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Dr. Giuffrida: We're back for another Thursday talk with Dr. Jeff Cantor and myself. And, today, we're talking about cervical stenosis, and I'm just excited as you are because Dr. Jeff Cantor probably takes care of more cervical stenosis patients than – I can't say anyone in the US – but he's in the top 5% for sure. We see a lot of cervical stenosis down here, and we're very good at taking care of it. Most of this is going to be done by Dr. Jeff Cantor. I'm going to ask him some questions and walk through it. I'll talk a little bit about my experience of when I see patients as well, but I'm going to give him the floor and let him go over a lot of the things about cervical stenosis. So first of all, easy question, what is cervical stenosis?
Dr. Cantor: What is cervical stenosis? The reason why we're talking about this now why we pick in this particular subject is we're in this COVID Virus situation, and we're really not doing elective surgery. We're doing more emergency type procedures. We're only taking care of people who really get into trouble. And what we find that we're really getting into trouble with pretty quickly and a lot of patients is cervical stenosis. So, lumbar stenosis is a common problem, probably a more common problem, but most folks don't need emergency surgery. So, cervical stenosis is really rising to the top in what is becoming an urgent problem, and often, this was something that was predictable and maybe could have been done differently from the beginning. So, what is cervical stenosis, and basically what is stenosis in general. The term for stenosis is when you have a tube, something in the body where blood vessels or nerves travel through, there's a conduit, there are tubes and when something starts to get into that tube and make it smaller, whatever's going through it gets pinched. Cervical stenosis and spinal stenosis is a term that basically means that stuff, mostly bone, mostly arthritis is growing into a space that's normally occupied by the nerves.
Dr. Giuffrida: What happens when our cord gets pinched or when the nerves get pinched?
Dr. Cantor: What this looks like, what happens when the cord gets pinched, is it causes problems. This is what it looks like. This is an example of cervical stenosis, and what you can see here is this is an example of a neck and base of the skull from the side. This is the base of the skull; these are the bones in the neck. And what you can see is once again, here's the skull. Here's the surgical portion of the neck, and inside there is a tube where the nerves travel through, and the spinal cord is inside that tube. And here you can see a very clear difference where instead of having a lot of room, you can see that tube is really narrow and the spinal cord coming through the tube is pretty severely pinched, and that is cervical stenosis. So the next question that Dr. G asked was, well, what happens, why is this a problem? What are the consequences of it and a lot of us are sports fans, we watch professional sports, and there's a lot of talk these days about concussions in athletes. And the NFL spends billions of dollars trying to figure out how we can predict and how we can potentially stop that problem. Well, what's important to know here is the brain and the spinal cord are basically the same thing. So if you look at a side view, this is the base of your skull. So once again, we're looking at this model, the base of your skull's here, and through the base of the skull, there's a hole, and through that hole, there's an extension. And through that hole, there's an extension of the spinal cord. So anything above that point, all this is brain, anything below that is the spinal cord. So the spinal cord and the brain are basically made out of the same stuff, and we do know that when the brain gets bumped into the brain gets damaged, it actually disappears. So if we get repeated concussions, the nerves in the brain actually turn into liquid, they completely go away. So also what we can see here is around the brain and around the spinal cord is this white stuff. This white stuff and this white stuff is water. So the brain is in the skull, and in the skull surrounding the brain is water. And as the brain exits through what's called the foramen magnum, it goes into the neck. There's also water, and the reason for that is around the brain, and the spinal cord is space. So if this black pen is the spinal cord, when we move, we move around it. So when we move our head, the spinal cord doesn't get bumped into the bones of the neck, basically flex and rotate around the spinal cord. Because just like the brain, when we bump into the cord, we can damage it. So the process of bumping into the cord actually can cause the spinal cord to degenerate.
