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Fact or Fiction: The Truth About Lumbar Spinal Injections
Episode 393rd January 2022 • Back Talk Doc • Sanjiv Lakhia - Carolina Neurosurgery & Spine Associates
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Lumbar spinal injections can help reduce back and leg pain and are a highly requested treatment at our offices.

But there are also plenty of misconceptions about them.

Can epidurals be a first-line treatment for low back pain? How well can they help us determine a source of pain? Can injections heal discs?

We brought on Dr. Joseph Zuhosky, who recently joined our team at Carolina Neurosurgery & Spine Associates, to get answers to these questions and more. Along the way, we hope to alleviate some myths and points of confusion about spinal injections.

Joe gives us his recommendations for when – and how – to treat pain with epidurals, explaining how they can not only help treat pain, but also help narrow down a pain’s source and identify further treatment.

“​​I think there definitely is a role for epidural steroid injections in identifying pain generators. And if it doesn't give our patient long-term, effective relief that they can live with, it helps our surgical partners to determine that it is, indeed, a level that we can reliably operate on.”

Toward the end of this episode, we also hear more about Joe’s personal experiences with disc herniations and how he’s been able to recommend exercises based on his own experience with the workout group he co-founded.

 

💡 Featured Expert 💡

Name: Joseph P. Zuhosky, MD

What he does: Before joining us recently as a physician at Carolina Neurosurgery & Spine Associates, Dr. Zuhosky went to medical school at The Ohio State University. He did his residency at the Rehabilitation Institute of Chicago at Northwestern University McGaw Medical Center and completed a fellowship, training in sports and spine rehab, at the Illinois SPINE & Sportscare Centers, Ltd. in Bloomingdale, Illinois.

Company: Carolina Neurosurgery & Spine Associates

Words of wisdom: “I don't think we should take all the credit for healing the disc … it's a thought of managing it going forward because even when the pain isn't there, you still have a weak area of your body that you're going to have to compensate for going forward.”

Connect: Website

 

⚓ Anchor Points ⚓

Top takeaways from this Back Talk Doc episode

★    Injections are more than just a band-aid. Some patients worry that getting a spinal injection will only be a temporary fix for their pain. But it actually does a lot more than that, as long as the injections are used appropriately. While pain relief may only be temporary, an injection can tell us more about where the pain comes from and gives us clues on further ways to treat the patient.

★    A ‘series of three’ injections can limit treatment options. The ‘series of three’ injections myth stems from a research study on sciatica originally published in 1960, but further research found this treatment is only effective two times out of three. Since doctors can only give a limited number of injections within a period of time, this method can also rule out other treatment options that offer quicker relief.

An epidural is only one part of treatment. While a shot can relieve pain, it can’t actually heal a damaged disc. Instead, the epidural steroid reduces the swelling and inflammation that causes pain, getting the patient through the acute stage while Mother Nature does the rest of the work.

 

⚕️ Episode Insights ⚕️

[00:00] Check out our sponsor: QxMD builds mobile solutions that drive evidence-based medicine and clinical practice.

[01:59] Meet Dr. Joe: Joseph Zuhosky is the newest member of Carolina Neurosurgery & Spine Associates. Before joining us, he did his residency at the Rehab Institute of Chicago at Northwestern University and a fellowship in sports and spine rehab in Bloomingdale, Illinois.

[04:05] From pediatrics to orthopedics: Dr. Zuhosky talks about his varied interests as a medical student, beginning in pediatrics and eventually landing in spine health.

[06:32] Fact or fiction: Lumbar spinal injections are a type of corticosteroid that can reduce inflammation and alleviate back pain in the back and leg. We clarify some misconceptions about the injections.

[07:33] Low back pain: Though a lot of patients seek lumbar spinal injections for low back pain, epidurals generally have a low success rate among this population.

[10:59] Specificity: An injection can be helpful in determining a source of pain and ways to treat it, as long as the injection is done appropriately.

[15:02] Series of three: Originally introduced in a 1960 paper, the ‘series of three’ injection treatment strategy is a myth: Since the number of injections that can be given to a patient is limited, this practice could limit further treatment options.

[18:49] Discs: The steroid injection does not necessarily “heal” a disc, but it does reduce the inflammation and pain caused by a herniated disc and can help patients through the acute healing phase.

[22:18] Spinal stenosis: There are advantages to using lumbar epidural injections to treat spinal stenosis, but to suggest that they can heal this condition is misleading. Spinal stenosis was discussed on a previous episode with Dr. Joe Cheatle.

[26:38] Center or side: A transforaminal epidural – or when the epidural is injected directly to the nerve root rather than off-center – tends to have a slightly higher response rate.

