During medical school, Dr. Patrick Jowdy was drawn to neurology and neurosurgery because of the challenges of the pathology and the importance of the work in improving patients’ lives. It was seeing the patients doing well post-op that finalized his interest in neurosurgery.

In this episode of Back Talk Doc, host Dr. Sanjiv Lakhia talks with colleague Dr. Jowdy, now a neurosurgeon at Carolina Neurosurgery & Spine Associates, about how he treats patients who may need second low back surgeries. 

“Whenever anybody presents with [recurring] issues, the main thing that you need to really tease out is what the history is and what's really bothering them,” says Dr. Jowdy. “Sometimes there could be problems from an error in judgment and not really technique. That's why it's really important to identify what the problem is to begin with.” 

In addition to discussing treatment options for second, or revision, spinal surgeries, Dr. Jowdy also offers guidance on how back pain sufferers can try to avoid needing a second surgery. Tune in to hear how surgeons approach patients who present recurrent back pain after surgery and tips for maintaining a healthy spine. 

💡 Featured Expert 💡

Name: Patrick Jowdy, MD

What he does: As a neurosurgeon at Carolina Neurosurgery & Spine Associates, Dr. Jowdy offers personalized care to his patients by using minimally invasive techniques and complex procedures to treat spine and brain pathologies.

Company: Carolina Neurosurgery & Spine Associates

Words of wisdom: “What I tell patients after the operation is, there is a defect that the disc herniated through in the first place. The best chance you can give it to heal is to take it easy for a couple of weeks after the surgery. So I tell them, no heavy lifting, no bending, no twisting, just to give your back a rest in the weeks that come after the surgery just to reduce the chance that more discs can re-herniate.”

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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 are 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. 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.

One of the great things about working at the country's premier and largest neurosurgery practice is that as a physiatrist, I get to work with terrific neurosurgeons and I consider them my backup of sorts. Obviously, my goal is to help people avoid surgery and live a very healthy and active life, but many times more help is needed than just injections, medications, therapy, and conservative interventions. That's why it's great to have such established and esteemed neurosurgeons in our practice to help our patients out, but there are times when sometimes one surgery just isn't enough. Today's topic of the show I like to refer to as take two, when one surgery isn't enough for your low back pain. I'm excited to interview my newest partner and colleague, Dr. Patrick Jowdy to help us break down this topic. Patrick, welcome to the show.

Thank you, Sanjiv. Thanks for having me.

All right. Let me introduce you. You come to us via Buffalo where you did a neurosurgery at the University of Buffalo in Buffalo, New York. Fellowship in complex spine surgery at the University of Buffalo. You did your medical school at the University of Buffalo, Buffalo Jacobs School of Medicine. Of course you did a bachelor of Science in biomedical science at the University of Buffalo. You are Buffalo native through and through and congratulations as well on a recent awesome NFL season for the Bills.

That's right. Close.

Yes. Oh, it was a great season. I really am glad to get you on the show to talk about this topic because as you and I both know, we get patients from all over the region and oftentimes we are their last stop after multiple stops. I'll joke with my staff that I'm a resort doctor, I'm the doctor of last resort for patients, though it's no joke when they've gone through a lot of conservative care, they've had back surgery and they've either done really well for a while and then they have recurrent pain or things just didn't go the way they wanted and they're seeking our group for a second opinion of sorts. It's a difficult topic, but it's one I think is worth talking about and providing information for people to consider as they navigate their own journeys. I told you beforehand, I'd like to break things down a little bit on a case basis, so something in real world scenario and then love to pick your brain, get your thoughts and have you share with listeners how you would kind of navigate these sort of issues.

So let's go ahead and jump in. The first scenario that oftentimes we'll see is someone comes in with let's say a one level disc herniation and is causing pain down the leg that will term a radiculopathy or some patients were referred to as just sciatica pain. We get an MRI and we see a disc herniation and it's touching their nerve and we've tried a bunch of things, injections, physical therapy, and oh, by the way, if you're new to the podcast, I have episodes on all of these topics.

