolerate therapy
and put an anti-inflammatoryaround there.
I don't know if we really knowfully if it's interfering or

(33:24):
delaying the resorption of thatdisc or the effects of healing,
but we all do it and it works.
It works.
For that reason I wasquestioning your perspective,
because we all know I'vereiterated this over and over
and over again the inflammationis often associated with redness

(33:45):
, warmth, pain and swelling.
All of those conditions areoccurring after a disc
herniation.
What do we do?
We give anti-inflammatory.
Sometimes we'll do prednisone,the medril dose pack or a local
anti-inflammatory around thenerve.
It works.
To me it's always been somewhatcounterintuitive in that we
need inflammation to promotehealing.

(34:05):
That being said, I raised thisarea of controversy, but it's
not really controversial becausewe all do it and it works.
But intuitively it doesn't makesense.
A little bit right.

Dr. Steve Aydin (34:20):
No, as Dr Boggi mentioned earlier, it's a very
avascular environment.
You need blood for healing whenthe response happens.
There's nothing to pull away.
The response, the epidural orthe injection therapies in
general is to mitigate theinflammatory response.
I'm not saying that we need toget rid of it, but I'm a big

(34:44):
believer that many times and ifyou think about an epidural and
what it's supposed to accomplishI'm supposed to introduce
steroid into an environment.
That doesn't happen immediately, that takes a few days for it
to metabolize and whatnot.
There is a subset of patientswhere I do an epidural and the
moment they get off the table,or in the day or two, they're so
much better, like significantlyimproved.

(35:07):
I think there is an element ofadherence.
That happens Just like youwould get a cut on your skin.
There's a time where it bleeds,the bleeding stops and then you
get that yellowish plasma layeron top of it.
That's a very sticky, goopyproduct.

(35:27):
That's when you do that flush.
When I do the epidural, there'sa flush component from the
medium of the—and that's why Imentioned Preserve, refrease,
saltwater and normal saline as abig component of it.
Because there are a subset ofclinicians that believe that you
don't even need to injectsteroid.
You just do a saline withlidocaine or just the saline
block.

(35:48):
I think there's inflammationthat's over-exaggerated, there's
inflammation that's needed toheal, but then there's also this
wash effect, this almostcleansing of the nerve or
freeing up the nerve.
That's why I think it's veryimportant, from an imaging
standpoint, that everyinterventionist knows exactly
what and where they're injecting, because if you know where to

(36:09):
put the product of injectate, Ithink you have much better
outcomes.

Robert A. Kayal, MD, FAAOS (36:13):
Then , finally, the patients have to
be comfortable to participate inchiropractics, acupuncture and
physical therapy.
We all know that we employthose modalities to try to fix
the problem.
Even if the epidural is notfixing the problem, it's making
them comfortable to allow themto do physical therapy, to
restore that proper lumbarlardotic posture, create that

(36:36):
negative pressure in the disc,hopefully allow that disc to go
back in place, like RobinMcKenzie describes in his book
Treat your Own Back withMcKenzie therapy.
We have to get the patientscomfortable to live their lives,
have some quality of life, goback to work and certainly
participate in chiropractic,physical therapy and acupuncture

(36:57):
Absolutely.
I'm sorry that was along-winded digression of what
you were describing.
Why don't you continue, DrAiden, and just talk more about
your options that you offer ourpatients with respect to
interventional pain management?

Dr. Steve Aydin (37:14):
We covered the epidural, so the approaches to
the epidural.
There's a third epidural thatyou can consider, which is a
caudal epidural, which is whereyou go from the very base of the
spine.
It's almost as if we were godlydesigned with this access point
to your spine from the sacrumand you can enter an access into
there.
Then sometimes there arepatients who've had surgery that

(37:35):
Dr Boggi and I will coordinatewith, where I need to get in
there with a catheter or a wireto get up to an area where
there's scar tissue Aftersurgery.
Sometimes patients, theiranatomy is a little bit variable
and I can't access the spinethe same way that I should be
able to.
So I run a wire or a catheterto get to those areas to break
up adhesions or scar tissue.

(37:57):
That's really the epidural.
The epidural is my first stepin a lot of the approach to
sciatic pain, because I'm a bigbeliever that the spine is a
tube.
Even the canal is a tube andthere are components that make
it up.
The front of it is the disc,the back of it is the joints and
the side of it is the nerves.
The epidural can introducemedication or a block into those

(38:19):
areas to cover all three.

