What happens when the doctor becomes the patient? In the first episode in this new series, Dr. Sanjiv Lakhia discusses personal back care journeys with some of his esteemed colleagues.

On this episode, he talks with Lindsey Howard, PA-C, a physician assistant in the physiatry department at Carolina Neurosurgery and Spine Care. Her spine care journey began with scoliosis. 

When she was 12, she was diagnosed with scoliosis during a routine school screening for the condition. Her spinal curve was 40 degrees and quickly progressed to 72 degrees. Her doctor recommended surgery or, he told her parents, she likely wouldn’t live past age 30.

She hadn’t experienced much pain, only discomfort, from her scoliosis, but she remembers some of her post-op pain clearly. It’s helped her become more empathetic with patients.  

“The resident was trying to peel off the bandage on my back — that was very painful,” she said. “So now when I remove bandages, I'm very, very sensitive to that for patients.” 

Thankfully, surgery allowed her to get back to a sporty lifestyle and allowed her to be a cheerleader in high school. And the experience as a whole inspired her to work in medicine. 

Originally, her plan was to go to medical school, with the goal of helping other girls who suffered from similar issues. But she ended up becoming a physician assistant because she liked to spend more time with patients in their care transitions. 

Tune in to this episode of Back Talk Doc to hear more of Lindsey’s story with scoliosis and how she uses that difficult experience to be a better care provider today.

💡 Featured Expert 💡

Name: Lindsey Howard, MPAS, PA-C

What she does: Lindsey has been a physician assistant with Carolina Neurosurgery and Spine Associates since she graduated in 2013. She works in the physiatry department with Drs. Wiercisiewski and Sumich. 

Company: Carolina Neurosurgery and Spine Associates 

Words of wisdom: “The main reason I got into this is because I don't want anybody to ever feel [alone]. I think whenever you go through a major illness or any major medical issue, you can sometimes feel really alone.” 

Connect: Website |  LinkedIn

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👉 If you enjoyed this episode of Back Talk Doc, check out our recent episode Talking Artificial Disc and Facet Replacement Surgery with Dr. Vince Rossi. 

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Welcome. You're listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

Welcome back, friends, to another episode of Back Talk Doc. 2023 is just rolling along. We've had a fabulous year on the podcast with numerous amazing guests on the show, and it's really been almost like a university level curriculum on back pain and back care. I hope you guys are enjoying it and utilizing the episodes and sharing them with your friends and family. If you haven't already, please take time to go on iTunes and give us a five star review. It really means a lot, and it helps me understand that this is a valuable service for everyone listening.

Our last episode was really cutting edge where we talked about cutting edge nonsurgical approaches to disc disease and arthritis. Today, folks, we're going to pivot to cutting edge surgical techniques. Even though I'm a physiatrist and nonsurgical care is in my heart, I have to admit that my most popular episodes have been the ones where interview my surgical partners and two of the more popular ones have been regarding minimally invasive spine surgery, and that was one of my earlier episodes with Dr. Mark Smith.

And then the other one was on cervical artificial disc replacements with Dr. Dom Coric. We'll link to both of those in the show notes. Today, though, we get to advance that topic quite significantly with a rising star in the field of neurosurgery in the Charlotte community. Dr. Vincent Rossi, welcome to the show.

Thank you for having me, Sanjiv. I appreciate it. I'm a longtime listener as well and have really enjoyed your podcast over the years. I think it's been great for patient education as well to be able to delve into these topics in a much deeper sense than what we have time for in the clinic to discuss. Thanks for championing this for our community.

I appreciate that. Vince is our newest neurosurgeon at Carolina Neurosurgery and Spine Associates. We're so excited to have him. Let me introduce you to everyone who aren't familiar with you. He comes to us from residency through Carolina Neurosurgery and Spine Associates at Carolinas Medical Center. And then after that underwent fellowship training in Australia, right, and fellowship in spine care, and well before that was from Chicago, Illinois for medical school with Rush University Medical Center and then Southern Methodist University in Dallas, Texas for undergrad.