[34:22] Personal experience: Dr. Zuhosky has personally experienced both lumbar and cervical hernias. He recommends a workout group with branches across the country called F3 that has helped with his lower back pain.

[40:15] Hamstring exercises: Dr. Zuhosky tells us more about hamstring stretches that won’t aggravate the back.

 

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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 carolinaneurosurgery.com.

Transcripts

Intro (:

This podcast is sponsored by our partner, QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out read for easy access to research personalized for you and calculate for over 500 easy to use decision support tools. Try them today at qxmd.com/apps.

Intro (:

Again, that is qxmd.com/apps. 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 & Spine Associates. We're providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years.

Intro (:

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.

Dr. Sanjiv Lakhia (:

Welcome to another episode of Back Talk, Doc. I am your Dr. Sanjiv Lakhia, Dr. Sanjiv Lakhia, a board certified specialist in physical medicine and rehabilitation. I am proud to be part of the team at Carolina Neurosurgery & Spine Associates, where we have offices throughout the Charlotte area.

Dr. Sanjiv Lakhia (:

And in particular, my office is down in Rock Hill, South Carolina, but we really are the premier destination for the Southeast United States for all of your brilliant spine needs. My mission over the last year and a half on this podcast has been to provide you the listener with the very best and most comprehensive information in the world of spine care so you can make an informed decision about your health.

Dr. Sanjiv Lakhia (:

On one of my first episodes, I did an interview with my partner, Dr. Andrew Sumich, where we touched on a little bit about lumbar and cervical spinal injections. And today I'm really pleased to circle back to this topic with the newest member of our team, Dr. Joe Zuhosky. Joe, welcome to the show.

Dr. Joe Zuhosky (:

Thanks for having me.

Dr. Sanjiv Lakhia (:

All right, very excited. Now, I want to give the listeners just a brief synopsis of your background. I have seen your CV and if I reviewed that, it would take up the entire episode. But in a nutshell, you did medical school at The Ohio State University, as you'd like to say.

Dr. Sanjiv Lakhia (:

You are a former resident at one of the premier programs in the country Rehab Institute of Chicago, out of Northwestern University and fellowship trained in sports and spine rehab through the Spine and Sports Center in Illinois Bloomingdale.

Dr. Sanjiv Lakhia (:

And for those that really know you, you are very, very well established through the course of your career as an authoritative expert in the field of electro diagnostics and interventional spine, and just a well-respected physiatrist in general. And I had the opportunity folks, to train with Joe during my residency. And we've been thrilled to have him join our team here. Joe, anything else you want to fill in the blanks about kind of your background that I'd left out?

Dr. Joe Zuhosky (:

No, I think that really covers it. I'm old enough that when I went through Ohio State, we were not the Ohio State University. We were simply the Ohio State University College of Medicine.

Dr. Sanjiv Lakhia (:

Fair enough.

Dr. Joe Zuhosky (:

So I'm showing my age a little bit.

Dr. Sanjiv Lakhia (:

Yeah, well, I'm a date and flyer. Actually, I'm from Cincinnati and most of my friends went to Ohio State University, but I try and honor them, otherwise they give me grief. But let's jump into this today a little bit.

Dr. Sanjiv Lakhia (:

Before we get into the topic and today's topic's going to be, I like to call this fact versus fiction lumbar spinal injections because there's a lot of issues that come up that really could benefit from clarification. But before we tackle that, share a little bit about your journey into the field of physiatry so we can get a general sense for why you love to do what you do.

Dr. Joe Zuhosky (:

That's a great question. I started off in medicine thinking I wanted to do pediatrics. When I got to my pediatrics rotation, I discovered that I really enjoyed treating children and enjoyed the children much more than the parents and found it very disheartening that often I cared much more about the patient, their child than I perceived that the parents did.

Dr. Joe Zuhosky (:

And so I was very fortunate to be at Ohio State University where we had a world-renowned physical medicine rehabilitation department. I got to meet and work with Dr. Ernie Johnson, Bill Pease, Darren Clinshot, amongst the Dr. Sanjiv Lakhia of other great mentors. And they introduced me to the field of PMNR. I went to the Rehab Institute of Chicago.

Dr. Joe Zuhosky (:

Was a very difficult decision to leave Ohio State and all the mentors that I had there, but Dr. Johnson always encouraged us to diversify our training and try to get as much training from as many different sources as we could. So I went to the Rehab Institute of Chicago. I was fortunate to be chief president there.

Dr. Joe Zuhosky (:

Went there thinking I was going to be a stroke doctor and really enjoyed stroke and the impact that we had on treating patients that came in and not able to use an entire side of their body and taught them to be independent again. But for myself personally, I realized within six months of doing stroke rehab that I really learned all that I could learn.