So, what we're really trying to prevent is getting to the point where we might start getting into trouble with this. So when we're born, we're born with a whole bunch of brain and a whole bunch of spinal cord. As we age, we lose brain, and we lose spinal cord, we lose kidney, we lose liver, we lose heart things that generate. And we know from most organs, we get down to about 20% of that particular organ until we start to get into trouble. We have about 20% of the function of our heart; we start running into heart failure. When we have about 20% of the function of our kidney left, we might start running into kidney failure. We also know when we have about 20% of the cells and the available structure of the spinal cord left, that's about the threshold for starting to get into trouble. So over time, we're always losing cells, so we're moving in this direction. And usually, folks get to this 20% point in about 85 years plus. So a lot of folks after 85 years old are starting to walk and start to have difficulty shuffling and really difficulty getting around. And that's a lot of times because their spinal cords just burned out. So if we take that normally aging spinal cord and we bump into it, we compress it, we take the space away from the cord, and we crush it. What can happen is we speed up this process. So, instead of getting to the point where we're down to what we don't have enough at 85, this might happen in somebody that's 55. So spinal cord compression advances the degeneration of the cord and potentially can cause neurologic problems in patients much younger than normal degeneration. So, why is that sometimes difficult to determine? And it's difficult because a lot of times we don't know what's happening. So a lot of spinal cord disease, cervical stenosis can severely damage the spinal cord without us knowing about it. And we'll talk about the symptoms in a little bit but most patients who have cervical stenosis that might end up losing their ability to walk. The reason for that is something called neuroplasticity. And there's a very good Novus special probably about two years ago talking about brains and how the brain adapts to damage and change, it's called neuroplasticity is a good idea if you're really interested in watching that it'll help learn quite a bit. But suffice to say that this is the spinal cord, there are billions and billions of cells in the spinal cord. And each group of these cells is responsible for a certain function. For argument sake, if this particular group of cells is responsible for using our right arm, when we bump into that area, when we pound into it, when we impact it, it gets damaged just like the brain gets injured with a concussion. When we pinch the spinal cord, it gets damaged. So what happens is we start to lose cells in that area. And if that loss of cells is fast, we'll lose the function of that in that area. So this was moving our right arm, and these cells get damaged quickly, we're going to lose function in our right arm. But what happens more commonly is this process is slow, particularly with cervical stenosis. This happens very slowly. So instead of losing all these cells quickly, we lose them slowly, and what happens is this function gets transferred somewhere else, and now these cells take over for what these were doing before. And that works just fine until these cells start to get damaged and then what happens is that function gets taken over somewhere else. And all this is completely unnoticed as long as the rate of recovery and the rate that other cells can learn the function is faster or equal to the rate that we're losing function. So if the loss is recovered fast enough, we'd have no idea this is happening. And when we start to become aware it's happening is when we start to run out of cells and then as things get damaged, there's nothing that replaces them. So the reason why we get down to that point where we're out of gas, where the tank becomes empty, and we're here and because we don't know it is the spinal cord is constantly adapting to the damage, and it happens without any obvious consequences.
Dr. Giuffrida: So I had a lot of patients come in with spinal stenosis, and they don't know it may be their only symptoms are they're unable to button their shirt, unable to put on their earrings or noticing that they're having trouble manipulate their fork or something like that, but they won't have any pain, why is that? Why is it there just having some fine motor skills, nothing too serious?
Dr. Cantor: Well, a lot of patients, as we mentioned earlier, come in with very, they can't put their earrings on. They have trouble buttoning a shirt; they find that when they're going up and down steps, they feel like they may have to hold on – where a month ago they didn't have to hold on. Or when they change directions in they're walking, they're unsteady, and they may have no pain while other patients come in you see all the time with terrible pain, pain in the arms, pain in the neck, tingling in the fingers. And the anatomy its very, very different where the stenosis can form, and it makes a big difference. So this is an example of a cross-section; this is actually an anatomical specimen from a cadaver looking at a spinal cord on end. So what we're looking at here is the bone in the front of the spine, is this the arch that covers the spine is this back here, the tube where the spinal cord goes through is here, and this is the spinal cord. And these are nerves coming off the spinal cord. And right here is called a nerve root. So what we see is we have a lot of space around the cord, and delicate nerves on the inside well protected all the way around by bone. So the question is, well, why are the symptoms different? Why are some folks in terrible pain and other folks really have no pain? Well, this is a simplified version of what I just showed you once again, what we can see is the bone is the black, the arch over the back which is also bone is also in black. The blue is the fluid protecting the spinal cord, and the yellow is the nerves. So this in the center is the spinal cord, and this is what's called the nerve roots. So at each level in the spine, a nerve comes out of the cord and forms a nerve root. The spinal cord has no sensation when you bump into the brain, and when you bump into the spinal cord, there isn't any sensation. So you can damage the brain, and you can damage the spinal cord without having any awareness of it, doesn't hurt. So if you develop stenosis and the bone spurs are forming and are pushing on the spinal cord. The cord is very delicate, it gets damaged, but it doesn't cause pain. The nerves that come out of the spinal cord that form the nerve roots that go into your arms are very sensitive. So when the stenosis forms off to the side and it pinches the nerves in this location that causes pain. So when folks have what we call Central Stenosis where the stenosis, the pressure on the nerves, is pushing on the spinal cord, they may eventually lose their ability to walk, but they may have no symptoms other than maybe some tingling or numbness or changing in dexterity. But when the pinching is off to the side and pinching the nerve roots, they may have severe pain. Now, a lot of patients have both and it's actually kind of lucky if you have cervical stenosis and cord compression that you have pressure off to the side because it may alert you that something's going on that may potentially be dangerous that you wouldn't, maybe wouldn't know about otherwise. So cervical stenosis, different symptoms hurt because of compression is either on the cord or on the nerve roots, or both each one of them presents with a different symptom complex.
