Episode 3 - The Narrowed path, Understanding Spinal Stenosis with Joe Cheatle, MD
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,Episode Summary
The things that you do in a single day, no matter how minor you think they may be, are going to have a profound effect on your body soon. Are you feeling sharp pain in your legs, for instance? It may be because you’re putting too much pressure on your spinal cord or your unhealthy habits are already taking a toll on your spine. In this episode of Back Talk Doc, neurosurgeon Joe Cheatle, MD – whose interests spans brain tumors and degenerative spinal disorders to name a few – dives deep into spinal stenosis. While this illness is pretty common, there’s little knowledge and understanding among patients about what it truly is. Joe then talks about the causes and symptoms to watch out for. There’s no one reason for spinal stenosis, with genetics and lifestyle playing a huge role in acquiring this condition. Although getting surgery is an option to treat lumbar spinal stenosis, Joe recommends exhausting all nonsurgical treatments and therapies first. Undergoing surgery should be the last resort as even medical professionals like himself want to avoid it if possible. Of course, if the pain is unbearable and changes the way you do your normal activities, then surgery would be the best option. There are different kinds of surgeries that you can take, which have their own risk levels and recovery times too, depending on the patient. At the end of the day, Joe believes that building habits like avoiding vices, eating right and exercising regularly and properly, is what’s going to keep your spine healthy and strong.
Key Moments In The Episode
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about gratitude and how having an attitude of gratitude can make a difference in a person’s overall physical and mental well-being. He provides scientific research that shows how doing activities such as journaling reduce physical ailments and mental stress. (18:19)
Links Mentioned In The Episode
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.
The things that you do in a single day, no matter how minor you think they may be, are going to have a profound effect on your body soon. Are you feeling sharp pain in your legs, for instance? It may be because you’re putting too much pressure on your spinal cord or your unhealthy habits are already taking a toll on your spine. In this episode of Back Talk Doc, neurosurgeon Joe Cheatle, MD – whose interests spans brain tumors and degenerative spinal disorders to name a few – dives deep into spinal stenosis. While this illness is pretty common, there’s little knowledge and understanding among patients about what it truly is. Joe then talks about the causes and symptoms to watch out for. There’s no one reason for spinal stenosis, with genetics and lifestyle playing a huge role in acquiring this condition. Although getting surgery is an option to treat lumbar spinal stenosis, Joe recommends exhausting all nonsurgical treatments and therapies first. Undergoing surgery should be the last resort as even medical professionals like himself want to avoid it if possible. Of course, if the pain is unbearable and changes the way you do your normal activities, then surgery would be the best option. There are different kinds of surgeries that you can take, which have their own risk levels and recovery times too, depending on the patient. At the end of the day, Joe believes that building habits like avoiding vices, eating right and exercising regularly and properly, is what’s going to keep your spine healthy and strong.
Key Moments In The Episode
- Personal habits to keep spine healthy and strong, promote wellness - 04:28
- What is stenosis - 06:47
- Common symptoms of lumbar spinal stenosis - 07:55
- Factors that contribute to the development of lumbar stenosis - 11:52
- Is spinal stenosis preventable - 15:03
- Percentage of patients who need to spinal surgery - 16:41
- Pain as an indication for surgery - 17:46
- Treating spinal stenosis symptoms to avoid surgery - 26:02
- Reasonable time frame for nonsurgical care - 27:13
- Indications for when surgery is needed - 28:57
- Common neurosurgical approaches - 31:01
- Recovery and rehab time for surgeries - 36:14
- New innovative surgical techniques for treating spinal stenosis - 38:02
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about gratitude and how having an attitude of gratitude can make a difference in a person’s overall physical and mental well-being. He provides scientific research that shows how doing activities such as journaling reduce physical ailments and mental stress. (18:19)
Links Mentioned In The Episode
- Joe Cheatle, MD
- Lumbar spine anatomy video
- The Grateful Brain by Dr. Alex Korb
- Article on neural biology of gratitude
- Five Minute Journal App
- 6-Phase Meditation
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: 00:01 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 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: 00:33 Hello, listeners. Welcome to episode three of Back Talk Doc, the podcast. I am your host, Dr. Sanjiv Lakhia, a physiatrist with Carolina Neurosurgery & Spine Associates with offices in North and South Carolina and predominantly centered around Charlotte, North Carolina.
Sanjiv Lakhia: 00:52 I'm excited to bring to you today a topic that comes up quite frequently in the office. We're going to be discussing spinal stenosis with my friend and colleague, Dr. Joe Cheatle. Dr. Cheatle comes to us from Nebraska where he's had his residency, but he's also been in training in the coast of the Carolinas before he came to us this fall. We've been very blessed to have him in our practice and I would consider him to be an expert on the topic of neurosurgery and lumbar stenosis in particular.
Sanjiv Lakhia: 01:22 So today we're going to get started with Dr. Cheatle. I know if you're listening today in your car or at home, your time is valuable and so is ours, so we're going to get right to it and try and get you with some good information that helps break down a complex topic. So, Joe, welcome to the show.
Joe Cheatle: 01:36 Thanks, Sanjiv.
Sanjiv Lakhia: 01:38 All right, Joe, why don't you go ahead and talk to us a little bit, share with the listeners your background with regards to your upbringing a little bit and your medical training if you can.
Joe Cheatle: 01:46 Yeah, for sure. Like you said, I'm from Nebraska. I still call Nebraska home. I was actually born in Oklahoma but raised for most of my life in Nebraska. I did my training there, both undergrad med school and residency at the University of Nebraska. And then after that I left and came to the Carolinas.
Sanjiv Lakhia: 02:05 All right. Tell us a little bit about your experience before you came to Carolina Neurosurgery & Spine Associates. I know you were in practice out in the coast of the Carolinas where you saw quite a bit of cases and really built up your skillset.
Joe Cheatle: 02:17 Yeah, so I was in practice on one of the beach towns in South Carolina and was one of two neurosurgeons in a about a million-strong city. So we were pretty busy, too busy actually. And so I saw, I mean a ton of patients and really got to build a pretty strong practice there.
Sanjiv Lakhia: 02:34 Dr. Cheatle is very humble in sharing his background and upbringing. He really, really is able to handle almost anything that comes our way, which makes him highly qualify for our topic today. But before we jump into discussing spinal stenosis, share with our listeners a little bit about what sparked you to go into the field of neurosurgery.
Joe Cheatle: 02:53 I was a third-year med student and I was on the neurosurgery rotation, which I was begrudgingly on. I did not want to do that. I was stuck on that because it was the hardest rotation. And so I got my last pick. So I was on rotation. It was my second day and we had a guy fall off actually an overpass. They were building an overpass in Omaha and he had a huge subdural, which is a bleed between the surface of the brain and the brain itself. And so we took him immediately to surgery. We did this really awesome craniotomy and I saw the brain pulsating for the first time. So the brain, for those of you guys who've never seen this, but the brain actually pulsates with every beat of your heart so you can see the beat of your heart in your brain. It's one of the most amazing things. It completely changed my life. And I knew right then and there that I was going to do neurosurgery.