I've done podcast episodes on spinal injections with Dr. Sumich and Dr. Zahosky and then multiple episodes on physical therapy approaches to disc herniations and we'll put links to those in the show notes. Assuming you're someone out there and you went through that and it ended up where you needed surgery and you had a micro disc surgery and did pretty good, but then maybe a year or two later you come back in with pain and it really feels like a bad memory. Same type of pain, same leg, same back situation. You call up Carolina Neurosurgery and Spine and you end up in Dr. Patrick Jowdy's clinic. Break down your initial thoughts in your head when someone comes in who's had previous lumbar disc surgery and they're having recurrent pain.

Sanjiv, typically the first thing we do is try to really establish a history and make sure that everything kind of fits the picture of what the patient is complaining of. I always ask the patient before the first surgery, what was the symptoms that you were having? If they tell me that it is pretty much the same exact symptoms they were having before the first surgery, then what I would do at that point is obtain imaging typically in the form of an MRI to find out exactly what's happening. In this case if it is in fact a re-herniated disc at the same level that they had an operation on previously, there are a couple things that we can do to address this. Number one, we typically will talk to them about a surgery that is similar to the one that they had the first time around, which is a microdiscectomy.

This surgeon can be formed in different ways, but typically how I perform it is through a small tube that we pass through the back and land it right on the area where the disc is pinching on the nerve. Now in the scenario where this is a reoperation, the surgery is going to be slightly more difficult because of the fact that there is scar tissue that has been set in at this point. If we're doing surgery on someone's back for the first time, the layers that we typically pass through are the skin, the fat, the fascia, which is a tough connective tissue layer right on top of the muscle. Then the muscle down to the bone. We usually drill through the bone and that's where we find the nerves. We basically pull the nerves aside and we can take out the offending disc material that is pushing on the nerve.

That's the first time around. If you come back again for a reoperation, all these layers, all these planes are obliterated. They're usually covered with scar. So the safest way to go about a revision spine surgery is to try to find normal tissue and work your way towards abnormal tissue. In doing so, as you can imagine, if we're going to now find normal tissue, it's going to be a slightly larger operation the second time around than the first time around. When we actually get down to the layer where the disc may be, sometimes we have to drill off a little bit more bone than the first time because you need to sneak around the nerves to get to the discs. As you can imagine, if we keep doing this and some people come back after their disc keeps herniating, there's only so much bone you can drill before the issue becomes bigger and needs a larger operation to address the problem.

What I'm referring to is a fusion. If it gets to the point where the disc keeps herniating, a complete discectomy is been performed where the disc is completely removed from in between the bones and hardware needs to be placed in there to lock those two segments together so that the disc that was taken out can no longer herniate.

Let's unpack that a little bit. It sounds like a couple considerations when you've had a prior lumbar disc surgery and you potentially need another one. If I hear you correctly, number one, that's still an option for people that you don't necessarily need to jump to a bigger surgery right away assuming everything lines up the way you said. Now it does sound like it might be a little more challenging technically, but certainly doable, but I think people can understand the idea of scar tissue when you've had surgery in an area and then a surgeon needs to navigate that some. In your experience, what percent of patients who have had, let's just say like an L5 S1 disc herniation requiring a microdiscectomy, what percent of them can actually herniate the same disc?

I've seen literature that gives numbers that are really spread out, but from what I've seen, I'd say about 5% to what's quoted in literature of the 20% can come back with a reherniation. Now, that being said, not everybody is created equal. Some people are more vulnerable to reherniation than others. What I tell patients after the operation is there is a defect there that the disc herniated through in the first place. The best chance you can give it to heal is to take it easy for a couple weeks after the surgery. I tell them no heavy lifting, no bending, no twisting, just to give your back rest in the weeks that come after the surgery just to reduce the chance that more discs can herniate.

Yeah, no, I think that's a great point. Obviously I wanted to talk about second surgeries or revision surgeries, but giving listeners some guidance on their first surgery to help them avoid a second I think is critical and I'm glad you did that. I've seen different recommendations from my partners even up to 12 weeks to allow for the disc to heal. I think if you're out there listening and you're thinking you might need a surgery and you're wondering how much time am I going to be away from my family and my work, a lot of it depends on what you do for a living and that's a individualized conversation I think with your surgeon, and I know Patrick working with you, it's been real exciting having you join our practice last year, folks, he's brought a ton of energy to our group and is very, very skilled.

