Episode 73 - Empathy and Compassion: The Journey from Spine Patient to Provider with Physician Assistant Lindsay Howard
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Episode Summary
What happens when the doctor becomes the patient? In the first episode in this new series, Dr. Sanjiv Lakhia discusses personal back care journeys with some of his esteemed colleagues.
On this episode, he talks with Lindsey Howard, PA-C, a physician assistant in the physiatry department at Carolina Neurosurgery and Spine Care. Her spine care journey began with scoliosis.
When she was 12, she was diagnosed with scoliosis during a routine school screening for the condition. Her spinal curve was 40 degrees and quickly progressed to 72 degrees. Her doctor recommended surgery or, he told her parents, she likely wouldn’t live past age 30.
She hadn’t experienced much pain, only discomfort, from her scoliosis, but she remembers some of her post-op pain clearly. It’s helped her become more empathetic with patients.
“The resident was trying to peel off the bandage on my back — that was very painful,” she said. “So now when I remove bandages, I'm very, very sensitive to that for patients.”
Thankfully, surgery allowed her to get back to a sporty lifestyle and allowed her to be a cheerleader in high school. And the experience as a whole inspired her to work in medicine.
Originally, her plan was to go to medical school, with the goal of helping other girls who suffered from similar issues. But she ended up becoming a physician assistant because she liked to spend more time with patients in their care transitions.
Tune in to this episode of Back Talk Doc to hear more of Lindsey’s story with scoliosis and how she uses that difficult experience to be a better care provider today.
Featured Expert
Name: Lindsey Howard, MPAS, PA-C
What she does: Lindsey has been a physician assistant with Carolina Neurosurgery and Spine Associates since she graduated in 2013. She works in the physiatry department with Drs. Wiercisiewski and Sumich.
Company: Carolina Neurosurgery & Spine Associates (CNSA)
Words of wisdom: “The main reason I got into this is because I don't want anybody to ever feel [alone]. I think whenever you go through a major illness or any major medical issue, you can sometimes feel really alone.”
Connect: Website | LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Traumatic experiences can make for a better provider. While Lindsey didn’t experience pain in her scoliosis and its surgical correction, she says the whole episode was traumatic. She uses the insights from her own experience as a patient to inform how she treats patients.
Sometimes surgery is necessary. Dr. Lakhia often talks about alternative solutions to surgery, but in some cases, surgery is the best option for an improved quality of life. Lindsey’s parents were told she wouldn’t live past age 30 if she didn’t get her scoliosis corrected. Her surgery was successful and she was able to live an active life afterward.
You are not alone. Having spinal issues or any major medical diagnosis can feel isolating. Many patients experience similar struggles. Both Lindsey and Dr. Lakhia point out that as your providers, they are there to go through the process with you.
Episode Insights
[01:46] Meet Lindsey Howard: Dr. Lakhia introduces Lindsey Howard, PA-C, a physician assistant for the physiatry department. Diagnosed with scoliosis at age 12, she’s had her own journey with spine care.
[04:30] “She won’t make it past 30”: After an unsuccessful few months of bracing, Lindsey’s doctor recommended surgery. Without it, the doctor said her lifespan could be cut tragically short.
[07:16] Trauma motivates a career: Lindsey acknowledges that her scoliosis surgery and recovery was traumatic. She chose to become a PA to help girls like herself with scoliosis.
[09:56] Relating to patients: While Lindsey never had pain from her scoliosis, she remembers certain painful aspects of the surgical process. Now she uses that experience to be gentler with her own patients.
[11:11] Other episodes: Dr. Lakhia has done two other episodes of Back Talk Doc where he covers scoliosis, one with Dr. Michael Bohl and one with Dr. Matt McGirt.
[14:59] Lindsey’s scoliosis today: Lindsey had a successful surgical correction for her scoliosis, but now at age 35, she’s needed some further care. She’s able to recommend things to patients from personal experience.
[16:47] Don’t run: For spine problems, Lindsey does not recommend running. If a certain form of exercising causes flare-ups, see if you can find something equally enjoyable.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Talking Artificial Disc and Facet Replacement Surgery with Dr. Vince Rossi.
Enroll in Dr. Lakhia’s 6 week course to lower inflammation.
Apply for an Integrative Medicine consult with Dr. Lakhia (NC/SC residents only).
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Check us out on the 15 Best Back Pain Podcasts list!
Subscribe in your favorite podcast app.
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.
What happens when the doctor becomes the patient? In the first episode in this new series, Dr. Sanjiv Lakhia discusses personal back care journeys with some of his esteemed colleagues.
On this episode, he talks with Lindsey Howard, PA-C, a physician assistant in the physiatry department at Carolina Neurosurgery and Spine Care. Her spine care journey began with scoliosis.
When she was 12, she was diagnosed with scoliosis during a routine school screening for the condition. Her spinal curve was 40 degrees and quickly progressed to 72 degrees. Her doctor recommended surgery or, he told her parents, she likely wouldn’t live past age 30.
She hadn’t experienced much pain, only discomfort, from her scoliosis, but she remembers some of her post-op pain clearly. It’s helped her become more empathetic with patients.
“The resident was trying to peel off the bandage on my back — that was very painful,” she said. “So now when I remove bandages, I'm very, very sensitive to that for patients.”
Thankfully, surgery allowed her to get back to a sporty lifestyle and allowed her to be a cheerleader in high school. And the experience as a whole inspired her to work in medicine.
Originally, her plan was to go to medical school, with the goal of helping other girls who suffered from similar issues. But she ended up becoming a physician assistant because she liked to spend more time with patients in their care transitions.
Tune in to this episode of Back Talk Doc to hear more of Lindsey’s story with scoliosis and how she uses that difficult experience to be a better care provider today.
Featured Expert
Name: Lindsey Howard, MPAS, PA-C
What she does: Lindsey has been a physician assistant with Carolina Neurosurgery and Spine Associates since she graduated in 2013. She works in the physiatry department with Drs. Wiercisiewski and Sumich.
