Episode 29 - A Pain in the Neck (and Back!): How Technology, Stress, and Genetics are Leading to Aches and Pains With Dr. Sameer Vemuri
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Episode Summary
By the numbers, a solid percentage of you are listening to this 29th episode of Back Talk Doc on your mobile device or in front of your computer. You may be hunched over peeping at the show notes on the screen, a noticeable strain rippling down your back. Whether you’re experiencing back or neck pain as you’re reading these words, this episode is here to help.
On today's episode of Back Talk Doc, our host Dr. Sanjiv Lakhia is accompanied by Dr. Sameer Vemuri, a partner at Carolina Neurosurgery and Spine Associates. Dr. Vemuri works at the Ballantyne and Mathews offices. Board-certified in physical medicine and rehabilitation, Dr. Vermuri received his medical training at the American University of the Caribbean School of Medicine, then went on to intern at Providence Hospital and Medical Center in Michigan. (2:27)
Dr. Lakhia and Dr. Vemuri discuss the burden of spine care in the United States. Both men care for a tremendous number of patients suffering from neck and back pain, with many patients suffering from both. Dr. Vemuri reveals four common factors leading to back pain: (1) genetics, (2) day-to-day stresses, (3) acute injuries, and (4) a big factor both doctors see: the use and overuse of technology devices. (8:59)
"Technology and our phones and our devices has really taken over our life and forced all of us to be looking down constantly and promoting somewhat of a rounded posture." (9:31) Dr. Vemuri explains that these postures place strain on the structural cervical spine in the neck region. "Eventually, you're going to have some changes in the structural anatomy of that spine, and afterwards, you're going to have more chances of irritation of some of these nerves that come through that spinal area." (10:27)
More topics discussed on this episode include:
· Providing patients with realistic expectations during the healing process (23:43)
· The importance of mind-body connections when discussing back and neck pains. (26:36)
· When a headache is more than just a headache: how to know when back and neck problems are leading to headaches. (31:36)
For more information on Dr. Sanjiv Lakhia’s practice, visit BackTalkDoc.com
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.
By the numbers, a solid percentage of you are listening to this 29th episode of Back Talk Doc on your mobile device or in front of your computer. You may be hunched over peeping at the show notes on the screen, a noticeable strain rippling down your back. Whether you’re experiencing back or neck pain as you’re reading these words, this episode is here to help.
On today's episode of Back Talk Doc, our host Dr. Sanjiv Lakhia is accompanied by Dr. Sameer Vemuri, a partner at Carolina Neurosurgery and Spine Associates. Dr. Vemuri works at the Ballantyne and Mathews offices. Board-certified in physical medicine and rehabilitation, Dr. Vermuri received his medical training at the American University of the Caribbean School of Medicine, then went on to intern at Providence Hospital and Medical Center in Michigan. (2:27)
Dr. Lakhia and Dr. Vemuri discuss the burden of spine care in the United States. Both men care for a tremendous number of patients suffering from neck and back pain, with many patients suffering from both. Dr. Vemuri reveals four common factors leading to back pain: (1) genetics, (2) day-to-day stresses, (3) acute injuries, and (4) a big factor both doctors see: the use and overuse of technology devices. (8:59)
"Technology and our phones and our devices has really taken over our life and forced all of us to be looking down constantly and promoting somewhat of a rounded posture." (9:31) Dr. Vemuri explains that these postures place strain on the structural cervical spine in the neck region. "Eventually, you're going to have some changes in the structural anatomy of that spine, and afterwards, you're going to have more chances of irritation of some of these nerves that come through that spinal area." (10:27)
More topics discussed on this episode include:
· Providing patients with realistic expectations during the healing process (23:43)
· The importance of mind-body connections when discussing back and neck pains. (26:36)
· When a headache is more than just a headache: how to know when back and neck problems are leading to headaches. (31:36)
For more information on Dr. Sanjiv Lakhia’s practice, visit BackTalkDoc.com
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.
Intro: 00:00
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Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. 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.
Sanjiv Lakhia: 01:05
Happy New Year to those of you listening today. Thanks for downloading the episode and tuning in to the 29th episode of Back Talk Doc. As you know, our podcast here is all about providing great information in the field of spine care for both clinicians and patients alike. We've really expanded our audience over the last year. We obtained a sponsorship through QXMD. And the podcast just continues to grow. So I want to start the new year with some gratitude for everyone who chooses to take some time and listen to, frankly, what I have to say.
For the most part, I focused on low back pain, but I wanted to start this new year off with a topic that is really related. It's very hard to separate the areas of the spine, because most of my patients who come in with back issues, guess what? They also deal with some neck pain. And many of you listening right now are probably on your device and either looking down or reclining on your chair or on your couch, and you're putting some strain on your neck. So I wanted to dive in today to the topic of neck pain and I couldn't think of anyone better than my friend and partner, Dr. Sameer Vemuri. Sameer, welcome to the show.
Sameer Vemuri: 02:18
Thank you, Sanjiv, for having me today. I'm really honored to be here and be part of this podcast.
Sanjiv Lakhia: 02:23
Great. Now, listeners, let me give you Dr. Vemuri's background. So he's the partner of mine here at Carolina Neurosurgery and Spine Associates and he works out of our Ballantine office and Matthews offices. And these are a couple offices in the suburbs of the Charlotte area. He is board certified in physical medicine and rehabilitation. He did medical school at the American University of the Caribbean, internship at Providence Hospital and Medical Center in Michigan. He did his residency at New England Medical Center, Tufts University, and he has done a fellowship in neuromuscular and electro-diagnostic medicine as well through Tufts.
So he's got a lot of background and has been a practicing physiatrist in our area for quite some time and has a pretty big patient following. And he is my go-to guy, particularly for neck pain and neck injections. Dr. Vemuri does a fantastic job with providing epidural steroid injections to the cervical spine for my patient population, as I'm not trained to do those. And I think he's really well qualified to educate you guys today on how to think about neck pain and understand how we diagnose different structural causes and what the treatment options are. But before we dive into that, Sameer, why don't you go ahead and share with the listeners, those who don't really know much about you, about your path into medicine, physiatry, and spine care in general?
Sameer Vemuri: 03:46
Thank you, Sanjiv. My path started back actually in medical school. I know our field, as you know, not many people really know about our field. It's almost like a hidden gem, I would think, in medicine with physical medicine and rehabilitation. But also, when I was going through medical school, going through my clinicals, I did not know much about physical medicine rehabilitation. All I knew is, I thought, "Hey, it's something to do with sports. It's got something to do with rehab with sports and things like that." And I was very much into athletics, into basketball, running, tennis, these kind of different athletic endeavors to some level. I thought, "Hey, what not a better place to look at and see what it's all about?"
So I ended up doing a rotation while I was out doing my clinicals in Michigan during medical school in physical medicine rehabilitation. And the attending that I had there was real, I mean, inspiration for me to get into the field and then develop my interest from a sports standpoint, but then as you get into the field, you start realizing it's more than just about sports rehab and that is much more vast as far as how you look at the body and the different systems and how we're looking at post-acute care, as well as in our outpatient setting, musculoskeletal care and spine care, as you know, you were talking earlier, we deal a lot with low back pain, but again, the neck is also another area where we have just as many patients that we deal with with neck pain.
This whole field for me started as going into it looking at it from a sports standpoint, but ended up being something I did more as time went on, it evolved into looking at things through a neuromuscular standpoint, as well as into a spine standpoint later on.