Dr. Joe Zuhosky (:

I wasn't going to do a lot more diagnosis. It would be very rewarding to take care of those patients, but I didn't think that I'd be intellectually satisfied doing that type of medicine. And again, I was fortunate, I was with Dr. Jeffrey Young and he was a great mentor for me during my residency and introduced me to sports and spine Rehabilitation and became obvious that one of the biggest impactors and disabling conditions in the country is back pain, neck and back pain.

Dr. Joe Zuhosky (:

And really the only options patients had were to see a surgeon or whatever their primary care doctor could offer them. And at the time there weren't a lot of people doing sports and spine medicine. And I was lucky enough to get a fellowship and great training through Frank Lagattuta. And I came here to Charlotte and the rest is kind of history.

Dr. Sanjiv Lakhia (:

One of the reasons I wanted to have you on for this topic is I think along with our partner, John Welshofer, you are one of the more established physiatrists in the Charlotte community. And you've seen the spectrum of evolution of how we take care of back pain throughout your career. So I felt like you'd have a great perspective to share with listeners about injections in general.

Dr. Sanjiv Lakhia (:

Let's dive into that, and we're just going to kind of go almost like a question answer format of which we'll call fact or fiction. Again, just for those of you who are listening with back pain and you haven't had lumbar epidural injections, as a brief intro, it's a tool in our toolbox where we can inject a type of corticosteroid essentially to reduce inflammation and help alleviate pain in your back and leg.

Dr. Sanjiv Lakhia (:

But many patients come to us requesting them, needing them or have had them before. So, all right, Joe, I'm about to hit you up with a question. So fact or fiction, lumbar epidural steroid injections are a first line treatment for low back pain.

Dr. Joe Zuhosky (:

That's fiction, unfortunately. As you said, a lot of patients come to us thinking that's exactly what they need when they have low back pain. When it's isolated low back pain, really belt line and above, in a few instances, an epidural steroid injection may be something that we consider but in most our success rate with that particular population with epidurals is not very good, even if they do have pathologies such as a disc herniation or stenosis.

Dr. Joe Zuhosky (:

It just really doesn't impact low back pain nearly as well as some of the other modalities and treatments that we utilize, medications, physical therapy, et cetera. I think there's a couple exceptions to that, and I've certainly seen this in my career and I certainly try to keep it in mind. When we have younger more fit athletes, they don't always present with a classic sciatica presentation.

Dr. Joe Zuhosky (:

And they often will have more of a low back pain that they isolate only to their belt lines or even slightly above, but they don't don't get true sciatica. But when you get their scans, these are really fit younger athletes in particular. They often just get back pain and they do tend to do well if you do an epidural steroid injection in a timely fashion.

Dr. Joe Zuhosky (:

The other group where it still may be beneficial is those patients who have purely and annular tear and isolated really more of an inflammatory reaction as opposed to a disc herniation that may be impacting a nerve root. Those patients still may benefit from an epidural steroid injection.

Dr. Joe Zuhosky (:

It's usually is not the first thing that we're talking about or offering to them, but those are the two patient populations that I've seen where isolated back pain and epidural steroid injection still is a good option. But for most patients we should be definitely pursuing different avenues.

Dr. Sanjiv Lakhia (:

Yeah, I totally agree with that. And I'll explain it to patients in this manner, the reason the injections don't necessarily work as well for the low back pain component, even if you have a disc herniation, is that there can be numerous factors that play into contributing to your back pain. And disc injury can simply just be one of them. And it can be very hard to delineate.

Dr. Sanjiv Lakhia (:

So for example, as you know, majority of back pain that comes into the office can be rather nonspecific or muscular or mechanical. So an epidural steroid injection would be totally ineffective for that. But you have so many structures in the spine, muscle ligamentus that can be pain generators, not to mention it can be postural or there can even just be visceral related referred back pain for which epidurals would be totally ineffective.

Dr. Sanjiv Lakhia (:

And I do like your two qualifiers, I would agree with that as well. In particular younger athlete. If I see an athlete or younger individual, let's say in their 30s or younger with a single level disc change on MRI, I do get suspicious that it's contributing to the pain. Because I wouldn't typically expect to see that in that patient population, but I think that's a very responsible way to look at injections for low back pain.

Dr. Sanjiv Lakhia (:

And it does catch some patients by surprise who do feel like and are hopeful that epidural steroid injection would eliminate the back pain. But as you know, eliminating low back pain can be quite complex and takes a lot of work. Okay, number two here. Fact or fiction, lumbar epidural steroid injections are very specific for helping to determine the source of the pain or pain generator.