Joe Cheatle: 03:40 So I started going to every conference. I went to national conferences, I went to every single journal club and every morning conference. I'd wake up early in the morning before my rotations and started going to that and just kind of made myself known and then I became a neurosurgeon.
Sanjiv Lakhia: 03:55 That's an amazing story. It really illustrates how there are moments in our life, which can really be game-changers for us and direct us along a path that we can really fulfill our dreams and help people out. And certainly you've done that. Help us also get to know you a little bit better. What are some of your personal habits? Joe, for those who don't know you, I would call you very energetic, a very positive person. Well, what are some of your personal habits that you rely on to promote wellness and keep your spine healthy and strong?
Joe Cheatle: 04:28 So that's actually changed over the years and neurosurgery training is highly intense and you basically do nothing but neurosurgery for seven years of your life. And so as I got through that and started practice, which is harder than residency, I kind of looked back and I decided that I'm not taking care of myself and I need to do that because I'm going to do no good to anyone by being sick. And so I started to basically make a daily regime and I've changed the habit. And that's really the hardest part is habits are hard to form and incredibly hard to break.
Joe Cheatle: 05:03 And so I now wake up every morning, I religiously go to the gym. I work hard. My goal is to try to do something and work hard. I know some days are better than others. Some days I'm really tired. I was on call the night before or I had a really hard case, but I try every day to try to do something for myself to make myself stronger. I do weight lifting or running or swimming or biking or a combination of all the above. I really like to do it if I can with my wife, which is the most fun when we can do something together. She loves yoga. So we do that sometimes, but something every day, at least five days a week, hopefully seven days a week where I take care of myself, exercise, get out there and try to be a little bit stronger than I was the day before.
Sanjiv Lakhia: 05:43 That's terrific. On Back Talk Doc, I cover a variety of spine topics, but I'm also heavily interested in health and wellness and sharing tips with our listeners. So I think if you're listening out there, take-home point is establish a routine. What Joe just described works for him. It gives him energy, it fuels his day, and it prepares him for the challenges that he faces.
Sanjiv Lakhia: 06:04 So if you can do that for yourself, whatever it is, whether it's a little bit of light exercise, a little bit of meditation, really supercharge your day in the morning and it'll set you on a path towards success for the rest of the day. All right, thank you for that, Joe. Let's get into spinal stenosis and I'm sure as your clinic is similar to mine, it's one of the most common conditions that we come across that patients are referred to for evaluations and treatment in our office. And I find that there is a times a lack of even simple understanding of the condition. Let's start with the term stenosis because it's thrown out there a lot in medicine. There's spinal stenosis, you can hear carotid artery stenosis, fascia stenosis. What exactly is stenosis?
Joe Cheatle: 06:47 Great question. And you're right, people ask about that all the time. And so stenosis basically means narrowing. And so specifically for spinal stenosis, it means narrowing of the spinal canal. So you've got the brainstem, which then becomes a spinal cord as it exits out the main hole in the skull, which is called the foramen magnum. And then there are vertebral bodies, which are the bones that surround the spinal canal and there's discs and ligaments around them. And so stenosis means that for some reason that the spinal canal is more narrow than it should be and that spinal canal diameter so that the width of the spinal canal changes as you go up and down and the stenosis can change based on what happens.
Joe Cheatle: 07:27 So you can have thickening of the ligaments, you can have disc bulges or disc herniations and all those cause narrowing or stenosis of the spinal canal.
Sanjiv Lakhia: 07:36 That's excellent. And again, it's similar to if you have stenosis in a blood vessel, plaque builds up in the blood vessel, it narrows the blood flow and then it can produce symptoms, for example, pain in your calf or foot. So I think that's a great definition of stenosis. What are some common symptoms of lumbar spinal stenosis?
Joe Cheatle: 07:55 So lumbar spinal stenosis can really present in two ways. So you can either have an acute, which means a sudden onset of stenosis or long-term onset of stenosis. For acute stenosis, most people usually complain of a pain and usually the leg, sometimes the back, or sometimes both in a very reproducible area. So oftentimes it's usually one single nerve root that is being pinched. And it's usually narrowing of more than nerve root hole called the foramen on the side.
Joe Cheatle: 08:26 That usually starts pretty suddenly over a day, even sometimes shorter than that. And it can be quite severe pain plus or minus weakness or numbness and tingling. Most people have no significant trauma before that but sometimes they do. And usually it's always in an area that you can describe. So they can say it's on the side of my leg or the back of my leg. It goes down to this area or it goes inside the leg into the groin. That's usually the result of an acute or a new disc herniation.
Joe Cheatle: 08:57 Chronic stenosis is when you have narrowing, usually due to arthritic-type problems. So you have thickening of the ligaments or thickening into the joints and that causes the spinal canal to decrease in size all the way around. And usually people complain of pain more associated with activity. And so usually they say, "When I walk more, I complain of increased pain. When I rest, then my pain goes away. When I start walking again, usually that pain comes right back." It's usually less descript. So it's usually the entire leg and often the back. But not as much in a single what we call dermatomal pattern. In other words along one single nerve root.
Sanjiv Lakhia: 09:38 For those of you that live in the Charlotte area. And that was a great description, but I like to describe it as well as central canal stenosis or stenosis within the canal is equivalent to a traffic jam on I-77 and spinal stenosis involving the nerve root would be an accident on one of the exits coming off the highway. They can both cause somewhat different problems in traffic and can have similar but also at times different presentations clinically.
Sanjiv Lakhia: 10:10 So that's really good and if that's hard to follow, I think Dr. Cheatle did a great job describing that, but we'll put a picture of the spine with some further clarification of that in the show notes for your listeners out there who are more visual learners. Joe, are there differences in presentation between stenosis that develops in the cervical spine or neck versus in the low back?
Joe Cheatle: 10:33 Yes, for sure. So the cervical spine is important in the fact that you have the spinal cord and the nerve roots that go down through the thoracic and lumbar spine as well. The lumbar spine just has the nerve roots for the legs. The cervical spine has the spinal cord as well as the nerve roots that to go to the arms and that are important for balance. So a lot of times people when they have neck stenosis, will complain of similar symptoms in their arms where they have pain along a certain region in their arm, but also sometimes complain of difficulty with balance or difficulty with their gait. And they don't walk as well or they walk to one side or the other or they trip or they are less balanced than they were before. And that's a sign that they have pressure on the spinal cord, which is causing not only symptoms in their arms but along the rest of the nerve root tracks that go down.
Sanjiv Lakhia: 11:24 And that's a good point. Very early in my career, I learned that lesson. I had a patient come in, a older gentleman who had some complaints of weakness in his leg, and ultimately the problem turned out to be coming from his neck. So when you come into our offices at Carolina Neurosurgery & Spine, you're typically going to get a comprehensive evaluation regardless of where your symptoms are located. What factors do you often see can contribute to the development of lumbar stenosis?
Joe Cheatle: 11:52 So stenosis both has modifiable and non-modifiable risk factors. And so the non-modifiable risk factors are basically genetic risk factors. So if you have family members who have spinal stenosis, you're at a greater risk of developing spinal stenosis, and you can't change that. You can't change your family, unfortunately. But for those things that you can change, smoking and drinking are huge and have significant risk of developing spinal stenosis. The other things are decreased activity and weight gain, put extra pressure on the spine.