Sanjiv Lakhia: 05:38
Yeah, the burden of spine care, spine pain in this country is just enormous. And if you talk to any of our physical therapists, they'll all tell you, the spine is connected. It's in medicine where we do compartmentalize things. If you have eye pain, you see an eye doctor, you have joint pains, ortho doctor, et cetera, but the body's not like that. And as you and I know when you look at biomechanics, most people have low back pain, they're going to have some sort of mechanical setup to add strain to their upper back, neck, and shoulders. So, share with the listeners though, your typical work day as an outpatient physiatrists.
Sameer Vemuri: 06:15
Typically what we're doing just about five days a week, we're seeing new patients and established patients with different musculoskeletal or spine problems. Each day I'm spending a little bit of time in the mornings, as well as early afternoons, doing these electro-diagnostic procedures, what we call electromyography and nerve conduction studies, looking at these different type of conditions that cause numbness, tingling, pain into the extremities. Each also about three to four half days of the week, we're doing these interventional spine procedures, what we call those epidural steroid injections and different types of related procedures. But it keeps us very busy, I'll tell you. From about 07:00, 07:30 in the morning to whenever we're done in the evening.
Sanjiv Lakhia: 07:01
No, absolutely. And if you haven't had a chance to listen to my podcast interview with Dr. Andrea Simmet, she did a really good job, we talked a lot about spinal injections. So we'll put a link to that in the show notes for you guys, if you haven't heard it.
All right, let's get into it, Sameer. Let's talk about neck pain. There's a lot to cover here. Just give people a general sense, if you see 10 patients, what percentage of them might have low back pain versus neck? How prevalent are you seeing neck conditions in our society today?
Sameer Vemuri: 07:31
I probably would say it's probably half and half of my patient population. Half of my patients that come in probably are going to be for back pain. Half of my patients are coming in are going to be for neck pain. Somewhere along the lines there, like you alluded to earlier, a lot of them have both. I mean, if you have issues, whether it's a structural in one area of the spine, you're tending to have issues in other areas of spine, whether it becomes symptomatic or not is the question.
Sanjiv Lakhia: 07:58
Right. Absolutely. Yeah. I think in my clinic, it's probably 60/40. But one of the things that I think, I think there's really been a change in our modern society that has led to an escalated prevalence of neck pain. What are some of the factors that you see predispose patients to developing neck pain?
Sameer Vemuri: 08:18
Well, there's a lot of things that go into neck pain. To me, I look at three different areas. One is actually genetics, I would say, has a large part to play with some of these structural issues, whether it's what we call disc related or what I want to just simply say like, arthritis related. I believe there's a predisposition to that genetically that will promote you to having that a little bit sooner than later throughout life.
Then the second category, I would say, is your day to day stresses, your day to day uses with your body and positions, the posture, the way you're doing things, it's going to lead to some of these neck issues, either slower or faster in certain people versus others.
Then the third category I look at is acute injuries. If you have a traumatic fall or some kind of accident, or even a motor vehicle accident where you have a sudden acceleration deceleration type of situation, you can lead into some of these issues with the neck as well. So when you take all three of those factors together, that's what leads to these neck issues and the timing of these neck issues within your life span.
Sanjiv Lakhia: 09:28
Yeah, no, that makes a lot of sense. In particular, what I was alluding to, I think, is the advent of technology and how technology and our phones and our devices has really taken over our life and forced all of us to be looking down constantly and promoting somewhat of a rounded posture. So that is kind of what we affectionately describe as tech-neck, right? Do you see that? Do you believe in tech-neck?
Sameer Vemuri: 09:56
Oh boy, is that something more and more? I mean, I would like to try to say, I don't believe in it, but I mean, there's no choice but to believe in it as more and more patients that you see. I mean, even when I'm coming into the room, coming to see a patient, what is everyone doing in that time? They're waiting for us to come into the room, they're on their phones. They're down in that, Sanjiv was referring to as that rounded posture where the shoulders are forward, their neck is either flexed forward or is both flexed forward and protruded forward looking at these screens.
These are things that puts more strain on the actual structural cervical spine, the neck region there. And it does over time, it's going to have its impact. Eventually you're going to have some changes in the structural anatomy of that spine, and eventually, you're going to have more chances of irritation of some of these nerves that come through that spinal area. Yeah. That is a definite issue over time that's going to probably become more and more prevalent as the generations go forward.
Sanjiv Lakhia: 10:54
Listeners, I am seeing more and more every day x-ray studies where the curve is backwards in the neck. And some of that, I think, as Dr. Vemuri alluded to is genetic, but I think a lot of that also is postural where you just reverse your curve over time through that type of abnormal posture.
But, I want to back up just a little bit here. When we're talking about neck pain today, we're largely discussing structural causes of neck pain. Now, there are other sources of neck pain. There's medical conditions and things. If someone is listening right now and is having pain in their neck, let's say in the back of their neck and they're kind of rubbing and massaging their neck, what do you think are some aspects of neck pain where someone could be really worried that it's something more than just muscle or joint or what have you? What are your concerning symptoms that you look out for when someone says their neck is hurting?
Sameer Vemuri: 11:47
So, yeah. I mean, we're going to go through life, you're going to have these cricks in your neck, you're going to sleep wrong and you'll get some of this pain that you're like, "Oh," you just shake off, in a day or two it's gone or whatnot. Whereas other times you're going to be having these issues where it may be related with some other symptoms as well. You may have some kind of what we call neurological type changes where you can get some of these numbness, tingling, maybe even pain down into the extremities, start noticing some weakness as well, which is a concerning thing that you would want to follow up with your medical doctor and one of us to look into that further.
The other kind of issues that really are concerning is if you're starting to have any kind of balance issues or even any kind of bowel, bladder function type changes, you want to also keep in the back of your mind that, hey, that could be my neck that's causing it. If there's pressure on the spinal cord, it could actually cause issues with your balance and your gait and also with your bowel, bladder functions. So those are really, really concerning things that you want to really get that looked at much sooner than later.
Sanjiv Lakhia: 12:54
Yeah. And I just want to reiterate that this podcast is really, I'm trying to provide everyone with good information, but this is not... We're not trying to diagnose or treat your problem over a podcast. If you're having signs and symptoms, please go get medical assessment through your regular doctor, or if you live in the greater Charlotte area, look to make an appointment with one of our physiatrists here. But please get things checked out, if you're listening right now and you're thinking to yourself, "Oh no, I may have some of these issues." Definitely get yourself evaluated.
When you mentioned the potential compressive effects of our posture and the tech-neck on the different structures in our neck, can you give people just a brief overview of the main players that we're focused on in terms of pain generators in the neck?
Sameer Vemuri: 13:40
Yeah. So different pain generators that would involve the neck, you got to worry about disc issues as one possibility. We always hear people talking about, "Oh yeah, I got this disc bulge." Or, "I got this disc herniation," or, "I blew out this disc." They're talking about these shock absorbers that are in between the vertebral bodies in the cervical spine that provide basically cushioning for your spine with these compressive type of forces. So these discs, just like you have a tire that can give out and wear out on you, they can give out and then become weak, and then eventually they can bulge or actually open up and the gel-like material within them can seep out.
Now, over time, those things can cause issues with pain in the neck, or if the location of where that disc is either bulging or has opened up and the material is irritating in the spinal canal, you could get issues with the spinal cord itself or the nerves feeding into different regions around the neck, as well as into the upper extremities. Now, when you have those kinds of symptoms, your body, if you're actually irritating a nerve, you will know that. I mean, you will get these symptoms radiating in the pattern of that nerve and from the neck into potentially even the arms.
The other issues that you can also get is related to the more bony structure where you have the joint, just like you have your knees and hips, you have joints in the spine that also can get arthritic change. So when you get some arthritis in the spine, sometimes that manifests as actual spurs, like bone spurs, calcium deposition that can grow into the areas where these nerves run and also cause these type of symptoms that can radiate from the neck into various patterns of these nerves as into the arms as well.