Dr. Giuffrida: For sure and I think I see a lot of those patients, and a lot of people out there have that nagging pain going down their arm, and that's I think those patients are lucky sometimes because they will come in earlier. And we'll get that MRI earlier and be able to check out their cervical spine. So, show us on the MRI what causes stenosis, what actually presses...... What happens?
Dr. Cantor: What happens within what causes cervical stenosis is, for the most part, arthritis. And if you look at your hands and you're over about 50 years old, most of us look at our fingers, and then you can look at this joint here is really large, and on this side, it's really small. This is an arthritic joint, arthritis causes bones to expand, and there are many joints in the neck. The neck is the most mobile joint structure in the body, it moves in multiple directions, and there's a lot of joints, so there's a lot of areas to develop arthritis, and there's a lot of areas for these joints to expand. So if you look this is a disc, this is a disc, all these are discs, and when a disc becomes arthritis, they're going to get bigger, and when they get bigger, they're going to start to grow into this space that's normally occupied by the spinal cord. Any arthritis can happen in both directions. So instead of having a wide-open spinal canal, now we start to get a situation where the spinal canal will start to get compromised, and the spinal cord can get pinched. And when that happens, it looks like this. So, these are the vertebral bodies, the bones, and normally, the spinal cord will travel down this channel. What's happened here, this is a very good example is the back of the bones are forming these very large bone spurs, and those spurs are pinching the cord. And what's happening, the space that's normally occupied by the very delicate nerves is now occupied by rock by disc herniations and bone spurs, and that's actually what causes the pinching of the spinal cord. So that's how spinal stenosis forms. So if you look at a normal example again, we looked at a side view initially; this is a normal spinal canal. So once again, you have the bone in the front, you have the arch and the channel where the nerves travel through and the cord in the center and all this white it's spinal fluid space. And when you develop stenosis which you're going to see is you're going to see bone growing into this space and that bone is going to start to compromise the spinal canal and ultimately pinch the spinal cord, and that looks like this. So this is a spinal cord that's severely compressed, and this large piece isn't supposed to be there, the normal disk and bone are here, all of this is arthritis. This is something called OPLL, and what it's doing instead of the spinal cord having a lot of space, it's now being crushed, and that crush will eventually cause damage.
Dr. Giuffrida: So we're seeing a lot of pictures here of bad stenosis, bad arthritis, which patient is in trouble, which patients are going to need surgery quickly, which patients can we watch, and how do we know?