Company: Carolina Neurosurgery & Spine Associates (CNSA)
Words of wisdom: “The main reason I got into this is because I don't want anybody to ever feel [alone]. I think whenever you go through a major illness or any major medical issue, you can sometimes feel really alone.”
Connect: Website | LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Traumatic experiences can make for a better provider. While Lindsey didn’t experience pain in her scoliosis and its surgical correction, she says the whole episode was traumatic. She uses the insights from her own experience as a patient to inform how she treats patients.
Sometimes surgery is necessary. Dr. Lakhia often talks about alternative solutions to surgery, but in some cases, surgery is the best option for an improved quality of life. Lindsey’s parents were told she wouldn’t live past age 30 if she didn’t get her scoliosis corrected. Her surgery was successful and she was able to live an active life afterward.
You are not alone. Having spinal issues or any major medical diagnosis can feel isolating. Many patients experience similar struggles. Both Lindsey and Dr. Lakhia point out that as your providers, they are there to go through the process with you.
Episode Insights
[01:46] Meet Lindsey Howard: Dr. Lakhia introduces Lindsey Howard, PA-C, a physician assistant for the physiatry department. Diagnosed with scoliosis at age 12, she’s had her own journey with spine care.
[04:30] “She won’t make it past 30”: After an unsuccessful few months of bracing, Lindsey’s doctor recommended surgery. Without it, the doctor said her lifespan could be cut tragically short.
[07:16] Trauma motivates a career: Lindsey acknowledges that her scoliosis surgery and recovery was traumatic. She chose to become a PA to help girls like herself with scoliosis.
[09:56] Relating to patients: While Lindsey never had pain from her scoliosis, she remembers certain painful aspects of the surgical process. Now she uses that experience to be gentler with her own patients.
[11:11] Other episodes: Dr. Lakhia has done two other episodes of Back Talk Doc where he covers scoliosis, one with Dr. Michael Bohl and one with Dr. Matt McGirt.
[14:59] Lindsey’s scoliosis today: Lindsey had a successful surgical correction for her scoliosis, but now at age 35, she’s needed some further care. She’s able to recommend things to patients from personal experience.
[16:47] Don’t run: For spine problems, Lindsey does not recommend running. If a certain form of exercising causes flare-ups, see if you can find something equally enjoyable.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Talking Artificial Disc and Facet Replacement Surgery with Dr. Vince Rossi.
Enroll in Dr. Lakhia’s 6 week course to lower inflammation.
Apply for an Integrative Medicine consult with Dr. Lakhia (NC/SC residents only).
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Check us out on the 15 Best Back Pain Podcasts list!
Subscribe in your favorite podcast app.
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.
Voice Over (00:01):
Welcome. You are listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your back talk doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia (00:39):
Welcome friends to another episode of Back Talk Doc. Over the last year, I've really tried to bring a ton of information from many different angles about treatments for spine care and injuries, and I've often found though there's no substitute for a good story. And I've been searching, trying to find out what would be a good testimonial to bring to you guys because I know you're all listing there trying to figure out ways to help your back pain and improve your life, and I've been real fortunate. In the next month or so, we're going to do a couple episodes with some of my colleagues at Carolina Neurosurgery & Spine Associates who have I would call the privilege of actually been through... having gone through the process of taking care of their back as a patient and now their providers. And I think it's a unique perspective. And today we're going to kick it off welcoming Lindsey Howard to the show. Lindsey, welcome to the show.
Lindsey Howard (01:32):
Hello. Thank you for having me.
Sanjiv Lakhia (01:34):
Now Lindsey is a physician assistant with our practice, and I know you're a graduate of Clemson, correct?
Lindsey Howard (01:40):
Yes, 2010. Go Tigers.
Sanjiv Lakhia (01:42):
Awesome. And where did you do your training for your PA?
Lindsey Howard (01:46):
So I'm originally from Rhode Island, so I ended up, my dad came down to South Carolina when I was 15, so I finished high school down here, went to college and then I actually went back up north to a school called Mass College of Pharmacy in Boston, and I did their three-year PA program. And then after that, I came back down here and got the job at Carolina Neurosurgery and I've been there ever since.
Sanjiv Lakhia (02:10):
And tell folks where do you work in the practice and who do you typically work with? What's your typical workday?
Lindsey Howard (02:16):
Yeah, so I work in the physiatry department with you guys. I work with Dr. W., Dr. Wiercisiewski and Dr. Sumich. And I feel very, very lucky. I think you're an amazing doctor too, but I feel really privileged to be able to work with those two guys. They're so kind and they're so nice and they're so helpful. That's all you can ask for being a PA. You want your collaborating physician to be somebody that you can go to without having any anxiety, and so they're super sweet. So I work with Dr. W. in the pediatric concussion program and then obviously doing all the outpatient spine care that we do. So new patient spine and follow-ups, evals, all that kind of thing.
Sanjiv Lakhia (02:56):
I would agree. Actually, Dr. Sumich and Dr. W. are probably the reason I'm here. Well, Wiercisiewski would like to say he trained me and that's true. He was one of my attendings in residency and then Dr. Sumich was a year ahead of me in residency, so they were a big draw for me to come back to Charlotte and I would echo your sentiments. Now, you reached out to me really with an idea that you wanted to tell your story to people who are interested and who are struggling with their own back issues. And I know you've had a journey dealing with scoliosis, so I'll let you kick that off. Kind of take us through how it all started for you and walk us through the journey you've been on over the course of your life with your back.
Lindsey Howard (03:38):
Yeah, so it's really kind of been my whole life. So back when I was in sixth grade, I did one of those school screenings and that's where they picked up that I had scoliosis and those school screenings, it's kind of like a positive-negative relationship. I think it was great, but also when you're 11 or 12 years old to be singled out, that was a little like, "Oh gosh, this is pretty scary." So they picked it up at just a run-of-the-mill school screening. And then I saw my primary and he referred me to orthopedics. They did the bracing thing for about I think three months or so. From what I remember, the orthopedic surgeon at the time, I think my curve was a little north of 40 degrees, I could be wrong, but she basically was like, "We're going to try the brace, see if it works. If it doesn't work, we're going to refer you to this other guy, Dr. Michael Ehrlich for the surgery."