The other issue is, sometimes you just have these areas that are not pressing on the nerves, but they're become symptomatic. You have pain in the neck and then your body and mind is connected in that you have these issues going on in the neck, the brain responds by trying to protect the area. How does it do that? It starts clenching up and tightening these muscles. So it gets into the cycle where, now you have these muscles around the spine that's also, by trying to protect the spine, is actually compressing that spinal area and may be causing more irritation and less mobility of the spine.
So you're getting into a bad cycle, which we'll talk about different types of treatments, like the physical therapy and those kinds of things where you're trying to loosen some of those muscles as breaking that cycle. So, there's a few different areas there that we're touching on that these neck issues can present as where you have these structural things going on, but it manifests as different things, different type of symptoms that you'll see.
Sanjiv Lakhia: 16:23
Yeah. And to me, that's what makes diagnosing neck pain sometimes very difficult. You can have, as you mentioned, those tight muscles can develop trigger points, which can refer symptoms into the shoulder blade or down the arm, mimicking a pinched nerve. And so can facet disease. As you mentioned, the joints, the cervical facets, I'll put a link in the show notes to a diagram that can show people where pain can be referred. So you can have actual pain in your shoulder blade or near your scapula, the origin of it could be a arthritic joint in your neck, or it could be a pinched nerve in your neck. There's a lot of overlap.
So, if you're listening and you've been struggling with it, hang in there and just get professional evaluation. Sometimes it does take a little bit of trial and error to figure things out in terms of where the pain is coming from in the cervical spine. Share with us your little algorithm or your process for how, someone comes in, let's say someone, I don't know, tonight we're recording this podcast and the day of the college football national championship game and let's say, Alabama loses and a fan just gets kind of crazy, is upset and they pick up a couch and throw it. And then they call you tomorrow morning saying, "I got pain on the right side of my neck." Walk the listeners through what your thought process is in your mind, what you're looking out for, and then how you'd evaluate and start to make some recommendations.
Sameer Vemuri: 17:54
Absolutely. I mean, so everything for me, when that first complaint comes in and it's about neck pain and I'm looking at this, I want to get a really, really good thorough history of what has happened before. Has there been any episodes of neck pain in the past? Has there been any kind of neck pain associated with pain or numbness, tingling symptoms going into the arms in the past? What is the duration? How long has this been going on? I mean, in this case, if it's just, there was a specific inciting event and then it was just overnight, that's one thing. Whereas if this has been going on for five years and it's been just chronic, that's a different thing.
Now, then once you get some of these history components, it allows you to tailor what you're going to be doing with some of the diagnostic testing and treatment options. Now, along with that history, you want to get a good, solid physical examination as well to really, for yourself, determine some of the severity is the way I would look at it of these presenting symptoms. If there is, always see us doctors coming in with those hammers, looking at these reflexes, if there's been any irritation of these nerves to a point that the transmission of that nerve impulse is deficient, you may have a decreased deep tendon reflex, it's called, in that pattern.
So those kinds of things give us a lot of information. We can also assess weakness with our physical examination. We can also obviously look at what we were talking about before, the really, really emergent type of situations, if there's been any issues with balance or things like that with looking at how the gait is. And then also, again, going back to the history part of it like bowel and bladder function obviously is critical, but these kinds of things, if we get this detailed history, history and physical examination, will lead us into what we need to do diagnostically.
Usually if it's something simple, like it's just recently, the pain just recently started, it's just in the neck, it hasn't been a long-term thing, there's no other systemic issues or radiating pain, we'll maybe start with just something very simple like a course of physical therapy to work on loosening some of the muscles to see how the patient responds. I look at physical therapy in those type of situations as a good barometer of where the patient is and how they're going to respond. I mean, sometimes I know we want things to be, you come in, you have this problem, you want it to be gone in a second. Sometimes with these issues with the spine, it does take some time and a little bit of trial and error, I would say, on figuring out how intense we need to be with our treatments and how aggressive we need to be. So, starting from a very conservative standpoint, working our way up I feel is the best way, unless there's certain issues that warrant us going quicker and faster, as far as our evaluation and treatment options.
Now, the other things that we would do in this workup, if there were some signs where this was a little bit more, like, let's say it wasn't just the neck pain, but he also presented with neck pain radiating into the arm, I may, at that first visit, also want to get some initial imaging just to make sure we're not missing anything. If there was something traumatic that happened, that we're not missing a fracture or something like that with at least some painful imaging of that neck, cervical spine region. From there, there's also certain type of medications that we will potentially consider, like anti-inflammatory medications, such as your typical non-steroidal anti-inflammatories like Ibuprofen or Aleve, or even something a little bit stronger such as steroids, short course of oral steroids to calm down the inflammation in some of these patients.
So, I mean, there are some treatment options that we can do to help facilitate some of the other treatments as well, like these anti inflammatories. I look at them as facilitators so that you can, sometimes if you're having some pain and you're not otherwise able to do your physical therapy, this will help you get to that point where you can then tolerate the physical therapy. From there, then we'll probably end up, this is over a few weeks' time once we get through some of the physical therapy and see how the responses are, we may consider even further imaging with more detailed scans like MRIs. Even at that point, if there are some radiating symptoms, we may consider at that point what we were talking about earlier about electro-diagnostic testing, where we're checking to see if a nerve is being pinched from the neck, or if there's some kind of overlapping [inaudible 00:22:21] such as carpal tunnel syndrome or ulnar neuropathy.
From there, I guess if you keep going down this pathway, we go to seeing how the response is, if the symptoms are still persistent, and then we have some findings on the MRI that warrant doing more to help facilitate progress with the physical therapy and the home exercises that we're trying to develop. We may, at that point, consider things like the epidural injections in the cervical spine to facilitate. And then even after that, if things aren't getting better, then we're looking at surgical options as almost a last resort if we can wait to that point. Now, if there are certain things that are neurologic changes that are happening that we can not, that may bump up some of these later treatment options higher up in that paradigm.
Sanjiv Lakhia: 23:07
Yeah. That was actually really good and well done. That's almost identical to how I triage patients that come in with neck pain. I think really the take home point there is A, you're absolutely right. You've got to give these problems some time, and B, that initial evaluation is critical and from the physician lens, we are largely on that initial evaluation, we're scanning and screening for bad things, right? We want to make sure nothing really serious is going on. Not that pain isn't serious, but neurologically in particular.
And barring that, I advise patients that I see that it's going to take anywhere from a few weeks to a few months even to get you back on track, particularly if there's a component of an inflamed nerve and pain down the arm. It does tend to take some time. We prescribe a lot of physical therapy. I refer a lot of patients to you for the epidural steroid shot. I find that to be invaluable for people who are struggling with pain and the medication's just not doing enough. What I say is sometimes prescription medication for these pain issues, it's like using a squirt gun to put out a house that's on fire. It's just not enough. So the epidural is invaluable.
Share your thoughts. I mean, I consider you to be basically the expert for the cervical epidurals and you've been doing them for so long. What's been your long-term view on their role in this treatment paradigm?
Sameer Vemuri: 24:33
Yeah. Thank you for saying that. I appreciate that. These cervical epidurals, I mean, it's like you said, I mean when I use these injections, I always like to give patients a good perspective on what to expect from them. I mean, sometimes people are going in there and they don't get that knowledge prior and they think that this is the cure. So they come in there with expectations that, I'm going to have this injection and then I'm going to be fixed. That is the actual not right thing to be thinking. You should understand what you're going to be getting with this injection.
Basically you're putting in a anti-inflammatory steroid into the epidural space in that cervical spine basically to decrease inflammation in that area. So this is not fixing if you have a disc herniation, you're not going to automatically after you have an injection not have a disc herniation. So what it's doing is taking care of some of the inflammatory particles that could be irritating the nerves because of these conditions that are happening in that spine, so that now with that decreased inflammatory state, you're now having a reaction from the body.