Dr. Cantor: Well, that's a good question because it's hard to know with the spinal stenosis often can be asymptomatic for your whole life, you can have severe stenosis and not ever get in trouble, or you can have stenosis and cord compression and be normal today, and two days later you can't walk, you can sneeze and become paralyzed, you can get in a fender bender and become paralyzed. You can get the flu, and all of a sudden, lose your ability to walk. So the question is well, who's at risk and who's not, and that goes back to the anatomical drawing that we did before. How much space is normally necessary for these nerves, and if you look at the model again, if you look at this on the spinal canal normally is this the bones in the front, the bones in the back, and there's this tube full of the blue water. And that tube normally from front to back, normally is about 12 to 14 millimeters. And the spinal cord itself, this part is typically about eight to nine millimeters. And around it is a tube and that tube when you add both sides, it's about one millimeter so, nine millimeters plus one is about 10. So the space that's normally necessary before something actually comes in contact with the cord is about 10 millimeters, and if you look at the textbooks, the definition of stenosis meaning too small is anything less than or equal to 10 millimeters. But most people don't get in trouble at 10 millimeters. So if you follow somebody for 15 years that has a 10-millimeter canal, in other words, this space gets narrow to where there are only 10 millimeters of space in here. Most folks do not get into trouble. The threshold where we see a lot of folks get into problems is about eight millimeters. So in about eight millimeters, one in three will potentially develop some problems; two out of three won't. So the question is which one will, who's going to get worse, who's likely to be somebody who might suffer from severe neurologic problems versus who's not. And one way we can predict that is the one the patients that already have symptoms and they are at eight millimeters are likely to get worse. And that can be rapid, or it can be very slow. So what we do is we see the old way of doing it is we see somebody that has an eight-millimeter canal, and they have no symptoms, we just watch them. We say we're going to reevaluate you in a year, and if they have nothing in a year, we'll say we'll reevaluate in two years. And a lot of times those folks will go along without developing symptoms, if they have symptoms at that point in time, we're going to start to consider doing something about it surgically, because cervical stenosis does progress and usually, people who have it do worse if they leave it than if they treat it, the prognosis is much better when the pressure is taken off the cord once you start to have spinal cord disease than if you let it go. So symptomatic patients at eight millimeters we typically fix so if you have symptoms, which is the one out of two, we do something about it, if you don't have symptoms, which is the two out of three, we follow them. At six millimeters, that's a problem. So equal to six millimeters or below that's pretty much dangerous, that's going to cause cord disease. Most folks, even if they're not symptomatic, will eventually become symptomatic. So six millimeters we're really going to start looking at it. Now, this is old school ways of looking at things. There are other ways, newer ways that we can predict. So the basic parameters are when a spinal canal gets less than a certain size that's too small for the cord, that's when we start thinking about doing something. The usual cutoff is about eight millimeters less than that is dangerous. There's a lot of other factors that really play into this, but that's much more complicated than we have time to talk about today.
Dr. Giuffrida: So, is there any way to know for sure, on MRI who's going to do poorly or who's going to do well or knowing how much nerve they have left? I know you showed that picture of the neuroplasticity with nerves dying, is there any way to see that on an MRI at this time?
Dr. Cantor: The answer is yes, and these are two examples of two patients that have spinal cord disease. And, if you look at the patient on the left side, you can see severe cord compression. And you can see the spinal cord is absolutely crushed. And if you look at the patient on this side, they have really just a mild amount of narrowing, and what's fascinating about this is that this person has no symptoms, and this person is having trouble walking. So we look at this you kind of a head scratch you say, well this one looks bad, this doesn't look so bad and why is that? And how can we predict and who's going to get into trouble? And with the old school ways of looking at things, most folks that have a neck like this probably are not going to get offered treatment. And folks like this might be told if you don't do something about it, you're potentially going to be paralyzed. What's also interesting is before we talked about the fact that when the brain gets injured, it goes away, it liquefies. And on an MRI scan, water is white. So this is all water, and this is water in this area; it's padding through the cord. This is all water that's padding through the brain. If you look at this cord, you can see the white spots in the cord that's called Milo Malaysia. That's dead spinal cord, that's gone. But because of the neuroplasticity because of the body's ability to recover and regain that function, you may be losing spinal cord and not have any idea that it's happening. So this is an example of an older individual with severe stenosis, severe spinal cord damage, very little symptoms. The cord is recovering as fast as the cord is getting damaged. So the patient, the individual, has no symptoms.