I know when he works with patients on this issue that he's listening and understanding and taking time to understand what are the risk factors for re-aggravation. It certainly is different, right Patrick, if you have someone you worked on did a discectomy on and they are operating heavy machinery or running a forklift or doing a lot of he repetitive bending and lifting, their restriction timeline would probably be different than someone who has a sedentary job, correct?

Absolutely. Absolutely. The more wear and tear you put on this already compromised disc, the higher likelihood that the disc can re-herniate.

You mentioned the idea of almost like when a patient can't have another minimally invasive surgery, and I touched on minimally invasive spine surgery quite a bit when I interviewed Dr. Mark Smith and will link to that in our show notes and that's one of our more popular episodes. But he made a comment to me that stuck with me during our interview and he said that minimally invasive surgery, for those who aren't aware, that's basically smaller incision, quicker recovery time surgery, he said minimally invasive surgery is no good if it's minimally effective. What he is talking about is it's not about someone getting the smallest amount of surgery, it's really about what's the right thing for that person because I would venture to guess when you're operating on a patient, your goal is to really try and fix their problem and prevent future recurrence.

For some people, that can be a less invasive surgery and for others it could be what you just said here where there's not enough disc material left or there's been too much work done that it would require a little more aggression, a little more stabilization with a fusion. At the end of the day, once they're healed, you want to see them stay healed.

That's right. What I would add to that is whenever anybody presents with these issues, the main thing that you need to really tease out is what the history is and what's really bothering them. Because a lot of these surgeries that are performed, sometimes there could be problems from an error in judgment and not really technique. That's why it's really important to identify what the problem is to begin with. Is there pathology and imaging that correlates with what that problem is and can you fix that problem?

No, I think that's a great point and that's why at Carolina neurosurgery, we have a team approach to this where physiatry and physical therapy and EMGs and in-house imaging, and I really feel like that is the model that serves spine care the best. When I send you patients, I try and work them up as best I can to answer those questions or at least rule out some other things to make sure that we're going in the right direction for the patient. Okay. The other take home of what you said I think is important is statistically still 80% to 95% of people don't require a second operation on their back after a microdiscectomy.

I think that is important to highlight because even though I'm the integrative spine guy in the practice, I refer people for surgery and I do quite often in the practice because I know the statistics are generally in their favor, particularly when we have people and surgeons who do good workups and techniques, not question at all in this practice, but I think there's a lot of fear when it comes to surgery and from a patient side seeing a neurosurgeon and signing up for surgery, microdiscectomy is one of those surgeries that really has been revolutionary in the last 20 years. That's at least my take on it. What are your thoughts on it?

Yeah, microdiscectomy is definitely a good surgery. It is minimally invasive, typically do very well after the operation. They usually go home the same day. The recovery, like I said, apart from taking it easy for a couple weeks, they can get back to work pretty quickly as long as it's not very strenuous work. It's a relatively safe procedure to have and it has a relatively good outcomes.

Excellent. Is there any difference in imaging for patients who've come to you with prior disc surgery and you want to get an updated image? Is there any difference in terms of the type of MRI or CT that you would order?

That's a great question. Typically, if somebody comes and they've had prior surgery on their spine and you're worried about a herniated disc, the trick now becomes to differentiate that between scar tissue and herniated disc. Typically, an MRI if you're talking about the lumbar spine here with or without contrast is what we order just to differentiate between scar tissue and actual disc.

Okay. The addition of contrast given through IV helps to distinguish healthy tissue versus scar tissue and just makes the MRI a little easier to interpret. That's a good take home point for people listening. Okay, so thank you for that. That was a good breakdown of someone with the possible recurrent disc herniation and who may need a second surgery. Now let's pivot. I'm going to throw something a little harder at you because I think that was a layup for you. The next case here, this is a case that I have in mind that I'll see in my office and it's a group of patients that really struggle and come to our group just looking for any sort of answers and help. It involves, let's just say an adult male fifties or sixties who's had a prior lumbar fusion. If you're listening and you're not familiar with fusion surgery, did a great interview with Dr. Hunter Dyer in our practice about kind of the ins and outs of fusion surgery and we'll link to that as well.

