Latest / The Driven Athlete / Spine Surgeon Dr. Phil Saville Discussing Surgical Approaches | Ep 81

Transcript

Spine Surgeon Dr. Phil Saville Discussing Surgical Approaches | Ep 81 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: Y'all, welcome back to the Driven Athlete Podcast.
• 0:14
  Speaker 1: It's your man, dr Kyle, and we've got a really cool special guest with us, dr Phil Seville.
• 0:18
  Speaker 1: He's a spine surgeon, orthopedic surgeon, and coming from a super busy schedule, he's been able to come hang out with us and share more about what he does and what you know the fat things he's into.
• 0:31
  Speaker 1: But introduce people like where you're at, what's your practice and what y'all do.
• 0:36
  Speaker 2: Well, thanks for having me, Kyle Good to get it done.
• 0:38
  Speaker 2: We've been talking about this for a while.
• 0:39
  Speaker 2: Yeah, it's been like honestly it's been like a little over a year.
• 0:51
  Speaker 2: Yeah, it's been a while, been like 18 months.
• 0:52
  Speaker 2: Yeah, well, that's my fault.
• 0:53
  Speaker 2: No, no, no, me too, me too, okay, um, so, yeah, my, my office in palm beach gardens.
• 0:55
  Speaker 2: We specialize in kind of minimally invasive uh spine surgery.
• 0:56
  Speaker 2: So less, less damage to the uh, the healthy tissues to fix the problem and, in particular, I'm interested in motion preservation.
• 1:02
  Speaker 2: So disc replacements, non-fusion options for patients, which is certainly gaining popularity.
• 1:09
  Speaker 2: People recover faster, get back to active lifestyles and have a lot less side effects down the down the line.
• 1:14
  Speaker 2: I trained in England, initially for med school, a place called Leicester, and then came over here, did my residency at University of Pennsylvania, my fellowship in HSS in New York and then came down to Florida around 2018 and opened up my own office about three years ago now cool.
• 1:36
  Speaker 1: yeah, that's because we had met um up in Juneau at Dr Daniel at one of his first there yeah, they had like an open house thing, exactly right and that was like right after you opened, is that?
• 1:46
  Speaker 2: right, yeah, that was uh.
• 1:47
  Speaker 2: Yeah, I was busy pounding pavements and just trying to meet everyone in the area because there's a new area.
• 1:52
  Speaker 2: I moved up from boca raton and, uh, I had to meet all the all the people up in the area.
• 1:56
  Speaker 1: But yeah, that was then so you all, right, I knew you were from london originally, right?
• 2:00
  Speaker 1: Let me tell by the accent if you guys can't tell.
• 2:02
  Speaker 1: But so you went to Leicester Medical School.
• 2:06
  Speaker 1: What brought you over to US?
• 2:08
  Speaker 1: To think?
• 2:09
  Speaker 1: To go to University of Pennsylvania?
• 2:11
  Speaker 2: It was.
• 2:11
  Speaker 2: I mean, the NHS is a socialist system and there were some issues with that.
• 2:17
  Speaker 2: But the main issue I noticed was the case volumes were just decreasing.
• 2:21
  Speaker 2: It's not a very efficient system, so surgeons weren't doing a lot of cases and the guys that were just decreasing.
• 2:24
  Speaker 2: It's not a very efficient system, so surgeons weren't doing a lot of cases and the guys that were a few years ahead of me in training didn't seem to be progressing and really achieving what the guys five or ten years before them were able to achieve.
• 2:36
  Speaker 2: So it was kind of a decision of do I stay here and and potentially extrapolate that trend and just not be very good, or do I go somewhere else and try and become good at what I do?
• 2:48
  Speaker 2: And that was what really drove the decision-making Interesting.
• 2:52
  Speaker 1: Did you always know you wanted to go to orthopedics or spine?
• 2:56
  Speaker 2: Not really.
• 2:56
  Speaker 2: It all kind of just happened.
• 2:58
  Speaker 2: In England the rugby boys all went into orthopedics.
• 3:03
  Speaker 2: I played rugby, so I went into orthopedics and then when I was doing my orthopedic rotations, I had an Irish surgeon, dennis Calthorpe, who did spine.
• 3:14
  Speaker 2: And we just got on and he just took me under his wing and that was it.
• 3:17
  Speaker 2: I was like I'll do spine.
• 3:19
  Speaker 1: And was that during one of your rotations in medical school?
• 3:24
  Speaker 2: It was actually after medical school, so I was doing some residency equivalent in the UK and worked for Dennis and I was on his service for like six months and we had a really good time.
• 3:33
  Speaker 2: It made sense and I just enjoyed the surgeries and it just kind of led from there really.
• 3:38
  Speaker 1: So, then, you started investigating residency programs in the US.
• 3:42
  Speaker 2: Yeah, I looked at a couple of options and canada and the us were kind of top of the list and ultimately the us was probably the better fit.
• 3:49
  Speaker 2: It's easier surprisingly actually to to match over here as a foreign grad than in canada.
• 3:55
  Speaker 2: Canada's really closed, closed shop, um and uh.
• 3:59
  Speaker 2: And yeah then came over here interviewed.
• 4:02
  Speaker 2: Uh, I was lucky enough to get into a good program in upenn and it all just kind of led on to each other really and was that?
• 4:10
  Speaker 1: I mean upenn?
• 4:11
  Speaker 1: Yeah, it's a great institution, yeah I was really lucky.
• 4:14
  Speaker 2: I just just got on well with the team there and and they they, you know made a spot for me and it went from there that's cool.
• 4:21
  Speaker 1: and uh, that first residency was it orthopedic residency, orthopedic residency, and then you do fellowship for spine, exactly so we do in orthopedics.
• 4:30
  Speaker 2: you do spine as part of your general rotations and you kind of do when you're done you're capable of doing spine surgery and general ortho surgery like joint replacements, fracture care.
• 4:42
  Speaker 2: But to get kind of the next level of training, you then go on to like a fellowship for a year, uh and, and that was done in new york at hss, which is obviously quite a well-known place down here, and um, that was kind of where we learned like the next level of really of how to treat spine care yeah, and do you?
• 5:01
  Speaker 1: is that specifically like cervical lumbar or lumbar, or like the whole spine Top to bottom?
• 5:06
  Speaker 1: Got it, and then, right now, for your guys' cases like do you see equally distributed like neck and back.
• 5:12
  Speaker 2: Yeah, probably 50-50,.
• 5:13
  Speaker 2: Pretty close actually.
• 5:14
  Speaker 2: I mean there's a little bit in the thoracic spine, but for various reasons you just get less pathology there.
• 5:21
  Speaker 1: Yeah.
• 5:22
  Speaker 2: Probably less than 5% in the thoracic spine.
• 5:24
  Speaker 2: The vast majority is in the neck or the the lumbar spine.
• 5:27
  Speaker 2: Um, you know, the books will say it's 60, 40 lumbar favored, but I think generally it's more like 50 50 now, yeah, pretty close like um, that's interesting and I remember we had you had referred somebody over.
• 5:41
  Speaker 1: He was a young guy mid 30s who had like thoracic.
• 5:44
  Speaker 1: I tell the story on other podcasts that were just also mentorship stuff with some of the fellows that we trained, but he was like a young dude early 30s and he had thoracic region pain and it was weird.
• 5:58
  Speaker 1: It was just like this is interesting, it's kind of puzzling, and it was referring like a dermal tunnel pattern like across his rib cage and I was like all right if it's neural, if it's musculoskeletal I'm thinking rib pathology, you know core stability, thoracic spine mobility is important.
• 6:13
  Speaker 1: Look at the tlga, like thoracic thoracolumbar junction mobility.