This individual is very different. This is a younger person in their 50s that is an elite athlete. That is every time the person jumps into a swimming pool, his arms go numb, he starts to lose strength, his balance is becoming a problem. And this individual he's been all over the place, and it's hard to figure out what's going on. Is it cervical stenosis, or is it not? So in this case, mild symptoms, severe stenosis, severe symptoms, mild stones, so is there a way that we can look at this and actually predict a little bit better. And this is something that Dr. G, we're going to talk a little bit about is a newer technique, and this is called diffusion MRI scan. And this is where science is going; this is where spinal cord disease, this is where brain disease already is. And the reason why brain injuries are so far ahead with this technology is because of the NFL because of the billions of dollars that had been dumped into research looking at brain injuries of athletes. Now, to this day, diffusion MRI scan isn't even covered by insurances, so it's expensive, it's difficult to access, and there are very few centers around that do it. So what this shows is this is an MRI scan that shows the typical spinal cord, and what you see is a black line or a gray line. This is a diffusion MRI scan, and this is the same as this. And what this shows is the actual nerve fibers. This quantitatively shows us a very, very healthy spinal cord that almost looks like the tail of a horse. So we can look at a diffusion MRI scan as opposed to just getting a picture of that's a black cord, and there's nothing really pinching it. This shows a healthy spinal cord with intact and healthy nerve fibers. And this is a cross-section, this is the same patient once again side view looking at the cord lengthwise and if we turn it over and slice this like you're cutting a hotdog, what it shows is the spinal cord here is very healthy, the healthy cord is red, damage cord becomes more, more yellow. And when the cord gets damaged, this nice horseman is going to start to fray, and it's going to start to look like it's getting damaged. So an example of a normal spinal cord, an example of a spinal cord that severely damaged. An individual that has pressure on their spinal cord that has a chord like this is not in trouble, an individual that has symptoms and has a cord that looks like this has significant problems. So how can we use this, how can we differentiate and this is very new technology. This stuff is really coming into the medical journals. We're about to publish some information that we've used here, looking at diffusion MRI to actually make decisions on who needs surgery and who doesn't, and it is remarkable, we're very effectively able to identify patients particularly that don't need surgery. And we have been able to identify some people where the symptoms are very unusual, and we've been able to identify, yes, this is cord disease we do fix them surgically we've had some remarkable results.
So this is another example of an individual, this is the same person we showed you before, but this is another example of somebody that has tingles in the fingers, some unusual symptoms and has moderate stenosis, it's bad enough where you think that might be a problem. This is an example where the stenosis is mild. So we go back to the first patient that looked bad. This is the example that I showed you before, where the diffusion MRI showed, the cord is healthy. So a young person with stenosis with a healthy spinal cord. This is somebody who probably doesn't need surgery, and we actually sent her to neurology, and they found other reasons why she was having numbness and ended up not having surgery and is now about four years out with no progression of symptoms. This is the individual that's the elite level swimmer, looking at the cord that's mildly pinched with severe damage, this person underwent surgery with almost 100% recovery.
Dr. Giuffrida: I think a lot of people out there are wondering, what do we do for this? When patients come to see me, we try conservative measures first. We can try things like anti-inflammatories, maybe an epidural, but usually, that doesn't fix the problem. If you're losing cord and you have nerve damage, the pressure needs to be taken off. It's nothing that an epidural or some Advil or some stretches can really take care of. What are we doing here in order to take care of these patients? What kind of techniques or treatments are we using?
Dr. Cantor: So the hardest thing to do is understand who we need surgery, it's pretty simple when somebody comes in, and they're falling, or they're progressively losing their ability to walk, or they can't use their hands or the pain is so severe and the old fashioned way, before we had, we're developing better ways to identify who's in trouble. The old fashioned way is to wait till you can't walk and the problem is that if we wait for you can't walk, we often can't get you to walk again. So the whole issue here and the holy grail of fixing cervical stenosis is that we can intervene early enough that we have a better prognosis? Can we pick out patients that are likely to get into trouble and fix them before the symptoms get to the point where they're unfixable?
Also, it's important to know, as we mentioned earlier, cervical stenosis usually progresses. And it can progress very quickly so if you draw a graph over this and you look at time and progression, if you draw a graph and you look at it worsening, we usually see something that looks like this. So it gets bad, and it gets better, it gets bad, and it gets better, it gets bad, and it gets better, but if you follow it over time, it typically creeps towards worse. So a lot of folks come in, I can't use my arm, and three weeks later, they can use their arm. Once again, back to neuroplasticity, the nerve rate of damage exceeded the nerve rate of recovery, and a couple weeks later, they recovered, they lose more cells, and then it gets bad again, and then they recover again. So they get bad, and they recover. They get bad, and they recover, but if you follow them over time, they tend to progressively get worse. Now some people can not find that course they can follow a course where they go from fine to bad and that you can fall, you turn your head, you can watch an airplane go over, you can trip and bump your head in the bathroom. But when you have cord compression, and you whack into that cord there are no buffers there's no padding and... - It's dangerous... - It's dangerous.