Dr. Joe Zuhosky (:

I'm going to qualify that one. I think they can be. I think it depends on the approach that you take and the volume of injection that you're utilizing. Our surgeons will frequently ask us through a specific level of injection because they're considering a surgery at that level. And as long as we can get a clear flow pattern for the contrast that we're injecting using fluoroscopy, the x-ray that we use to guide the injection and confirm we're in the right spot.

Dr. Joe Zuhosky (:

And we're really trying to confirm two things. One, that we're in the right position and two, that we're not injecting into a blood vessel. As you well know the lumbar spine and cervical spine as well are filled with plexus of veins and small arteries that are feeding the nerves and the spinal cord at the specific levels that you're at.

Dr. Joe Zuhosky (:

And so it's very common for us to be in a blood vessel at which point, and for injecting a steroid in the anesthetic. And it's being carried away systemically into the bloodstream. It's really not going to have any specificity at all, or likely any efficacy. It's just not going to help.

Dr. Joe Zuhosky (:

So I do think if you are using appropriate contrast medium and you're minimizing the injection volume that we're not giving, I often read reports where patients are getting 10CCs plus of injection volume. That's simply too much injection volumes to really have any specificity.

Dr. Joe Zuhosky (:

But I definitely do believe that when we can reproduce the patient's pain during the procedure, when they get immediate relief from the anesthetic procedure, and then they get hopefully some sustained relief from the steroids beyond that, I think there definitely is a role for epidural steroid injections identifying pain generators.

Dr. Joe Zuhosky (:

And if it doesn't give our patient long-term effective relief that they can then live with, helps our surgical partners to determine that that is indeed a level that we can reliably operate on. We have seen and I've seen in my career unequivocally that if we do an injection, it really has no impact at all. I'm very reluctant to have that patient go to surgery because they rarely get a good result.

Dr. Sanjiv Lakhia (:

Yes. And the reason I wanted to bring that is for the point you just touched on, I do have a lot of people that will see me and say, I don't want a shot. It's just a bandaid. And I'm sure you hear that from people. And I understand that, but what you just said illustrates that injections in the low back, while we certainly hope for a long-term therapeutic benefit, even in circumstances where it's short-lived, there could be significant diagnostic value.

Dr. Sanjiv Lakhia (:

And it makes me feel much more comfortable being able to look someone in the eye and say, you know what? I understand the injection didn't fix your problem. But the fact that you had two or three weeks of excellent pain relief, supports that we are in the right zip code in terms of where your pain is coming from.

Dr. Sanjiv Lakhia (:

It's very helpful for the spine surgeon in localizing where to do the operation and potentially can minimize the amount of surgery that's needed and take you from needing a multi-level fusion to a more focal intervention. So I think that's an important point for people to understand as they're getting evaluated by their physiatrist or physician who may be recommending an injection.

Dr. Sanjiv Lakhia (:

We certainly understand that the steroid injections don't necessarily reverse problems, but they can certainly therapeutically eliminate the inflammation and provide relief and then diagnostically be of value. So that was a good distinguishing point you brought up. All right, moving on to the third fact versus fiction.

Dr. Sanjiv Lakhia (:

Patients with lumbar radiculopathy or in layman terms, pain that kind of radiates down the leg with maybe some weakness or numbness, require a "series of three" injections to alleviate pain. What are your thoughts on the series of three?

Dr. Joe Zuhosky (:

That one's absolutely fiction. The series of three injections really comes all the way back from the origins of when steroids were first utilized in the epidural space to treat sciatica, because all the way back to a paper, there was the first real large series of patients. It was almost 240 patients. It was published in 1960/61.

Dr. Joe Zuhosky (:

So on that timeframe, by a doctor Gobert, G-O-E-B-E-R-T, if you want to look it up. And they did a epidural steroid injection as if they were doing an epidural on a patient in pregnancy and did a series of three of them and that was his published results. And he had good results with that series. They were using methyl prednisone and Novocain were the two things that they were injecting.

Dr. Joe Zuhosky (:

We know now with subsequent research, even the most skilled hands when you're doing a blind midline epidural as they were doing, your success rate is at probably at best two out of three are in the epidural space and actually delivered to the spot where it has a potential to help sciatica.

Dr. Joe Zuhosky (:

So when you couple that with the fact that we're limited in how many injections we can do, there's only, most of us, although we certainly see people in the community that don't always follow these guidelines, but most of us follow rather strict guidelines of no more than three epidural steroid injections in six months and no more than four in a year.

Dr. Joe Zuhosky (:

So if we're doing three right in a row at one or two week intervals and different intervals have been proposed, it really makes for a long year if you're trying to help the patient manage the symptoms and avoid surgery, not just acutely, but down the road as well. So I've never been a believer in the series of three epidurals. I've never really done that. It never made sense to me.