(04:30):
So I did the brace for a few months and I never really had any pain. I think probably the biggest thing for me at that time was the fact that I was 12 and I had to wear a brace and I had to sit out a gym class and those kinds of things. There was no pain involved, just kind of social pain I guess you could call it. And so the bracing obviously didn't work. And so she referred us to Michael Ehrlich and he was just another orthopedic surgeon in the Providence Rhode Island area. And he did probably one of the most thorough physical exams I've ever had in my entire life, like a Dr. Petty exam times a million. And so he looked at me and he just basically recommended surgery.
(05:12):
I think my curve had progressed by the time I had seen him. I'm not sure what it was by that time, but I do know that he said to my parents, "If you don't do this, of course there's always the option not to do surgery, but if you don't do this, she likely won't make it past 30 years old." And those words kind of stuck out to me, and I never really thought about those actually until I started getting older into my twenties and started working at CNSA and all that kind of thing. So then I went through the surgery and that whole process, there's a lot... I can delve into it a lot deeper, but that whole process of not just having the surgery but the things I had to do before the surgery, the being at the hospital after the surgery, it was a lot.
(05:56):
It was traumatic. And I think a lot of kids just, especially at 12 years old, you kind of just stay really quiet and you internalize a lot. You don't really say what's going on in your head. And I certainly was one of those kids. And so I'll be honest, after I had that surgery and everything kind of got cleared, it did really cause a little bit of PTSD and a little bit of, I had a hard time falling asleep. It was a trauma. And so when I was trying to figure out what I wanted to do and go through high school and college and all of that, I had originally decided to go to college because I was like, "I'm going to go to medical school. That's what I'm going to do. I want to help girls like me. That's it, period." And so I actually ended up majoring in food science and human nutrition because I wanted something a little bit different than your typical biology and chemistry and all of that.
(06:47):
So I mean, I had my eye on the prize, I was volunteering at the hospitals, I was working, I was doing all the extracurriculars, I was getting everything all set up to go to medical school. And then I think it was my junior year in college when I had to sit and take the MCAT and I was like, "I don't know if I want to be a surgeon. I thought it was cool. I definitely had some times where I got to shadow in the OR," and it was definitely amazing. Don't get me wrong, that was great, but it just didn't feel like it clicked with me.
(07:16):
And so I actually sat down with a family friend, Navin Bhojwani, he's a OB-GYN here in Charlotte, and he sat me down. We just had a long conversation and he was like, "So what is it that you want to do?" And I'm a very analytical person, almost to a fault. So I really took that question and tried to dive deep and figure out the root like what is it that I want to do? And all I really wanted to do was help those kids that are going to have to go through what I went through because when I was in the hospital, and rightfully so, it is a lot of work. I saw the surgeon, I think once. The residents were exhausted and burnt out and they were just obviously doing their thing, same thing with the nurses and the kindest person to me when I was in the hospital was the orderly.
(08:09):
He took the time to sit down and talk to me. And I just remember actually the relief that he gave to me just talking to me about what was going on on a day-to-day basis, and nobody had taken the time to do that. And that relief was something that I treasured and I remember obviously to this day. And so I was like, "There needs to be a role. There needs to be... obviously people are stressed out in the healthcare system, there needs to be somebody else there to help get these surgical patients from point A to point B." I mean the way we have it obviously isn't enough. And then I learned about the role of a PA and I didn't choose to do anything for the glitz or the glamour or whatever. I really just felt like there needed to be a role in the hospital for these surgical patients before and after. And I do still strongly feel that being a PA is a great way to kind of fill that hole.
Sanjiv Lakhia (09:00):
Okay. Let's pause right there. A lot of stuff I want to unpack a little bit for you. That was really good synopsis of how your life's unfolded. I'm going to return back to when you were younger, just contemplating being 12 years old, were you having symptoms or was this just a matter of the screen led to the evaluation? How were you handling the scoliosis? How did it impact your life?
Lindsey Howard (09:25):
So I actually did not have any pain. It was just picked up through the screening and then the curve eventually progressed to 72 degrees before surgery and I was 12 at the time. And so I had a little difficulty. I don't think I ever told my parents this or anything. I didn't have pain, but I had a little difficulty taking a deep breath and it would lead to coughing sometimes. But outside of that, like I said, I really didn't have any pain, even postoperatively.
(09:56):
I remember one time in the hospital now I remember being anxious and being like, "I don't want to feel pain," so I would preemptively hit that PCA button. I do remember doing that. But then even after when I was up on the floor, there was only one time that I really remember feeling like this excruciating pain. And then the other time was when the resident was trying to peel off the bandage on my back. That was very painful. So now when I actually remove bandages, I'm very, very sensitive to that for patients. I remember he was pulling that off and I was just like, I started screaming that stuff is on there tight and it was very painful. And the resident just looked at me and he was just like, "What do you want me to do? You want me to just leave it on there?" And I was like, "Okay. All right."
Sanjiv Lakhia (10:37):
What you're describing and people are hearing are the little things that our patients go through that make all the difference that sometimes when you're on the side of providing the healthcare, you don't pay attention to. And for you it's been a great teacher, you've kept those memories with you and experiences with you and applied them to the people you serve. I think with the scoliosis and not having pain, someone may be wondering then, "Well, why were you told you have to have this procedure done?" And we've done some episodes and we'll link to those in the show notes guys where I interviewed Dr. Bohl and I've done one with Dr. McGirt where we've really done deep dives into scoliosis and what's the definition and how was it treated, but what were you told that you can remember as a very young child, how was it described to you that you needed to have this done?
Lindsey Howard (11:33):
So Dr. Ehrlich, I remember him saying that I needed to have it done because like I said, at the time my curve was 72 degrees, so it was very large and it was already starting to rotate a little bit. So my ribs were essentially going to crush along and create an issue later on in life if I didn't get this fixed. Especially since he didn't go into that much detail. I'm ad libbing that. He basically told my parents, "If you guys don't do this, there's a high likelihood she won't make it past 30 years old." He might've gone into more detail about the anatomy changes and the science behind it. I just don't remember that part.