Dr. Giuffrida: I had a gentleman – high-level functioning playing tennis – went up to get a shot up front flipped over the net, paralyzed. And he didn't break his neck. He didn't, you know, he just the way he fell...
Dr. Cantor: Just bumped his head.
Dr. Giuffrida: He had a little bit of stenosis, bumped his head, and he didn't have enough cord left, and I think he was going up-down, up-down, and also took off.
Dr. Cantor: The most complicated part of the treatment is using the newer technologies and really understanding the disease and knowing who's in trouble and who's not. So the diffusion imaging is a very good way for us to really predict, potentially who we can avoid surgery. So we get somebody who comes in and has mild symptoms. We do a diffusion MRI scan, the cord looks healthy, we say listen, you're really not in trouble at this point, versus we do an MRI scan and see that the cord is much worse and the goal is to intervene and fix it before it gets really bad. So what is the goal of treatment, and the real concern with cervical stenosis is sometimes the more traditional and the older treatments, the treatment sometimes is worse than the problem. And what's interesting about patients is they come to me, and they're unable to walk, and years ago we would fix their neck, and six months later, they're walking fine and then a year later they came back and say, Doc, I wish I never did this operation, my pain is worse now than it was before. And I didn't have a problem before, and we can actually share them on video that they were having trouble walking, but patients forget quickly. So when a patient tells you that I'm not happy with my result, we have to listen to that. We really have to be aware that the surgery that we're doing even though we think we're fixing things, the patients aren't happy with it. So the basic concept of how we treat cervical stenosis, we have to make room, this spinal cord that is severely pinched, we have to open up this channel again, we have to rebuild that channel. So there's room for the nerves, and that requires typically one of two options. Either this is the face the front of the neck, this is the back of the neck. And that either involves going in from the front of the neck and removing these bones or parts of these bones, putting them together with fusions and rebuilding that channel or going in the back of the neck and removing the covers. And if you look at this on and once again, if you look at this side view, this is a cross-section view, and this here is the cover of the canal. So what we do the old way of doing this is what's called a laminectomy, lamina means the cover ectomy names to remove it. So laminectomy takes this cover off. So, cross-section, this cover here comes off, and what it does, it opens up this space. The problem is a significant number of patients that have laminectomy will go from having their head upright, and you can see the spine. Shoulders are here, the head is well balanced on the spine and nice smooth curve. The same individual after having an operation goes from having the head over the shoulders to the head falls forward. And that right there is the problem with the cervical spine with neck surgery, the ability to do an operation that fixes stenosis and to keep the head in a position where it's able to be held up comfortably is really where things get challenging. So the question is why and what can we do to prevent that. So if you look at an MRI scan, what you can see is this is the base of the skull and these bones in the back of the neck, so if you touch the back of your neck, you can feel a bump at the base of your skull. Then it gets soft, and then you feel another bump down below. This is the base of your skull, and the second bump is down here. And there's a cable that goes between there and that cable is called the nuchal ligament and that cable holds your head up. The problem is the cable is attached to the bones that are pinching the cord, and the lamina are these bones, and we talked before about laminectomy, laminectomy means to remove the lamina. So when we remove this bone and the connection of this cable, you can no longer hold your head up. And the result of that is very similar to if you had a bridge and the bridge stanchions. So what holds the bridge up are these uprights. If you remove the attachment of those uprights, the bridge ends up in the water. So by removing the cable attachments in the back of your neck with a laminectomy or the older techniques, what happens is the head falls lower. So, in order to solve that problem we do fusions and a lot of fusions, I'm not knocking fusions, they're necessary for a lot of patients. They're 100% necessary in certain situations that involve spine disease. But fusions are done in many cases with cervical stenosis to rebuild something that we surgically removed. So we take something out that's necessary, and we have to put screws and rods and plates there to fix that. Now, this is a fusion from the front of the neck, which is a good operation. Patients feel good; it works; it's a very effective way to get the pressure off the cord. It's a very effective way to treat spinal cord disease. The problem is when we do a fusion, and we eliminate all of these separate bones, and we turn them into one bone, what happens is this becomes solid rock. All the movement is now transferred above and below, and these joints wear out. So shortly after we do a multiple level fusion, we're probably going to be back doing it again. So multiple levels, cervical fusion leads to more fusions. So we do one, and then the same problem comes back, so this area is fused, then we have stenosis within five years at the next level. And folks that have a tendency to form stenosis are going to do it even more rapidly if it's fused and I can show example after example of patients who had an operation that had another operation and another operation and another, so it becomes a recurrent problem when we do multiple level fusions. One of the most common operations we do now is a revision, a redo, spinal stenosis operation for fusion, and there are better ways to do it versus fusing it again. Now, this is a bigger operation called a post year fusion, we go in the back of the neck, we take all the lamina out, we use long rods and screws to essentially screw the head back on the shoulders.