Dr. Joe Zuhosky (:

I understand the origins of it and how it came about, but I know if it was my family I'd want to do one, evaluate, see how much impact it had, take advantage of the other treatment modalities we have in terms of physical therapy. Try needling, acupuncture, et cetera. Not do the series of three immediately and kind of paint myself into a corner where I don't have other options.

Dr. Sanjiv Lakhia (:

Yeah, thank you for that. I actually was not aware of and have not read that paper. So we will find that and put a link to that in our show notes. I think that's a great resource. I feel like the series of three injections was more of a community standard years ago, but certainly has shifted.

Dr. Sanjiv Lakhia (:

And on a practical note now from insurance payment perspective, the guidelines are stricter on getting injections covered and I think for the better. Meaning, we need to demonstrate that they're helping reduce pain as well as improve function for a period of time. And I follow the same practice style that you do, set up an injection, do a follow-up, document effectiveness.

Dr. Sanjiv Lakhia (:

It's just one part of the equation though. Working at Carolina Neurosurgery & Spine, we're certainly blessed with a wonderful physical therapy department and I've interviewed several of them on the podcast. And I think the collaborative approach gives you the best outcome.

Dr. Sanjiv Lakhia (:

So I'm really glad you clarified that, where that series of three came from, because it is something that I think patients here and they ask about as well. And it's nice to know the origin of that. It's a good transition point to the next fact versus fiction, lumbar epidural steroid injections can heal disc.

Dr. Joe Zuhosky (:

Again, that's going to be an equivocation of some fact, some fiction. So what the epidural steroid injection does do is it helps reduce swelling right at the site where you're injecting it. Reduces inflammation. A lot of the symptoms that disc causes are not due to direct compression of the nerve, but actually inflammation that it creates. We know there's a whole Dr. Sanjiv Lakhia of inflammatory mediators within the disc.

Dr. Joe Zuhosky (:

The first one identified was phospholipase A2. Now there have been interleukins for a whole Dr. Sanjiv Lakhia of them. I think the last time I looked, it was over 23 different identified inflammatory mediators had been identified within disc material. So when a disc is in its natural state and sequestered away from the bloodstream and the body's immune system, there's no issue whether there's an inflammatory mediator within the polyglyconates within the disc at all, because you're not exposed to it the rest of your body.

Dr. Joe Zuhosky (:

But once there's a defect in the annulars that's holding the disc in place, whether it be an annular tear or a disc herniation, that's when the inflammatory mediators leak out. And so as I've tried to tell patients, there's two different ways a disc can cause pain. One is direct pressure on the nerve and frequently that does require surgery.

Dr. Joe Zuhosky (:

Those are the ones that do best with surgery, but two is the inflammation that it causes. We know what time the natural history is. Disc tend to shrink, the body's own immune system tends to help treat the inflammation. And if we can just get patients through the acute phase of it, we can, as I like to say, help mother nature in the healing process for the acute part and let her take over for the long-term part.

Dr. Joe Zuhosky (:

And if we're successful getting patients through the acute phase, I don't think we should take all the credit for healing the disc, but I think it's part of the process. And again, it's a thought of managing it going forward because even when the pain isn't there, you still have a weak area of your body that you're going to have to compensate for going forward.

Dr. Sanjiv Lakhia (:

I'll often be asked by someone I'm working with after they get an injection and they feel much better, they'll say, hey, should we get a new MRI and see if it's healed? And I think to your point, the epidural steroid injections are reducing, eliminating that inflammatory cascade, but I don't personally expect to see structural changes on an MRI within a month or two. That is more of a long-term process of healing and scarring down. Do you feel the same way?

Dr. Joe Zuhosky (:

Absolutely, and what I like to tell my patients is what the injection does occurs at acellular level. The reduction inflammation, the swelling, all occurs at acellular level that you're not going to see at the macroscopic level of getting an MRI.

Dr. Joe Zuhosky (:

Now, if we could do electron microscopy and really dive down that deep with it, then I think we could see those changes. And we certainly do when we do animal models. But that's simply not practical in humans, nor is it going to really help us know what to do going forward.

Dr. Sanjiv Lakhia (:

Yeah, no, that's excellent. Totally agree. Moving on, we are doing fact versus fiction here with Dr. Joe Zuhosky and we have a couple left. Next one here is lumbar epidural steroid injections can fix spinal stenosis, fact versus fiction?

Dr. Joe Zuhosky (:

That one's, I would say more fiction than fact, but they certainly have a role in treatment. And similar to what I said earlier, what we are hoping to... Most patients that have spinal stenosis, and I know you've seen this hundreds if not thousands of times in your career, a patient will come in and they said, I was fine until whatever date they say.