The other thing about your bio people should know is that you have an MBA from the University of Cincinnati. You may not know, I am from Cincinnati and I'm a Bengals fan. I don't expect you to be that high of a standard since you only did MBA there. But curious to know before we get into the topic of the day, which is going to be artificial disc and facet replacement surgery, tell me a little bit about that MBA, what to that in your career path and where does that come into play in your day-to-day life?

I think like many of us in the field of medicine, it's been hard to stay separate from the business side of it in order to understand it, in order to take care of patients, in order to figure out how to advocate for patients. You have to know the infrastructure of how the healthcare system works in this large system that we have currently. I felt the need to understand that more.

Like many people during COVID, things slowed down a little bit for us. Like many of us in medicine, we always find a way to find something else to keep us busy. That's what I did during COVID. I took that on as well and was able to get my MBA during residency. Really taught me a lot about the healthcare economics and business decisions in medicine, but a lot of leadership pearls and things too that I found have been extremely helpful.

That's amazing. One other thing that when patients go to our website and read your bio, it discussed there's a strong and long family tradition in healthcare in your personal life and background. You want to elaborate on that for people?

Yeah. Without going too far into the weeds, my grandfather in the 1950s started a small hospital in a rural town in Illinois with only about 1,000 people in the whole town. He had 11 kids. Many of those kids grew up to be physicians and surgeons, anesthesiologists, and the majority of them worked at that small hospital. It's been a family run hospital and one of those physicians was my father.

I grew up in that environment. I was raised around healthcare. I was raised around figuring out how to make healthcare work in a situation such as a small thousand person town where it shouldn't work, but we had to do it to help the patients. That was the environment I was raised in and why this runs deep in my veins.

And then also elaborate a little bit on your experience in Australia. What was that like?

Our residency training program was very supportive of us going international for a year to get an experience, and I really wanted to go somewhere where they were doing a high volume of something we don't do as frequently here in the US and one of those is arthroplasty, particularly lumbar arthroplasty.

The way the Australian healthcare system works, patients just have access to more available... They have access to these technologies that are much more available frequency based on how their insurance runs there. I was able to get a high volume experience that I probably would've taken me five years to see here, I was able to do in just a year there.

Vince, that's a perfect segue into the topic of today. I really wanted to get you on to talk about spinal disc and joint arthroplasty or joint replacement surgery. There's rarely a week that goes by where I don't get a question as a physiatrist about that, because as you know, patients are really interested in surgeries that have quicker recovery times. I think that's why Dr. Smith's episode that we did years ago remains one of the more popular download episodes on minimally invasive spine surgery.

Real thrilled that you've had this experience and we can get into it. Let's start out by, again, for people who are new or don't have a high level understanding, just maybe a 30,000-foot overview of what is arthroplasty and why is it relevant in the world of spine care now?

The 30,000-foot view is arthroplasty is a concept of replacing a joint with an artificial joint. Spine surgery, the difference between spine and the other joint pathologies is that if you have a hip problem, there's only one hip joint, whereas with your spine, there's a multitude of different joints all throughout the spine, dozens of joints, and it becomes much more complex to simulate that biomechanically that has been historically for a hip or a knee arthroplasty has really become standard of care in those fields.

I think the importance of spine arthroplasty and the role for it is really when we think about all the ways we address other pathologies of the human body, it's very rare where we replace or fix a problem in the body by doing something that's not natural and not what the normal anatomical, normal physiological function of that organ is. For instance, if you imagine with hip replacements, they're not fusing the hip together. That was the way they used to do it decades and decades ago.

But now the standard of care is a hip replacement for that. I think as we've understood more with the spine and better diagnose the pain generators of the spine, when the pathology requires surgical intervention and fails non-conservative measures, that if we could correctly figure out which patients are arthroplasty candidates, then I think we'll see that will be a very sustained and successful outcome for those patients.

When you reference arthroplasty, you're referring to discs and joints, is that correct?

Correct. Historically, if you spoke about spine arthroplasty, for many years, that's really just referred to disc replacement. There's cervical disc replacement where we're replacing the disc, and then there's lumbar disc replacement where we're replacing the lumbar disc. Those were really the mainstays of arthroplasty for spine for many decades until just recently really. We can dive into it deeper in the conversation, but there's particularly two newer technologies out there that go beyond just replacing the disc and really replacing the whole functional unit of the spine.