Essentially, just to keep it really simple, I call it the Home Depot special where you get some rods and screws put in the back to stabilize either a bone segment that's moving too much or there's just such severe arthritis and back pain. There's multiple reasons to get a fusion. Let's say you have this person in your office and they had a few years ago fusion, maybe a couple levels in their back and they're just having increasing back pain. A change in symptoms. They did well for a few years and all of a sudden the pain has returned, it's in their back and going down their leg and they're feeling really despondent and desperate about that. That's a much different animal than just a disc herniation per se. Walk us through your thought process. Again, kind of key elements that you're looking for in your history, maybe things on the exam, and then certainly talk about some of the options that you look at and discuss in terms of testing to help solve the problem and figure out a plan.

Sure. These patients definitely are tricky patients to take care of. The reason being is because there's a couple different things that could be going on depending on the timeframe at which they present. I usually approach these patients systematically just to outline things that could be going on and anybody who has had prior spine surgery, if they present at an early time period, meaning in the first few weeks after surgery, things that you worry about if they're having increasing back pain, I would be bleeding any kind of bleeding in the surgical site that they could be experiencing if the wound itself is swollen, indurated, if there's some drainage, you're worried about infection at that point. If they're having headaches that get worse every time they stand up, you could be worried about cerebral spinal fluid leakage occurring. These are the kind of things that occur early on after a spine surgery.

The middle complications that can occur usually months after first operation would be things that revolve around a failure of the fusion. So anytime we do a fusion surgery, all that we're doing is we're putting hardware into the spine to hold the two segments of bone together so that they do not move. The idea here is that over time the bones will fuse to each other and become essentially one segment and eliminate motion at that level. The hardware they're putting in there is acting as a fancy cast. It's no different than if you had a broken bone and they put you in a cast for a couple weeks and then they take that cast off. The difference here is this is a cast that's inside the body.

Really what happens with the fusion is that it's a race between the bones fusing and the hardware failing because the hardware will undoubtedly fail over time if there is motion and stress continuing on the hardware. If the bones fuse, then the motion's eliminated off the hardware and the goal of the surgery is met, which is a fusion. These are complications that can happen with fusion five weeks, months after the first surgery. Now the late complications to look for, which are, I hate to say they're complications are these are things that can happen after any spine fusion there. These are usually revolving your own adjacent level issues. What does that mean? That means if you fuse a portion of the flexible spine and make it rigid, the rest of the spine is still flexible. That junction where the flexible spine meets the rigid spine can see more stress, more wear and tear over time. Because this flexible spine is adjacent to the area that's fused, that's what we refer to as adjacent level issues. There can be more wear and tear, more disc degeneration at the levels above the prior fusion.

That's why anytime we talk to somebody about fusion surgery, we always mentioned to them that in the years that come in the future there may be a possibility of needing more spine surgery. It can almost turn into a domino effect a little bit. Keeping those that kind of temporal relationship in mind between things that can happen early, things that can happen months after the first surgery and things that can happen later years down the line, that's typically how I approach these patients who come in with new pain after a prior fusion. Now again, so what I said earlier, the most important thing with these patients is to obtain a good history and a good exam. Oftentimes if patients come in complaining of new pain after the surgery, I really spent time trying to find out why did they have the first surgery in the first place?

What were their symptoms the first time around? Did those symptoms improve? If they did and they resolved and now they're having new pain that's unrelated to what they had last time, then they can kind of hone me into where the problem is now versus somebody who comes in that had symptoms prior to the first surgery, that did not improve at all. And if I look at the imaging and I say to myself, "Gee, I would've done the same thing that the surgeon did originally." Then maybe more surgery at this point is not the answer. It's really trying to tailor the treatment to what each person's problems individually are.