• 6:17
  Speaker 1: But anyway he's like I'm gonna, mri, just to you know, rule out some stuff and he anyway his symptoms were like it hurts when he was sleeping.
• 6:25
  Speaker 1: He didn't feel good in general, like general lethargy.
• 6:29
  Speaker 1: I remember you're talking about now, yeah, and then he we talked, spoke on the phone and he was going to mri.
• 6:33
  Speaker 1: I was like, hit me back, you know, check out the imaging and then hit me back and we'll schedule.
• 6:37
  Speaker 1: But anyway I didn't hear from him and I reached out.
• 6:40
  Speaker 1: I was like, have you heard from this patient?
• 6:41
  Speaker 1: You're like, yeah, he had actually had a tumor.
• 6:42
  Speaker 1: Yeah, no, he did.
• 6:43
  Speaker 2: Yeah, he's fine, he had an intradural tumor, I think that was, um, just uh, yeah, it's unexpected.
• 6:52
  Speaker 2: Uh, certainly a young person, right?
• 6:54
  Speaker 2: Uh, he actually went up to new york, I think to some of the guys I trained with, to get it fixed.
• 6:58
  Speaker 2: We sent him up to uh sloan catering.
• 7:00
  Speaker 2: Have you heard from since?
• 7:02
  Speaker 1: uh, I haven't, actually no with a young he was in his early 30s.
• 7:07
  Speaker 1: Uh, somebody coming in with like mid thoracic region, pain hurts with breathing right across like the rib cage.
• 7:15
  Speaker 1: Yeah, um, but besides, like what other pathology?
• 7:19
  Speaker 1: What would be the, what would be the protocol for that?
• 7:21
  Speaker 1: It's like, hey, immediately just imaging, just to rule things out.
• 7:29
  Speaker 2: Yeah.
• 7:29
  Speaker 2: So I mean it depends on history and duration.
• 7:30
  Speaker 2: So I mean the vast majority of 30-year-olds with thoracic level pain, it's going to be something benign, nothing to worry about.
• 7:38
  Speaker 2: So it's going to be a muscle sprain.
• 7:41
  Speaker 2: They've been playing tennis, golf, something's happened.
• 7:43
  Speaker 2: But if it's not getting better, if it's interfering with sleep, if it's been going on for a while, then that's more of a red flag and that's something more that would send us towards workup, towards.
• 7:55
  Speaker 2: Is there something more going on?
• 7:56
  Speaker 2: If the pain's kind of coming across like a dermatomal distribution, so it kind of starts in the middle of the back and comes along and a rib uh in a line to the middle.
• 8:05
  Speaker 2: But that sounds a lot more like nerve pain.
• 8:08
  Speaker 2: So you maybe start thinking about is this a disc herniation?
• 8:11
  Speaker 2: Pushing on, pushing on a thoracic nerve can even be something uh unusual, like a um shingles flare.
• 8:18
  Speaker 2: I've seen young patients with that.
• 8:19
  Speaker 2: I had one last week who uh had some uh pain raining down his arm in his shoulder.
• 8:27
  Speaker 2: Everyone thought it was a disc herniation and that the disc MRI was negative.
• 8:31
  Speaker 2: That he came with and I asked him to take his shirt off to actually examine him.
• 8:34
  Speaker 2: He had a classic shingles rash all down.
• 8:37
  Speaker 2: And so we sent him to his primary care doctor actually to get antiviral treatment, and it all got better Interesting.
• 8:44
  Speaker 1: So besides before that, nobody does like take your shirt off no, no, I mean he'd.
• 8:48
  Speaker 2: He kind of came to me um slightly unusual.
• 8:51
  Speaker 2: He's a friend of a friend.
• 8:52
  Speaker 2: I saw him out, uh, when we're out having drinks one night and his friend was like hey, go go see phil, he'll, you know, he'll be able to help you out, figure out what's going on.
• 9:01
  Speaker 2: So he came to see me the next day and uh had his mri already and it it was really unimpressive and I just, you know, by chance, asked him to take his shirt off, which you don't often do, to be fair and he just had this clear uh dermatomal rash and it was shingles, uh 100.
• 9:20
  Speaker 2: And now you got better, uh, just with um antivirals and a bit of time interesting yeah, uh, yeah, that's super interesting.
• 9:29
  Speaker 1: And then with your.
• 9:30
  Speaker 1: So you did your fellowship with hss.
• 9:32
  Speaker 1: Were you employed with them at all?
• 9:34
  Speaker 1: Like, what did you do when you work with them while, like right after fellowship, or did you immediately come down to boca?
• 9:39
  Speaker 2: no, I came down here immediately.
• 9:41
  Speaker 2: My um, my wife, uh, is from brazil and wanted to be done in florida and, yeah, away from new york.
• 9:48
  Speaker 2: Yeah, I mean when when we met, she was moving to miami.
• 9:51
  Speaker 2: But uh put that on hold because of me, and so we we made the deal that you know, if we were still together at the end of training, we're coming down to down to florida and, and so I had to keep keep that deal.
• 10:02
  Speaker 2: So we came down here, I joined a group down in Boca and it was a good experience, but ultimately I wanted to do something a little bit different and be my own boss, and that's what led that to change in about three years ago now.
• 10:18
  Speaker 1: What things different?
• 10:21
  Speaker 2: I tend to run a lower volume practice.
• 10:24
  Speaker 2: So I mean, I guess the term down here is concierge, but it's kind of more lower volume out of network and able to spend a little bit longer with the patients where I was before.
• 10:36
  Speaker 2: It was a good practice, but it was.
• 10:38
  Speaker 2: It was a volume volume play.
• 10:41
  Speaker 2: Basically had to see new patients every 15 minutes and it's hard to examine someone, take their shirt off and you know, talk to them about surgery in 15 minutes and then do your documentation, yeah, and you know if people have questions, if they've got, um, you know a little bit of understanding that they're going to have a lot of questions before you operate on them and it becomes challenging to do that, and so the the goal was to run something a little bit more like yourself, where you're able to focus more on you know individual, what's actually going on with them, what the right thing to do for them is, rather than just you know this is what we do, this is what we do, this is what we do give me, uh, what give listeners an idea of, like, what if a new patient came to see you, right?
• 11:27
  Speaker 1: hey, I'm dr seville nice to meet you, right?
• 11:29
  Speaker 1: It's day one.
• 11:30
  Speaker 1: What does that first day usually look like?
• 11:33
  Speaker 2: I mean it depends really.
• 11:35
  Speaker 2: I mean ideally they've had an mri, uh, already.
• 11:39
  Speaker 2: So it could be a more, more fruitful discussion if, if they come in with you know symptoms and mri, then yeah, it's going to be a more, more fruitful discussion.
• 11:44
  Speaker 2: If, if they come in with you know symptoms and mri, then yeah, it's going to be like 25, 30 minutes.
• 11:47
  Speaker 2: We'll go through exam, looking at the imaging, talking about what the options are, depending on what they've done already.
• 11:53
  Speaker 2: We may go for some injections if they come fresh and have had nothing done, if they've done a load of injections already.
• 11:59
  Speaker 2: This has been going on for months and they're kind of getting to the point now where they hey, like let's just get this fixed and we start talking about surgery.
• 12:04
  Speaker 2: To the point now where they hey, like let's just get this fixed and we start talking about surgery.
• 12:06
  Speaker 2: And it really depends where in that spectrum these people come in.
• 12:10
  Speaker 2: You know some people come in haven't dealt with this for years and done injections for years and injections stopped working.
• 12:15
  Speaker 2: Other people that you know they tweak the back two weeks ago and and you know that's clearly not a surgical talk, that's that's more of a let's try something to settle this down, maybe get you over to see Kyle do some therapy, and then we go from there.
• 12:27
  Speaker 2: Yeah, yeah, gotcha.