Robert A. Kayal, MD, FAAO (38:21):
Thank you for that, dr Aiden.
By the way, dr Boggi, at thisstage of patient care, are you
typically involved?
When the patient was seen by,say, myself or a physician
assistant or another doctor,patients having sciatica, we
ordered the MRI.
Clearly the patient needs anepidural or some type of
interventional pain management.

(38:41):
Were you involved at this stageof the?

Paul Bagi, MD, FAAOS (38:44):
patient care?
That's a great question, DrKale.
The answer is definitely yes.
As I said before, most peopleare not going to need surgery,
but it's very important forpatients to have every
specialist involved in theircare, because we each look at
the issues from a differentperspective.

(39:04):
We can each help quarterbacktheir care with other modalities
that can help them feel better.
So even very early on, I liketo see patients who are coming
in with sciatic pain and discherniations and this way I can
also explain to them maybe whatthe process would be if they did

(39:26):
end up needing surgery, andthen they're much more
comfortable knowing that they'retrying different modalities and
they're still not feelingbetter.
Or maybe they're developingweakness and now we need to move
forward with surgery.
So I think that's very, veryimportant.

Robert A. Kayal, MD, FAA (39:38):
That's exactly my point, and we make
it of a policy, the modusoperandi at the Kailor
Orthopedic Center.
When a patient is being seenfor back pain or sciatica, we
get all our specialists involvedbecause we all add a certain, a
different element of care tothat patient.
Different level of expertise.

(39:59):
Our training is different andwhat we can offer our patients
is going to be different fromeach specialty.
And the fact of the matter iseverybody helps the patient get
better, whether it's thechiropractor, the acupuncturist,
the massage therapist, thephysical therapist, the
orthopedic surgeon, the PA, theinterventional pain management

(40:20):
or, as a last resort, the spinesurgeon.
But we always employ theexpertise of our spine surgeons
because they're the experts inthe spine.
So it is incumbent upon us toemploy their expertise to
evaluate the MRI and, god forbid, the patient makes a turn for

(40:40):
the worse and all of a suddenthe pain is intractable or worse
.
Yet there's that cortoquinasyndrome that develops, that Dr
Boggi alluded to, or asignificant area of motor
weakness.
The patient doesn't need tohave an emergent introduction to
the spine surgeon and then getscheduled immediately for

(41:00):
surgery.
That patient already hasenjoyed a doctor-patient
relationship with our spinesurgeons and feels comfortable.
So they're highly trained andspecialized.
They did additional fellowshiptraining in the area of spine
and we certainly will employthat to offer our patients the
best medical care in the area oftheir spinal disorder.

(41:23):
What else can you offer, drAydin, to our patients If, for
instance, epidurals fail?
You've tried different types ofepidurals.
You've done an intralaminarepidural transferaminal, maybe
even a caudal.
What's next?
Does the patient go right forsurgery, or is there anything
else in your armamentarium thatyou can offer our patients?

Dr. Steve Aydin (41:46):
So I mean in general, if we've established
the diagnosis as really beingthat disc and we've tried a
round of one or two or threeepidurals and they've really not
turned the corner, at somepoint you have to say, well, how
much more cortisone or how manymore injections can I do for
someone?

Robert A. Kayal, MD, FAAOS (42:03):
What about regenerative medicine?
Are there any regenerativemedical therapies that you can
offer our patients?

Dr. Steve Aydin (42:08):
I mean certainly.
Those are options that can beconsidered.
We can always consider doingregenerative options like PRP.

Robert A. Kayal, MD, FAAOS (42:15):
What are some examples?

Dr. Steve Aydin (42:16):
Yeah, so some of them are PRP.
And then there's bone marrowaspirate which can be injected
in or around the disc or intothe disc.
Those are kind of a little bitdifferent than outside the box
Insurance companies and theresearch is not really robust.
What?

Robert A. Kayal, MD, FAAOS (42:34):
is PRP, just for those that don't
understand.

Dr. Steve Aydin (42:37):
So PRP is Platonel rich plasma and it's
basically removal of your ownblood, processing it, removing
the red blood cells and theheavy products and leaving the
upper layer of the plasma.
And the plasma is where wethink a lot of the growth
factors and the healing factorsare.
And many times we'll introducethat into, say, a tendon,
ligament, disc or around an areaof inflammation to help promote

(43:01):
a healing cascade.
And there is a fair amount ofresearch out there that does
show, it does have promise, butit hasn't really achieved the
standard of care that we've kindof had in medicine with a lot
of our other treatments.