Sanjiv Lakhia (12:13):
Well, I think 30,000 foot view, if someone's wondering that degree of curvature will definitely have an effect on the organ systems of the body. And what Lindsey's describing is the effect on her vital capacity, her ability to take a deep breath. And most patients who come to see us with scoliosis, they go through that process you described particularly in their youth. And as Dr. Bohl had explained on a previous episode, you want a brace during the growth spurt during the adolescent age and that can sometimes stave off progression of curvature. But for you, I feel like the timing it sounds like in retrospect was almost perfect that you were able to get involved with healthcare and get the care of a surgeon and get this thing corrected when you're younger in life before it became even more problematic. So get back into the postoperative phase if you can recall. How was that that first three months after such a major surgery? You said you had a T4 to L4 fusion.
Lindsey Howard (13:09):
Yeah, so postoperatively, so I had an NG tube. I remember that because I remember I was coughing up blood. It's the funny, it's the weirdest things you remember, but I remember that the hospital course was uncomplicated. I talk like a PA now even though this is not how I thought when I was 12, the hospital course was uncomplicated. I was in the ICU for a day and then up on the floor until the following Saturday, I think.
Sanjiv Lakhia (13:35):
You had physical therapy then afterwards?
Lindsey Howard (13:37):
Yeah, I had PT, I had all those things. I was up walking around. Again, I don't know if it's because I was 12 if I compartmentalized it, which I bet I did. And I feel like people who are older probably do too. You kind of go through this fight or flight, you're kind of like, "Okay, I need to do this, so I'm just going to get up and we're just going to keep rolling here and see what happens." So then I was out of school for a month and then going to physical therapy, obviously doing the PT. My mom was religious about me doing the toe taps. So I've been doing toe taps ever since I was 12. And then back then I actually had to, not only did you have the post-op pain meds and the muscle relaxers, but I had to get a blood transfusion and they don't do this anymore obviously, but I had to drink liquid iron because I couldn't take pills.
(14:20):
I remember that. That was not fun. That was pretty nasty. And then the curve, it got corrected. I don't remember how well it was corrected to. Dr. Bohl might be able to tell you more because he's actually seen my films, but I think it's a pretty well done correction. And then I went through after that I did really well. So I actually ended up becoming a cheerleader. I was really active in high school. I really, again, did not have much in the way of pain in terms of people, I always hear them talk about range of motion and they're scared of losing range of motion.
(14:51):
And I'm lucky because this all happened to me when I was 12, so I don't remember anything different. But now I'm 35 now I've started to have some issues and thankfully I've been working with Dr. Plummer and so I'm starting to find different ways and different things to help manage it. That I think is really helpful when I talk to patients because I can be like, "I've used this cushion before for your car, it's amazing, trust me. Use it," and it's actually not just some ad hoc thing.
Sanjiv Lakhia (15:23):
I think it's great to share that you were able to get through that and then you were still able to have and currently do have a very active adolescence and then into sports. That's a good point to illustrate that you can come out the other side of these surgeries and live a high quality life. Wouldn't you agree?
Lindsey Howard (15:41):
Oh, 100%. Absolutely.
Sanjiv Lakhia (15:44):
Because Lindsey, the biggest thing I encounter in my practice and just getting feedback from people is there's a lot of fear about spine surgery. It's justified, but sometimes seeing a good surgeon right place, right time, it's really what you need. As much as I who myself am a big advocate for conservative, integrative, holistic spine care, I also know when it's time to call, pick up the bat phone and call someone who can really fix these problems.
Lindsey Howard (16:12):
Oh yeah.
Sanjiv Lakhia (16:12):
So I think if anyone's listening, a major take home point from what she's sharing is that yes, it was tough. Even some of the stuff she just shared was... kind of made me cringe a little bit hearing the postoperative course and these things that you remember as a patient, but you got your life back, preserved a whole lot of function, high quality of life. And it's not as if though you never had the issue, it's something you're going to have to manage your back your whole life. And you're going through some of that right now. What do you think are some lessons that you learned as a patient that you now apply as a physician assistant or healthcare provider?
Lindsey Howard (16:47):
That's a great question. I have so many and there's probably going to be so many different people are like, "Oh, I don't agree with what she said," but I would say, don't run. So that was probably, I wish somebody had told me that.
Sanjiv Lakhia (17:01):
Wait a second. You see Dr. Plummer in our practice and she runs like-
Lindsey Howard (17:05):
I know.
Sanjiv Lakhia (17:06):
Three marathons in a week though. That's pretty funny. But go ahead. Sorry, I didn't mean to cut you off.
Lindsey Howard (17:11):
Well, okay. But she is awesome. So if I have somebody like I had a 20... I had a younger person the other day who obviously has a genetic predisposition to not having a great spine and every time she would run, it would flare up. And so I actually got into running when I was like 25, 26. And it was great and I loved it. But I just feel like from my personal history and granted my history is going to be a lot different than somebody with just a simple degenerative disc. I get it.
Sanjiv Lakhia (17:37):
For sure.
Lindsey Howard (17:38):
But I feel like if you can find a way to be physically fit that you enjoy that is not something that has been your diehard for your whole life and it can give you the same pleasure as going for a run, I say go for it.
Sanjiv Lakhia (17:51):
So what do you do? What do you like to do?
Lindsey Howard (17:54):
I do Pilates. I'm a huge Pilates fan. I go to Iron Butterfly in the south end. That has probably been that and yoga are probably the two main things. And walking on an incline, I'm a big fan of that.
Sanjiv Lakhia (18:05):
Okay. Why the incline? Why specifically?
Lindsey Howard (18:08):
I feel like I can get some good core stability with that. So I feel like I'm not just plain old walking. I can get core stability. I can get my glutes activated, so it's a little bit more intense than just walking flat. And also I do enjoy getting my heart rate elevated, so going on a treadmill and putting on the incline can give me the same cardiovascular workout as if I were to go for a run.