• 12:29
  Speaker 1: And then exam-wise what would people expect when you do an exam on somebody Like range of motion?
• 12:37
  Speaker 2: Yeah, so it's range of motion, the neck, the lumbar spine.
• 12:39
  Speaker 2: Then we look at you know painful motions, you know.
• 12:49
  Speaker 2: We look at you know painful motions, you know.
• 12:49
  Speaker 2: Does it hurt when you're rotating, when you're looking up, looking down?
• 12:50
  Speaker 2: Then we start looking at the individual muscles which are supplied by the nerves in the area.
• 12:52
  Speaker 2: So in the neck, we're looking at the arms, looking at the shoulders, the biceps, the triceps, the hands, the wrists, looking to make sure there's no weakness associated with nerve compression.
• 12:58
  Speaker 2: Right, check the sensation.
• 13:00
  Speaker 2: Again, each patch of skin is supplied by individual nerve roots from the neck or the low back, and so we test each of those, check your reflexes in the neck, we'll often check balance and coordination.
• 13:12
  Speaker 2: A lot of people are surprised to know that compression on the, the spinal cord, may be painless but can affect your balance and coordination.
• 13:19
  Speaker 2: So that's something we always like to check, especially on the neck patients.
• 13:22
  Speaker 2: Right, like cervical myelopathy.
• 13:24
  Speaker 2: Exactly myelopathy is what we're looking for in that case.
• 13:27
  Speaker 2: Um, and, and that's that really.
• 13:29
  Speaker 2: Again, it's kind of tailored depending on what's going on with that.
• 13:32
  Speaker 2: Uh, yeah, someone it's just got a little bit of back pain when they're golfing and it's on the kind of the follow-through and we're probably not going to maybe do quite so much.
• 13:42
  Speaker 1: On then on someone who's come in with with more neurologic symptoms gotcha and if something come in neurological symptoms, um, where you're discovering, like testing, myotomes and dermatomes, like weakness in the hands and arms, um, leaning more towards and they've had pain for a long time then you're talking surgical considerations and that you guys are.
• 14:02
  Speaker 2: You said you're leaning more towards, like, as an example, if needed, disc replacements over instead of fusions yeah, so disc replacements are something that have really become a lot more popular over the last five to ten years.
• 14:13
  Speaker 2: Uh, you look at initially, uh, around 20 years ago when they started being put in, they were being put into very young patients who had no degeneration in their neck or the low back and they were for for soft disc herniations, which is kind of what we describe an acute disc herniation without any degenerative changes.
• 14:32
  Speaker 2: Certainly over the last five years that that has kind of changed a lot.
• 14:37
  Speaker 2: And now really quite degenerative necks that we would not have put a disc replacement in 10 years ago and now becoming candidates for disc replacements.
• 14:47
  Speaker 2: The advantages of a disc replacement over a fusion are pretty well known and well studied now.
• 14:52
  Speaker 2: You have a lot less pain.
• 14:55
  Speaker 2: You maintain range of motion.
• 14:57
  Speaker 2: You have less revision surgeries at the level of surgery and at the adjacent levels.
• 15:03
  Speaker 2: So if you have a fusion in the neck or the low back, you end up transferring motion at the levels above and below, so they try to maintain your range of motion, so they work twice as hard, which means those discs then wear out and so you end up chasing yourself up up the neck or the low back with further surgeries and I think you know most listeners will have known someone who had a surgery and had another surgery, had another surgery in their back and it's's kind of not a great story right?
• 15:28
  Speaker 2: Everyone always is worried about that, whereas with disc replacements we see that that's not the case.
• 15:33
  Speaker 2: You have far lower rates of adjacent segment wear out and less surgeries at the index level as well.
• 15:40
  Speaker 1: Interesting, interesting with uh disc injury, right, what would cause like an acute, non-degenerative type of a disc soft disc injury, like you said it?
• 15:54
  Speaker 2: can be anything.
• 15:54
  Speaker 2: Um, I mean, it's nice when there's a like a clear precipitating event.
• 16:00
  Speaker 2: So you know you lean forwards to pick up something heavy, you feel a pop in your back.
• 16:04
  Speaker 2: That story is nice and everyone kind of agrees and understands that's when it happened.
• 16:09
  Speaker 2: But often that doesn't happen.
• 16:12
  Speaker 2: You can have like just a disc that's been injured years ago.
• 16:15
  Speaker 2: It's hanging on by a thread and then one day it just goes.
• 16:19
  Speaker 2: It can be when you sneeze, when you roll over in bed, and it can be something so innocuous that starts it.
• 16:23
  Speaker 2: The way to think about a disc is it's really made up of two layers.
• 16:27
  Speaker 2: You have the outer layer, which is like a thick car tire it's rubbery and the inner layer is kind of like a gooey crab meat type material and so it works well together as like a shock absorber.
• 16:37
  Speaker 2: And when you have a disc herniation what happens is that outer layer gets a hole in it and so the crab meat can squeeze out, pushes on the nerves and it really can be like you hurt your back playing football or at the gym 10 years ago and it's just hanging on and one day that thread just goes and then you get some disc squeeze out interesting.
• 16:59
  Speaker 1: Um what, what evidence?
• 17:00
  Speaker 1: Or like what do uh cause?
• 17:02
  Speaker 1: People will ask me like do discs heal?
• 17:04
  Speaker 1: What have you?
• 17:06
  Speaker 2: found in the research for that.
• 17:07
  Speaker 2: So it depends what you mean by heal.
• 17:11
  Speaker 2: So if you injure a disc, it will break down.
• 17:14
  Speaker 2: Unfortunately, the disc doesn't have any real blood supply, so it doesn't have a tremendous healing potential.
• 17:20
  Speaker 2: And once you injure a disc it will go down a degenerative cascade, but that may or may not be painful and a lot of people will come in and they will have very degenerative backs or necks and they have no symptoms.
• 17:35
  Speaker 2: And that's just because some people go down this cascade where it's not painful and other people go down this cascade where they have a lot of back pain and there's some genetic component to that and I don't think we entirely know that yet, but it's certainly.
• 17:49
  Speaker 2: Some people have no pain, some people have a lot of pain.
• 17:51
  Speaker 2: If you're getting a lot of low back pain and we look at the mri and you've got one or two of these worn out discs at the bottom of the back then and you've tried all the other things like the, the therapy to strengthen the core, the injections and all these things aren't working, then you may be a candidate for a disc replacement where we scrape out the disc and we put a new one in, and in my experience, patients have been very, very happy with those and do very well return to activity.
• 18:17
  Speaker 2: I mean, we have several videos on our website now of young patients who couldn't play with their kids, couldn't lean over to pick them up, and now they're back playing sports with their kids, which is what they you know they want to do it's amazing.
• 18:31
  Speaker 2: Yeah, yeah, it's, it's been, it's been really changing, for I think spine surgery, that the arthroplasties, and that's still what's the with the invasive nature, like with our, it's arthroscopic no so.
• 18:42
  Speaker 2: So disc replacements in the lumbar spine we do with an anterior incision okay interesting we we make a transversal, vertical incision, depending on the level, and we go between the um, the abdominal muscle, the abdominal muscle, so we're not cutting muscle going through the tendon in between which we can stitch and heals well.
• 18:58
  Speaker 2: And then from the front we have an approach surgeon, a vascular surgeon typically, who moves the uh, the blood vessels, and the, the peritoneum, the, the bowels, out the way.
• 19:08
  Speaker 2: So we're looking straight at the spine and we just scrape out the disc, open up the nerves if there's any compression on the nerves and then put the new disc in um.
• 19:17
  Speaker 2: It takes about an hour, maybe an hour and a half if you're taking a bit longer for a single level.