Robert A. Kayal, MD, FAAOS (43:16):
That was my point, I think.
For the patient that isinoperable, for instance, and
you've exhausted otherinterventional treatment
alternatives, you can't keepgiving steroids, steroids,
steroids, but the patient is notmedically clearable to undergo
a spinal procedure.
And as a last resort, we dooffer regenerative medical

(43:40):
therapies where, like Dr Aidensaid, we do harvest a certain
amount of blood from patientsveins.
We take that whole blood, weplace it in a centrifugation
system that we have in ouroffice or at the hospital or
surgical center, we spin thatblood from anywhere from five to
17 minutes and separate thewhole blood into red blood cells

(44:02):
, white blood cells andplatelets and then we take the
portion of their whole bloodwhich is enriched with proteins
and activated growth factors.
It's called the autologouscondition plasma or
platelet-rich plasma, which isthen subsequently injected in
and around the area of diseaseand inflammation and a lot of
people feel that it has profoundhealing potential,

(44:25):
anti-inflammatory properties.
But again, it is consideredexperimental cutting edge, not
often approved by insurancecompanies, but for patients that
are desperate or can't havemore injection therapy or can't
have surgery or can beultimately opposed to having
surgery, just refuse to havesurgery.

(44:46):
It is something that we canoffer our patients.
We just want you to be aware ofthat.
So now it sounds like we'vefailed.
Non-traditional spinal surgicalinterventions.
We've tried everything.
We've tried physical therapy,anti-inflammatories, steroids,

(45:08):
chiropractic acupuncture,trigger point injections, you
name it everything we'vedescribed.
This is where you often willcome into play, right, Dr Bogg?
You've already met the patient.
You've prepared the patientthat we're going to try
conservative management.
We're going to try to put thatdisk back in place, we're going
to try to reduce your pain andinflammation, but for whatever

(45:29):
reason, the pain persists.
The patient has developedweakness, possibly bowel or
bladder dysfunction, numbnessaround the perineal region, leg
weakness in both legs, issuesthat are now causing surgery to
become now imminent.
Where do you?

Paul Bagi, MD, FAAOS (45:49):
start.
So at this point the situationis usually due to a few things.
It can either be a mechanicalissue, as Dr Aiden mentioned
earlier.
The nerve is actually gettingcompressed by the disc
herniation and all themodalities that we've used thus
far haven't been enough to takethe pressure off the nerve.
The other issue could be thatit's now turning into more

(46:13):
chronic inflammation.
We've done everything we can todecrease that inflammation, but
it persists and that continuesto put pressure on and irritate
the nerve.
So now is when we startedthinking about actually using
surgical options to go into thespine and remove that mechanical
compression or to remove thepiece of disc that is causing

(46:37):
the inflammation.
So spine surgery has evolvedquite a bit over time and in the
past even this surgery waspretty invasive.
So a large incision, a lot ofmuscle dissection to get down to
the spine, removing quite a bitof bone to actually be able to
see the disc herniation and thentake it out.

(46:58):
Over the past few decades thathas changed quite a bit and we
don't need to do that anymore.

Robert A. Kayal, MD, FAAOS (47:05):
So the traditional way to and, by
the way, this is the purpose oftoday's podcast.
I know we've spent a lot of timeleading up to this, but really
the focus of today's podcast isto really focus our attention on
describing the evolution ofspine surgery with respect to
our Dr Boggs and Dr Denizo'sapproach to surgical management

(47:29):
of disc herniations and sciaticin particular.
And I'm going to ask Dr Boggsto start from least invasive,
from most invasive rather to theleast invasive, most cutting
edge techniques, from openincisions to tubes, and then
something he's going tocommunicate to you which I'm
sure you'll all be excited aboutas much as we are.