Before we do that then, describe to people the different types of pain presentations that you might feel like could suggest itself towards arthroplasty in terms of discogenic pain and facet related pain. We've covered some of that before on some previous episodes, but I'd love to hear how you triage a patient in your mind based upon their symptoms.

Yeah, absolutely. Just to simplify the conversation, I'll answer that in the perspective of circa just five years ago when it was all mostly disc replacements we're referring to. For those patients that would be potential disc arthroplasty candidates, particularly in the lumbar spine, those would be patients with discogenic low back pain or symptomatic degenerative disc disease. Our spine consists of obviously the vertebral body, a block of bone, connected with another block of bone, the other vertebral body, and a disc that connects them.

In the back, we have the two joints in the back that connect the posterior elements or the facet joints. That really makes up the functional unit of the spine or the three joint complex of the spine. Patients that have degenerative disc disease have a problem with that disc in the spine, and it really is a very complex cascade of events that occur that starts with small amount of microtrauma and damage to the disc that ultimately causes the disc to degenerate and involute and causes severe pain and hypersensitization of the pain due to abnormal vasculature growing and abnormal neural connections.

And that can become very sensitive and severely painful for patients that present with discogenic low back pain. Those patients typically have axial low back pain, meaning focused in the middle of the back, that's severe. It's aching. It's usually a burning pain. It's worse with any movement that increases that pressure within the discs that irritates the sensitization such as Valsalva maneuvers, coughing, sneezing. Oftentimes these patients have marked sitting intolerance, meaning they can't sit for longer than 5, 10, 15 minutes sometimes because the pain is so severe.

Commonly I'll see these patients come into my office, they will literally be carrying a seat cushion with them to bring into the office because they know on certain surfaces their pain is so bad when they sit down. Those are really the classic patient that has failed non-surgical measures and failed over six months of non-surgical therapies that might be a candidate for disc arthroplasties, particularly in the lumbar spine.

Wow, okay. That's a great take home point, the sitting intolerance, which we see quite often. As a neurosurgeon, we know the statistics on degenerative disc findings on imaging in terms of aging, clinically relevant versus not. How do you go about as a neurosurgeon distinguishing a degenerative disc that's symptomatic versus one that is more natural history of aging and not necessarily a pain generator?

Yeah, that's really where the nuance of patients doing well from this treatment methodology, it really comes true because that's really what... You're exactly right. We need to figure out which patients are truly having an issue with that particular disc or two discs that we're treating. The way we do that, and you're exactly right, the studies show that if you took any group of people over 50 years old and did an MRI at their lumbar spine, over 90% of them would have degenerative disc disease, but not 90% of them have severe discogenic low back pain.

You're trying to distinguish what's an actual true presentation and what's just incidental finding, as you're saying. The way that works best is for patients that are younger and have more healthy spines and they have a one or two level problem and the rest of their spine looks pretty well, it's much easier to sort that out and determine what levels are their pain generators versus a patient that has pretty severe advanced degenerative disease of the spine or arthritis of the spine.

Those patients, there's so many potential pain generators that arthroplasty is probably not going to be a good viable option for them.

That's a key feature. Perhaps a little bit of a younger patient population where there's not so many findings that are abnormal on an imaging study where it's almost a little more obvious. Vince, are you utilizing discograms in a diagnostic workup?

I do like to utilize discogram. It's controversial. There are theories that the mere act of introducing a needle into the disc space causes some injury to the disc, but I think the value of it in terms of knowing you're going to have a positive control response to increasing the pressure inside the disc. For those listening, the discogram is where a physiatrist stick a needle in the disc space and inject some small amount of fluid and contrast in the disc to increase the pressure in the disc.

And that can simulate the discogenic pain symptoms that patients get. They do it at a level that we think is suspicious of where the problem is and one that's a control that might be less degenerated. If it's a positive control or if it matches, then we're more confident that that's the disc and the problem that the patient's presenting with. I think it's very helpful, particularly in patients that have two or three degenerative discs and you're not sure which one might be contributing if it's just one or if it's just two.