I look at it as, now your brain is now going to tell the neck, "Hey. Oh, things are getting a little bit better here. We don't have to clench up these muscles as much." Now, you're going to be able to treat these neck issues from a conservative standpoint with physical therapy, much easier is the hope. So I look at these injections more as a facilitative event to do the more long-term treatments with the physical therapy, your home exercises, what I like to call your spine safe lifestyle as well. I mean, doing the front end work of avoiding bad positions, postures, all those things that we had been talking about a little bit earlier. But when I look at these injections, they're not a cure, but they facilitate the event to help further with your conservative treatment plan with your physical therapy and home exercise routines.
Sanjiv Lakhia: 26:21
Oh, that's awesome. And can I steal that spine safe lifestyle and use that in clinic? That was awesome. I really-
Sameer Vemuri: 26:27
I wanted to trademark that, because I use that in my notes, but I haven't done it, so yeah, yeah.
Sanjiv Lakhia: 26:33
Absolutely.
Sameer Vemuri: 26:33
You can use it the way you want right now.
Sanjiv Lakhia: 26:36
That's exactly correct. If you're listening, a primary care doc or patient, and what I tell patients is, your MRI of your neck will look the exact same after your injection. Even if your pain is gone, it definitely makes a facilitator for healing, it allows you to do better with your posture and what's your therapy. And on some level, I do think, I totally agree, I do think there's a mind-body connection there. And then you turn the switch down on the pain response, and now you're initiating the immune response to help heal the inflammation and heal with the disc pain. Folks, that is an absolutely perfect perspective on epidural steroid injections. So I appreciate you sharing that.
When things aren't going well, though, what are some of the one or two things you start thinking about, "This patient might need surgery?"
Sameer Vemuri: 27:26
Now we're going down that paradigm here. We've tried physical therapy, we've tried injections, we've tried some of these medications, at that point I probably have already gotten some electro-diagnostic testing that's going to give me a little more diagnostic information from a function standpoint. And that's one thing I would like to mention too, is we get all of these structural tests with these x-rays and MRIs and all of this, the imaging, but then the electro-diagnostic testing is actually another way of looking at this information from a functional standpoint.
So when we're looking at this electro-diagnostic testing, it's a functional test of these nerves. So it gives us almost like a second piece to the puzzle from a structural, now a functional standpoint on what's going on from that spine and the related nerves that are fed from the spine out, and let's say from the cervical spine area into the upper extremities.
So with this electro-diagnostic testing, we're testing those nerves based on what we call electromyography, but placing a very small, almost like an acupuncture size needle into various muscles and listening to the electrical activity that's sent from the spinal nerves and into the end point of these muscles. So basically, we're kind of teasing out, is there one level that's affected versus another level with this electro-diagnostic testing, which is functional information, which is completely different from the structural.
So sometimes with an MRI, I mean, as good as those studies are, they may miss a few little, I mean, structurally you may not see something clearly even on the level of an MRI, whereas this gives you another piece of information from a different standpoint, from a functional standpoint to see, is there irritation on a specific nerve root coming from the neck. And also helps us tease out confounding things such as these peripheral entrapment neuropathies like carpal tunnel or ulnar neuropathy that can also result in pain or can also result in numbness and tingling into the upper extremities. So those kind of testing does help significantly in determining, when do we need to go to that later step of actually doing more that's surgical?
Now, if you have like an acute radiculopathy is what we call it on this nerve testing, that's one indicator. If you're going through all of these treatments and you're still having significant, what I would say, not just pain, what you alluded to before, pain is such a big variable is the way I look at it. So, sometimes it can be very emotional, there's so many factors involved with pain that I like to tell patients, "If you're going to make that decision for surgical intervention, you should really try to not just look at your symptoms and pain and all of this, but also how is all of this clinically presenting symptoms affecting your day to day function?"
I like to say, "The objective measure of when you're going to surgery," I mean, this is assuming that you don't have something that... You're having neurological deficits that you absolutely have no choice but to go to surgery, but you've gone through the entire spectrum of conservative treatments and you're still having these symptoms, how is it affecting your function on a day-to-day basis? If your function is compromised to a great degree, that's when you objectively, I would say, are ready for looking at a more definitive treatment option, such as surgical options.
Sanjiv Lakhia: 30:36
Yeah. And what's nice about the EMG as well is you can almost get a prognostic value from that, meaning we can look at these injuries and kind of tell, are they in the acute stage? Are they healing? Is it trying to regenerate? Rule out other things, but there also are scenarios where the EMG is normal, but that doesn't mean you don't have a structural issue in your neck. So I like to say, when I'm talking to patients who come with neck pain, particularly neck pain that's referring down the arm, and we're trying to obtain a clear diagnosis and treatment plan, it's always nice when the history, the MRI, the injection, and the nerve tests are congruent and line up. I like to have at least three of the four, I want them to line up before I even suggest surgery, barring a major surgical emergency, but that's great. That's a great bit of insight into how the EMG comes into play.
So, I think we've covered quite a bit today. That was kind of on my agenda that I wanted to pick your brain and get it out there for people who are struggling with neck pain. The only area or idea that I wanted to get your thoughts on was the correlation in your practice between what you see between neck pain and headaches. Because headaches is a black hole for a lot of patients and practitioners. And when should someone think that their headaches could be coming from their neck?
Sameer Vemuri: 32:07
Sanjiv, you know this as well as I do, it's so common, what we call myofascial headaches because of everything that we've been talking about today, about these cervical spine issues can cause the muscles in that neck to get really tight. And then you can get these referral pain patterns to different areas. One of those areas happens to be the head. You get a lot of these headaches that can be related to this myofascial pain, we call it.
Now, the unfortunate thing is this could also be the same stress, these myofascial headaches could be the same stressors to set off other type of headaches as well, like some of these migrainous headaches can be set off because of these myofascial headaches. These myofascial headaches for sure are very, very common part of my practice with treating neck pain and patients with cervical spine issues. The thing that makes it a little bit hard is, when you're looking at these headaches, then you have patients that also have these issues with migraine headaches and other types of headaches, it can also be a stressor that sets off these other types of headaches as well.
Sanjiv Lakhia: 33:10
Yeah. And what I tell people is, I don't really know for sure if your headaches are coming from your neck as a sole cause, but treating the muscle tension in your neck can be one part of a solution of treating your headache syndrome in general. I wanted to throw that out there that the head and neck are connected, so getting some physical therapy, some massage therapy, some acupuncture, something to treat the myofascial component can help with the healing response there as well.
Sameer Vemuri: 33:39
Can I just mention one thing about that too? And then we're blessed, our physical therapy department, their myofascial release techniques are phenomenal. They have a lot of different things that they do that help with these, really help us tease that out, I would say, because a lot of times I'll send my patients over to physical therapy. They'll do some techniques, especially lately with the dry needling has been so beneficial in helping with this myofascial pain and helping with these headaches and really helping me tease out some of the causes of these headaches, as well as related to some of the muscle tightness in the neck versus something else that's more from the head itself.
Sanjiv Lakhia: 34:16
Yeah. And I did a whole episode deep dive on acupuncture versus dry needling. If you haven't heard that one, please download it, we'll link to that one as well. All right. I want to respect Dr. Vemuri's time. He so graciously has, at last minute kind of jumped on the podcast for an interview today. Let's close a little bit with, you know me, Sameer, I'm always into health and wellness, love sharing with the listeners how the partners in my group try and take care of their mind and their body. Do you have any health habits or your health routine aspects that you want to share with people that you think they could benefit from hearing?