• 19:22
  Speaker 1: Would y'all do multiple levels at once?
• 19:24
  Speaker 2: yeah, yeah, I would do two.
• 19:25
  Speaker 2: Two is typically at once, one or two um three can be pushing it through a lot, but usually it's one or two.
• 19:31
  Speaker 1: Level pathology so a two level would be like two levels at the same time.
• 19:35
  Speaker 2: Hour and a half surgery hour and a half to two hours.
• 19:38
  Speaker 1: Yeah, interesting so there's two surgeons in there the same like you, and then a vascular surgeon, correct?
• 19:44
  Speaker 2: yeah.
• 19:44
  Speaker 1: He moves everything out of the way.
• 19:45
  Speaker 2: Yeah, so it's interesting it depends where you train.
• 19:48
  Speaker 2: In Europe a lot of the spine surgeons will do their own approaches In the US for mainly medical legal reasons.
• 19:57
  Speaker 2: There's an approach surgeon there.
• 19:59
  Speaker 2: I think on balance it makes sense because the real risk is if you injure one of the blood vessels when you're exposing the spine and to have the specialist to fix them there.
• 20:11
  Speaker 2: That just makes sense.
• 20:13
  Speaker 1: Yeah, for sure.
• 20:13
  Speaker 1: I mean the descending aorta.
• 20:17
  Speaker 1: Where does it split into the common iliac artery?
• 20:21
  Speaker 1: Is that correct?
• 20:26
  Speaker 2: the common iliac order.
• 20:26
  Speaker 2: Is that correct?
• 20:27
  Speaker 2: Yeah, so it's variable um.
• 20:27
  Speaker 2: I'll tell you that l5, s1 is definitely not split there, so you've got a wide open window to the bottom level.
• 20:30
  Speaker 2: L45 is usually around the level of the bifurcation and it actually tends to be the vein.
• 20:36
  Speaker 2: That's more of an issue because it's it's less um, less robust, so it doesn't take me flimsy's flimsy, yeah, yeah.
• 20:43
  Speaker 2: So four, five is technically the harder level to get, and so it's essential to have a good approach surgeon, which we're blessed with several in the area, and then, above that, l34 is actually easier, again, because you're dealing without the bifurcation there.
• 20:58
  Speaker 2: So four, five's the the hard level interesting.
• 21:01
  Speaker 1: Uh, if it does, if an accident happens like that and the vascular surgeon is there to repair, is it just a quick stitch Like how's that work?
• 21:10
  Speaker 2: Yeah, I mean typically, yeah, If.
• 21:12
  Speaker 2: If we're doing these regularly with with experienced approach surgeons, it's usually like a small branch of the vessel pulls off.
• 21:21
  Speaker 2: Oh, I see.
• 21:22
  Speaker 2: And so it's just a small stitch and it's an easy fix, but not the trunk, yeah, basically.
• 21:26
  Speaker 1: And I'm actually super and I'm sure it's super uncommon.
• 21:30
  Speaker 2: Yeah, Very, very uncommon.
• 21:31
  Speaker 2: I mean it happens a couple of times a year, it's not.
• 21:33
  Speaker 2: It's not like it's every week with vessel injuries.
• 21:36
  Speaker 2: That would not be.
• 21:37
  Speaker 1: But that's really, I mean, that makes a lot of sense.
• 21:39
  Speaker 1: That's also, I'd imagine, very um uh, makes people feel more secure.
• 21:44
  Speaker 2: Yeah.
• 21:44
  Speaker 1: Having two surgeons on hand right there doing it?
• 21:46
  Speaker 1: I think so.
• 21:47
  Speaker 2: And and it's, I think it just makes sense.
• 21:49
  Speaker 2: It makes me, uh, feel a lot more comfortable having the specialist there to get it all ready for me, and then I can just focus on getting the disc in right, and he just focuses on the blood vessels.
• 22:02
  Speaker 2: So it just makes sense.
• 22:04
  Speaker 1: Yeah, that's good.
• 22:04
  Speaker 1: Do the best job possible.
• 22:05
  Speaker 1: Yeah, so, patients, you don't go through the abdominal muscle tissue, you go through the tendon that heals up quick with a stitch and then physical therapy after that.
• 22:15
  Speaker 1: Like what do you all recommend?
• 22:19
  Speaker 2: So for the first uh week I asked them to wear a back brace, just when they're up walking around, just because the bone grows into the implant so it becomes part of them, and that takes a few weeks.
• 22:26
  Speaker 2: You can't really speed that up, yeah, and then they're just walking for the next six weeks.
• 22:30
  Speaker 2: Okay, once they get out to six weeks we start to use the elliptical, the stationary bike.
• 22:34
  Speaker 2: Then once you get out to three months, you can go back to full activity at the gym.
• 22:37
  Speaker 2: Now we'll start some gentle PT around six weeks.
• 22:40
  Speaker 2: Got it?
• 22:41
  Speaker 2: Okay, we don't want to crank on it.
• 22:43
  Speaker 2: You don't want to dislodge the implants because then you're going to have to go back in and redo it.
• 22:48
  Speaker 2: So you just got to wait and be patient while the bone grows into the titanium which they spray the ends with mimics bone, so the bone grows into it.
• 22:57
  Speaker 2: It looks like bone to bone and so it makes this solid bond too.
• 23:01
  Speaker 2: That's really cool, yeah, it's cool.
• 23:03
  Speaker 2: And the neck similar.
• 23:04
  Speaker 2: It's an anterior incision in the neck.
• 23:06
  Speaker 2: Usually hide it in one of these creases that most of us have and we just go between the muscles here, so we're not cutting any muscle again.
• 23:13
  Speaker 2: And the same thing.
• 23:15
  Speaker 2: That and the same same thing.
• 23:20
  Speaker 2: That's done usually just by me.
• 23:21
  Speaker 2: There's no approach surgeon up there um the uh, the vessels aren't such an issue there that's good, and the the trachea also.
• 23:27
  Speaker 1: Yeah, so you just move that away yeah, it's all.
• 23:30
  Speaker 2: It all moves very easily out the way.
• 23:31
  Speaker 2: I mean the issues up in the neck.
• 23:34
  Speaker 2: Some people will have a little bit of a sore throat for a few days afterwards.
• 23:37
  Speaker 2: Um, but it usually settles pretty quick and we put them in a collar again for a week.
• 23:44
  Speaker 2: They take it off to sleep just when they're up, walking around really, um and similar.
• 23:48
  Speaker 2: No lifting anything heavier than a gallon of milk for the first six weeks.
• 23:52
  Speaker 2: Then six weeks you start doing gentle therapy, gentle um activity with the elliptical, the stationary bike, and then at then at three months you're back golfing, tennis, full go yeah.
• 24:03
  Speaker 1: Do y'all do multiple levels at this neck, the same way as the lumbar spine?
• 24:07
  Speaker 1: Pretty commonly?
• 24:08
  Speaker 2: Yeah, yeah, so frequently we're doing like three levels at the same time now in the neck.
• 24:12
  Speaker 2: It's not uncommon.
• 24:13
  Speaker 1: Interesting Timeframe.
• 24:15
  Speaker 1: How long is the surgery for that?
• 24:16
  Speaker 1: About an hour level typically what we recommend.
• 24:19
  Speaker 1: Oh, okay, gotcha.
• 24:21
  Speaker 2: So three hours for three levels or two hours for two levels.
• 24:24
  Speaker 1: And what are the most common levels?
• 24:25
  Speaker 1: You guys usually do Five six.
• 24:29
  Speaker 2: Yeah, four to seven is probably the most common, and I think five, six and six, seven are the most common too.
• 24:36
  Speaker 1: Interesting, yeah, and that makes sense from what we've gathered've gathered yeah, it's to do with the angulation, the shear.