But in a patient where they otherwise have a very healthy looking spine and have a severely degenerated L5-S1 disc with severe sitting intolerance, it's a little bit easier to be sure that's their pain generator.

Okay, so that's the patient with discogenic back pain. Go ahead and describe for people listening facet related pain in terms of those characteristics and a little bit about the replacement options with facets.

Facet related pain, the facets are the two joints in the posterior portion of the spine, and they're what connected the level above and the level below. They become degenerated or have advanced what we call just arthritis of the spine or degeneration as the disc wears out and the whole spinal unit starts degenerating and having micro instability to it. With that inflammation, bone spurs occur. There's hypervascularization. There's hyperinflammation, and you get severe inflammatory response that causes pain, and that's facet mediated pain.

That often is axial back pain. That's very mechanical, meaning worse with movement, and it oftentimes has a referred pattern that can radiate to the buttock area. It's typically tendered to palpation if you manually palpate the facets that are most spondylotic or the most arthritic. Typically, if you look on the imaging, those patients have large bone spurs at that area where these advanced changes are occurring.

The best first line treatment for those patients that have failed physical therapy for facet mediated pain would be trialing facet injections such as medial branch blocks and seeing if they're a candidate for radiofrequency ablation.

We did a great episode with Stephanie Plummer where she broke that down. Folks, if you're listening, you're not really familiar with RFA, go ahead and we'll link to that one in the show notes as well and take a listen. A lot of this stuff overlaps and what he's talking about, discogenic back pain, facet related back pain, we've covered some of this on previous episodes from a nonsurgical perspective.

But today, we're really talking about if you're out there and you feel like you've tried these other things and it's just not giving you the response you're looking for, this is where arthroplasty could come into play. Before you dive into the details of exactly what someone could expect going through these types of surgeries and these devices, what is the standard of care for discogenic back pain and facet pain from a neurosurgical perspective let's say prior to the emergence of arthroplasty options?

Prior arthroplasty and still to this day, the standard of care, if a patient comes in with a degenerated disc and they're symptomatic from it, have symptomatic degenerative disc disease or discogenic low back pain, the standard of care is still physical therapy, over the counter pain medications, lifestyle modification. If there's a reasonable option for any interventional procedure or injections, then those are all the first line treatment for that patient.

If we look at the FDA trials for all the arthroplasty devices, in order to even be included in that trial, the patients had to fail at least six months of conservative treatment and have that documented. At the very minimum, six months. But for me, the younger the patient is, the longer I make them wait before we talk about arthroplasty. Even if they've done six months and they're a young, mid 20s year old, I want them to give their body as much chance as possible to heal that on their own.

That's really good to know that it's really something that you want to work through all the conservative options first. All right, let's fast-forward though. Let's say I'm 42, I've got a degenerative desiccated L4-5 disc on imaging. I got a lot of pain. I'm coming in to see Dr. Rossi. I need three cushions to sit on. I've been through the physiatry team. I just haven't gotten sustained results, and I'm ready to talk about disc replacement. Walk us through what that conversation would look like and on a high level what the procedure is and how this works.

The first meetings I have with patients that come in requesting to see if they're a potential candidate for arthroplasty, it's really just a conversation about what their symptoms are, if this is truly discogenic low back pain, what makes it better, what makes it worse, what they've tried so far, making sure that they've at least started or completed a lot of the conservative therapies, and getting a sense for really what their baseline disability is from this.

All my patients that I see particularly for lumbar arthroplasty, I do full baseline quality outcomes, patient reported outcomes on them to get a sense for what their ODI scores are, the disability scores are, or what their vast scores are, so that I can show them and compare them to what the trial showed in terms of these patients having elevated ODIs preoperatively. And then at the six month, one year, five year marks where they can expect on average those patients would get a response in terms of reduced disability and reduced back pain and leg pain scores.

That's really the first conversation is just having a discussion about the symptoms, what they've tried so far. I never offer arthroplasty the first time I see a patient, even if they've already had conservative treatment extensively elsewhere, because it's really a relationship that the provider builds with that patient in terms of trying to figure out what they've done so far to try to get this pain better.