Paul Bagi, MD, FAAOS (47:51):
Yeah, thank you, dr Kale.
So we were talking about thelarge, open approaches.
So the key is to be able to seethe disc and remove it safely
without injuring the nerves orany of the other important
structures in the area.
And in the past the only way tosee it was to really have a
large incision and look into it,usually with loops, and that

(48:14):
magnifies it while we're lookinginto the incision.
But now what we're able to dois.
So the two main ways to do thisis one you can make a small
incision and usually, as wetalked about earlier, the disc
herniation is on one side.
So what we can do is, once wemake the small incision, we will
only dissect the muscleslightly to be able to get down

(48:36):
to the bone.
Then what we do is we use amicroscope to be able to see
through that small incision andremove a tiny little window of
bone.
And this does not change themechanics or the structure of
the spine at all.
We only make enough so we cansee in there and we move the
nerve over and we take out thepiece of disc, and usually

(48:56):
people will feel better very,very quickly, sometimes
immediately afterwards,sometimes if the compression has
been there for some time.
It can take a few days for theinflammation and the nerve to
calm down, but usually peoplewill have 95 up to close to 100%
improvement just in a matter ofa few weeks.

(49:18):
So then what we started doingwas using tubular, minimally
invasive approaches.
So what this does is we can uselarger and larger tubes to
dilate the muscle rather thancutting through it.
So what this does is it movesthe muscle away so we can see,
and through the tube we look inwith a microscope.

(49:39):
Then the procedure is the samefrom there, remove a tiny little
bit of bone, find the disc andtake it out.

Robert A. Kayal, MD, FAAOS (49:46):
So instead of making a big incision
, you make a small incision,dilate with larger and larger
tubes, which then stretches thesoft tissues in the skin, but
the incision is tiny, typically.
How big is that incision for aone level microdiscectomy?

Paul Bagi, MD, FAAOS (50:00):
So it could be a centimeter and a half
.
It's incredible.
So half an inch and recovery isvery, very quick after this.
So people usually have someback discomfort, of course for a
couple of days, usually don'teven need pain medication to
treat it, anti-inflammatories,muscle relaxers for a few days

(50:21):
and then people are feeling alot better.
Actually, the bigger issue withthese is not so much how big
the incision is we just talkedabout with the tubular approach
you can get that pretty smallit's actually the restrictions.
So the reason for therestrictions is that the disc is
injured.
So Usually there's a tear in theback of the disc and the piece

(50:44):
of disc is a little bit like aniceberg.
Most of it is out in the canalhitting the nerve, but a little
bit of it is in the disc space.
It's a great description.
So when we take the piece outthere's going to be a tear in
the back of the disc.
And the back of the disc ispretty flimsy and that's why it
tends to have an issueespecially in this area.
So we can't put stitches intoit to close the area because

(51:07):
they'll tear out.
So we need to wait for the backof the disc to scar down and,
just like when somebody has apretty bad soft tissue injury,
it takes a while for it to scarand heal.
Usually that timeline is sixweeks.
So in six weeks, just as with ascar, it's healed and the body
is done with the healing processand it's not going to make it

(51:29):
any stronger.
So we usually have restrictionsin place for that six weeks to
prevent another piece of disccoming out while the disc is
healing.
And the restrictions are noheavy lifting and usually we use
gallon of milk as a guide,which is around eight pounds no
bending, no twisting, which, aswe talked about earlier, are the

(51:51):
movements that are putting themost pressure on the disc.
And more often than not peoplewill tell me I'm having trouble
keeping these restrictionsbecause I feel so much better.
So it's not really the recoveryprocess, it's us putting the
restrictions on them to keepanother disc from herniating.

(52:11):
So now the technique that we'reusing, which really solves both
of these issues how invasive isthis, and the restrictions is
endoscopic spine surgery.
So what is endoscopic spinesurgery?
It's a little bit likearthroscopic for different
joints, like the shoulder, thehip, the ankle, the knee, or

(52:31):
like laparoscopic for abdominaland pelvic procedures.
So we can make an even smallerincision, in this case usually
seven millimeters, becausethat's the size of the camera.
We could put the camera downinto the spine and the camera
lets us see everything we needto see without making a larger
incision.
Then, using that, we can takeout the piece of disc through

(52:55):
the same cannula that the camerais in, and so the incision
stays seven millimeters.
We're able to remove the discvery minimal disruption of
tissue.
We don't have to dilateanything because the camera is
what we're using to see.
And more often than not therestrictions are only for a few
days while someone's recovering,and then they can go back to

(53:17):
full activities, back to work,back to sports, back to
recreational activities, withouthaving those six weeks of
restrictions.
And the reason for that is evenwhen we're working on the disc
space to get out the piece, weusually have to make the disc

(53:38):
tear a little bit bigger withtraditional approaches to get
the piece out.
But with the camera we canactually put that, sometimes
even into the disc space andthen use small micro instruments
to tease out the piece of discwithout making the tear in the
back any bigger.
So that's where the advantagescome in.