• 24:42
  Speaker 2: So um the the five, six and six, seven are at the most angle, so they see more shear force.
• 24:48
  Speaker 2: Those discs tend to wear out faster.
• 24:50
  Speaker 2: Discs don't do very well under shear.
• 24:52
  Speaker 2: That's similarly why the five one wears out the fastest in the low back.
• 24:55
  Speaker 1: It's just it's the most sheer yeah, you had mentioned um to me in the past about uh like a multifidus muscle stimulator post-op or just for back pain.
• 25:06
  Speaker 2: Yeah, so that's the reactivate uh device.
• 25:10
  Speaker 2: Um, it's interesting, it's did very well in clinical trials so it had um around like a 70 improvement in people with this chronic low back pain without any real surgical target.
• 25:23
  Speaker 2: I think in practice most people feel it's not quite as successful as that.
• 25:31
  Speaker 2: It's probably more like 50-50.
• 25:32
  Speaker 2: I think it's useful in the older patients who have had a lot of muscle wasting.
• 25:40
  Speaker 2: And I've implanted in a few patients who have had scoliosis and with just back pain, no nerve symptoms, no neurologic, just pure back pain, and where the fix would be a 7-8 level fusion, which is a pretty big surgery and not something that they were either medically able to undertake or had the had the desire to undertake.
• 26:01
  Speaker 2: And so we've implanted in those patients and I think we've we've had good success with those um.
• 26:07
  Speaker 2: Certainly their back pain's improved.
• 26:08
  Speaker 2: They've avoided a much larger surgery.
• 26:11
  Speaker 2: There's some uh thinking that the multifidus muscle, which stabilizes the lumbar spine, when you have a painful stimuli it turns off.
• 26:20
  Speaker 2: It's a reflex muscle.
• 26:21
  Speaker 2: It's not one that you can just, you know, do a bicep curl to strengthen.
• 26:25
  Speaker 2: It's one that you subconsciously contract and it stabilizes the spine by by giving you a solid base.
• 26:30
  Speaker 2: So now, if you've got a bad disc, you've got a bad joint in the lumbar spine.
• 26:33
  Speaker 2: If you were to compress it would hurt.
• 26:35
  Speaker 2: So your body doesn't do that and over time, when that insult's gone away, so it's no longer painful, that muscle doesn't turn back on, and so you have this instability in the back, which which causes some pain.
• 26:46
  Speaker 2: And so this, this um device, stimulates that muscle for 30 minutes twice a day and there's some neuroelasticity where you re-innovate that muscle and it starts to get back under the reflex control from the spine.
• 26:59
  Speaker 2: And I say it's certainly interesting.
• 27:02
  Speaker 2: I don't think we've got all the answers yet for it, but it certainly is another tool in the toolbox, right, yeah yeah, exactly what of the disc replacements, or just like a debridement discectomy?
• 27:18
  Speaker 1: I'm sure you guys do a lot of that too.
• 27:19
  Speaker 2: yeah, so I do a lot of just disc herniations, uh, decompression.
• 27:23
  Speaker 2: So if you've got really no back pain, mainly leg pain, uh, going down down the legs when you walk or when you're standing up, um, then yeah, you really just want to remove the compression on the nerves and so you do that a couple of ways.
• 27:37
  Speaker 2: If it's a younger patient, it tends to be a disc herniation.
• 27:40
  Speaker 2: So you just make a small incision, remove that fragment of disc, leaving the rest of the disc behind, take the pressure off the nerve and the pain goes away.
• 27:48
  Speaker 2: I'm sure we've we've had patients with that do very well.
• 27:52
  Speaker 2: It's a finger width incision, um, and takes, you know, 40 minutes probably.
• 27:56
  Speaker 2: If it's an older patient where they've got more arthritis and it's more of a stenosis type picture, well then you have to kind of do a little bit more work.
• 28:03
  Speaker 2: The same size incision takes a little bit longer, more like an hour, hour and 20 minutes and you're kind of removing some of the arthritic bone and some of the hypertrophied ligament that's compressing on the nerves.
• 28:15
  Speaker 2: Both do very well and you're avoiding a fusion, you're avoiding any metal being put in the back, which is great.
• 28:24
  Speaker 1: Would that be the ligamentum flavum?
• 28:26
  Speaker 2: Is that the main one?
• 28:28
  Speaker 1: Exactly the flavum.
• 28:29
  Speaker 1: Yeah, describe to people what stenotic changes mean.
• 28:35
  Speaker 2: So stenosis just means narrowing, I mean, I think the way to think about it is we're just like plumbers essentially.
• 28:40
  Speaker 2: The spinal canal is a big, long pipe and the spinal cord and the spinal nerves run through it.
• 28:47
  Speaker 2: As you get older and the arthritis in the joints, the facet joints in the spine, and the disc starts to degenerate and bulge, it starts to narrow and you get these kinks in the pipe, the pipe, and so the the nerves get pinched and the the signal, the flow doesn't go down the nerves very well.
• 29:05
  Speaker 2: So all we do is go in there and just basically, like a rotor router guy that cleans out your toilet, we just open up the nerve shave off the um yeah, so trim the ligament, shave some of the arthritic joint sometimes it's discs, because we remove some of the discs.
• 29:19
  Speaker 2: It really depends on on, you know, when you look at the MRI, sometimes it can be a cyst.
• 29:23
  Speaker 2: You can have a cyst from one of the uh facet joints and in that case we just remove the cyst and and uh and open up the nerves between uh this, discectomy and debridement, decompression and anterior disc replacement.
• 29:39
  Speaker 1: What do you find yourself doing?
• 29:40
  Speaker 1: More like most most often um in the lumbar spine.
• 29:44
  Speaker 2: I think we probably still do more decompressions um than than disc replacements.
• 29:50
  Speaker 2: Some of that's the population down here.
• 29:52
  Speaker 2: I mean we have an older population.
• 29:54
  Speaker 2: They're not all necessarily candidates for disc replacements, but disc replacements growing um.
• 29:59
  Speaker 2: Some of it's just patient awareness.
• 30:01
  Speaker 2: Uh, we're getting more and more patients I've been told they have to have a fusion coming in and being told well, actually, no, you, you're probably a candidate for disc replacements.
• 30:09
  Speaker 2: I think over the next few years that number's going to change, you're going to continue to go in that direction?
• 30:13
  Speaker 1: I think so, yeah, interesting.
• 30:15
  Speaker 1: Uh, what do you do for your own back?
• 30:17
  Speaker 1: Uh, like, how was your back?
• 30:20
  Speaker 2: it's surprisingly good.
• 30:21
  Speaker 2: Actually, I played rugby and uh other silly things when I was younger um well, rugby's fun.
• 30:29
  Speaker 1: It's not silly, right like sports.
• 30:30
  Speaker 2: Yeah, you pay for it in the long run, exactly I mean I try to stay in shape, which is I've got two young kids and a busy practice.
• 30:39
  Speaker 2: I'm not doing quite as well as you at that, it seems, but that's always a goal.
• 30:45
  Speaker 1: For practice management, oh man.
• 30:46
  Speaker 2: No, staying in shape for me.
• 30:49
  Speaker 1: Oh well, I'm trying, you know.
• 30:50
  Speaker 1: It makes it easy when my clinic's a gym.
• 30:53
  Speaker 1: You know I have no excuse at that point.
• 30:55
  Speaker 2: Yeah, maybe I'll need to put a gym in my office and something like that.
• 30:58
  Speaker 2: But yeah, I mean just trying to stay in shape, work on the core strengthening.
• 31:03
  Speaker 2: Putting on weight, especially for men, is bad for your back.
• 31:06
  Speaker 2: We tend to carry the weight out in front and that just puts extra force on the low back.