Sameer Vemuri: 34:52
I don't know if they can benefit from hearing any of these things. I mean, my biggest thing has been just trying to stay as active as possible, as physically active as possible while taking care of your body with the stretching. And I mean, a lot of the things that we send our patients to do in physical therapy, I realized, I mean these are the things we need to all be doing in order to stay healthy. So I mean, a lot of my stretching exercises and things I've developed from my knowledge through our own physical therapists. I do those before, I'm pretty active playing tennis and basketball.
So I hate to say, as I'm getting older, my recovery time is getting longer and longer, but I'll tell you doing these pre and post-stretches and exercises from a spine standpoint has helped me as I do deal with a little bit of back and neck pain that if I weren't doing them, I would be playing one day and probably not being able to play again for a couple of weeks. Whereas with these exercises, I'm able to recover quick enough that I can play almost consecutive days now without too much problems.
So, just stretching exercises and doing things daily, I think, is a critical thing. It's not to let things go when, do it when you need to do it, but then let it go for a couple weeks or a month. You got to stay in it daily to really get the benefit and the lasting benefit is what I would advise.
Sanjiv Lakhia: 36:08
Yeah. Consistency is key. And I'd second that. I mean, you know I've been rehabbing my own back issue. I'm the Back Talk Doc and I treat back pain for a living, but that doesn't make me immune. I hurt my back doing a squat and I lost my technique a little bit. It's been two months and I'm doing better. I'm in PT. And so I understand it from both sides of the coin, that's for sure. And these challenges, they happen, and sometimes you do everything right and they happen, but I would encourage listeners out there, don't give up and really, like he said, I think the daily stretching, the consistency is key. So, if you do get hurt, you can bounce back a little sooner than most.
All right, my friend, thank you so much for your time and you continue to stay active and take care of your mind and body and look forward to catching up with you soon.
Sameer Vemuri: 36:56
I will. Thank you so much for having me, Sanjiv, it's been a pleasure.
Outro: 37:01
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
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Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. 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.
Sanjiv Lakhia: 01:05
Happy New Year to those of you listening today. Thanks for downloading the episode and tuning in to the 29th episode of Back Talk Doc. As you know, our podcast here is all about providing great information in the field of spine care for both clinicians and patients alike. We've really expanded our audience over the last year. We obtained a sponsorship through QXMD. And the podcast just continues to grow. So I want to start the new year with some gratitude for everyone who chooses to take some time and listen to, frankly, what I have to say.
For the most part, I focused on low back pain, but I wanted to start this new year off with a topic that is really related. It's very hard to separate the areas of the spine, because most of my patients who come in with back issues, guess what? They also deal with some neck pain. And many of you listening right now are probably on your device and either looking down or reclining on your chair or on your couch, and you're putting some strain on your neck. So I wanted to dive in today to the topic of neck pain and I couldn't think of anyone better than my friend and partner, Dr. Sameer Vemuri. Sameer, welcome to the show.
Sameer Vemuri: 02:18
Thank you, Sanjiv, for having me today. I'm really honored to be here and be part of this podcast.
Sanjiv Lakhia: 02:23
Great. Now, listeners, let me give you Dr. Vemuri's background. So he's the partner of mine here at Carolina Neurosurgery and Spine Associates and he works out of our Ballantine office and Matthews offices. And these are a couple offices in the suburbs of the Charlotte area. He is board certified in physical medicine and rehabilitation. He did medical school at the American University of the Caribbean, internship at Providence Hospital and Medical Center in Michigan. He did his residency at New England Medical Center, Tufts University, and he has done a fellowship in neuromuscular and electro-diagnostic medicine as well through Tufts.
So he's got a lot of background and has been a practicing physiatrist in our area for quite some time and has a pretty big patient following. And he is my go-to guy, particularly for neck pain and neck injections. Dr. Vemuri does a fantastic job with providing epidural steroid injections to the cervical spine for my patient population, as I'm not trained to do those. And I think he's really well qualified to educate you guys today on how to think about neck pain and understand how we diagnose different structural causes and what the treatment options are. But before we dive into that, Sameer, why don't you go ahead and share with the listeners, those who don't really know much about you, about your path into medicine, physiatry, and spine care in general?
Sameer Vemuri: 03:46
Thank you, Sanjiv. My path started back actually in medical school. I know our field, as you know, not many people really know about our field. It's almost like a hidden gem, I would think, in medicine with physical medicine and rehabilitation. But also, when I was going through medical school, going through my clinicals, I did not know much about physical medicine rehabilitation. All I knew is, I thought, "Hey, it's something to do with sports. It's got something to do with rehab with sports and things like that." And I was very much into athletics, into basketball, running, tennis, these kind of different athletic endeavors to some level. I thought, "Hey, what not a better place to look at and see what it's all about?"
So I ended up doing a rotation while I was out doing my clinicals in Michigan during medical school in physical medicine rehabilitation. And the attending that I had there was real, I mean, inspiration for me to get into the field and then develop my interest from a sports standpoint, but then as you get into the field, you start realizing it's more than just about sports rehab and that is much more vast as far as how you look at the body and the different systems and how we're looking at post-acute care, as well as in our outpatient setting, musculoskeletal care and spine care, as you know, you were talking earlier, we deal a lot with low back pain, but again, the neck is also another area where we have just as many patients that we deal with with neck pain.
This whole field for me started as going into it looking at it from a sports standpoint, but ended up being something I did more as time went on, it evolved into looking at things through a neuromuscular standpoint, as well as into a spine standpoint later on.
Sanjiv Lakhia: 05:38
Yeah, the burden of spine care, spine pain in this country is just enormous. And if you talk to any of our physical therapists, they'll all tell you, the spine is connected. It's in medicine where we do compartmentalize things. If you have eye pain, you see an eye doctor, you have joint pains, ortho doctor, et cetera, but the body's not like that. And as you and I know when you look at biomechanics, most people have low back pain, they're going to have some sort of mechanical setup to add strain to their upper back, neck, and shoulders. So, share with the listeners though, your typical work day as an outpatient physiatrists.
Sameer Vemuri: 06:15
Typically what we're doing just about five days a week, we're seeing new patients and established patients with different musculoskeletal or spine problems. Each day I'm spending a little bit of time in the mornings, as well as early afternoons, doing these electro-diagnostic procedures, what we call electromyography and nerve conduction studies, looking at these different type of conditions that cause numbness, tingling, pain into the extremities. Each also about three to four half days of the week, we're doing these interventional spine procedures, what we call those epidural steroid injections and different types of related procedures. But it keeps us very busy, I'll tell you. From about 07:00, 07:30 in the morning to whenever we're done in the evening.
Sanjiv Lakhia: 07:01
No, absolutely. And if you haven't had a chance to listen to my podcast interview with Dr. Andrea Simmet, she did a really good job, we talked a lot about spinal injections. So we'll put a link to that in the show notes for you guys, if you haven't heard it.
All right, let's get into it, Sameer. Let's talk about neck pain. There's a lot to cover here. Just give people a general sense, if you see 10 patients, what percentage of them might have low back pain versus neck? How prevalent are you seeing neck conditions in our society today?
Sameer Vemuri: 07:31
I probably would say it's probably half and half of my patient population. Half of my patients that come in probably are going to be for back pain. Half of my patients are coming in are going to be for neck pain. Somewhere along the lines there, like you alluded to earlier, a lot of them have both. I mean, if you have issues, whether it's a structural in one area of the spine, you're tending to have issues in other areas of spine, whether it becomes symptomatic or not is the question.
Sanjiv Lakhia: 07:58
Right. Absolutely. Yeah. I think in my clinic, it's probably 60/40. But one of the things that I think, I think there's really been a change in our modern society that has led to an escalated prevalence of neck pain. What are some of the factors that you see predispose patients to developing neck pain?