And then on the follow-up visit, I'll usually see them back in a few months after we've discussed and we'll have a little bit more in-depth conversation about whether arthroplasty might be a good option for them. During that time, I go through the trials in a little bit more detail and explain what the clinical benefit is of arthroplasty versus fusion and explaining what the benefits are of fusion versus arthroplasty.

Okay, that's juicy right there. Can you get into a little more detail with that? Lumbar spinal fusion obviously is a well-known entity. A lot of great results doing fusions on patients who are properly selected, but I'd love for you to share what are maybe some advantages or disadvantages of arthroplasty versus fusion when you're talking with patients?

Especially within the context of discogenic low back pain, the pain is originating from the disc. When we do these procedures and all the trials really compare doing a lumbar arthroplasty where we go in from the front of the spine and take out the entire disc, putting an arthroplasty device in replacement of that disc, versus taking out the entire disc and putting a fusion device, like a fusion cage that would fuse the two vertebral bodies together.

Both of those surgeries are taking away the pain generator, which is the disc, and all the abnormal inflammation, the abnormal cytokines, the abnormal angiogenesis, the vasculature, the abnormal sensitized neurons, taking all that away. Clinically, in terms of back pain, leg pain, patients do very similar fusion versus arthroplasty, and that's what all the studies have shown from the clinical symptoms.

The benefit of arthroplasty is preserving the motion, and preserving the motion gives some patients a little bit more of a benefit in terms of disability and motion and the feeling of feel like they can recover more quickly. And also more importantly, it reduces the stress loaded that gets shared at the adjacent levels above and below where the surgery was. And that reduces the chances of you needing further surgery down the road.

That right there could be the game changer. As a physiatrist, that is probably my number one concern. More so when I'm referring a patient of mine maybe in their 40s, 50s, early 60s, I'm worried a little bit about fusion and the statistical incidents of adjacent level disc disease stenosis developing.

Having an option that potentially could reduce that risk, I think it's a really exciting thing that you can at least talk to people about. If you do end up putting a patient on your schedule for a lumbar disc arthroplasty, compare and contrast a little bit, if you don't mind, some of the postsurgical recovery timeline versus... Let's just do a comparison versus a one level fusion. Does that look any different or is it pretty much similar?

That's a great question. The difference between the arthroplasty versus a fusion is you're not waiting for fusion through the entire disc space from one vertebral body to the other. The recovery is much more quick because you aren't having to wait for six months for there to be bony bridging occurring from a vertebral body to another vertebral body, which could be a width of 10, 12 millimeters sometimes. Whereas with arthroplasty, the device is put in there and the whole point is for there to be motion immediately and for there never to be fusion there.

You get a much quicker recovery in that sense. The device itself still needs to fuse to the end plates above and below, but that occurs much faster than it takes to fuse all the way across a disc space, a centimeter and a half versus just fusing right at the level of the implant. Really a lot of the theory and studies and histology for arthroplasty has shown that at six weeks the device is pretty much fused to the end plates and that's really when patients start. We start acting and plugged in physical therapy much earlier than we otherwise would with a fusion.

That's a significant difference though in the fusion timeline. Definitely worth noting. Now, when someone has completed their fusion and they go through their course of physical therapy, are there any long-term considerations that they have to be concerned about, or is it pretty much if they heal up, they're pretty good, maintain proper spine hygiene, physical fitness, the stuff that I talk about all the time, and they're in a good shape?

For arthroplasty, just to clarify?

Yeah, for arthroplasty.

Once the device has been implanted and then the fusion of the device to the end plates has occurred, that's that first six weeks where you're really just getting over the operation from the exposure from the abdominal incision and really getting back to light activity during that first six weeks.

From the six weeks on, it's just building back your core strength and building back your healthy spine, working on core strengthening exercises, doing spine physical therapy, getting back in the gym, starting jogging, starting to get back into light weightlifting and working into it, getting back on the golf course, getting back on the bike. Those activities where you don't necessarily need to do anything to protect your spine, but you should be focusing at that point on on restoring your quality of life and overall spine health.