• 31:11
  Speaker 2: Women tend to put it more lower down, more pear-shaped, and that tends to be less problematic for back pain.
• 31:18
  Speaker 1: Yeah, yeah, yeah.
• 31:19
  Speaker 1: But yeah, I mentioned with your wife because we had worked together for some stuff a little bit, and she's doing her the med spa, the re-spa, which we'll talk about in a sec too.
• 31:29
  Speaker 1: She was saying that you guys do you all work out together at Tremble or the kickboxing?
• 31:35
  Speaker 1: She goes to Tremble.
• 31:39
  Speaker 2: Sometimes we tremble, or the kickboxing, or is that only she goes to tremble?
• 31:41
  Speaker 2: Um, sometimes we'll go to like lifetime together and just just work out there.
• 31:43
  Speaker 2: I tend to go to there.
• 31:43
  Speaker 2: I do a little bit of um like jujitsu mma at a local gym, just something to, to learn something new and challenge myself really keep it fresh yeah, because it gets a bit boring, just kind of lifting weights every day yeah, that's one of my goals.
• 31:57
  Speaker 1: You know, I have never really done any MMA.
• 31:59
  Speaker 1: I did some kickboxing a little bit back a little while ago, but because I think it's just also fun like to get some aggression out and like hit some stuff yeah.
• 32:08
  Speaker 2: I mean I'm pretty lucky there's a gym really near our house.
• 32:11
  Speaker 2: I found them during COVID because everything else was shut and he was still running it because it was kind of I guess he had different rules because it was a smaller, smaller business and it was only one-on-one and he was like, hey, look, if you're okay with it, I'm okay with it.
• 32:23
  Speaker 2: And I was, yeah, let's give it a go.
• 32:25
  Speaker 2: And I've been going and you know when I get busy that gets cut out, unfortunately my schedule.
• 32:30
  Speaker 2: But I need to see I'll come back there more.
• 32:32
  Speaker 2: But it's excellent.
• 32:32
  Speaker 2: It's really really challenging.
• 32:34
  Speaker 2: He does a lot of like body weight stuff, movement stuff, so kind of bear crawls and hops and stuff like that to try and work coordination.
• 32:41
  Speaker 2: It's just stuff you don't do as an adult anymore.
• 32:43
  Speaker 2: Yeah, I think that stuff's important yeah, I uh.
• 32:47
  Speaker 1: No, I definitely have visions of trying to get into jujitsu or muay thai or something.
• 32:51
  Speaker 1: You know it's humbling, that's what I've heard.
• 32:54
  Speaker 2: Yeah, it's um, I mean, I'm pretty strong and used to doing physical stuff and uh, yeah, you lose every time so people like have your size.
• 33:07
  Speaker 2: They're like yeah old people that you are like this guy should be no challenge and they, they destroy you every time.
• 33:15
  Speaker 2: That's funny.
• 33:16
  Speaker 2: Yeah, so, but that's good, though.
• 33:17
  Speaker 1: Yeah, get get ready for that.
• 33:19
  Speaker 1: It's definitely humbling.
• 33:20
  Speaker 1: What so are you doing Brazilian jiu-jitsu or what's-.
• 33:25
  Speaker 2: Yeah, I think that's what they describe it as.
• 33:28
  Speaker 1: Where are you right now?
• 33:28
  Speaker 1: On like your journey with your belt.
• 33:30
  Speaker 2: Oh, it's not.
• 33:31
  Speaker 2: I'm not doing any belts or anything like that, it's more just kind of casual Gotcha.
• 33:35
  Speaker 2: I'm casual gotcha.
• 33:35
  Speaker 2: I mean I'm sure we could go through gradings if we wanted, but yeah no, it's more just something to do for fun.
• 33:40
  Speaker 2: Yeah, that's cool but also I mean, like you know, and I think a little um self-defense and confidence yeah, I mean, I used to do karate when I was younger, and so it's kind of something I've always done and been around, um yeah, but it's definitely, um, definitely interesting.
• 33:57
  Speaker 1: It's definitely something, something good so, besides, all right, anything else, what?
• 34:02
  Speaker 1: So?
• 34:02
  Speaker 1: What would you recommend, like from the patients that you've seen in success stories, for patients that have had battling back pain and you're you did a decompression on them or, um, maybe not even doing that, but you're like, definitely need to do this to help your back.
• 34:16
  Speaker 1: I mean losing weight.
• 34:17
  Speaker 2: You said, I think losing weight, I think definitely doing some therapy or just strengthening your core, whether you do that with yoga, uh, yourself just doing planks, or with directed therapy or someone like yourself.
• 34:31
  Speaker 2: I mean, I think those are the simple things that you know you should be able to try yourself.
• 34:35
  Speaker 2: If those aren't working, if you're still battling back pain, then I think you need to get an MRI and see someone and you know whether that's injections you try next or other options really comes down to what's going on, how bad it is, you know.
• 34:50
  Speaker 2: If this is, you know it aches once a year.
• 34:52
  Speaker 2: If you do a little bit too much, well, yeah, then it's probably not worth doing too much.
• 34:56
  Speaker 1: I was going to say much.
• 34:57
  Speaker 1: Well, yeah, then it's probably not worth doing too much.
• 34:59
  Speaker 1: It doesn't say, like patients ask me.
• 35:01
  Speaker 1: Well, I'll frequently like at what point do we get an mri?
• 35:03
  Speaker 2: what do you recommend for that?
• 35:03
  Speaker 2: So if you're getting neurologic symptoms like pain down the legs, weakness in the legs, heaviness in the legs, then yeah, definitely time for an mri.
• 35:12
  Speaker 2: If it's just back pain, I mean, the red flags are if you're having weight loss, if you you're having night pains that wake you up, then yeah, you should get an MRI to make sure it's not cancer or something serious that we're missing.
• 35:25
  Speaker 2: Otherwise, it just comes down to quality of life.
• 35:28
  Speaker 2: If you're getting to the point where you can't do what you want to do, then I think it's time to think about getting an MRI.
• 35:35
  Speaker 2: Take some action.
• 35:35
  Speaker 2: Yeah, and those goals are different for everyone.
• 35:44
  Speaker 2: You know some patients come in and they're frustrated because they can't do two iron men in the same month and other people's goals are.
• 35:47
  Speaker 2: You know, I want to be able to walk to the fridge, get some food and sit down and and you've got to understand, like, what everyone's goals are and that's different for everyone.
• 35:56
  Speaker 2: And that's one of the advantages of having a slightly lower volume practice is you have the time to figure that out and talk to them and understand where they're trying to be and where they are now, Because that's really it's unique and it's different for everyone.
• 36:11
  Speaker 1: Yeah, it's interesting.
• 36:12
  Speaker 1: You say like I'm battling some back pain, I ran it.
• 36:16
  Speaker 1: Like I'm saying, like I get a patient that comes in, I'm battling some back pain.
• 36:18
  Speaker 1: I ran it.
• 36:18
  Speaker 1: Like I'm saying like I get a patient that comes in, I'm battling back pain I've had, or knee pain, whatever.
• 36:21
  Speaker 1: I ran an Ironman, I'm training for another one, I have a marathon coming up next week.
• 36:24
  Speaker 1: Yeah, I mean, we get that.
• 36:26
  Speaker 1: That's awesome, you know.
• 36:27
  Speaker 2: Hey, I love the enthusiasm you know we get them and then we get the other people.
• 36:31
  Speaker 2: Minutes, my back hurts and you've got to try and figure out.
• 36:41
  Speaker 2: You know what they're looking for and what's realistic.
• 36:42
  Speaker 2: Because you know if they're coming to you because they want to be able to do do that second iron man in the same month and you know the goals are it's going to be hard to make that goal, yeah.