Okay. That was great. I actually learned a lot. I like that analogy about the fusion and the caste, and I think a lot of people believe that the hardware put in to fuse the bones is the actual fusion, when in fact it's really the bone growth that develops over time that stabilizes the vertebral bodies. That's an important distinguishing factor. It sounds like it's pretty important to have evidence that that actually happened to determine how successful the surgery was. Honestly, some of that's not dependent upon the surgery. It's more dependent upon the body's response to the surgery over time. Is that correct?

That's correct. There are things that patients can look out for and even influence before they come to surgery that can help optimize their chances of fusion and chances of a good outcome. These variables have been mentioned in guidelines that congress of neurosurgery, which is one of the societies all of us neurosurgeons look to and learn from. In this particular study that they did look at all the studies referring to diabetes, smoking, and they did find that there is a correlation with certain levels of sugar in the blood being too high. It can definitely sabotage a fusion and a good outcome after an operation like this. Same thing with smoking. That's why anytime I see patients and I think about doing surgery on them, I always counsel them and tell them the best way to help ensure that there's a good outcome for you is to really get your blood sugar under control and really to stop smoking.

Wow. Now you're speaking my love language, Patrick. You know me, the holistic nutrition guy. I've done several episodes on food and inflammation, the Mediterranean diet. We'll link those as well. What he just said is so key. You know what we're talking about, this topic today is not a terrific topic. It's not going to make people feel great listening to some of this information. However, it's real world. For anyone who's had surgery and is considering surgery again, you know how desperate you can feel. So I wanted to get an expert on the show and kind of break this down in a way that's understandable. What he just said is, there are some things you can control and that's the importance of healthy eating, exercise, nutrition, not smoking. Boy, isn't it funny how almost every health condition can come back to those factors? I'm really thankful you mentioned that.

The other thing here, you broke it down in the timeline in terms of when the symptoms present versus how long it's been from the prior surgery. Now obviously some of the first things you mentioned are things that patients and surgeons are looking out in that immediate period after a surgery that can happen. Folks, I think we share this information to inform, but not to frighten per se. I think the more educated you are, the better outcomes can be. Let's touch a little bit on one thing you mentioned, and that's this concept of adjacent level issues. To clarify that, if you have a fusion, let's say between L4 and L5, there's a chance over time that the disc and joints above and below that, let's say at L three four and L five S one will wear down at a quicker rate than normal. How frequent do you observe that in your practice? I've read some data that it's in the single digits or maybe the low double digits. What's your thought in real world, what you've seen?

I've seen it across the board at a bunch of different times being sometimes I see people come back two to three years after the first operation. Other times I see people come back 20 years after the first operation. I really feel that a lot of that depends on the lifestyle the patient has after the surgery. Probably a component of genetics. It's hard to know who's going to have a problem and who's not. This is something that we really think critically about, especially in anybody young, because if somebody comes who's younger and needs a fusion, that's something that can become a real problem for them because they have a long life ahead of them. Who knows what's going to happen in 30, 40, 50 years with that hardware being in there. It's hard to say who's going to develop this? It's hard for me to tell you how often I see it cause it's really patient dependent. I've seen it, like I said early on after some surgeries. I've seen it much later in other people. It's just really kind of hard to pinpoint that.

I think the take home point here is as a patient, your work isn't done once the surgery is completed and deemed to be successful. It's just starting. I definitely believe, at least I've observed, I think there are some lifestyle factors that patients can control that help their cause. One is maintaining good posture throughout their life, avoidance of excessive sitting. Another one is just maintaining active lifestyle with some emphasis on core stability principles that a good physical therapist can review with individuals. I said today at least five times, I tell patients back pain relief is a journey. It's not a destination. What I mean by that is it's a chronic condition.

People understand if you're a diabetic, that's more likely than not a chronic condition that you're going to be dealing with the rest of your life. It's harder to grasp that with orthopedic and spinal conditions because people want to fix. I understand that. When you're in pain, you want to fix and you can get it and Dr. Jowdy and friends offer those fixes. But I think if you just stop there, your chances of having another issue down the road go up. Adjacent level disease certainly is a consideration and I think the data needs to be teased out further over time in terms of research in terms of who's more vulnerable to that versus who isn't.