All right, so there are some definite advantages that you've outlined that people should take note of. It sounds like the surgery itself may be a little less morbidity, the recovery time a little bit quicker, the actual time for the implant to fuse far quicker than a typical osseous fusion after a traditional hardware-based fusion surgery, and then reduced incidents or maybe no incidents of a disc above or below wearing out. Is that a pretty good synopsis of some of the advantages of this approach?

Yeah, absolutely. The motion preservation in terms of having the sustained motion across the level of the operation, and that's going to give the patient the sense of not just flexibility, but distribution of forces throughout the spine. We don't say that there's no chance of having adjacent segment disease above or below, but the goal is to reduce the chances compared to fusion.

I mean, oftentimes the spine may be degenerating already at the level above before we even are involved. There's a lot of different multifactorial contributors to adjacent segment disease. But yes, the goal is to reduce the chances of you needing further surgery down the road.

I know I have some engineers out there who are going to ask what exactly is the device that's put in? Are you able to share some of the materials, or what does the disc look like, what's it made from?

In the lumbar arthroplasty devices, there's really only two that are FDA approved and they're both very similar. They both have titanium end plates with a high polyethylene polymer core in the middle, just like hip and knee implants. That's really the basic design. The reason they're designed that way is because those are the materials that have been tried and true in terms of having the repetitive motions for thousands and thousands and thousands of cycles for years and years and years without there being abnormal wear or tear or debris that may cause the body to react normally.

It brings up a good question. When someone goes in for a total knee or hip, at least when I was in training, the standard talking point was you're going to get about 10 to 15 years of shelf life on that before you may have to have it revised or replaced again. Is there a shelf life on the artificial disc?

All of these devices before they can even be implanted in a trial have gone through biomechanical testing that have simulated multiple lifetimes. There's never a situation where a patient might live longer than these devices have been tested to sustain in terms of biomechanical forces.

Wow.

Now, that's in a lab setting with determining the different forces and artificially created forces in the lab testing the biomechanics of the device, but that's to say that these devices are designed to last more than anyone could ever use them.

Well, that's very exciting. We talked earlier about the facets. Do you want to elaborate a little bit on some of those options there in terms of facet replacement, or is it fairly similar to what we've just walked through?

That's a really good point, and I purposely was trying to wait until a little bit further in the conversation to bring it up because I didn't want to make it too confusing of all the different possible pathologies. But really what's happened over just the last few years and is really happening as we speak in front of us is the pie in the circle for potential patients that might be able to get a motion preserving procedure to address their pain generator has massively increased.

Before it used to be just that small little circle of patients that were discogenic low back pain from severe degenerative disc disease, one or two levels, otherwise a pretty healthy spine, young, active, must be able to have an anterior procedure. That's a pretty small portion of patients. Now, all of a sudden, these new arthroplasty devices have come out and they can actually do arthroplasty for lumbar stenosis.

They can do arthroplasty for spondylolisthesis. They can do lumbar arthroplasty for pretty significant facet disease. Now, all of those patients potentially have an option for arthroplasty, which has been an incredible addition to the field.

I don't want to keep you here all night, but you brought it up. Elaborate a little bit on the idea of arthroplasty for lumbar stenosis, because that's the second most popular downloaded episode we have is the one with Dr. Cheadle on surgical approaches to spinal stenosis. I know people are out there struggling with stenosis, which is very difficult condition to treat. Share your thoughts on that please.

Sure. Obviously if it's lumbar stenosis alone with neurogenic claudication and has failed nonsurgical measures and considering a surgical intervention, a minimally invasive decompression alone would be the standard of care.

But for patients that have lumbar stenosis in conjunction with severe disc disease, with severe facet disease, maybe even with a spondylolisthesis, patients that would otherwise be getting a fusion because a disc replacement wouldn't be sufficient to address all of that, now we have options for posterior, meaning from the back of the spine, placed arthroplasty motion preserving devices that allow us to decompress all of those neural elements in the back, decompress the nerves, decompress the spinal canal, so remove the spinal stenosis, even reduce the spondylolisthesis, meaning putting it back in alignment and placing an arthroplasty device in the back to replace those parts of the spine.