• 36:52
  Speaker 2: But if they're just coming to say, hey, look, I just can't stand anymore, then then you know, I think your, your runway for success is much clearer.
• 37:00
  Speaker 1: Yeah, you mentioned red flags.
• 37:02
  Speaker 2: Explain to people what that means, so red flags are symptoms that should warn your, your provider, that there's something more serious going on, and and would prompt um more investigation.
• 37:19
  Speaker 2: So you know, classically we worry about back pain.
• 37:23
  Speaker 2: As you know, is this a manifestation for cancer, because a lot of cancers do spread to the back, and so you know people that complain of, you know, just increasing pain, pain that's just out of proportion.
• 37:33
  Speaker 2: So you know people that complain of, you know, just increasing pain, pain that's just out of proportion.
• 37:36
  Speaker 2: So you know you can't function.
• 37:37
  Speaker 2: Pain that wakes you at night, um, and if you're having weight loss, these are all things that that would make someone concerned that this is more than just simple back pain, and so we should get a good investigation.
• 37:48
  Speaker 2: Other things that go along with it are, you know, night sweat.
• 37:51
  Speaker 2: So if you have your okay during the, but at night you're profusely sweating, well, that may be an indication that there's something more going on.
• 37:58
  Speaker 2: It's either hematological or effective, and so that's something that we should bump up to the red flag for let's get an MRI and make sure it's not anything serious before we just say this is back pain.
• 38:08
  Speaker 1: Right, like you're good, let's just work on this, just to rule things out and then go from there.
• 38:14
  Speaker 1: Exactly, yeah, and we've had a couple mutual patient success stories.
• 38:19
  Speaker 1: People have come in One of them, I think, is coming in tomorrow to see me again, but just for continuous stuff.
• 38:26
  Speaker 1: But they're like man, I feel amazing.
• 38:29
  Speaker 1: I feel a lot better.
• 38:30
  Speaker 1: I think they just had a decompression, just from what I'm thinking in particular.
• 38:34
  Speaker 1: The other one's very similar actually.
• 38:36
  Speaker 1: She actually just texted me today.
• 38:37
  Speaker 1: I'm not going to say their names, but both of which had just decompression surgery and the incision's like literally half an inch long.
• 38:48
  Speaker 2: Yeah.
• 38:49
  Speaker 2: So I mean, what's different about the way we do a decompression as opposed like the?
• 38:54
  Speaker 2: The standard is I do it through a tube, so the tube is about 16 millimeters in diameter, about half an inch the width of my finger, and so what we do is I make an incision and we put this hollow tube down to the spine and then I work through that with a microscope, with special instruments and the.
• 39:10
  Speaker 2: The more classic way is you make a bigger incision, you strip all the muscle off the bone and push it out of the way, so you're looking at the spine, so it's obviously a lot less damaging yeah and a lot less painful, and the reason for that is most of the pathology in the spine focuses around the disc level.
• 39:28
  Speaker 2: So if you imagine the spines build up of vertebrae stacked up on top of each other and there's a disc in between, either through an evolution or a design flaw, depending on what your beliefs are, what tends to happen is at the level of the disc.
• 39:40
  Speaker 2: You've got the joint which can become arthritic and expand into the spinal canal.
• 39:44
  Speaker 2: You've got the disc which, as it ages and degenerates, will tend to bulge into the spinal canal.
• 39:50
  Speaker 2: It's like if I go let the air on your car tires, the car sinks down right.
• 39:53
  Speaker 2: Well, the tire bulges into the, into the spinal canal, so that that creates problem and the ligament of flavin, which you spoke about earlier, also um infolds at that exact level and hypertrophies as it gets more unstable as the disc breaks down.
• 40:09
  Speaker 2: So you're trying to stabilize the segment.
• 40:11
  Speaker 2: So all those pathologies just line up at this same level and you'll see on the MRI, if you look at it carefully, that you'll have narrowing at the level of the disc and then as you go up the vertebrae it opens up and looks normal and then it narrows again at the disc above and you can repeat it to the pathological normal level.
• 40:29
  Speaker 2: So you just really need to go in and address that that little level.
• 40:32
  Speaker 1: You don't need to strip the whole spine, you just need to target the levels where it's narrowed and open them up interesting, uh, the, and with the tube that you and like the incision, are you able to move a lot of the muscle out of the way?
• 40:47
  Speaker 1: Or do you have to go through the multifidus or the right, your spinning group?
• 40:51
  Speaker 2: yeah, so you, you go through the muscle, um, so you, but you're going through the body of the muscle and the muscle fibers run longitudinally, so you end up just splitting between the fibers.
• 41:00
  Speaker 2: So you're not really cutting the muscle, you're not removing muscle, um, you're certainly not detaching the muscle from the, from the bone, which is the important part, whereas if you go midline, the more classic way of doing it, then you have to strip the muscle off the um, off the bone, and you often actually de-innovate it.
• 41:17
  Speaker 2: So the segmental branches, the nerves, and as you're stripping the muscle off, you're going to end up damaging those, and so the muscle becomes de-innovated.
• 41:25
  Speaker 1: Interesting, yeah um, wasn't it like another interesting one of these patients I was describing doing really well?
• 41:32
  Speaker 1: Um, they had decompression because they had pain in their leg and then also sensory.
• 41:38
  Speaker 1: Their sensor was affected right, it was less sensory and then she had a lot more pain down her leg, down her ankle and her foot and she was at foot weakness.
• 41:47
  Speaker 1: They had decompression surgery but the residual nerve involvement still lingers for a couple, like for several weeks, you know yeah, I mean.
• 41:57
  Speaker 2: So if you're actually getting weakness in the ankle, the foot drop, um, that that doesn't always come back.
• 42:03
  Speaker 2: So depending on how weak it is, uh, we grade it out of five.
• 42:07
  Speaker 2: Um, if you've still got some strength, kind of like a three or four out of five power, it'll probably come back.
• 42:13
  Speaker 2: But if you start getting down to the ones or the zeros where there's really no motion, it's kind of 50 50.
• 42:19
  Speaker 2: If that comes back and that's just due to the, the nerves been injured and it has to regrow along the, um, the, the sheath of the nerve, the, the myelin sheath, which is what coats the nerve, like an electrical cable.
• 42:33
  Speaker 2: Unfortunately it grows really slowly, about a millimeter a day, and by which point the, the muscle, may no longer be receptive to the nerve once it grows back in and in, the, uh, in respire, which which you kind of touched on just now.
• 42:47
  Speaker 2: We've actually got some interesting technology there called the m sculpt and we've been using that in these patients that come in with this weakness.
• 42:53
  Speaker 2: This foot drop, either in the legs or in the arms we have some arm weakness as well but we stimulate the, the muscle outside the body.
• 43:01
  Speaker 2: So we use like a, an electrical plate and it gives them like 20 000 contractions in a 30 minute cycle and uh, and we've been finding that actually that keeps the muscle ready.
• 43:12
  Speaker 2: So when the nerve finally does grow back in, you're actually getting higher recovery rates.
• 43:15
  Speaker 2: It's actually pretty, pretty exciting because it can be pretty debilitating if you can't lift your ankle up, you, you walk funny and you trip on it and it's a problem.
• 43:22
  Speaker 2: And we were actually part of the fda study for approval for this device because it's actually used in the um, in the body sculpt, in the beauty world.
• 43:32
  Speaker 2: Initially that's what it's designed for and that's what it's sold as.
• 43:34
  Speaker 2: But the the company has started to realize, as as more and more orthopedic surgeons have been been using it, actually there may be something here for rehab, and so it's now got approved for post-op rehab, so for like knee replacements, hip replacements, to try and regain the muscle that's injured and damaged during those surgeries, and similarly after spine surgery for like muscle weakness as well.