Dr. Joe Zuhosky (:

And you get the MRI and they've got severe stenosis and they look at you and they say, how in the world do I have severe stenosis? I've never had pain until this time. And as I try to advise them, is that, look, you've been walking alongside a cliff, right on the edge of it for quite a while now and just didn't realize it.

Dr. Joe Zuhosky (:

And you're right, the stenosis isn't something that came about overnight, but something came about that did trigger an inflammatory response where all of a sudden the same amount of space you've had potentially for months or years prior to this has all of a sudden become too little space for what your nerves need to operate happily and efficiently and without symptoms.

Dr. Joe Zuhosky (:

And so if we can just get you back again at a cellular level, reducing the inflammation, reducing the swelling, creating a little bit more breathing space for that nerve. Again, not at a level you're going to see on an MRI, but at acellular level, then we can get you back where you were potentially two months ago where you really weren't having that much in the way of symptoms.

Dr. Joe Zuhosky (:

Or we can continue to do this going forward and help you avoid surgery, at least put it off till things are further down the line. Because we do know there's a distinct advantage to having surgeries later in life when you're not quite as active and there's less time in your lifespan to develop the adjacent level changes that we frequently see after surgery.

Dr. Joe Zuhosky (:

So there's really distinct advantages to doing it. But to say that it's going to heal or change the degree of stenosis, I think that's a little misleading.

Dr. Sanjiv Lakhia (:

Yeah, I totally agree. I will tell people that these types of conditions, again, we're talking about, I think, you and I are talking about lumbar spinal stenosis more in an adult population. So chronic degenerative. And if someone comes to me with the symptoms, with an MRI in hand and I show them, let's say severe stenosis at L4, L5, and again, for those that are novices, stenosis is synonymous with narrowing effect.

Dr. Sanjiv Lakhia (:

So for example, you can have carotid artery stenosis where plaque has narrowed the blood vessel and limits of blood supply in the spine. We're talking more about narrowing and compression of where the nerves live and it can present with back pain and numbness in the legs, pain in the legs while standing and walking.

Dr. Sanjiv Lakhia (:

It's oftentimes better with sitting, but I will tell them if we did this MRI a month ago or even a year ago, more likely than not it would look exactly the same as it does today. And then they'll say just what you said, but I didn't have any symptoms then. So I use it to illustrate that the body can learn to adapt with it.

Dr. Sanjiv Lakhia (:

If you can, utilizing non-operative measures, reduce some of the inflammation in the pain, maybe open the space up a little bit functionally with a Williams based flexion rehab program through PT. You certainly can have a better quality of life with it. But having said that, when it's quite severe and you cannot even walk to your mailbox without having to sit down, there certainly can be a role for surgery.

Dr. Sanjiv Lakhia (:

And I did a podcast interview with Dr. Joe Cheatle on lumbar stenosis. In fact, it's one of our most popular episodes and we will link to that in the show notes as well, but there's a time and a place. And for spinal stenosis, I feel like it's slightly different than acute disc pain and nerve pain from a herniated disc.

Dr. Sanjiv Lakhia (:

In that I don't have as much of a runway for having people go through months and months and months of non-operative care. If they're functionally debilitated, I think there's reasonable and excellent outcomes with surgical interventions if the scenario justifies it and the risk benefit ratio's in their favor.

Dr. Joe Zuhosky (:

Absolutely. I would agree with that 100%.

Dr. Sanjiv Lakhia (:

All right, now we're getting to our last fact versus fiction. And I do believe I touched on this a little bit when I interviewed Andrew Sumich, but I want to get your thoughts on the idea that transforaminal, so these are injections that are done more from a cyto bleak approach, transforaminal lumbar epidural steroid injections work better than interlaminar epidural steroid injections, are more of a direct kind of central or slightly off midline approach.

Dr. Sanjiv Lakhia (:

Now this is a technique question where in the community of physiatrists and anesthesiologist, pain providers, different training and background, physicians will use different techniques. So I want you to share your thoughts on these two different injection approaches, both maybe from a literature perspective, but more importantly kind of real world experience with the different techniques.

Dr. Joe Zuhosky (:

Yeah, I think I kind of have a unique perspective again, because of my age and my training. I'm old enough that when I first started learning how to do epidural steroid injections, one of the hospitals that we were working out of didn't have a fluoro unit, and so a C-arm that we could manipulate and change the angle of the view. And so all we had was literally a platform standard fluoro that was imovable.

Dr. Joe Zuhosky (:

So you had two options. You could either try to oblique the patient somewhat, which was difficult or you could kind of learn to visualize it and try to think three dimensionally. So from a standpoint of training, I think it was great. It helped me to think three dimensionally very well. But our default was because we had just a standard platform fluoro, was we would do more interlaminar epidural steroid injections there.