Joe Cheatle: 12:25 And then also on the other end are activities that put a lot of pressure on the spine. So like laborers or people who do construction and things like that that do something repetitive every day. Just like people who develop carpal tunnel if they type, or they use their hands a lot because of repetitive motion. Repetitive motion happens in every joint and so people who do a lot of heavy lifting on a regular basis have an increased risk of spinal stenosis.
Sanjiv Lakhia: 12:51 What are your thoughts on runners?
Joe Cheatle: 12:52 That's a great question. So as we get more data, there seems to be differences in what our parents told us was bad for us. And people always say runners get bad knees. And there's actually some more recent studies that show that runners actually have better knees than non-runners. Now, the exception to that is people who run ultra marathons or who do hundred mile runs. There is a limit to how much is good and the best idea is always to be moderate in what you do. So running a marathon once or twice in your life is probably no problem. But running six or seven marathons a year or ultra marathons, probably cross that barrier between good and harmful. And so running is good. Too much running can be bad, just like cake is good but too much cake is sometimes bad.
Sanjiv Lakhia: 13:46 That's great. I would agree with that. I've read some research that discusses about a 20-mile a week threshold in terms of the risk of advancing degenerative changes, but it's really not well established. I do think when you're talking about running and back conditions in general, you have to also break it down into someone who has a documented injury on MRI, for example, a hernia to lumbar disc. I think you would have to be a little more cautious with the amount of mileage and pounding you're putting on the spine in that scenario versus just counseling an individual if you're out there and you're relatively healthy with your back. I think following Dr. Cheatle's advice makes perfect sense.
Sanjiv Lakhia: 14:23 And the other consideration, if you haven't had a chance to go and download our second podcast episode where I interviewed Ryan Klomparens on the role of the glutes, he went over some terrific tips for runners on how to prevent back pain and stay strong. So thank you for that, Joe. That kind of plays into our next question. Do you believe spinal stenosis is preventable? I get that a lot where patients come in and say, "Hey, my had it. My mom was in a wheelchair. I'm 45 years old. Is this predestined for me?" And it sounds like you broke it down a little bit into genetics versus environmental. Do you have anything to elaborate on that?
Joe Cheatle: 15:03 There is a genetic component and we know that, you can't change that. That being said, practicing really good health or avoiding smoking, drinking, staying fit and trim. And on top of that, doing when you do do exercise, doing the mechanism correctly. So doing exercises and doing the motion wrong is no better than not doing the exercise to begin with. And sometimes you need help. That's one thing that we do have in this practice is therapists that help us because sometimes you're doing an exercise, but if you're doing too much exercises on the extensors versus the flexors, then you can cause problems. Or if you are overly strong in your legs and not strong in your arms, then you'll oftentimes complain of pain despite the fact that you may be able to squat 800 pounds and you'll still have pain.
Joe Cheatle: 15:53 So I've seen personally professional squatters who did one squat wrong and herniated a disc and felt it and knew it right then and there. So really one of the prevention mechanisms is to do things right and do it correctly. And sometimes you need help to know what to do.
Sanjiv Lakhia: 16:10 And we're recording this podcast just prior to the holidays coming up. And I would definitely piggyback on that. If you're looking to spend a little bit of money on yourself on the holidays, invest some money into a few sessions with a personal trainer or go see a qualified physical therapist to help teach you correct exercise techniques is probably the best form of medicine. And in terms of injury prevention. And that's also, we also discussed that on our last episode as well with Ryan. So again, if you haven't had a chance to download that, I think you would find that to be highly informative.
Sanjiv Lakhia: 16:43 So, Joe, as a neurosurgeon... This is a question I get a lot; as a neurosurgeon, what percent of patients that you're asked to consult on actually end up needing spine surgery to treat their stenosis?
Joe Cheatle: 16:55 In general, I'd say between 85 and 90% of patients can avoid surgery most of the time. My general practice and most of the neurosurgeons that I know, try to find every way to avoid surgery if at all possible. So oftentimes there's medical treatments and then like you, a physiatrist, that really help find ways to avoid surgery if we possibly can. Spine surgery has a negative connotation to it and that's unwarranted because spine surgery can be really helpful, but the problem is is spine surgery, just because you have a spine problem on an MRI, oftentimes doesn't make people better. It has to be very selective and as minimal as possible to help patients. And so the vast majority of my patients ended up not needing surgery.
Sanjiv Lakhia: 17:43 Do you consider pain an indication for surgery?
Joe Cheatle: 17:46 It can be, but in general I like to avoid doing surgery just for pain unless it changes their lifestyle. So if pain becomes so significant that they can't participate in the normal activities that make them happy, then that crosses a threshold. If we can treat the pain with medicines or with injections or therapy, then that's not necessarily something that requires surgery.
Sanjiv Lakhia: 18:08 Our next set of questions, we're going to dive deeper into the treatment options for lumbar stenosis and we will get to that right after this.
Sanjiv Lakhia: 18:19 Welcome to today's health matters segment. For those that know me, I am a big advocate of health and wellness and I hope on each episode to provide some tips that you can take home to further improve your health that are easy to implement in your life, low cost and highly effective. And as we come up on the Thanksgiving holiday, I thought it'd be appropriate to discuss a topic that I practice in my daily routine and that is gratitude. Having a attitude of gratitude or an attitude of appreciation can make a big difference in your overall mental and physical well-being. Now, when we were growing up and in grade school, we always would practice writing a list of what we're thankful for on Thanksgiving. And you may wonder, well, what does this have to do with health?
Sanjiv Lakhia: 19:07 Well, in modern day neuroscience research, there has been a tremendous amount of information provided about the effects of having an attitude of gratitude on your health and wellness. And I like to review with you some information from an article titled The Grateful Brain that was put out by Dr. Alex Korb. And we'll put a link to his article in the show notes. And he goes through a few studies that have been done on gratitude. And I want to share with you some of the information. And one study that was done in 2003, they looked at a group of young adults who kept a daily journal of things that they were grateful for. And then they assigned another group of young adults to keep a journal about things that annoyed them. And they compared kind of how these approaches affected them on a day-to-day basis.
Sanjiv Lakhia: 19:56 And it turns out that the young adults assigned to keep gratitude journals showed greater increases in determination, attention, enthusiasm, and energy compared to the other groups. And what this really illustrated is that having an attitude of gratitude can affect your mindset on a day-to-day basis. Now, what is gratitude? They define gratitude as requiring an appreciation of the positive aspects of your situation; not a comparison of what else is going on for other people.
Sanjiv Lakhia: 20:26 The second group of individuals that were studied was adults. And in this study, the adults were assigned to keep a weekly gratitude journal. So documenting once a week about the things they were appreciative about showed to have benefit. This showed an increase in optimism, which is obvious and that makes sense. But remarkably, journaling once a week on the items in your life that make you feel good, that you're happy about also led to changes in behavior. So behaviors such as following through on your exercise program or your nutritional changes. And it also illustrated or a reduction in physical ailments. So this is where it begins to tie in. If you're suffering with low back pain, I think keeping a gratitude journal can be a viable tool. Subjects had fewer aches and pains than those who did not journal.