Sameer Vemuri: 08:18
Well, there's a lot of things that go into neck pain. To me, I look at three different areas. One is actually genetics, I would say, has a large part to play with some of these structural issues, whether it's what we call disc related or what I want to just simply say like, arthritis related. I believe there's a predisposition to that genetically that will promote you to having that a little bit sooner than later throughout life.
Then the second category, I would say, is your day to day stresses, your day to day uses with your body and positions, the posture, the way you're doing things, it's going to lead to some of these neck issues, either slower or faster in certain people versus others.
Then the third category I look at is acute injuries. If you have a traumatic fall or some kind of accident, or even a motor vehicle accident where you have a sudden acceleration deceleration type of situation, you can lead into some of these issues with the neck as well. So when you take all three of those factors together, that's what leads to these neck issues and the timing of these neck issues within your life span.
Sanjiv Lakhia: 09:28
Yeah, no, that makes a lot of sense. In particular, what I was alluding to, I think, is the advent of technology and how technology and our phones and our devices has really taken over our life and forced all of us to be looking down constantly and promoting somewhat of a rounded posture. So that is kind of what we affectionately describe as tech-neck, right? Do you see that? Do you believe in tech-neck?
Sameer Vemuri: 09:56
Oh boy, is that something more and more? I mean, I would like to try to say, I don't believe in it, but I mean, there's no choice but to believe in it as more and more patients that you see. I mean, even when I'm coming into the room, coming to see a patient, what is everyone doing in that time? They're waiting for us to come into the room, they're on their phones. They're down in that, Sanjiv was referring to as that rounded posture where the shoulders are forward, their neck is either flexed forward or is both flexed forward and protruded forward looking at these screens.
These are things that puts more strain on the actual structural cervical spine, the neck region there. And it does over time, it's going to have its impact. Eventually you're going to have some changes in the structural anatomy of that spine, and eventually, you're going to have more chances of irritation of some of these nerves that come through that spinal area. Yeah. That is a definite issue over time that's going to probably become more and more prevalent as the generations go forward.
Sanjiv Lakhia: 10:54
Listeners, I am seeing more and more every day x-ray studies where the curve is backwards in the neck. And some of that, I think, as Dr. Vemuri alluded to is genetic, but I think a lot of that also is postural where you just reverse your curve over time through that type of abnormal posture.
But, I want to back up just a little bit here. When we're talking about neck pain today, we're largely discussing structural causes of neck pain. Now, there are other sources of neck pain. There's medical conditions and things. If someone is listening right now and is having pain in their neck, let's say in the back of their neck and they're kind of rubbing and massaging their neck, what do you think are some aspects of neck pain where someone could be really worried that it's something more than just muscle or joint or what have you? What are your concerning symptoms that you look out for when someone says their neck is hurting?
Sameer Vemuri: 11:47
So, yeah. I mean, we're going to go through life, you're going to have these cricks in your neck, you're going to sleep wrong and you'll get some of this pain that you're like, "Oh," you just shake off, in a day or two it's gone or whatnot. Whereas other times you're going to be having these issues where it may be related with some other symptoms as well. You may have some kind of what we call neurological type changes where you can get some of these numbness, tingling, maybe even pain down into the extremities, start noticing some weakness as well, which is a concerning thing that you would want to follow up with your medical doctor and one of us to look into that further.
The other kind of issues that really are concerning is if you're starting to have any kind of balance issues or even any kind of bowel, bladder function type changes, you want to also keep in the back of your mind that, hey, that could be my neck that's causing it. If there's pressure on the spinal cord, it could actually cause issues with your balance and your gait and also with your bowel, bladder functions. So those are really, really concerning things that you want to really get that looked at much sooner than later.
Sanjiv Lakhia: 12:54
Yeah. And I just want to reiterate that this podcast is really, I'm trying to provide everyone with good information, but this is not... We're not trying to diagnose or treat your problem over a podcast. If you're having signs and symptoms, please go get medical assessment through your regular doctor, or if you live in the greater Charlotte area, look to make an appointment with one of our physiatrists here. But please get things checked out, if you're listening right now and you're thinking to yourself, "Oh no, I may have some of these issues." Definitely get yourself evaluated.
When you mentioned the potential compressive effects of our posture and the tech-neck on the different structures in our neck, can you give people just a brief overview of the main players that we're focused on in terms of pain generators in the neck?
Sameer Vemuri: 13:40
Yeah. So different pain generators that would involve the neck, you got to worry about disc issues as one possibility. We always hear people talking about, "Oh yeah, I got this disc bulge." Or, "I got this disc herniation," or, "I blew out this disc." They're talking about these shock absorbers that are in between the vertebral bodies in the cervical spine that provide basically cushioning for your spine with these compressive type of forces. So these discs, just like you have a tire that can give out and wear out on you, they can give out and then become weak, and then eventually they can bulge or actually open up and the gel-like material within them can seep out.
Now, over time, those things can cause issues with pain in the neck, or if the location of where that disc is either bulging or has opened up and the material is irritating in the spinal canal, you could get issues with the spinal cord itself or the nerves feeding into different regions around the neck, as well as into the upper extremities. Now, when you have those kinds of symptoms, your body, if you're actually irritating a nerve, you will know that. I mean, you will get these symptoms radiating in the pattern of that nerve and from the neck into potentially even the arms.
The other issues that you can also get is related to the more bony structure where you have the joint, just like you have your knees and hips, you have joints in the spine that also can get arthritic change. So when you get some arthritis in the spine, sometimes that manifests as actual spurs, like bone spurs, calcium deposition that can grow into the areas where these nerves run and also cause these type of symptoms that can radiate from the neck into various patterns of these nerves as into the arms as well.
The other issue is, sometimes you just have these areas that are not pressing on the nerves, but they're become symptomatic. You have pain in the neck and then your body and mind is connected in that you have these issues going on in the neck, the brain responds by trying to protect the area. How does it do that? It starts clenching up and tightening these muscles. So it gets into the cycle where, now you have these muscles around the spine that's also, by trying to protect the spine, is actually compressing that spinal area and may be causing more irritation and less mobility of the spine.
So you're getting into a bad cycle, which we'll talk about different types of treatments, like the physical therapy and those kinds of things where you're trying to loosen some of those muscles as breaking that cycle. So, there's a few different areas there that we're touching on that these neck issues can present as where you have these structural things going on, but it manifests as different things, different type of symptoms that you'll see.
Sanjiv Lakhia: 16:23
Yeah. And to me, that's what makes diagnosing neck pain sometimes very difficult. You can have, as you mentioned, those tight muscles can develop trigger points, which can refer symptoms into the shoulder blade or down the arm, mimicking a pinched nerve. And so can facet disease. As you mentioned, the joints, the cervical facets, I'll put a link in the show notes to a diagram that can show people where pain can be referred. So you can have actual pain in your shoulder blade or near your scapula, the origin of it could be a arthritic joint in your neck, or it could be a pinched nerve in your neck. There's a lot of overlap.
So, if you're listening and you've been struggling with it, hang in there and just get professional evaluation. Sometimes it does take a little bit of trial and error to figure things out in terms of where the pain is coming from in the cervical spine. Share with us your little algorithm or your process for how, someone comes in, let's say someone, I don't know, tonight we're recording this podcast and the day of the college football national championship game and let's say, Alabama loses and a fan just gets kind of crazy, is upset and they pick up a couch and throw it. And then they call you tomorrow morning saying, "I got pain on the right side of my neck." Walk the listeners through what your thought process is in your mind, what you're looking out for, and then how you'd evaluate and start to make some recommendations.