Once again, a very effective way of fixing the stenosis patients don't like it. If you ask a patient two years later, if they would do this operation again, the majority would say that they really won't. They don't like how they feel their motion is so limited, it's very difficult to become pain-free and again, most folks forget why they had the operation. All they know a year later is the fact that they're in pain. So the newer technology really offers a lot of different things. And this is a quick video that shows the difference between a traditional cutting tool that we remove bone with like a bar or a Dremel. And what that does next to something delicate. And this is an ultrasonic cutter and what an ultrasonic cutter does is it uses vibration, it's much more powerful, it cuts hard things like bone better, much more quickly. But because it vibrates and it doesn't spin and tear, you can put it on a balloon or on a delicate nerve even in direct contact, and it won't damage it. So what this does is it allows us to work in very small spaces. So instead of having to make an incision that's 10 inches, we can make an incision that's one inch. And instead of having to take out the structure that holds your head up, we can work under it and around it, and if we don't have to remove it, we don't have to rebuild it. So this is an example of a patient with multiple level stenosis, six-level stenosis that had a decompression, that had the spinal canal cleaned out from here all the way down with no fusions. All plastically reshaped, and what that does is it allows us to fix cervical stenosis without compromising structure or mobility. And before surgery, you can see, this is what the neck looks like initially, this is what the neck looks like after surgery. And if you're not really looking close, it almost looks identical. The mobility is good, the ability to return to sports the ability to return to almost normal activities, assuming that the spinal cord is not too severely damaged and advanced is very good. So what this does these newer technologies allow us to do is to intervene earlier because the consequences of the surgery are lesser. So if you're doing an operation that's going to lead to more operations or operation that you're not going to be happy with later because of pain or of loss of mobility, we really wanted to lay it out as much as possible. But if you're doing a procedure that can intervene and fix the stenosis and allow you to get back to a very healthy lifestyle and an active lifestyle and what your lifestyle really, what you want to do, we have the ability to fix these problems earlier. So once again, the traditional techniques where we have to rebuild with screws and rods and fusions what we take out in these two examples, versus the newer technology, where we can actually just plastically rebuild things. Now, this doesn't apply to everybody. We combine mix and match operations, but the goal is to fix something without compromising something else.
Dr. Giuffrida: So I think we have some questions. That was excellent going through everything that causes stenosis, treatment of stenosis. Some of the questions we had come in are, "Can you do anything to prevent stenosis?"
Dr. Cantor: Well, the answer is it's hard, stenosis is mostly a biologic problem associated with bone formation with arthritis. Some people get bad arthritis, some people don't. In the neck, it's hard, in a lumbar spine, sometimes weight control fitness and things like that it's hard to get really fit in your neck. So you really can't prevent the bone growth that causes the stenosis. Now, what you can do is if you have stenosis and your neck is becoming stiff, so a lot of folks we get a little bit older I'm already at the point where my neck is becoming a little bit stiff I'm 59. And I feel that I can't move it as much as I was able to move it before that problem is the bones are starting to grow together, stenosis is forming. I don't really have cervical stenosis, but my bones are expanding. The more you force it, the faster the bone grows. So by doing light mobility up and down, side to side get up in the morning, let the shower run on your shoulders, kind of light motion, but if you're forcing it, you're putting tension on the ligaments, and that tension on the ligaments actually increases the rate of bone growth. Now, manipulations, osteopathic, chiropractic, physical therapy is not good for stenosis. Now chiropractors do a fantastic job, osteopaths, physical therapists do a great job with manipulation, and I have nothing against them. But cervical stenosis with high-velocity manipulations bumps into the cord and could cause severe injuries. Most chiropractors are going to tell you don't manipulate it anyway. So if you have stenosis, forming forced mobility is not good for and can cause it to progress.