Sanjiv Lakhia: 21:20 The last study that he reviewed was on keeping a daily attitude of gratitude without journaling. So simply just looking at things throughout your day that you're appreciative for and keeping a mental note of that. And those individuals who kept a daily attitude of gratitude, this had a remarkable effect on several health measures. Number one, they slept better; and number two, they had less anxiety and less depression. So folks, that's quite remarkable that by simply maintaining a positive attitude, it can improve your sleep parameters and reduce your stress and anxiety.
Sanjiv Lakhia: 21:58 So where does this all lead to? Neurologically and in the field of neurobiology and neuroscience, the National Institutes of Health has researched how a gratitude approach to life can affect areas of the brain. And they used technology called a functional MRI. And a functional MRI essentially can identify areas of changes of blood flow within various regions of the brain. And it turns out in a 2009 study, that subjects who showed more gratitude overall on a daily basis had higher levels of activity in the hypothalamus.
Sanjiv Lakhia: 22:32 So what's the hypothalamus? Well, the hypothalamus is an area on the base of the brain that is below the thalamus and above the brainstem. And it is a very important player and tie in with our endocrine system. And the hypothalamus is responsible for controlling a huge list of essential bodily functions, including eating, drinking, and sleeping. And it really correlates with your daily stress levels by its direct effect on your cortisol levels.
Sanjiv Lakhia: 23:00 So by maintaining a gratitude approach to life, you will alter the activity levels in your hypothalamus in a positive way. This also illustrates how improvements in gratitude could have a wide ranging effect from increased exercise and improve sleep to decrease in depression and fewer aches and pains. So it really ties in.
Sanjiv Lakhia: 23:20 And lastly, when you walk around feeling good about life and feeling appreciative, it can affect your neurotransmitter levels, particularly the neurotransmitter dopamine. Most of you may know that dopamine is kind of your feel-good reward neurotransmitter. But what you may not know is that elevated levels of dopamine correlate with initiating action. So that means that increases in dopamine make you more likely to do the thing that you just did or to follow through on healthy habits. So there you go. This is not voodoo science folks, it's real neurobiology and real neuroscience that a simple act such as daily journaling or keeping a positive outlook on life can affect how you feel physically and help you at least cope with your back pain if not reduce it.
Sanjiv Lakhia: 24:07 So how do you do this on a day-to-day basis? I'll share with you two tips. One, there is an app, the Five Minute Journal app, and we'll put a link to that in the show notes that you should download. It's only a few dollars and it walks you through listing about two or three items that you're appreciative for that day and some things that you're looking forward to that day. And then you can even add in a photograph of a loved one. And that's kind of your daily journal entry and that's a simple health habit. It takes about one to two minutes that you can do on a daily basis.
Sanjiv Lakhia: 24:37 If you want to get more involved, I personally like to practice the 6-Phase Meditation and this is a meditation program that has been developed by Vishen Lakhiani of MindValley. And it walks you through almost a guided process for covering topics such as gratitude, forgiveness, and visualization. I'll put a link to his meditation that he has posted on YouTube. It only takes about 20 minutes and it's something that I highly encourage you to look at. So as you approach Thanksgiving this year, I hope you find at least one or two things to be grateful for. I myself am quite grateful that you've taken the time to listen to our podcast and I hope you found this health matters segment to be useful.
Sanjiv Lakhia: 25:23 All right, let's move on into the next set of questions. If you're just joining us, we have a interview today with Dr. Joe Cheatle, a neurosurgeon with Carolina Neurosurgery & Spine Associates, and we're covering the topic of lumbar spinal stenosis from top to bottom. And our initial set of questions so far, we've kind of set the table for our listeners, put out some definitions on what stenosis is, just kind of described how it presents. But now I really want to get into some questions that I get in the office and from friends and family that are very important to them. Number one here at this point, what are your top recommendations to help patients treat their symptoms and avoid or postpone surgery?
Joe Cheatle: 26:02 In general, I think a good working team is what's most important. So having a team of physicians, physical therapists, physiatrists, the surgeon that all worked together to help try to avoid surgery if at all possible. So oftentimes, there's a lot of things that go into making the decision for surgery. And the first thing is have we tried everything that's not surgical. So we can do physical therapy, you can do acupuncture, you can do chiropractic manipulations, you can do injections, you can do medicines. There are so many things to do before surgery becomes an option or something that's even required that oftentimes help avoid surgery and having a surgeon that sits and says, "Wait, there are other things we haven't tried yet. Let's try those first," is often the most important step in avoiding surgery.
Sanjiv Lakhia: 26:51 Can you counsel the listeners on what you think would be a reasonable time frame for a trial of nonsurgical care? Assuming they don't have an acute neurologic issue, a foot drop, something emergent. If it's mostly kind of pain and numbness and decreased functional activity, what do you think is a reasonable time frame? Are we talking about in four weeks, three months, six months?
Joe Cheatle: 27:13 It really depends on the patient and it depends on kind of their personalities. So some patients literally go crazy if they're less active in six days. And so they'll come into your office and they're like, "Doc, I've been down in the couch for like four days. I'm dying," and so sometimes it takes a lot of effort to say, "Wait, wait, let's rethink this. We're not dying. This is not a life threatening situation."
Joe Cheatle: 27:38 In general, I try to go three to six months if at all possible. If they have no neurologic deficit, we have plenty of time. We try to do everything we can. Now, like you said, if they have a neurologic deficit, completely different game, completely different situation. We may try some conservative therapy, but we're much more aggressive on if they have a weakness or if they have significant numbness or if they're having problems with gait or are at risk because of their injury. But in general, for pain only, I try to push it off if at all possible for as long as possible.
Sanjiv Lakhia: 28:11 Dr. Cheatle covered numerous treatment options there that if you're not familiar with them, stay tuned. We're going to have future episodes where we go into things like acupuncture, the research on injections, more information on exercise, approaches to spine conditions because there is a lot of misunderstanding and misinformation and we'll be clarifying that in future episodes. But what he just described is a real comprehensive approach where oftentimes patience pays off. You certainly can improve your quality of life with non-operative care in many situations. But after you've tried that and if things haven't gone your way as a neurosurgeon, what are the indications that you're looking for that really tell you this individual's going to need surgery to address their pain and function from spinal stenosis?
Joe Cheatle: 28:57 That's a good question. Like we said a little bit ago, if they have a neurologic deficit, surgery becomes a much higher and a much quicker option that we're going to.
Sanjiv Lakhia: 29:06 All right, let's clarify that for the listeners. What is a neurologic deficit?
Joe Cheatle: 29:10 Good question. So neurologic deficit usually means weakness and that usually is weakness in a certain muscle group that's traceable back to our nerve root that's injured. And so sometimes it'll be what's called a foot drop, which is weakness of the foot, and you'll see people walking around the mall; if you go to the mall any day of the week, there's at least one person you see that flops their foot down and they usually had weakness secondary to disc herniation.