There's two main ones out there now. There's one that just underwent FDA trial and just completed its FDA trial and it's now an FDA approved and currently getting on boarded with many insurance companies, probably will be commercially available starting in January of 2024, but that's the TOPS device. That's an artificial facet device, where it's placed in the back of the spine after we decompress all the neural elements. And instead of fusing the spine, we place this device to replace the posterior elements of the spine and replace the facet joints.

I feel like this is a rapidly evolving field, and I may just have to have you back on once a year just to update people on the options out there. You've done a terrific job going over. For me, it's been a little bit of an enigma as a physiatrist, disc replacement surgery was things that people would fly to Mexico to get done or Germany to get done, or anytime I brought it up, insurance wasn't covering it and the trials weren't necessarily showing it to be fruitful.

But it feels like it's really evolved now and is almost ready for prime time at this point. It's real exciting to have you in the practice and able to have these discussions with patients. Anything else you'd like patients to know, people to know who are considering, wondering if this is an option for them?

I'd just like to share the historical context of spine arthroplasty within Charlotte and within Carolina Neurosurgery and Spine. Arthroplasty, a lot of these trials, some of these devices are the most rigorously studied devices in all of medicine. They've gone through more rigorous trials before they were implanted and before they were approved than any other medical devices implanted in the body.

A lot of those studies have been done here at CNSA, at Carolina Neurosurgery and Spine and at our outpatient surgery center, and then our clinics, thanks to leadership like Dom Coric, who's a big champion for a lot of arthroplasty and my mentor of arthroplasty. Many of the devices that are approved today, FDA approved, were approved because they were studied at CNSA and effectively went through trials and showed how effective these devices were.

I think that's just important that when patients know when they come to CNSA and they get motion preservation options, they're not just getting someone that just knows how to implant these devices, they're getting an organization that really has brought this technology available locally, nationally, and internationally.

I appreciate you bringing that up. It's a great perspective to share with people who are listening. Certainly if you're in the Charlotte area or even beyond, reach out to our practice and we can certainly get consultations set up for you or your loved one and find out if this or other options would work for your issues. Last question for you because I know you got to go. These artificial devices are nice, but it's always better to avoid any surgery. I'm wondering what you, a busy neurosurgeon, do on a daily basis to keep your back healthy and strong and just stay fit and healthy overall?

Yeah, absolutely. I think that's extremely important. Maintenance is a much easier task than trying to repair a year's worth of damage to the spine. I try to stay as healthy as possible in regards to my spine. I'm very conscious, especially with having two young kids, of a lot of bending over at the waist and not doing proper lifting techniques. Make sure bending and lifting with the knees and the legs and not with your lower back. I'm a huge stickler on that.

Especially with the little kids grabbing and lifting and doing any rotational motion while holding a lot of weight, I try to avoid that to reduce the axial and rotational forces on my spine. And then I'm big about just making sure I try to do as much core strength exercises as possible, and I certainly need to hold myself to a more rigorous schedule with it. But I'm a big believer in planking and activating all those core muscles, that 360 degrees of muscles that surround the spine, that stabilize it.

They give it the stability to allow it to maintain its function of supporting our body and protecting all those important nerves and structures.

Yeah, that's great to hear. We need you healthy. We need you upright and serving the community. Keep it simple, folks. If you haven't listened to my interview with the great Dr. Stuart McGill, probably the world's top biomechanic or bioscientist when it comes to spine, he's a PhD researcher, also does some clinical work, but he uses the McGill Big 3, and I talk about it all the time. We're talking about bird dogs, we're talking about side planks, and he has a modified curl up. We put a YouTube video where I interviewed Dr. McGill.

It's on our Carolina Neurosurgery YouTube channel, or just Google the McGill Big 3. It's a great place to start if you're suffering from back pain, and I think it's something that pretty much everyone would benefit from. Well, thank you so much for your time today. It's been an exciting topic, and I'm sure we're going to touch base down the road. I'm really excited to see how your career evolves. I think you're just going to get so busy you don't really know what to do with yourself.

Thanks for having me on. I really enjoyed it and looking forward to hearing more of your future episodes and hopefully being the guest again in the future.

All right, sounds good. Thank you.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.