Sanjiv Lakhia (18:31):
All right, so that's a great life lesson. What else do you have to share?
Lindsey Howard (18:35):
SI support belts work. They really work. I love them. I wear one around the house. I think it's great. I don't wear one out because they're not super cute yet. Another life lesson I would say is be patient and be kind with yourself, especially if you're younger and you have these issues, even if you're not younger and if you're older, because sometimes I hear the frustration in patients' voices. And so that's one thing for me that I've tried to really learn and hone in over the last year is just being patient. Be kind to yourself. You don't need to go from zero to 60 like it's okay to slow down your workout to maybe gain some muscle in another group that you really haven't worked on for years. It's about being fit for your whole life, not just fit for right now. And so I use that a lot with my patients.
Sanjiv Lakhia (19:28):
I like that. Definitely like that. I would also add, especially as I get older, I'm becoming more a fan of intuitive exercise than following a rigid structure weekly plan.
Lindsey Howard (19:39):
100%. Yeah.
Sanjiv Lakhia (19:41):
Some days if I wake up and all my schedule was I was going to do exercises X, Y, and Z, but I might feel a little tightness in my hip today or feel something different and I feel like a different exercise would serve me better. I've learned that that's okay. It's really not a race. I like what you said there about planning your movement strategies serve you now, but also I think that's critical. It's very easy when you're much younger to feel pretty invincible. And I know I went through that phase as well. But over time for all of us, you're going to be reminded that your body changes and your capacity to heal changes. And particularly when you're dealing with spine issues, I think sometimes less is more. And underestimating recovery time is something that I observe quite often for people.
(20:28):
Though and our body heals only when we're getting good deep sleep, our muscles hypertrophy and grow on our rest days from our workout days. So if you're out there, I don't know that you need to be really exercising seven days a week, or if you are and you're not seeing dividends or you're seeing increased injuries, think about that. Think about sprinkling in some recovery time. So that's a great life lesson. What else do you want to share that you learned going through this as a patient that you feel like you pass along to your patients now?
Lindsey Howard (21:05):
I feel like those are probably the main kind of bullet points. I guess the last little tidbit, I would say again, the main reason I got into this is because I don't want anybody to ever feel, I think whenever you go through a major illness, this isn't really an illness per se, but any major medical issue you can sometimes feel really alone. I had a patient today who was like, "I just feel like I'm the only one dealing with this and I'm the only one going through all of this." And just to remind them and that's usually when I bring up my story and I'm like, "Just to remind you, you are not alone. There's tons of people in this world who are going to go through similar situations, your providers included, we're right there with you. You may be driving the car, but we're going to be right in the front seat with you helping you."
(21:50):
So I think just trying to let them know that they're not the only ones that are going through this, there is a light at the end of the tunnel, although you may not feel like it in the moment. There always is. Nothing is permanent and that we as providers in the spine world are going to be there for you no matter what.
Sanjiv Lakhia (22:07):
And that's the lesson you didn't mention. You learned high levels of empathy and compassion, Lindsey. And I think you can hear it in your voice and how you describe your interactions with your patients. And I know it resonates with people and that's why people love to see you. So folks, if you're in the Charlotte area and you're looking for an evaluation and you want to see a very compassionate, experienced provider, look her up. You work out of the Baldwin office right in our Charlotte main office?
Lindsey Howard (22:36):
Yes. 225 Baldwin, come see me.
Sanjiv Lakhia (22:39):
There you go. Thank you so much for taking time to share your experience. I know it's a very personal story and I know it's going to resonate with others who are going through similar things, particularly in the world of scoliosis, which can be really frightening for moms and dads when they hear these diagnoses for their kids or just anyone in general going through a back issue. One of the things I like to do with this podcast is provide a little bit of hope for people. I always say that dealing with a spine issue sometimes is worse than being told you're a new diabetic or you have high blood pressure because those medical diagnoses, you can't feel. They don't disrupt your social life, they don't disrupt your ability to travel and they don't affect your personality the way pain does and functional change does. So I think we're doing a good job spreading the word. Thanks again for sharing your story and look forward to collaborating with you in the future.
Lindsey Howard (23:29):
All right. Sounds good. I'll talk to you soon.
Sanjiv Lakhia (23:31):
Okay, take care.
Lindsey Howard (23:32):
All right. Bye-bye.
Voice Over (23:37):
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. 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.
Welcome. You are listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your back talk doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia (00:39):
Welcome friends to another episode of Back Talk Doc. Over the last year, I've really tried to bring a ton of information from many different angles about treatments for spine care and injuries, and I've often found though there's no substitute for a good story. And I've been searching, trying to find out what would be a good testimonial to bring to you guys because I know you're all listing there trying to figure out ways to help your back pain and improve your life, and I've been real fortunate. In the next month or so, we're going to do a couple episodes with some of my colleagues at Carolina Neurosurgery & Spine Associates who have I would call the privilege of actually been through... having gone through the process of taking care of their back as a patient and now their providers. And I think it's a unique perspective. And today we're going to kick it off welcoming Lindsey Howard to the show. Lindsey, welcome to the show.
Lindsey Howard (01:32):
Hello. Thank you for having me.
Sanjiv Lakhia (01:34):
Now Lindsey is a physician assistant with our practice, and I know you're a graduate of Clemson, correct?
Lindsey Howard (01:40):
Yes, 2010. Go Tigers.
Sanjiv Lakhia (01:42):
Awesome. And where did you do your training for your PA?
Lindsey Howard (01:46):
So I'm originally from Rhode Island, so I ended up, my dad came down to South Carolina when I was 15, so I finished high school down here, went to college and then I actually went back up north to a school called Mass College of Pharmacy in Boston, and I did their three-year PA program. And then after that, I came back down here and got the job at Carolina Neurosurgery and I've been there ever since.
Sanjiv Lakhia (02:10):
And tell folks where do you work in the practice and who do you typically work with? What's your typical workday?