Joe Cheatle: 29:35 There's other causes. You can have weakness in the hip or weakness in the arm and oftentimes that does require surgery. Now, that being said, my mentor had weakness in his hand and he couldn't operate and he didn't need surgery and ended up doing physical therapy. So sometimes even weakness can result in nonsurgical treatment, but it's something that you need to look at and have surgery as an option if therapy doesn't work or if the injections don't work. But a neurologic deficit basically is usually weakness, numbness or bowel or bladder problems. Now, bowel or bladder problems are one that require usually surgery right away.
Sanjiv Lakhia: 30:13 Pain brings people in to see us and what Dr. Cheatle just elaborated on, emphasizing weakness as a criteria for surgery. And just to clarify for the listeners, we look at weakness on a higher level of importance simply because if it develops and becomes permanent, weakness can translate into permanent functional disability, which no one wants to see happen. So thanks for that clarification, therefore, as Dr. Cheatle.
Sanjiv Lakhia: 30:40 All right, moving forward now. Here we go. We're going to get right into your wheelhouse. Can you break down, in simplistic terms, what are the common neurosurgical approaches to treating lumbar stenosis? And I want you to cover the top risks associated with a surgery and just help listeners understand how risky is surgery and these different approaches.
Joe Cheatle: 31:01 In general, the way I talk to patients about it is we start from the least invasive to most invasive, so the smallest incision to the biggest incision. And sometimes small incisions can be pretty invasive. So the smallest surgery is a microdiscectomy, which that is, is a small little incision on the back. It's a small little opening in the bone of the back called the lamina or the roof of the spine. You move the nerve root out of the way, you take the disc out and you close up. That can be done either through a tube or through small little micro instruments and that's usually a very simple surgery, 45 minutes, home the same day. That has a risk; everything we do has risks. The main risks are going to be spinal fluid leaks and infections. Very, very rarely could you damage the nerve root.
Joe Cheatle: 31:46 And then last but not least the disc could re-herniate out again. A little bit more aggressive would be a laminectomy. So like we said, the lamina is the roof of the spine, so to take off that roof you take out the thickened ligament, you open up the nerve roots a little bit wider, you free up nerve roots on both sides and again that can be done either through a small incision or through a tube. Same risks; bleeding, infection and spinal fluid leak and usually still patients go home that same day or maybe the next morning. Pretty simple surgery, pretty quick recovery as well.
Joe Cheatle: 32:19 Then we talk about doing more complex surgeries; surgeries that include fusions. And so fusions can be done from the front, the side or the back. Every patient is different. Some patients require both. Some patients require rods and screws, some patients don't, and that's a decision that's much more complex to make.
Sanjiv Lakhia: 32:38 Sure. Yeah.
Joe Cheatle: 32:39 Now, those surgeries can be actually really quick recoveries as well, sometimes home that day even. So they can be really good surgeries and even though patients get really scared when you say, "I'm going to need a fusion," in general, those surgeries have much better recoveries than they used to. That being said, again, we do a lot of minimally invasive through small little stab incisions to put in the rods and screws nowadays and patients oftentimes do much better. The difference between those first two surgeries and then the fusion surgery really is going to be instability. And that is where that decision tree is branched, where if you have instability, then you need something to stabilize you and those are where you put in hardware. If you don't have instability, oftentimes you can get away with a smaller surgeries. So instability, the medical term you'll see on your MRI report when you read it at home is called spondylolisthesis. Huge term, but basically it means the bones have started to slip. In other words, the bones are unstable and that requires a more aggressive surgery, but not necessarily a harder surgery for the patient.
Sanjiv Lakhia: 33:44 All right, so Thanksgiving is coming up and you're home talking with one of your family members and they just heard our podcast and they still have questions. So let's drill this down even into more simplistic understanding about risk. So on a scale of 1 to 10 if 10 was the most risk you could have in a surgery and one was virtually no risk, give me the rating for those three surgeries. So first of all, for microdiscectomy, what number would you give it?
Joe Cheatle: 34:17 So for a microdiscectomy, I would say is a two.
Sanjiv Lakhia: 34:19 A two, okay.
Joe Cheatle: 34:20 Very low risk.
Sanjiv Lakhia: 34:21 And then for a lumbar laminectomy?
Joe Cheatle: 34:22 2.5.
Sanjiv Lakhia: 34:24 And then for, now, I know there's multiple different approaches for fusions, but in general a lumbar fusion.
Joe Cheatle: 34:29 So a lumbar fusion, you're talking there's a lot more risk. Probably a five or a six. It's not a 10, which would be open-heart surgery or brain surgery.
Sanjiv Lakhia: 34:36 There we go.
Joe Cheatle: 34:37 But it's definitely more risk because you're doing much more work. You're putting in hardware and so although risks are still incredibly rare, there's a lot more opportunity for risk.
Sanjiv Lakhia: 34:50 You mentioned earlier, there's a risk of the disc re-herniating. Is there documented literature that gives you a percentage risk that we can reference?
Joe Cheatle: 34:59 Unfortunately, the literature is all over the map on that. And the way I describe that is a disc is a jelly doughnut, right? So you've got your doughnut, everybody knows jelly doughnuts, they're amazing and that little area on the back where they put the jelly in the doughnut, you always start eating there. Unfortunately what happens with the disc herniation is you have a weakening of the outside of the disc and then that jelly squirts out. We take out just the squirted out jelly when you do a microdiscectomy, you don't take out everything. The rest of the disc is there. Unfortunately, until that heals up, which can take weeks or even months, there's a risk of that jelly squirts back out. So it really depends on the individual human and what they do. That's why we make you be a little less active to help prevent that.
Joe Cheatle: 35:42 The rate of disc re-herniation can be up to 20% after these surgeries. But again, it depends on the surgeon, it depends on the patient. So it can be as low as three to 5% and as high as 20.
Sanjiv Lakhia: 35:54 3 to 5% is about what I've observed in my patient population that I refer out for surgery. So I appreciate that clarification. Now, moving on, what are some of the rehab or recovery times? Again, let's just use those three types of surgical approaches you mentioned. So for a microdisc surgery, is there a recovery time and do they typically need to miss work?
Joe Cheatle: 36:14 So for microdisc, in general, you go home the same day and most people, depending on what they do for work can go back pretty quickly. Now, again, so my laborers, so a patient that does heavy lifting may be out for even up to three months depending on how bad the disc herniation was and how aggressive of a job they have. But if you have a desk job, oftentimes if you had surgery on Thursday, you're recovering ready to go back on Monday.
Sanjiv Lakhia: 36:41 Awesome. So it's really dependent upon the type of work you're looking at going back to. Is there a longer rehab recovery time for a lumbar fusion?
Joe Cheatle: 36:50 For a lumbar fusion, for sure. And that takes quite a bit longer to repair from because you're trying to get the bones to fuse. From that standpoint, recovery is pretty similar at the beginning where you start increasing activity at a pretty similar rate, increasing walking and being more active. But to go back to this long work, so sitting in a chair can be really uncomfortable for long hours of the day or labor. So oftentimes patients are out for six to eight weeks, even after a big surgery. Again, it depends on the patient and it really depends on their recovery. Some patients are super strong and some patients just require more time to get better because their muscles hurt worse.