Sameer Vemuri: 17:54
Absolutely. I mean, so everything for me, when that first complaint comes in and it's about neck pain and I'm looking at this, I want to get a really, really good thorough history of what has happened before. Has there been any episodes of neck pain in the past? Has there been any kind of neck pain associated with pain or numbness, tingling symptoms going into the arms in the past? What is the duration? How long has this been going on? I mean, in this case, if it's just, there was a specific inciting event and then it was just overnight, that's one thing. Whereas if this has been going on for five years and it's been just chronic, that's a different thing.
Now, then once you get some of these history components, it allows you to tailor what you're going to be doing with some of the diagnostic testing and treatment options. Now, along with that history, you want to get a good, solid physical examination as well to really, for yourself, determine some of the severity is the way I would look at it of these presenting symptoms. If there is, always see us doctors coming in with those hammers, looking at these reflexes, if there's been any irritation of these nerves to a point that the transmission of that nerve impulse is deficient, you may have a decreased deep tendon reflex, it's called, in that pattern.
So those kinds of things give us a lot of information. We can also assess weakness with our physical examination. We can also obviously look at what we were talking about before, the really, really emergent type of situations, if there's been any issues with balance or things like that with looking at how the gait is. And then also, again, going back to the history part of it like bowel and bladder function obviously is critical, but these kinds of things, if we get this detailed history, history and physical examination, will lead us into what we need to do diagnostically.
Usually if it's something simple, like it's just recently, the pain just recently started, it's just in the neck, it hasn't been a long-term thing, there's no other systemic issues or radiating pain, we'll maybe start with just something very simple like a course of physical therapy to work on loosening some of the muscles to see how the patient responds. I look at physical therapy in those type of situations as a good barometer of where the patient is and how they're going to respond. I mean, sometimes I know we want things to be, you come in, you have this problem, you want it to be gone in a second. Sometimes with these issues with the spine, it does take some time and a little bit of trial and error, I would say, on figuring out how intense we need to be with our treatments and how aggressive we need to be. So, starting from a very conservative standpoint, working our way up I feel is the best way, unless there's certain issues that warrant us going quicker and faster, as far as our evaluation and treatment options.
Now, the other things that we would do in this workup, if there were some signs where this was a little bit more, like, let's say it wasn't just the neck pain, but he also presented with neck pain radiating into the arm, I may, at that first visit, also want to get some initial imaging just to make sure we're not missing anything. If there was something traumatic that happened, that we're not missing a fracture or something like that with at least some painful imaging of that neck, cervical spine region. From there, there's also certain type of medications that we will potentially consider, like anti-inflammatory medications, such as your typical non-steroidal anti-inflammatories like Ibuprofen or Aleve, or even something a little bit stronger such as steroids, short course of oral steroids to calm down the inflammation in some of these patients.
So, I mean, there are some treatment options that we can do to help facilitate some of the other treatments as well, like these anti inflammatories. I look at them as facilitators so that you can, sometimes if you're having some pain and you're not otherwise able to do your physical therapy, this will help you get to that point where you can then tolerate the physical therapy. From there, then we'll probably end up, this is over a few weeks' time once we get through some of the physical therapy and see how the responses are, we may consider even further imaging with more detailed scans like MRIs. Even at that point, if there are some radiating symptoms, we may consider at that point what we were talking about earlier about electro-diagnostic testing, where we're checking to see if a nerve is being pinched from the neck, or if there's some kind of overlapping [inaudible 00:22:21] such as carpal tunnel syndrome or ulnar neuropathy.
From there, I guess if you keep going down this pathway, we go to seeing how the response is, if the symptoms are still persistent, and then we have some findings on the MRI that warrant doing more to help facilitate progress with the physical therapy and the home exercises that we're trying to develop. We may, at that point, consider things like the epidural injections in the cervical spine to facilitate. And then even after that, if things aren't getting better, then we're looking at surgical options as almost a last resort if we can wait to that point. Now, if there are certain things that are neurologic changes that are happening that we can not, that may bump up some of these later treatment options higher up in that paradigm.
Sanjiv Lakhia: 23:07
Yeah. That was actually really good and well done. That's almost identical to how I triage patients that come in with neck pain. I think really the take home point there is A, you're absolutely right. You've got to give these problems some time, and B, that initial evaluation is critical and from the physician lens, we are largely on that initial evaluation, we're scanning and screening for bad things, right? We want to make sure nothing really serious is going on. Not that pain isn't serious, but neurologically in particular.
And barring that, I advise patients that I see that it's going to take anywhere from a few weeks to a few months even to get you back on track, particularly if there's a component of an inflamed nerve and pain down the arm. It does tend to take some time. We prescribe a lot of physical therapy. I refer a lot of patients to you for the epidural steroid shot. I find that to be invaluable for people who are struggling with pain and the medication's just not doing enough. What I say is sometimes prescription medication for these pain issues, it's like using a squirt gun to put out a house that's on fire. It's just not enough. So the epidural is invaluable.
Share your thoughts. I mean, I consider you to be basically the expert for the cervical epidurals and you've been doing them for so long. What's been your long-term view on their role in this treatment paradigm?
Sameer Vemuri: 24:33
Yeah. Thank you for saying that. I appreciate that. These cervical epidurals, I mean, it's like you said, I mean when I use these injections, I always like to give patients a good perspective on what to expect from them. I mean, sometimes people are going in there and they don't get that knowledge prior and they think that this is the cure. So they come in there with expectations that, I'm going to have this injection and then I'm going to be fixed. That is the actual not right thing to be thinking. You should understand what you're going to be getting with this injection.
Basically you're putting in a anti-inflammatory steroid into the epidural space in that cervical spine basically to decrease inflammation in that area. So this is not fixing if you have a disc herniation, you're not going to automatically after you have an injection not have a disc herniation. So what it's doing is taking care of some of the inflammatory particles that could be irritating the nerves because of these conditions that are happening in that spine, so that now with that decreased inflammatory state, you're now having a reaction from the body.
I look at it as, now your brain is now going to tell the neck, "Hey. Oh, things are getting a little bit better here. We don't have to clench up these muscles as much." Now, you're going to be able to treat these neck issues from a conservative standpoint with physical therapy, much easier is the hope. So I look at these injections more as a facilitative event to do the more long-term treatments with the physical therapy, your home exercises, what I like to call your spine safe lifestyle as well. I mean, doing the front end work of avoiding bad positions, postures, all those things that we had been talking about a little bit earlier. But when I look at these injections, they're not a cure, but they facilitate the event to help further with your conservative treatment plan with your physical therapy and home exercise routines.
Sanjiv Lakhia: 26:21
Oh, that's awesome. And can I steal that spine safe lifestyle and use that in clinic? That was awesome. I really-
Sameer Vemuri: 26:27
I wanted to trademark that, because I use that in my notes, but I haven't done it, so yeah, yeah.
Sanjiv Lakhia: 26:33
Absolutely.
Sameer Vemuri: 26:33
You can use it the way you want right now.
Sanjiv Lakhia: 26:36
That's exactly correct. If you're listening, a primary care doc or patient, and what I tell patients is, your MRI of your neck will look the exact same after your injection. Even if your pain is gone, it definitely makes a facilitator for healing, it allows you to do better with your posture and what's your therapy. And on some level, I do think, I totally agree, I do think there's a mind-body connection there. And then you turn the switch down on the pain response, and now you're initiating the immune response to help heal the inflammation and heal with the disc pain. Folks, that is an absolutely perfect perspective on epidural steroid injections. So I appreciate you sharing that.
When things aren't going well, though, what are some of the one or two things you start thinking about, "This patient might need surgery?"