Let me add also as a surgeon, there are things that we can do to try to prevent people from having problems in the future. This is where it becomes very important for a surgeon to think about the spine as a whole entity and not just those two segments, L4 and L5 that they're fusing. So something that I learned throughout my career is that you really need to take into account the whole spine and really the balance of the spine. So there are different parameters that a spine surgeons look at for anybody who comes in needing a fusion or a revision surgery, that's the concept of the spine as a whole and what its balance is and how you will affect the balance with a fusion.

To put it simply, one of the common things we look at is a sagittal balance. What that means is some people are walking around and they're kind of leaning forward, their upper body is leaning forward, they're kind of hunched over. As you can imagine, that's going to become painful over time because all the muscles in the lower back are working really hard to stop you from toppling forward. A lot of these patients come in complaining of exquisite back pain and if you just touch their back, they almost jump off the table because their muscles are so fatigued and tired out. These are things that can develop from adjacent segment disease with the rest of the spine wearing out over that rigid part of the spine that's fused. As a surgeon, something we always pay attention to is what the symptoms are that you're coming in with today, what can we do to treat those? If we treat those, what can we do to ensure that our treatment does not cause you problems in the future?

Oh, that's terrific. It's definitely a more whole person structural viewpoint. Thanks for sharing that. Now, getting back to that patient in question, what are your considerations from an imaging testing perspective? Because I think it's probably a little bit different than just someone who's had a recurrent disc herniation.

If someone's coming to me with prior back surgery and they're having increased pain, I usually start with x-rays. Like I mentioned, I like x-rays where I see the whole spine as the person is standing, I want to see what the whole spine is doing in relation to all the hardware that's been placed previously. After that, typically I would get a CAT scan to assess the hardware, even more specifically to look at if there's any kind of loosening of the hardware, if there's any kind of bone breakdown fractures that might not be apparent on the x-ray. And then after that, if the patient is also having what we call radicular pain or pain that's caused by a nerve being pinched, typically a burning, tingling, sharp shooting pain, we can get an MRI which will help us assess the soft tissue and the nerves themselves to see if those are being pinched in a specific area that's correlating to the patient's symptoms.

When do you consider a CT myelogram?

Typically, a CT myelogram is reserved for patients who have a lot of hardware in their spine. The reason why is because when the MRI is a big magnet and it creates the picture based off of a magnet. If somebody has a lot of metal or hardware in their spine, the MRIs can be really distorted and very hard to interpret what's going on between all that hardware. Cause all the nerves are passing between those screws. If those screws are sending out these big shadows, it's going to be really hard to interpret what's happening with the MRI.

That's why we would talk about a CT myelogram. What that is it's a procedure that is invasive. It involves putting a small spinal needle into the lower back into the area where the brain fluid is, and we inject dye that basically percolates through the spine up into the brain and they get a CAT scan at that point. With the dye on the CAT scan, you can see where the dye is flowing and you can see if there's any blockage within the spinal canal that could show you where there is areas of stenosis or tightening of the nerves, things like that. That's where a CT myelogram would be useful.

The point there is folks there's a lot of different options if you had a prior fusion and having issues, there's a lot of different ways to look at it, and Dr. Jowdy just outlined quite a bit of those. As we wrap up the case here, the number one thing people want to know when they come in the office who've had surgery fusion before and I want to refer them to you or a colleague is, "Okay, but if I get more surgery, what's that going to look like? Are they going to take everything out? Are they going to add to it?" Give us just a 30,000 foot view. You don't have to get too far into the nitty gritty per se, but just a 30,000 foot view thought process around how you make those decisions and what people can kind of be on the lookout for.

I would say, before I answer that question, it was difficult to prepare for this topic because it's such a variable topic and every patient is coming in with a unique set of problems. There's so many different ways to try to address these issues. As far as patients who come in and if they need all their hardware removed or if they need just additional hardware placed on their existing hardware, that really is patient dependent. It depends on where the problem is. If they are just purely having an adjacent segment disease at one level above the previous hardware, we can typically just add on hardware and decompress the level in question. It's really hard to say without looking at the picture and seeing what the whole spine looks like. That's what I would emphasize is you really have to take the whole spine into account before you do any fusion surgery, in my opinion.