Sanjiv Lakhia: 37:27 And I think, some of the points that Dr. Cheatle made earlier about staying fit, eating healthy, those are factors that can play a major role in how long it takes you to recover from surgery. So if you go into a surgery already in really good shape, having good nutritional habits in place, good exercise routine in place, your typical recovery time would be much less than if you had those other challenges to begin with. All right, we're coming towards the end of our interview here with Dr. Joe Cheatle where he's been giving us the lowdown on lumbar spinal stenosis. Joe, are there any new innovative surgical techniques on the horizon for treating spinal stenosis that you can share?
Joe Cheatle: 38:02 The biggest new technique that's really coming out there is robotic surgery. So robotic surgery is just in its infancy in neurosurgery. It's much more well-defined in general surgery and in GYN surgery. But for neurosurgery, robotic surgery is just starting to take off. It looks like robotic surgery is going to help make surgery safer, make surgery smaller, make surgery more efficient for the patients, which is important and it's going to hopefully standardized surgery a little bit more so that every surgeon is able to do exactly what they intended to do, even though there's variations in the patients. So I think in the next five to 10 years, we're really going to see a renaissance in that.
Sanjiv Lakhia: 38:43 That sounds very exciting. Looking forward to learning more about that. And on future episodes, we may have a few other people on who can elaborate on robotics in surgery. And our final question for you today, Dr. Cheatle, do you have any specific take-home tips or helpful tools to recommend to our listeners who may be suffering with lumbar stenosis? Can you give them a little bit of hope?
Joe Cheatle: 39:02 So in general, lumbar stenosis can be quite debilitating, but the vast majority of patients, 95% of patients that undergo treatment, oftentimes nonsurgical treatment can get better and live a normal, happy, productive, aggressively energetic life. It just takes some time and to be patient, do your therapy, and really kind of go through that recovery and most people do awesome.
Sanjiv Lakhia: 39:30 Thank you so much for that. I really appreciate your time today. I know this was a topic that comes up almost daily in our offices and I think you did a tremendous job clarifying in simplistic terms for our listeners, what is spinal stenosis and really how can it be treated from both a surgical and nonsurgical perspective. So I really appreciate your time, Joe.
Joe Cheatle: 39:50 Thank you.
Outro: 39:52 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 carolinaneurosurgery.com.
Sanjiv Lakhia: 00:33 Hello, listeners. Welcome to episode three of Back Talk Doc, the podcast. I am your host, Dr. Sanjiv Lakhia, a physiatrist with Carolina Neurosurgery & Spine Associates with offices in North and South Carolina and predominantly centered around Charlotte, North Carolina.
Sanjiv Lakhia: 00:52 I'm excited to bring to you today a topic that comes up quite frequently in the office. We're going to be discussing spinal stenosis with my friend and colleague, Dr. Joe Cheatle. Dr. Cheatle comes to us from Nebraska where he's had his residency, but he's also been in training in the coast of the Carolinas before he came to us this fall. We've been very blessed to have him in our practice and I would consider him to be an expert on the topic of neurosurgery and lumbar stenosis in particular.
Sanjiv Lakhia: 01:22 So today we're going to get started with Dr. Cheatle. I know if you're listening today in your car or at home, your time is valuable and so is ours, so we're going to get right to it and try and get you with some good information that helps break down a complex topic. So, Joe, welcome to the show.
Joe Cheatle: 01:36 Thanks, Sanjiv.
Sanjiv Lakhia: 01:38 All right, Joe, why don't you go ahead and talk to us a little bit, share with the listeners your background with regards to your upbringing a little bit and your medical training if you can.
Joe Cheatle: 01:46 Yeah, for sure. Like you said, I'm from Nebraska. I still call Nebraska home. I was actually born in Oklahoma but raised for most of my life in Nebraska. I did my training there, both undergrad med school and residency at the University of Nebraska. And then after that I left and came to the Carolinas.
Sanjiv Lakhia: 02:05 All right. Tell us a little bit about your experience before you came to Carolina Neurosurgery & Spine Associates. I know you were in practice out in the coast of the Carolinas where you saw quite a bit of cases and really built up your skillset.
Joe Cheatle: 02:17 Yeah, so I was in practice on one of the beach towns in South Carolina and was one of two neurosurgeons in a about a million-strong city. So we were pretty busy, too busy actually. And so I saw, I mean a ton of patients and really got to build a pretty strong practice there.
Sanjiv Lakhia: 02:34 Dr. Cheatle is very humble in sharing his background and upbringing. He really, really is able to handle almost anything that comes our way, which makes him highly qualify for our topic today. But before we jump into discussing spinal stenosis, share with our listeners a little bit about what sparked you to go into the field of neurosurgery.
Joe Cheatle: 02:53 I was a third-year med student and I was on the neurosurgery rotation, which I was begrudgingly on. I did not want to do that. I was stuck on that because it was the hardest rotation. And so I got my last pick. So I was on rotation. It was my second day and we had a guy fall off actually an overpass. They were building an overpass in Omaha and he had a huge subdural, which is a bleed between the surface of the brain and the brain itself. And so we took him immediately to surgery. We did this really awesome craniotomy and I saw the brain pulsating for the first time. So the brain, for those of you guys who've never seen this, but the brain actually pulsates with every beat of your heart so you can see the beat of your heart in your brain. It's one of the most amazing things. It completely changed my life. And I knew right then and there that I was going to do neurosurgery.
Joe Cheatle: 03:40 So I started going to every conference. I went to national conferences, I went to every single journal club and every morning conference. I'd wake up early in the morning before my rotations and started going to that and just kind of made myself known and then I became a neurosurgeon.
Sanjiv Lakhia: 03:55 That's an amazing story. It really illustrates how there are moments in our life, which can really be game-changers for us and direct us along a path that we can really fulfill our dreams and help people out. And certainly you've done that. Help us also get to know you a little bit better. What are some of your personal habits? Joe, for those who don't know you, I would call you very energetic, a very positive person. Well, what are some of your personal habits that you rely on to promote wellness and keep your spine healthy and strong?
Joe Cheatle: 04:28 So that's actually changed over the years and neurosurgery training is highly intense and you basically do nothing but neurosurgery for seven years of your life. And so as I got through that and started practice, which is harder than residency, I kind of looked back and I decided that I'm not taking care of myself and I need to do that because I'm going to do no good to anyone by being sick. And so I started to basically make a daily regime and I've changed the habit. And that's really the hardest part is habits are hard to form and incredibly hard to break.
Joe Cheatle: 05:03 And so I now wake up every morning, I religiously go to the gym. I work hard. My goal is to try to do something and work hard. I know some days are better than others. Some days I'm really tired. I was on call the night before or I had a really hard case, but I try every day to try to do something for myself to make myself stronger. I do weight lifting or running or swimming or biking or a combination of all the above. I really like to do it if I can with my wife, which is the most fun when we can do something together. She loves yoga. So we do that sometimes, but something every day, at least five days a week, hopefully seven days a week where I take care of myself, exercise, get out there and try to be a little bit stronger than I was the day before.