Sameer Vemuri: 27:26
Now we're going down that paradigm here. We've tried physical therapy, we've tried injections, we've tried some of these medications, at that point I probably have already gotten some electro-diagnostic testing that's going to give me a little more diagnostic information from a function standpoint. And that's one thing I would like to mention too, is we get all of these structural tests with these x-rays and MRIs and all of this, the imaging, but then the electro-diagnostic testing is actually another way of looking at this information from a functional standpoint.
So when we're looking at this electro-diagnostic testing, it's a functional test of these nerves. So it gives us almost like a second piece to the puzzle from a structural, now a functional standpoint on what's going on from that spine and the related nerves that are fed from the spine out, and let's say from the cervical spine area into the upper extremities.
So with this electro-diagnostic testing, we're testing those nerves based on what we call electromyography, but placing a very small, almost like an acupuncture size needle into various muscles and listening to the electrical activity that's sent from the spinal nerves and into the end point of these muscles. So basically, we're kind of teasing out, is there one level that's affected versus another level with this electro-diagnostic testing, which is functional information, which is completely different from the structural.
So sometimes with an MRI, I mean, as good as those studies are, they may miss a few little, I mean, structurally you may not see something clearly even on the level of an MRI, whereas this gives you another piece of information from a different standpoint, from a functional standpoint to see, is there irritation on a specific nerve root coming from the neck. And also helps us tease out confounding things such as these peripheral entrapment neuropathies like carpal tunnel or ulnar neuropathy that can also result in pain or can also result in numbness and tingling into the upper extremities. So those kind of testing does help significantly in determining, when do we need to go to that later step of actually doing more that's surgical?
Now, if you have like an acute radiculopathy is what we call it on this nerve testing, that's one indicator. If you're going through all of these treatments and you're still having significant, what I would say, not just pain, what you alluded to before, pain is such a big variable is the way I look at it. So, sometimes it can be very emotional, there's so many factors involved with pain that I like to tell patients, "If you're going to make that decision for surgical intervention, you should really try to not just look at your symptoms and pain and all of this, but also how is all of this clinically presenting symptoms affecting your day to day function?"
I like to say, "The objective measure of when you're going to surgery," I mean, this is assuming that you don't have something that... You're having neurological deficits that you absolutely have no choice but to go to surgery, but you've gone through the entire spectrum of conservative treatments and you're still having these symptoms, how is it affecting your function on a day-to-day basis? If your function is compromised to a great degree, that's when you objectively, I would say, are ready for looking at a more definitive treatment option, such as surgical options.
Sanjiv Lakhia: 30:36
Yeah. And what's nice about the EMG as well is you can almost get a prognostic value from that, meaning we can look at these injuries and kind of tell, are they in the acute stage? Are they healing? Is it trying to regenerate? Rule out other things, but there also are scenarios where the EMG is normal, but that doesn't mean you don't have a structural issue in your neck. So I like to say, when I'm talking to patients who come with neck pain, particularly neck pain that's referring down the arm, and we're trying to obtain a clear diagnosis and treatment plan, it's always nice when the history, the MRI, the injection, and the nerve tests are congruent and line up. I like to have at least three of the four, I want them to line up before I even suggest surgery, barring a major surgical emergency, but that's great. That's a great bit of insight into how the EMG comes into play.
So, I think we've covered quite a bit today. That was kind of on my agenda that I wanted to pick your brain and get it out there for people who are struggling with neck pain. The only area or idea that I wanted to get your thoughts on was the correlation in your practice between what you see between neck pain and headaches. Because headaches is a black hole for a lot of patients and practitioners. And when should someone think that their headaches could be coming from their neck?
Sameer Vemuri: 32:07
Sanjiv, you know this as well as I do, it's so common, what we call myofascial headaches because of everything that we've been talking about today, about these cervical spine issues can cause the muscles in that neck to get really tight. And then you can get these referral pain patterns to different areas. One of those areas happens to be the head. You get a lot of these headaches that can be related to this myofascial pain, we call it.
Now, the unfortunate thing is this could also be the same stress, these myofascial headaches could be the same stressors to set off other type of headaches as well, like some of these migrainous headaches can be set off because of these myofascial headaches. These myofascial headaches for sure are very, very common part of my practice with treating neck pain and patients with cervical spine issues. The thing that makes it a little bit hard is, when you're looking at these headaches, then you have patients that also have these issues with migraine headaches and other types of headaches, it can also be a stressor that sets off these other types of headaches as well.
Sanjiv Lakhia: 33:10
Yeah. And what I tell people is, I don't really know for sure if your headaches are coming from your neck as a sole cause, but treating the muscle tension in your neck can be one part of a solution of treating your headache syndrome in general. I wanted to throw that out there that the head and neck are connected, so getting some physical therapy, some massage therapy, some acupuncture, something to treat the myofascial component can help with the healing response there as well.
Sameer Vemuri: 33:39
Can I just mention one thing about that too? And then we're blessed, our physical therapy department, their myofascial release techniques are phenomenal. They have a lot of different things that they do that help with these, really help us tease that out, I would say, because a lot of times I'll send my patients over to physical therapy. They'll do some techniques, especially lately with the dry needling has been so beneficial in helping with this myofascial pain and helping with these headaches and really helping me tease out some of the causes of these headaches, as well as related to some of the muscle tightness in the neck versus something else that's more from the head itself.
Sanjiv Lakhia: 34:16
Yeah. And I did a whole episode deep dive on acupuncture versus dry needling. If you haven't heard that one, please download it, we'll link to that one as well. All right. I want to respect Dr. Vemuri's time. He so graciously has, at last minute kind of jumped on the podcast for an interview today. Let's close a little bit with, you know me, Sameer, I'm always into health and wellness, love sharing with the listeners how the partners in my group try and take care of their mind and their body. Do you have any health habits or your health routine aspects that you want to share with people that you think they could benefit from hearing?
Sameer Vemuri: 34:52
I don't know if they can benefit from hearing any of these things. I mean, my biggest thing has been just trying to stay as active as possible, as physically active as possible while taking care of your body with the stretching. And I mean, a lot of the things that we send our patients to do in physical therapy, I realized, I mean these are the things we need to all be doing in order to stay healthy. So I mean, a lot of my stretching exercises and things I've developed from my knowledge through our own physical therapists. I do those before, I'm pretty active playing tennis and basketball.
So I hate to say, as I'm getting older, my recovery time is getting longer and longer, but I'll tell you doing these pre and post-stretches and exercises from a spine standpoint has helped me as I do deal with a little bit of back and neck pain that if I weren't doing them, I would be playing one day and probably not being able to play again for a couple of weeks. Whereas with these exercises, I'm able to recover quick enough that I can play almost consecutive days now without too much problems.
So, just stretching exercises and doing things daily, I think, is a critical thing. It's not to let things go when, do it when you need to do it, but then let it go for a couple weeks or a month. You got to stay in it daily to really get the benefit and the lasting benefit is what I would advise.
Sanjiv Lakhia: 36:08
Yeah. Consistency is key. And I'd second that. I mean, you know I've been rehabbing my own back issue. I'm the Back Talk Doc and I treat back pain for a living, but that doesn't make me immune. I hurt my back doing a squat and I lost my technique a little bit. It's been two months and I'm doing better. I'm in PT. And so I understand it from both sides of the coin, that's for sure. And these challenges, they happen, and sometimes you do everything right and they happen, but I would encourage listeners out there, don't give up and really, like he said, I think the daily stretching, the consistency is key. So, if you do get hurt, you can bounce back a little sooner than most.
All right, my friend, thank you so much for your time and you continue to stay active and take care of your mind and body and look forward to catching up with you soon.
Sameer Vemuri: 36:56
I will. Thank you so much for having me, Sanjiv, it's been a pleasure.
Outro: 37:01
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.