Lindsey Howard (02:16):
Yeah, so I work in the physiatry department with you guys. I work with Dr. W., Dr. Wiercisiewski and Dr. Sumich. And I feel very, very lucky. I think you're an amazing doctor too, but I feel really privileged to be able to work with those two guys. They're so kind and they're so nice and they're so helpful. That's all you can ask for being a PA. You want your collaborating physician to be somebody that you can go to without having any anxiety, and so they're super sweet. So I work with Dr. W. in the pediatric concussion program and then obviously doing all the outpatient spine care that we do. So new patient spine and follow-ups, evals, all that kind of thing.
Sanjiv Lakhia (02:56):
I would agree. Actually, Dr. Sumich and Dr. W. are probably the reason I'm here. Well, Wiercisiewski would like to say he trained me and that's true. He was one of my attendings in residency and then Dr. Sumich was a year ahead of me in residency, so they were a big draw for me to come back to Charlotte and I would echo your sentiments. Now, you reached out to me really with an idea that you wanted to tell your story to people who are interested and who are struggling with their own back issues. And I know you've had a journey dealing with scoliosis, so I'll let you kick that off. Kind of take us through how it all started for you and walk us through the journey you've been on over the course of your life with your back.
Lindsey Howard (03:38):
Yeah, so it's really kind of been my whole life. So back when I was in sixth grade, I did one of those school screenings and that's where they picked up that I had scoliosis and those school screenings, it's kind of like a positive-negative relationship. I think it was great, but also when you're 11 or 12 years old to be singled out, that was a little like, "Oh gosh, this is pretty scary." So they picked it up at just a run-of-the-mill school screening. And then I saw my primary and he referred me to orthopedics. They did the bracing thing for about I think three months or so. From what I remember, the orthopedic surgeon at the time, I think my curve was a little north of 40 degrees, I could be wrong, but she basically was like, "We're going to try the brace, see if it works. If it doesn't work, we're going to refer you to this other guy, Dr. Michael Ehrlich for the surgery."
(04:30):
So I did the brace for a few months and I never really had any pain. I think probably the biggest thing for me at that time was the fact that I was 12 and I had to wear a brace and I had to sit out a gym class and those kinds of things. There was no pain involved, just kind of social pain I guess you could call it. And so the bracing obviously didn't work. And so she referred us to Michael Ehrlich and he was just another orthopedic surgeon in the Providence Rhode Island area. And he did probably one of the most thorough physical exams I've ever had in my entire life, like a Dr. Petty exam times a million. And so he looked at me and he just basically recommended surgery.
(05:12):
I think my curve had progressed by the time I had seen him. I'm not sure what it was by that time, but I do know that he said to my parents, "If you don't do this, of course there's always the option not to do surgery, but if you don't do this, she likely won't make it past 30 years old." And those words kind of stuck out to me, and I never really thought about those actually until I started getting older into my twenties and started working at CNSA and all that kind of thing. So then I went through the surgery and that whole process, there's a lot... I can delve into it a lot deeper, but that whole process of not just having the surgery but the things I had to do before the surgery, the being at the hospital after the surgery, it was a lot.
(05:56):
It was traumatic. And I think a lot of kids just, especially at 12 years old, you kind of just stay really quiet and you internalize a lot. You don't really say what's going on in your head. And I certainly was one of those kids. And so I'll be honest, after I had that surgery and everything kind of got cleared, it did really cause a little bit of PTSD and a little bit of, I had a hard time falling asleep. It was a trauma. And so when I was trying to figure out what I wanted to do and go through high school and college and all of that, I had originally decided to go to college because I was like, "I'm going to go to medical school. That's what I'm going to do. I want to help girls like me. That's it, period." And so I actually ended up majoring in food science and human nutrition because I wanted something a little bit different than your typical biology and chemistry and all of that.
(06:47):
So I mean, I had my eye on the prize, I was volunteering at the hospitals, I was working, I was doing all the extracurriculars, I was getting everything all set up to go to medical school. And then I think it was my junior year in college when I had to sit and take the MCAT and I was like, "I don't know if I want to be a surgeon. I thought it was cool. I definitely had some times where I got to shadow in the OR," and it was definitely amazing. Don't get me wrong, that was great, but it just didn't feel like it clicked with me.
(07:16):
And so I actually sat down with a family friend, Navin Bhojwani, he's a OB-GYN here in Charlotte, and he sat me down. We just had a long conversation and he was like, "So what is it that you want to do?" And I'm a very analytical person, almost to a fault. So I really took that question and tried to dive deep and figure out the root like what is it that I want to do? And all I really wanted to do was help those kids that are going to have to go through what I went through because when I was in the hospital, and rightfully so, it is a lot of work. I saw the surgeon, I think once. The residents were exhausted and burnt out and they were just obviously doing their thing, same thing with the nurses and the kindest person to me when I was in the hospital was the orderly.
(08:09):
He took the time to sit down and talk to me. And I just remember actually the relief that he gave to me just talking to me about what was going on on a day-to-day basis, and nobody had taken the time to do that. And that relief was something that I treasured and I remember obviously to this day. And so I was like, "There needs to be a role. There needs to be... obviously people are stressed out in the healthcare system, there needs to be somebody else there to help get these surgical patients from point A to point B." I mean the way we have it obviously isn't enough. And then I learned about the role of a PA and I didn't choose to do anything for the glitz or the glamour or whatever. I really just felt like there needed to be a role in the hospital for these surgical patients before and after. And I do still strongly feel that being a PA is a great way to kind of fill that hole.
Sanjiv Lakhia (09:00):
Okay. Let's pause right there. A lot of stuff I want to unpack a little bit for you. That was really good synopsis of how your life's unfolded. I'm going to return back to when you were younger, just contemplating being 12 years old, were you having symptoms or was this just a matter of the screen led to the evaluation? How were you handling the scoliosis? How did it impact your life?
Lindsey Howard (09:25):
So I actually did not have any pain. It was just picked up through the screening and then the curve eventually progressed to 72 degrees before surgery and I was 12 at the time. And so I had a little difficulty. I don't think I ever told my parents this or anything. I didn't have pain, but I had a little difficulty taking a deep breath and it would lead to coughing sometimes. But outside of that, like I said, I really didn't have any pain, even postoperatively.