Sanjiv Lakhia: 05:43 That's terrific. On Back Talk Doc, I cover a variety of spine topics, but I'm also heavily interested in health and wellness and sharing tips with our listeners. So I think if you're listening out there, take-home point is establish a routine. What Joe just described works for him. It gives him energy, it fuels his day, and it prepares him for the challenges that he faces.
Sanjiv Lakhia: 06:04 So if you can do that for yourself, whatever it is, whether it's a little bit of light exercise, a little bit of meditation, really supercharge your day in the morning and it'll set you on a path towards success for the rest of the day. All right, thank you for that, Joe. Let's get into spinal stenosis and I'm sure as your clinic is similar to mine, it's one of the most common conditions that we come across that patients are referred to for evaluations and treatment in our office. And I find that there is a times a lack of even simple understanding of the condition. Let's start with the term stenosis because it's thrown out there a lot in medicine. There's spinal stenosis, you can hear carotid artery stenosis, fascia stenosis. What exactly is stenosis?
Joe Cheatle: 06:47 Great question. And you're right, people ask about that all the time. And so stenosis basically means narrowing. And so specifically for spinal stenosis, it means narrowing of the spinal canal. So you've got the brainstem, which then becomes a spinal cord as it exits out the main hole in the skull, which is called the foramen magnum. And then there are vertebral bodies, which are the bones that surround the spinal canal and there's discs and ligaments around them. And so stenosis means that for some reason that the spinal canal is more narrow than it should be and that spinal canal diameter so that the width of the spinal canal changes as you go up and down and the stenosis can change based on what happens.
Joe Cheatle: 07:27 So you can have thickening of the ligaments, you can have disc bulges or disc herniations and all those cause narrowing or stenosis of the spinal canal.
Sanjiv Lakhia: 07:36 That's excellent. And again, it's similar to if you have stenosis in a blood vessel, plaque builds up in the blood vessel, it narrows the blood flow and then it can produce symptoms, for example, pain in your calf or foot. So I think that's a great definition of stenosis. What are some common symptoms of lumbar spinal stenosis?
Joe Cheatle: 07:55 So lumbar spinal stenosis can really present in two ways. So you can either have an acute, which means a sudden onset of stenosis or long-term onset of stenosis. For acute stenosis, most people usually complain of a pain and usually the leg, sometimes the back, or sometimes both in a very reproducible area. So oftentimes it's usually one single nerve root that is being pinched. And it's usually narrowing of more than nerve root hole called the foramen on the side.
Joe Cheatle: 08:26 That usually starts pretty suddenly over a day, even sometimes shorter than that. And it can be quite severe pain plus or minus weakness or numbness and tingling. Most people have no significant trauma before that but sometimes they do. And usually it's always in an area that you can describe. So they can say it's on the side of my leg or the back of my leg. It goes down to this area or it goes inside the leg into the groin. That's usually the result of an acute or a new disc herniation.
Joe Cheatle: 08:57 Chronic stenosis is when you have narrowing, usually due to arthritic-type problems. So you have thickening of the ligaments or thickening into the joints and that causes the spinal canal to decrease in size all the way around. And usually people complain of pain more associated with activity. And so usually they say, "When I walk more, I complain of increased pain. When I rest, then my pain goes away. When I start walking again, usually that pain comes right back." It's usually less descript. So it's usually the entire leg and often the back. But not as much in a single what we call dermatomal pattern. In other words along one single nerve root.
Sanjiv Lakhia: 09:38 For those of you that live in the Charlotte area. And that was a great description, but I like to describe it as well as central canal stenosis or stenosis within the canal is equivalent to a traffic jam on I-77 and spinal stenosis involving the nerve root would be an accident on one of the exits coming off the highway. They can both cause somewhat different problems in traffic and can have similar but also at times different presentations clinically.
Sanjiv Lakhia: 10:10 So that's really good and if that's hard to follow, I think Dr. Cheatle did a great job describing that, but we'll put a picture of the spine with some further clarification of that in the show notes for your listeners out there who are more visual learners. Joe, are there differences in presentation between stenosis that develops in the cervical spine or neck versus in the low back?
Joe Cheatle: 10:33 Yes, for sure. So the cervical spine is important in the fact that you have the spinal cord and the nerve roots that go down through the thoracic and lumbar spine as well. The lumbar spine just has the nerve roots for the legs. The cervical spine has the spinal cord as well as the nerve roots that to go to the arms and that are important for balance. So a lot of times people when they have neck stenosis, will complain of similar symptoms in their arms where they have pain along a certain region in their arm, but also sometimes complain of difficulty with balance or difficulty with their gait. And they don't walk as well or they walk to one side or the other or they trip or they are less balanced than they were before. And that's a sign that they have pressure on the spinal cord, which is causing not only symptoms in their arms but along the rest of the nerve root tracks that go down.
Sanjiv Lakhia: 11:24 And that's a good point. Very early in my career, I learned that lesson. I had a patient come in, a older gentleman who had some complaints of weakness in his leg, and ultimately the problem turned out to be coming from his neck. So when you come into our offices at Carolina Neurosurgery & Spine, you're typically going to get a comprehensive evaluation regardless of where your symptoms are located. What factors do you often see can contribute to the development of lumbar stenosis?
Joe Cheatle: 11:52 So stenosis both has modifiable and non-modifiable risk factors. And so the non-modifiable risk factors are basically genetic risk factors. So if you have family members who have spinal stenosis, you're at a greater risk of developing spinal stenosis, and you can't change that. You can't change your family, unfortunately. But for those things that you can change, smoking and drinking are huge and have significant risk of developing spinal stenosis. The other things are decreased activity and weight gain, put extra pressure on the spine.
Joe Cheatle: 12:25 And then also on the other end are activities that put a lot of pressure on the spine. So like laborers or people who do construction and things like that that do something repetitive every day. Just like people who develop carpal tunnel if they type, or they use their hands a lot because of repetitive motion. Repetitive motion happens in every joint and so people who do a lot of heavy lifting on a regular basis have an increased risk of spinal stenosis.
Sanjiv Lakhia: 12:51 What are your thoughts on runners?
Joe Cheatle: 12:52 That's a great question. So as we get more data, there seems to be differences in what our parents told us was bad for us. And people always say runners get bad knees. And there's actually some more recent studies that show that runners actually have better knees than non-runners. Now, the exception to that is people who run ultra marathons or who do hundred mile runs. There is a limit to how much is good and the best idea is always to be moderate in what you do. So running a marathon once or twice in your life is probably no problem. But running six or seven marathons a year or ultra marathons, probably cross that barrier between good and harmful. And so running is good. Too much running can be bad, just like cake is good but too much cake is sometimes bad.
Sanjiv Lakhia: 13:46 That's great. I would agree with that. I've read some research that discusses about a 20-mile a week threshold in terms of the risk of advancing degenerative changes, but it's really not well established. I do think when you're talking about running and back conditions in general, you have to also break it down into someone who has a documented injury on MRI, for example, a hernia to lumbar disc. I think you would have to be a little more cautious with the amount of mileage and pounding you're putting on the spine in that scenario versus just counseling an individual if you're out there and you're relatively healthy with your back. I think following Dr. Cheatle's advice makes perfect sense.