Sometimes the answer is more surgery isn't the right answer. I tell people a lot that pain that's not responding to treatment is not necessarily an indication for a major surgery because individuals will feel pretty desperate and willing to have anything done. A good neurosurgeon, at least in my estimation, I'm older than you, but I grew up here in Kenny Rogers, know when to hold them, know when to fold them, know when to walk away, and know when to run. The Gambler. Sometimes the best a neurosurgeon can do for you is not to operate and take a bad situation and make it worse, but don't despair. That's why we've got comprehensive options in our practice for people, terrific team, culture, and environment.

I appreciate you really just letting us get inside your thought process and tackle a very difficult topic that a lot of people really struggle with from a patient side and even a physician side and trying to understand what happens, what to do when things recur or don't necessarily go the way you plan upfront. I appreciate that. Now, before I let you go and resume your evening, I always like to ask my guests a little bit about their own personal story and even their own daily health habits. The listeners have really understood the neurosurgical side of Patrick Jowdy, and before I let you go, why don't you share with them what kind of brought you into the world of neurosurgery and from Buffalo into the Carolinas?

For me, I first became interested in medicine when I worked as a nurse's aid in the emergency room in college. That's kind of what got me into medicine in the first place. When I went to medical school, I really liked every subject that was being taught, but I particularly liked neurology and neurosurgery because of how challenging the pathology was, how challenging the issues are that patients face, and also quite frankly, some of these problems can be quite debilitating. I really felt that I could make a difference in the field, and that's what drew me to it to begin with. Once I started doing the rotations and doing the surgeries in neurosurgery, I really enjoyed taking care of patients and seeing patients do well after surgery, and that's kind of what drew me into going into neurosurgery training.

Fantastic. Now, obviously as a guy who deals with these sort of tough cases that I just threw in your lap today, that's got to provide a lot of stress and challenge. So what do you do on the health side of the equation to keep your energy high, your thinking clear and just feeling and staying healthy?

I think the important thing for all of us is having regular physical exercise. For me, I try to commit to at least 45 minutes a day of some kind of activity, whether it be on a bike, weightlifting, just something that'll make me sweat. The other thing that took me a while to realize is that there are days where I'm not going to be up to doing 45 minutes a day, and it's on those days. I feel that as long as you can do something, that's all it takes. Even 10 minutes, 10 minutes of some activity that's going to make your mind clear and keep you in shape. Have you heard of that book Atomic Habits by James Clear?

Absolutely. Yeah. Terrific.

Yeah, that book really stuck with me just because it really just talks about if you do something small every day, it really adds up over time. So that's how I look at this physical activity. Some people say do two hours, three hours of working out a day. Nobody really has time for something like that. At least I don't, but as long as I do 45 minutes at least, or on days I can't get to that timeframe, 10 minutes is enough and it keeps adding up over time, and you feel good about yourself.

I love that. Those daily micro wins, they're very, very important and it's really good awareness to say to yourself, some days I'm just not there to do a full intense workout, but even just something small to keep patterning, that habit can really lead to great things down the road. That's a good take home point for even if you're struggling with pain right now and you're listening to this, find something on a daily basis that fills your cup up a little bit, whether it's going for a 10 minute walk, I like to tell people, "I want you to move, but I don't want you to torture yourself while moving, so how long can you walk?" They'll sometimes say, "I can walk for 15 minutes. Then the pain starts going down my leg." Then my recommendation is let's walk for 10 minutes twice a day.

Our physical therapists call that exercise snacks. Take little bits of it throughout your day, even if it's you're doing your bridges or you're doing a 30 second plank three, four times a day, just find moments during your day to snack on exercise instead of snacking on junk food. It can really, really lead to some great things. All right. Well, very good. This was awesome. I think you did a great job on a challenging topic, and I'm hopeful that even if one person can hear this information and it can help make their life better, then today was a success.

Thanks for having me, Sanjiv. Appreciate it.

All right. 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 back talk.dot 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.