Dr. Joe Zuhosky (:

And we would tend to reserve our transforaminal approaches for our other hospitals, where we had a C-arm where we could change the image view much easier. And so throughout my training would see the difference between those patients that we did interlaminar and those that we did transforaminal, and I saw definite... And the literature bears it south somewhat.

Dr. Joe Zuhosky (:

It's not dramatically different, but there have been studies that have looked at both approaches and transforaminals tended to be a little bit better response. And the rationale and the thinking behind that and the reason why I do almost exclusive transforaminals lumbar now is a few reasons.

Dr. Joe Zuhosky (:

Number one, when you're doing an interlaminar epidural steroid injection, we know from cadaver studies as well as just from injecting, contrast, that there's often a septa that keeps the medication on one side or the other of the spine and doesn't always allow it to go to the other side in a cylinder like fashion that you would anticipate most patients epidural spaces are.

Dr. Joe Zuhosky (:

So it may limit your injection to only one side or the other when you're doing it that way. Number two, as we said earlier, we have the advantage when we're injecting in a transforaminal approach to put the medicine right around the nerve root that's being impacted by the pathology.

Dr. Joe Zuhosky (:

The thought is there's an advantage for the medicine to follow the nerve root in the epidural sleeve right up to where the disc herniation or the lateral resus stenosis or the parametal stenosis, wherever the narrowing or the pathology is. If we're injecting around the nerve that's actually impacted, if we inject in that epidural sleeve, it's going to follow to where the pathology actually is and the medicine will get to the right spot.

Dr. Joe Zuhosky (:

The next reason that we... So we have a diagnostic benefit, potentially a deposition location benefit of where we're putting it. And I think the third factor is we're much less likely to have the most common complication occur, which is a dural puncture, when patients get a spinal headache. So it would be very unusual for a transforaminal approach to create a spinal headache in a patient.

Dr. Joe Zuhosky (:

So for all of those reasons because of my experience, because of what the literature says, and it's not dramatic within the literature, I'll be the first one to admit it, certainly the absence of any significant risk of a dural puncture is all those things are significant. And for those reasons, again, what I try to do is treat all the patients as if I was treating my own family and I'd want my own family member to have a transforaminal approach.

Dr. Sanjiv Lakhia (:

Yeah, I think one of the arguments against the transformational approach would be from the risk perspective of maybe a little more frequent vascular access when you come in from the side. But in my experience, and what I've seen is when you're using proper technique and training with C-arm and live contrast injection, it doesn't eliminate that 100%, but it significantly reduces that risk.

Dr. Sanjiv Lakhia (:

Now I think it's a slightly different story though in the cervical spine where you're looking at these two different techniques of a transforaminal versus a interlaminar. And there's debate throughout all of this, but certainly the thought there would be in the cervical spine, the risk of a catastrophic vascular complication is perhaps higher than doing a interlaminar approach.

Dr. Sanjiv Lakhia (:

Although I do believe when that thought process came out and the movement went towards more interlaminar injections that we started to see more epidural hematomas and some of these other complications emerge. So at the end of the day, I think it really boils down to the training, the competency of the physician or the using evidence based guidelines when performing the procedures.

Dr. Joe Zuhosky (:

Yeah, I agree with that as well. And I actually was probably supplied the most patients for one of the studies on intravascular uptake during epidural steroid injections. My patient population was the largest one within the study group. It doesn't get quoted as much. Bill Sullivan is the lead author on that paper.

Dr. Joe Zuhosky (:

Mike Furman beat us to the punch by about a month and so his paper's always the one that's cited, even though we had a much larger patient population than he did that we looked at. But you're absolutely right. And back when I was training, we didn't have readily accessible dexamethasone, which is non particulate steroids.

Dr. Joe Zuhosky (:

So in addition to the vascular complications of a hematoma, you also had the risk of intravascular uptake of a particulate steroid, which created a lot of the problems as well.

Dr. Sanjiv Lakhia (:

Right. That's a big game changer too, using to dexamethasone, which is why I get a little nervous with supply chain shortages. And hopefully we have that, we can continue to offer to our patient community. So, all right, I think we covered a lot of excellent, I don't want to say controversial points, but maybe some points of confusion regarding lumbar spinal injections today.

Dr. Sanjiv Lakhia (:

So I appreciate you taking the time to do this. And before I close, I always like to pick the brains of my Dr. Joe Zuhoskys and see if we can share if you have any personal habits that maybe you've relied upon to promote wellness in your life, keep your back healthy and strong. Anything that you have benefited from that you think someone listing out there could adapt to their daily routine and see some impact.