(09:56):
I remember one time in the hospital now I remember being anxious and being like, "I don't want to feel pain," so I would preemptively hit that PCA button. I do remember doing that. But then even after when I was up on the floor, there was only one time that I really remember feeling like this excruciating pain. And then the other time was when the resident was trying to peel off the bandage on my back. That was very painful. So now when I actually remove bandages, I'm very, very sensitive to that for patients. I remember he was pulling that off and I was just like, I started screaming that stuff is on there tight and it was very painful. And the resident just looked at me and he was just like, "What do you want me to do? You want me to just leave it on there?" And I was like, "Okay. All right."
Sanjiv Lakhia (10:37):
What you're describing and people are hearing are the little things that our patients go through that make all the difference that sometimes when you're on the side of providing the healthcare, you don't pay attention to. And for you it's been a great teacher, you've kept those memories with you and experiences with you and applied them to the people you serve. I think with the scoliosis and not having pain, someone may be wondering then, "Well, why were you told you have to have this procedure done?" And we've done some episodes and we'll link to those in the show notes guys where I interviewed Dr. Bohl and I've done one with Dr. McGirt where we've really done deep dives into scoliosis and what's the definition and how was it treated, but what were you told that you can remember as a very young child, how was it described to you that you needed to have this done?
Lindsey Howard (11:33):
So Dr. Ehrlich, I remember him saying that I needed to have it done because like I said, at the time my curve was 72 degrees, so it was very large and it was already starting to rotate a little bit. So my ribs were essentially going to crush along and create an issue later on in life if I didn't get this fixed. Especially since he didn't go into that much detail. I'm ad libbing that. He basically told my parents, "If you guys don't do this, there's a high likelihood she won't make it past 30 years old." He might've gone into more detail about the anatomy changes and the science behind it. I just don't remember that part.
Sanjiv Lakhia (12:13):
Well, I think 30,000 foot view, if someone's wondering that degree of curvature will definitely have an effect on the organ systems of the body. And what Lindsey's describing is the effect on her vital capacity, her ability to take a deep breath. And most patients who come to see us with scoliosis, they go through that process you described particularly in their youth. And as Dr. Bohl had explained on a previous episode, you want a brace during the growth spurt during the adolescent age and that can sometimes stave off progression of curvature. But for you, I feel like the timing it sounds like in retrospect was almost perfect that you were able to get involved with healthcare and get the care of a surgeon and get this thing corrected when you're younger in life before it became even more problematic. So get back into the postoperative phase if you can recall. How was that that first three months after such a major surgery? You said you had a T4 to L4 fusion.
Lindsey Howard (13:09):
Yeah, so postoperatively, so I had an NG tube. I remember that because I remember I was coughing up blood. It's the funny, it's the weirdest things you remember, but I remember that the hospital course was uncomplicated. I talk like a PA now even though this is not how I thought when I was 12, the hospital course was uncomplicated. I was in the ICU for a day and then up on the floor until the following Saturday, I think.
Sanjiv Lakhia (13:35):
You had physical therapy then afterwards?
Lindsey Howard (13:37):
Yeah, I had PT, I had all those things. I was up walking around. Again, I don't know if it's because I was 12 if I compartmentalized it, which I bet I did. And I feel like people who are older probably do too. You kind of go through this fight or flight, you're kind of like, "Okay, I need to do this, so I'm just going to get up and we're just going to keep rolling here and see what happens." So then I was out of school for a month and then going to physical therapy, obviously doing the PT. My mom was religious about me doing the toe taps. So I've been doing toe taps ever since I was 12. And then back then I actually had to, not only did you have the post-op pain meds and the muscle relaxers, but I had to get a blood transfusion and they don't do this anymore obviously, but I had to drink liquid iron because I couldn't take pills.
(14:20):
I remember that. That was not fun. That was pretty nasty. And then the curve, it got corrected. I don't remember how well it was corrected to. Dr. Bohl might be able to tell you more because he's actually seen my films, but I think it's a pretty well done correction. And then I went through after that I did really well. So I actually ended up becoming a cheerleader. I was really active in high school. I really, again, did not have much in the way of pain in terms of people, I always hear them talk about range of motion and they're scared of losing range of motion.
(14:51):
And I'm lucky because this all happened to me when I was 12, so I don't remember anything different. But now I'm 35 now I've started to have some issues and thankfully I've been working with Dr. Plummer and so I'm starting to find different ways and different things to help manage it. That I think is really helpful when I talk to patients because I can be like, "I've used this cushion before for your car, it's amazing, trust me. Use it," and it's actually not just some ad hoc thing.
Sanjiv Lakhia (15:23):
I think it's great to share that you were able to get through that and then you were still able to have and currently do have a very active adolescence and then into sports. That's a good point to illustrate that you can come out the other side of these surgeries and live a high quality life. Wouldn't you agree?
Lindsey Howard (15:41):
Oh, 100%. Absolutely.
Sanjiv Lakhia (15:44):
Because Lindsey, the biggest thing I encounter in my practice and just getting feedback from people is there's a lot of fear about spine surgery. It's justified, but sometimes seeing a good surgeon right place, right time, it's really what you need. As much as I who myself am a big advocate for conservative, integrative, holistic spine care, I also know when it's time to call, pick up the bat phone and call someone who can really fix these problems.
Lindsey Howard (16:12):
Oh yeah.
Sanjiv Lakhia (16:12):
So I think if anyone's listening, a major take home point from what she's sharing is that yes, it was tough. Even some of the stuff she just shared was... kind of made me cringe a little bit hearing the postoperative course and these things that you remember as a patient, but you got your life back, preserved a whole lot of function, high quality of life. And it's not as if though you never had the issue, it's something you're going to have to manage your back your whole life. And you're going through some of that right now. What do you think are some lessons that you learned as a patient that you now apply as a physician assistant or healthcare provider?
Lindsey Howard (16:47):
That's a great question. I have so many and there's probably going to be so many different people are like, "Oh, I don't agree with what she said," but I would say, don't run. So that was probably, I wish somebody had told me that.