• 43:55
  Speaker 2: Yeah, and we've had really good results with that that's awesome.
• 43:58
  Speaker 1: Um this and this patient.
• 43:59
  Speaker 1: I was saying like I would imagine, like the expected um protocol, like expectations of development, if somebody's been battling like a kind of a severe it's been going on for a couple months like nerve referred pain, they would still have some of that after surgery.
• 44:19
  Speaker 1: It would just take a little bit of time for that to come it varies, it varies.
• 44:24
  Speaker 2: So what do you find with that?
• 44:25
  Speaker 2: Often the leg pain is significantly better immediately after surgery or more like, depending on which site you're operating on.
• 44:33
  Speaker 2: They may still have a little bit, but it's a lot better at some point during the recovery.
• 44:39
  Speaker 2: As the nerve heals, it becomes super sensitive.
• 44:41
  Speaker 2: So they may have a return of the pain, usually around two weeks after surgery.
• 44:45
  Speaker 2: But that's variable and it's just due to the fact that as the nerve heals it becomes super sensitive.
• 44:49
  Speaker 2: So stimuli that should not be painful, like your clothes rubbing on it, the bed sheets, someone touching it can generate pain and some people say they feel like ants on the skin, they feel fire or just pain, and that can variable.
• 45:03
  Speaker 2: It doesn't always happen, but definitely can happen.
• 45:06
  Speaker 2: The sensation loss tends to be slower, so it'll often be better after surgery, but that can take a few weeks or months to fully resolve and it doesn't always fully come back.
• 45:17
  Speaker 2: So you may have some numbness in the tip of the toes or something like that which never really comes back unfortunately.
• 45:22
  Speaker 1: Yeah, yeah, we have another patient that um has been badly hit.
• 45:27
  Speaker 1: This person had a stroke and uh and also back pain and had referred like sadicus type symptoms on their leg and foot drop because of that.
• 45:38
  Speaker 1: But the stroke wasn't related to his foot and this part, like he.
• 45:43
  Speaker 1: We've been working this similar kind of thing with m sculpt and working on foot strength and stuff and just reactivation.
• 45:48
  Speaker 1: It's getting better, which is cool, and he's older, you know.
• 45:50
  Speaker 1: So, my god, the ceiling of expectation here is a little lower than somebody maybe who yeah definitely would be in their 20s, you know, but anyway, um, and residual like toe, and he like foot numbness, um, but anyway, previous to that he on the other leg had a similar thing going on and he said after two years all of a sudden turned a corner and his sensation returned it's 24 months post yeah, like there's the beginning of this pain.
• 46:16
  Speaker 1: It'd be developing unusual but yeah it's super, anyone's like because it's interesting.
• 46:20
  Speaker 1: I would agree with you like it seems like most times it's like there's a lower ceiling at this point, depending how involved it is, and then randomly get some people that's like after like an 18 to 24 month period, for some reason just came back.
• 46:32
  Speaker 2: I mean, there's a lot we still don't know.
• 46:33
  Speaker 2: There's definitely some.
• 46:34
  Speaker 2: I think it's super interesting in the brain that there's some like ability to rewire.
• 46:38
  Speaker 2: Some people have more more than others.
• 46:40
  Speaker 2: Um, I mean, there's definitely some degree of the longer the compression on the nerve before surgery.
• 46:47
  Speaker 2: You know we arbitrarily have this one year cut off, that you do better after less than a year or worse after a year, but it's definitely a continuation.
• 46:57
  Speaker 2: So you know, six months is probably worse than three months and 18 months is worse than 12 months.
• 47:02
  Speaker 2: Yeah, yeah, um, but there's also this individual variation that some people are just able to heal nerve tissue better than others and interesting it is.
• 47:11
  Speaker 2: It really is unpredictable and it's always hard to explain to some patients that, look, you're just in the slower recovery group.
• 47:18
  Speaker 2: I think we're going to get there, but it's going to take a little longer.
• 47:21
  Speaker 2: Yeah, and and you know most people understand that but it and they'll say oh you know, I heal slow.
• 47:26
  Speaker 2: Anyway, you're off to other surgeries and usually that's.
• 47:29
  Speaker 2: They kind of have this like history of just slow healing.
• 47:33
  Speaker 1: Yeah um, so that's about respawn.
• 47:35
  Speaker 1: So you guys in your office, uh, where you do your consults and your clinical, you also have like a med spa type facility so it's more like a functional med spa.
• 47:46
  Speaker 2: Um.
• 47:46
  Speaker 2: It's my wife's um passion project really.
• 47:49
  Speaker 2: I think she um after her pregnancy, uh, in particular I think she had well, we had twins and I think it hit her pretty hard and so she was looking at like ways to to get back to her activity level and and that was kind of when we discovered this m sculpt and the m cellar, these kind of um machines that use um radio frequency and uh electromagnetic field to to stimulate muscle uh growth and strengthening and and uh.
• 48:21
  Speaker 2: I mean there's pretty impressive results when you when you pair the m sculpt on the abs and the m cellar for the pelvic floor in terms of um like uh young mothers who are, who are like one or two years postpartum, in terms of recovery of urinary function, strength and back pain regeneration is pretty impressive.
• 48:46
  Speaker 2: And even in the elderly patients, in some of the studies that got the machine approved for the rehab, they looked at 65-year-olds and stimulated the core with the m sculpt on the abs and the low back and the pelvic floor and they showed improvements in agility.
• 49:03
  Speaker 2: So time to get up and go, how long it takes them to stand up and walk a distance and sit down again.
• 49:08
  Speaker 2: Back pain was significantly improved and, uh, more interestingly was their ability to stand on one leg, how long they could do a single leg stance improved, and that's actually the most predictable about your longevity.
• 49:22
  Speaker 2: So once you get over the age of 65, the longer you can stand on one leg without falling over and losing balance indicates how long you're going to live, and it's actually the best predictor of that, which is very little known fact interesting.
• 49:35
  Speaker 1: Yeah, yeah, um, and I would imagine like kind of a correlation with that would be the um in order to be able to balance on one leg.
• 49:44
  Speaker 1: There's like a lot that needs to kind of be maintained in order to do that.
• 49:48
  Speaker 2: Oh yeah I mean it's so.
• 49:50
  Speaker 2: It's just.
• 49:50
  Speaker 2: I think it's a marker for your general um, just function overall functionality fitness yeah totally well, that's cool.
• 49:58
  Speaker 1: Well, I appreciate you coming in.
• 49:59
  Speaker 1: Uh, where can people find you?
• 50:01
  Speaker 1: Like how can people reach out if they're battling back issues neck pain, nerve related pain, like I think they get a consult or check it out.
• 50:07
  Speaker 1: Where how do I how they reach you?
• 50:09
  Speaker 2: yeah, so I mean you can just email info at seville spine or or look on the website at SevilleSpinecom and there's lots of like chatbot and forms to just put your details in and one of the team will call you same day, next day, and we'll see what we can do to help Gotcha.
• 50:25
  Speaker 2: Well, thanks for coming in.
• 50:27
  Speaker 1: Kyle thanks for having me.
• 50:28
  Speaker 1: I'm glad we did it.
• 50:28
  Speaker 1: Yeah, I'm glad we finally got it on the books and we'll definitely be collaborating and stuff and patients in the future.
• 50:34
  Speaker 1: And if you have any questions, don't hesitate to reach out.
• 50:36
  Speaker 1: We're always open to questions, comments, concerns, conflicting opinions and if you're already battling any issues that you feel like we could help, feel free to reach out.
• 50:43
  Speaker 1: The best way to reach us is probably our phone number at 561-899-8725.
• 50:48
  Speaker 1: Or like our website, like Dr Phil is saying for his too, and then we'll catch.