Dr. Joe Zuhosky (:

Yeah, it's like a Bosley hair commercial, not only am I a doctor, but I'm a client. I've had the pleasure of experiencing both lumbar and cervical disc herniations. And so it is something that's part of my daily life that I've learned to manage. And it's like I share with my patients, I helped found a workout group here in north Charlotte. The original group was called F3.

Dr. Joe Zuhosky (:

It was founded in Charlotte, North Carolina. And it was just a group of guys get together and work mornings, boot camp style workouts predominantly, but it's evolved into a lot of other things as well, and it's participant led. And so I went down and learned about the program and came back and brought it up to the Lake Norman area here outside of Charlotte.

Dr. Joe Zuhosky (:

And I've been doing at now for over 10 years. I do it most mornings of the week, not every single morning. I run one of the groups locally. The person that's in charge is called the cue and the person that runs that particular site on that particular day is called the master cue.

Dr. Joe Zuhosky (:

And so I've been the master cue of a couple different workouts, really ever since the beginning, which means I either have to lead the workout or I have to find someone else to do it. And so each of those, when I'm leading it, I really try to focus on making sure we probably do a little bit more flexibility work.

Dr. Joe Zuhosky (:

And I've taught the guys that I work out with a lot of the stretches that I do for my low back. And especially hamstrings is probably the most critical one of all. It's not the only one we do, but if I had one exercise to teach all my patients would be how to appropriately stretch their hamstrings without stressing their disc.

Dr. Joe Zuhosky (:

But when I lead the workouts, I tend to focus a lot on core strength and we do a lot of planks. We do a lot of crunches. We do a lot of other dead bug and other exercises that if other listeners have heard your podcasts with the therapist, I'm sure they've discussed.

Dr. Joe Zuhosky (:

But I try to incorporate a lot of that into the workouts that we do, and it's been great for me. If I take even three days off of my exercise regimen, I start to get pain again. So I know that I may not do it every day, but if I take more than three days off, I'm going to feel it.

Dr. Sanjiv Lakhia (:

I tell you what, first, thanks for sharing that. That's incredible. I didn't remember you telling me that before. So, that is just amazing. And I've talked about on this podcast before that I've had issues with my back in the past.

Dr. Sanjiv Lakhia (:

I'm doing really great now, thankfully, but the one thing I would say as a provider, particularly a spine provider when you've gone through that on your own, it does give you some instant credibility when you're talking to your patients about these types of treatments and the importance of them. I'm curious to know, you mentioned the hamstring stretches.

Dr. Sanjiv Lakhia (:

How exactly do you instruct people to do that? Is this where you're laying on your back and lifting your leg up or what's kind of your go-to way to stretch the hamy's without aggravating the back?

Dr. Joe Zuhosky (:

Yes, I want the spine to stay as neutral as possible, because most patients when they stretch their hamstrings, all they're doing is either putting their leg up on a piece of furniture or a fence or something outside and then reaching over and touching their toes or simply bending over and trying to grab their toes.

Dr. Joe Zuhosky (:

We know that with flexion, we're really increasing the pressure within the disc significantly. And not either you're going to get symptoms and not be able to hold the stretch long enough to get a benefit or you're really potentially creating more of an issue within your own disc.

Dr. Joe Zuhosky (:

So I really try to teach patients to do it lying flat on their back with a posterior pelvic tilt where they're really pushing this small of their back into the floor and holding it there and either putting their leg up in a door frame and getting their buttocks as close to the doorframe as their flexibility will allow to give them a good stretch.

Dr. Joe Zuhosky (:

And then when they get really good, we'll have them stretch the other leg out in the doorframe as well. But again, maintaining your back flat against the floor so you're not increasing the pressure on the disc. You can do it as well with, they sell these fancy, some people just use a big beach towel, they sell the fancy ropes that have the loops that you can put around your foot and those work fine as well.

Dr. Joe Zuhosky (:

And you can do it appropriately that way also, but I really prefer either the doorframe or using something around it. And again, not only keeping your low back against the floor, but also making sure you're not lifting your neck as well.

Dr. Sanjiv Lakhia (:

Well, I think if you follow his advice, folks, you're going to minimize your need for one of these spinal injections that we were talking about for the last half hour or so. Although, sometimes it takes a little bit of everything to keep you on track. As you know, back pain can be complex but there's definitely hope. And today I really enjoyed going over this topic with you, Joe. I just want to thank you so much for your time.

Dr. Joe Zuhosky (:

My pleasure. Thanks so much for having me.

Outro (:

Thank you for listening to this episode of Back Talk Doc brought to you by Carolina Neurosurgery & 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.

Outro (:

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.

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