Sanjiv Lakhia (17:01):
Wait a second. You see Dr. Plummer in our practice and she runs like-
Lindsey Howard (17:05):
I know.
Sanjiv Lakhia (17:06):
Three marathons in a week though. That's pretty funny. But go ahead. Sorry, I didn't mean to cut you off.
Lindsey Howard (17:11):
Well, okay. But she is awesome. So if I have somebody like I had a 20... I had a younger person the other day who obviously has a genetic predisposition to not having a great spine and every time she would run, it would flare up. And so I actually got into running when I was like 25, 26. And it was great and I loved it. But I just feel like from my personal history and granted my history is going to be a lot different than somebody with just a simple degenerative disc. I get it.
Sanjiv Lakhia (17:37):
For sure.
Lindsey Howard (17:38):
But I feel like if you can find a way to be physically fit that you enjoy that is not something that has been your diehard for your whole life and it can give you the same pleasure as going for a run, I say go for it.
Sanjiv Lakhia (17:51):
So what do you do? What do you like to do?
Lindsey Howard (17:54):
I do Pilates. I'm a huge Pilates fan. I go to Iron Butterfly in the south end. That has probably been that and yoga are probably the two main things. And walking on an incline, I'm a big fan of that.
Sanjiv Lakhia (18:05):
Okay. Why the incline? Why specifically?
Lindsey Howard (18:08):
I feel like I can get some good core stability with that. So I feel like I'm not just plain old walking. I can get core stability. I can get my glutes activated, so it's a little bit more intense than just walking flat. And also I do enjoy getting my heart rate elevated, so going on a treadmill and putting on the incline can give me the same cardiovascular workout as if I were to go for a run.
Sanjiv Lakhia (18:31):
All right, so that's a great life lesson. What else do you have to share?
Lindsey Howard (18:35):
SI support belts work. They really work. I love them. I wear one around the house. I think it's great. I don't wear one out because they're not super cute yet. Another life lesson I would say is be patient and be kind with yourself, especially if you're younger and you have these issues, even if you're not younger and if you're older, because sometimes I hear the frustration in patients' voices. And so that's one thing for me that I've tried to really learn and hone in over the last year is just being patient. Be kind to yourself. You don't need to go from zero to 60 like it's okay to slow down your workout to maybe gain some muscle in another group that you really haven't worked on for years. It's about being fit for your whole life, not just fit for right now. And so I use that a lot with my patients.
Sanjiv Lakhia (19:28):
I like that. Definitely like that. I would also add, especially as I get older, I'm becoming more a fan of intuitive exercise than following a rigid structure weekly plan.
Lindsey Howard (19:39):
100%. Yeah.
Sanjiv Lakhia (19:41):
Some days if I wake up and all my schedule was I was going to do exercises X, Y, and Z, but I might feel a little tightness in my hip today or feel something different and I feel like a different exercise would serve me better. I've learned that that's okay. It's really not a race. I like what you said there about planning your movement strategies serve you now, but also I think that's critical. It's very easy when you're much younger to feel pretty invincible. And I know I went through that phase as well. But over time for all of us, you're going to be reminded that your body changes and your capacity to heal changes. And particularly when you're dealing with spine issues, I think sometimes less is more. And underestimating recovery time is something that I observe quite often for people.
(20:28):
Though and our body heals only when we're getting good deep sleep, our muscles hypertrophy and grow on our rest days from our workout days. So if you're out there, I don't know that you need to be really exercising seven days a week, or if you are and you're not seeing dividends or you're seeing increased injuries, think about that. Think about sprinkling in some recovery time. So that's a great life lesson. What else do you want to share that you learned going through this as a patient that you feel like you pass along to your patients now?
Lindsey Howard (21:05):
I feel like those are probably the main kind of bullet points. I guess the last little tidbit, I would say again, the main reason I got into this is because I don't want anybody to ever feel, I think whenever you go through a major illness, this isn't really an illness per se, but any major medical issue you can sometimes feel really alone. I had a patient today who was like, "I just feel like I'm the only one dealing with this and I'm the only one going through all of this." And just to remind them and that's usually when I bring up my story and I'm like, "Just to remind you, you are not alone. There's tons of people in this world who are going to go through similar situations, your providers included, we're right there with you. You may be driving the car, but we're going to be right in the front seat with you helping you."
(21:50):
So I think just trying to let them know that they're not the only ones that are going through this, there is a light at the end of the tunnel, although you may not feel like it in the moment. There always is. Nothing is permanent and that we as providers in the spine world are going to be there for you no matter what.
Sanjiv Lakhia (22:07):
And that's the lesson you didn't mention. You learned high levels of empathy and compassion, Lindsey. And I think you can hear it in your voice and how you describe your interactions with your patients. And I know it resonates with people and that's why people love to see you. So folks, if you're in the Charlotte area and you're looking for an evaluation and you want to see a very compassionate, experienced provider, look her up. You work out of the Baldwin office right in our Charlotte main office?
Lindsey Howard (22:36):
Yes. 225 Baldwin, come see me.
Sanjiv Lakhia (22:39):
There you go. Thank you so much for taking time to share your experience. I know it's a very personal story and I know it's going to resonate with others who are going through similar things, particularly in the world of scoliosis, which can be really frightening for moms and dads when they hear these diagnoses for their kids or just anyone in general going through a back issue. One of the things I like to do with this podcast is provide a little bit of hope for people. I always say that dealing with a spine issue sometimes is worse than being told you're a new diabetic or you have high blood pressure because those medical diagnoses, you can't feel. They don't disrupt your social life, they don't disrupt your ability to travel and they don't affect your personality the way pain does and functional change does. So I think we're doing a good job spreading the word. Thanks again for sharing your story and look forward to collaborating with you in the future.
Lindsey Howard (23:29):
All right. Sounds good. I'll talk to you soon.
Sanjiv Lakhia (23:31):
Okay, take care.
Lindsey Howard (23:32):
All right. Bye-bye.
Voice Over (23:37):
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. 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.