Dr. Giuffrida: I think we kind of went over these two, "what are the best treatments for stenosis?" We try conservative stuff; first, we try anti-inflammatories; we try epidurals every now and then, but once the cord is starting to die and you're really starting to get those symptoms of imbalance or trouble using your hands. The only option is to take the pressure off the cord we kind of spoke about that.
"What happens if my stenosis isn't treated?" I mean, the end would be either paralyzed or extreme loss of your mobility. You can have problems with your bowel and bladder where you're not able to hold your water or hold your stool in those are more severe symptoms of cervical stenosis, and the worst would be a paraplegic or quadriplegic if it's high up.
Dr. Cantor: Coming in at the cervical stenosis is the most common cause of quadriplegia in adults. The number one most common cause, but most people that have cervical stenosis don't become paralyzed it's actually quite rare. So what we're trying to do here, we can talk for hours about how the decision process who needs surgery, who doesn't need surgery and who is going to do just fine without treating it. We're developing better and better techniques for being able to identify patients at risk to be able to quantitate how much cord damage there is. In other words, is it likely to be a problem or not? This stuff can't really be discussed in a 30-minute discussion. It really is something that if you want to go into detail, we can do a whole load of those other discussions on how to make decisions on who will get worse and who doesn't. So cervical stenosis is asymptomatic, often doesn't need surgery, cervical stenosis is symptomatic, and progressively worsening untreated, it's a totally different animal. So if you have cervical stenosis is getting worse, you're losing function, you do much better treated than not if you have stenosis and don't have any symptoms, it may not need surgery at all, and that's where the pain management modalities come in. But it really needs to be looked at by somebody who really understands the problem and understands what the risk factors are. And that way, you can work together to come up with smart ideas.
Dr. Giuffrida: Another question we had was, "can you get modic changes in the cervical spine and mostly in the lumbar spine, and do they associate with cervical stenosis?" You can get modic changes in the cervical spine. I don't think there's a direct correlation between modic changes and stenosis. Mostly there's a correlation between modic changes and degeneration of that disc or that joint. So if you're more likely to have stenosis if you have degeneration of that disk or joint like Dr. Cantor talked about, but they can happen in the cervical spine for sure we see them all the time and to be honest, a lot of times patients with modic changes and cervical stenosis say they have extreme neck pain. The neck pain is likely coming from the modic change and not from the stenosis.
Dr. Cantor: A lot of folks out there don't know what a modic change is.
Dr. Giuffrida: That's true, yes.
Dr. Cantor: So I'm trying to find a picture where we actually show an example of it. Doctor G will show us, there's an image of a modic change, so tell, "what is a modic change?"
Dr. Giuffrida: So right here with the modic change, so you have your vertebral body, I'm not as good as you with the drawings. So you have your vertebral body here; you have the disc vertebral body, and this is what normal looks like you have a nice healthy disk, hydrated disk. So then if you delete that, here you can see that the disk is degenerating and what the modic change is is this white fluffiness that goes in the bone and it's actually inflammation going into the bone, and that's what hurts coz there're nerves in the bone and on the endplates of the discs that transmit that pain back to the spinal cord and back to your brain. So you have the modic change here is this associated with stenosis, not all the time because the worst the stenosis in this patient is at these three levels here, no modic changes or inflammation in the actual material body themselves but they have stenosis with disc degenerating. So, two different processes of the disc degenerating, but they can be associated, but one does not cause the other and vice versa.
Dr. Cantor: And what's from a surgical standpoint for fixing this and somebody does have severe evidence of inflammation which you described as modic changes, it may alter what we're going to do surgically. So if you have stenosis and you don't have severe inflamed arthritis, and you don't have severe neck pain, we don't have to address the bad joints. If you have stenosis and you have severe neck pain, then you may have to address those damaged joints, and it's a whole different process of how that's done. And once again, these are not one fits all – there are multiple options, and we mix and match. And we really define what's the best option for each individual.
Dr. Giuffrida: And that's the art of it. That's what we're here to do, we're here to help you. I hope this information of sessions is helpful, gives you some insight into the way we think and the way we take care of patients. We're hoping to do one of these a week for you to write in on the website or on Facebook and tell us what you'd like to hear about. There's plenty of things that we treat, we have a whole list of things we can go over anything you'd like to know just let us know. Thank you, Dr. Cantor, that was great. I was watching and learning a lot, as well. So everyone has a good one out there and stay safe.
Dr. Cantor: Thank you.
Dr. Giuffrida: See you, guys.