(53:59):
Now, in some patients, the tearcan be huge already, and so
they may need restrictions, nomatter what we do.
So of course, those are a caseby case basis, but more often
than not we can do this.

Robert A. Kayal, MD, FAA (54:12):
That's incredible.
I mean.
Well, I'm a little upsetbecause we were supposed to
start talking about that sectionof this podcast.
Dr Aiden was going to give us adrum roll before we started
talking about endoscopic surgery.
Anyway, you beat me to it.
But yeah, we are so excited, soexcited to pioneer endoscopic

(54:34):
spine surgery at the CatoOrthopedic Center with both Dr
Boggy and Dr Denizo.
The analogy I can give, I guess, is very much akin to the
evolution of meniscus surgery inthe knee Years ago.
Before I started, 25 years ago,and even before that, the

(54:55):
common condition called themedial meniscus tear, for
instance, or the lateralmeniscus tear, would be treated
through an open incision.
An incision would be made aboutthis long in the front of the
knee.
It would be an open procedure.
We'd work our way down into theknee and then subsequently take
a smiley knife and essentiallyenucleate the entire meniscus

(55:21):
out of the knee through an openprocedure.
Over the years there has been anevolution of meniscus surgery
with the advent of arthroscopicsurgery, where we now make
puncture sites very much akin towhat Dr Boggy is describing in
the spine.
Now it's essentially sportsmedicine of the spine.

(55:42):
We're doing arthroscopicsurgery of the spine.
We call that endoscopic becausewe're not going into a joint,
we're going into a space.
Essentially it's a sportsmedicine procedure on the spine,
just like arthroscopic surgeryis so, so common now and so

(56:03):
successful in the area ofshoulder, ankle, elbow, hip,
knee.
They have now pioneeredendoscopic surgery of the spine,
which is actually incredible.
It's unbelievable what can bedone now through the endoscope.
We're just so proud to have DrBoggy and Dr Denizo at the Kale

(56:24):
Orthopedic Center to helppioneer this unbelievably
successful cutting edgeadvancement in the area of spine
surgery.
Thank you for bringing thatexpertise and offering those
minimally invasive techniques toour patients.
At the Kale Orthopedic Centerwe're always working in earnest,
year after year to try to trainourselves in the latest and

(56:48):
greatest technologies.
We never practice on patients.
We always go to labs and spendhours and hours and hours first
operating on the cadavers thathave been so generous, giving
back to society, allowing us tooperate on them and their bodies
, to learn these techniques andtechnologies.
We're very thankful to thevendors that offer these

(57:12):
technologies and allow us totrain on the cadavers at their
labs.
We're just so appreciative ofthat because it allows us to
offer our patients the latestand greatest cutting edge
techniques.
That's what we've always beenproud of at the Kale Orthopedic
Center.
That's what we feel ourpatients deserve.

(57:33):
Is there anything else you'dlike to add, dr Aiden, to this?
I know you're very familiarwith these endoscopic approaches
because you've always donethings in a minimally invasive
manner.
Where do you see the endoscopepotentially working in your area
of expertise as aninterventional pain management

(57:54):
specialist?

Dr. Steve Aydin (57:57):
There's a lot of crossover between the
specialties.
Now, as aggressive as you wantto be as an interventionalist,
you can get into a very similarapproach to doing treatments
that Dr Boggi and Dr Denizo orother spine surgeons are doing
For me.
I think interventional painreally has its own space to stay

(58:21):
in.
We're not true surgeons in thesense that I can go in there and
operate, god forbid somethinggoes wrong.
As an interventionalist, I haveto know my limitations.
I have to know how to managecomplications for things that I
do, whereas if I do somethingand the complication occurs
within the spinal cord, I needto call Dr Boggi or have Dr

(58:42):
Boggi as the second backup for acomplication that could happen.
Where I'm cavalier in the sensethat I want to learn everything
and be able to do everything, Ialso know there are limitations
on what I can do within myexpertise to providing optimal
care for patients.
It's sort of a great doctor.
I've certainly pushed theenvelope with many procedures

(59:07):
like minimally invasive lumbardecompressions are a mild or
interspinous space or implants,but again, I'm never really
entering the spinal canal, notgetting to the nerve where Dr
Boggi and Dr Denizo are actuallyinside, near the nerve, near
the vascular supply of the nervewhere you could potentially
compromise or even interrupt andcause an infection inside the

(59:32):
spinal canal.
Those are things that we allneed to think about when we're
approaching these things.
I did have some questions for DrBoggi about the endoscopic.
You mentioned themicrodyskectomies and there is
such a high rate of reherniationwith that.
Has there been a lot ofliterature that looks at the

(59:54):
difference between endoscopicand microdisc for reherniation?
Because, like we talked aboutearlier, patients just want to
be fixed.
They don't want to worry about.
Can this happen to me again?
But I know with microdiscthat's a conversation that we
often have you got to reallywatch it for six weeks because
there's still a hole in the backof your disc.

(01:00:14):
No matter how much glue we putthere, it can still leak out.

Paul Bagi, MD, FAAOS (01:00:19):
That's a great question.
So there's two timelines tolook at here.
So there's the short timelineof reherniation and then a
longer timeline of months toyears.
So the research actually showsthat the immediate or short-term
reherniation rates are lowerwith endoscopic A little bit of

(01:00:39):
the reason is what we talkedabout before not having to
extend the tear in the back ofthe disc to get out the piece,
less disruption of thestructures around the spine that
help support it and protect thedisc.
But when you look at long-termrates of reherniation they're
more similar, and the reason forthat is once there's a

(01:01:01):
herniation there's injury to thedisc and, as we talked about,
with the blood supply to thedisc, the blood supply is poor
and so the disc is not great athealing itself.
And disc is made up of collagenand once that collagen is
injured it's not able to providethat same support or that
cushion that a normal disc does,and so over time additional

(01:01:24):
pieces can break off andreherniate.
Notice that back of the disc isalways a weak point and even if
the scar is small versus large,over time that becomes less of
a differentiating factor.
But still, the fact that thereare less reherniations in the
beginning is very important,Because that's actually when it

(01:01:48):
can be the most limiting,Because now someone has just
gone through this episode ofbeing in extreme pain, missing
work, missing activities, andthey are finally getting back to
it and it happens again, andthat's something we definitely
want to avoid.

Robert A. Kayal, MD, FAAO (01:02:02):
Right .
Well, I think this has been anawesome podcast.
I appreciate having both of you.
It's been a great panel.
I think it's important to takehome really here is if our
patients are suffering from backpain, don't ignore it.
We want you to come in, getassessed, because it's certainly
much easier for us ashealthcare providers to take
care of you and avoidpotentially surgery or even

(01:02:25):
interventional pain managementprocedures the sooner we see you
.
It can be a lifestylemodification.
It could be abnormal posture,it could be excessive weight, it
could be that you need somestrengthening exercises and
physical therapy to restore thatlumbar lordotic posture that we
described, and we can certainlypotentially prevent further

(01:02:47):
injury or herniation of yourdisc and nerve compression.
So would you all agree thatthat's probably the take home
here that they should see ussooner than later so we can
assess them, find out theetiology of their problem, get
appropriate imaging, find outthe severity of the problem and
maybe be able to prevent evenhaving to see you guys for any

(01:03:10):
type of surgical orinterventional management.

Paul Bagi, MD, FAAOS (01:03:14):
Anyway, if there's any question in
anyone's mind about what's goingon, are my symptoms not bad
enough that I need to be seen?
That's never the case.
Come and see us and we can helpyou make that determination and
point you in the rightdirection.

Dr. Steve Aydin (01:03:32):
Yeah, totally agree.
I think the longer somethinghangs around, it becomes harder
for us to treat and at the endof the day, our goal is to treat
and get you better with theeasiest things.
And I tell patients all thetime I'm not here to do the
procedure, I'm just here torecommend it and if you need it,

(01:03:55):
we will offer it to you.
But, as we mentioned earlier,there's a gamut of conservative
options that can be offered thatcan get you to a place of
significant recovery where, ifyou're not pursuing those things
, you don't know.
And then you may get to a pointwhere you get to a head and
you're like now I'm stuck andnow we have to be much more
aggressive where we may havebeen much more preventative.

Paul Bagi, MD, FAAOS (01:04:18):
Amen Well, dr Aiden it was a pleasure
having you back.

Robert A. Kayal, MD, FAAOS (01:04:23):
Dr Boggi, thank you so much.
Viewing audience, listeningaudience.
We appreciate your time.
We hope that you find thishelpful and again, if you have
any issues, we're happy to seeyou Take care.