Sanjiv Lakhia: 14:23 And the other consideration, if you haven't had a chance to go and download our second podcast episode where I interviewed Ryan Klomparens on the role of the glutes, he went over some terrific tips for runners on how to prevent back pain and stay strong. So thank you for that, Joe. That kind of plays into our next question. Do you believe spinal stenosis is preventable? I get that a lot where patients come in and say, "Hey, my had it. My mom was in a wheelchair. I'm 45 years old. Is this predestined for me?" And it sounds like you broke it down a little bit into genetics versus environmental. Do you have anything to elaborate on that?
Joe Cheatle: 15:03 There is a genetic component and we know that, you can't change that. That being said, practicing really good health or avoiding smoking, drinking, staying fit and trim. And on top of that, doing when you do do exercise, doing the mechanism correctly. So doing exercises and doing the motion wrong is no better than not doing the exercise to begin with. And sometimes you need help. That's one thing that we do have in this practice is therapists that help us because sometimes you're doing an exercise, but if you're doing too much exercises on the extensors versus the flexors, then you can cause problems. Or if you are overly strong in your legs and not strong in your arms, then you'll oftentimes complain of pain despite the fact that you may be able to squat 800 pounds and you'll still have pain.
Joe Cheatle: 15:53 So I've seen personally professional squatters who did one squat wrong and herniated a disc and felt it and knew it right then and there. So really one of the prevention mechanisms is to do things right and do it correctly. And sometimes you need help to know what to do.
Sanjiv Lakhia: 16:10 And we're recording this podcast just prior to the holidays coming up. And I would definitely piggyback on that. If you're looking to spend a little bit of money on yourself on the holidays, invest some money into a few sessions with a personal trainer or go see a qualified physical therapist to help teach you correct exercise techniques is probably the best form of medicine. And in terms of injury prevention. And that's also, we also discussed that on our last episode as well with Ryan. So again, if you haven't had a chance to download that, I think you would find that to be highly informative.
Sanjiv Lakhia: 16:43 So, Joe, as a neurosurgeon... This is a question I get a lot; as a neurosurgeon, what percent of patients that you're asked to consult on actually end up needing spine surgery to treat their stenosis?
Joe Cheatle: 16:55 In general, I'd say between 85 and 90% of patients can avoid surgery most of the time. My general practice and most of the neurosurgeons that I know, try to find every way to avoid surgery if at all possible. So oftentimes there's medical treatments and then like you, a physiatrist, that really help find ways to avoid surgery if we possibly can. Spine surgery has a negative connotation to it and that's unwarranted because spine surgery can be really helpful, but the problem is is spine surgery, just because you have a spine problem on an MRI, oftentimes doesn't make people better. It has to be very selective and as minimal as possible to help patients. And so the vast majority of my patients ended up not needing surgery.
Sanjiv Lakhia: 17:43 Do you consider pain an indication for surgery?
Joe Cheatle: 17:46 It can be, but in general I like to avoid doing surgery just for pain unless it changes their lifestyle. So if pain becomes so significant that they can't participate in the normal activities that make them happy, then that crosses a threshold. If we can treat the pain with medicines or with injections or therapy, then that's not necessarily something that requires surgery.
Sanjiv Lakhia: 18:08 Our next set of questions, we're going to dive deeper into the treatment options for lumbar stenosis and we will get to that right after this.
Sanjiv Lakhia: 18:19 Welcome to today's health matters segment. For those that know me, I am a big advocate of health and wellness and I hope on each episode to provide some tips that you can take home to further improve your health that are easy to implement in your life, low cost and highly effective. And as we come up on the Thanksgiving holiday, I thought it'd be appropriate to discuss a topic that I practice in my daily routine and that is gratitude. Having a attitude of gratitude or an attitude of appreciation can make a big difference in your overall mental and physical well-being. Now, when we were growing up and in grade school, we always would practice writing a list of what we're thankful for on Thanksgiving. And you may wonder, well, what does this have to do with health?
Sanjiv Lakhia: 19:07 Well, in modern day neuroscience research, there has been a tremendous amount of information provided about the effects of having an attitude of gratitude on your health and wellness. And I like to review with you some information from an article titled The Grateful Brain that was put out by Dr. Alex Korb. And we'll put a link to his article in the show notes. And he goes through a few studies that have been done on gratitude. And I want to share with you some of the information. And one study that was done in 2003, they looked at a group of young adults who kept a daily journal of things that they were grateful for. And then they assigned another group of young adults to keep a journal about things that annoyed them. And they compared kind of how these approaches affected them on a day-to-day basis.
Sanjiv Lakhia: 19:56 And it turns out that the young adults assigned to keep gratitude journals showed greater increases in determination, attention, enthusiasm, and energy compared to the other groups. And what this really illustrated is that having an attitude of gratitude can affect your mindset on a day-to-day basis. Now, what is gratitude? They define gratitude as requiring an appreciation of the positive aspects of your situation; not a comparison of what else is going on for other people.
Sanjiv Lakhia: 20:26 The second group of individuals that were studied was adults. And in this study, the adults were assigned to keep a weekly gratitude journal. So documenting once a week about the things they were appreciative about showed to have benefit. This showed an increase in optimism, which is obvious and that makes sense. But remarkably, journaling once a week on the items in your life that make you feel good, that you're happy about also led to changes in behavior. So behaviors such as following through on your exercise program or your nutritional changes. And it also illustrated or a reduction in physical ailments. So this is where it begins to tie in. If you're suffering with low back pain, I think keeping a gratitude journal can be a viable tool. Subjects had fewer aches and pains than those who did not journal.
Sanjiv Lakhia: 21:20 The last study that he reviewed was on keeping a daily attitude of gratitude without journaling. So simply just looking at things throughout your day that you're appreciative for and keeping a mental note of that. And those individuals who kept a daily attitude of gratitude, this had a remarkable effect on several health measures. Number one, they slept better; and number two, they had less anxiety and less depression. So folks, that's quite remarkable that by simply maintaining a positive attitude, it can improve your sleep parameters and reduce your stress and anxiety.
Sanjiv Lakhia: 21:58 So where does this all lead to? Neurologically and in the field of neurobiology and neuroscience, the National Institutes of Health has researched how a gratitude approach to life can affect areas of the brain. And they used technology called a functional MRI. And a functional MRI essentially can identify areas of changes of blood flow within various regions of the brain. And it turns out in a 2009 study, that subjects who showed more gratitude overall on a daily basis had higher levels of activity in the hypothalamus.
Sanjiv Lakhia: 22:32 So what's the hypothalamus? Well, the hypothalamus is an area on the base of the brain that is below the thalamus and above the brainstem. And it is a very important player and tie in with our endocrine system. And the hypothalamus is responsible for controlling a huge list of essential bodily functions, including eating, drinking, and sleeping. And it really correlates with your daily stress levels by its direct effect on your cortisol levels.
Sanjiv Lakhia: 23:00 So by maintaining a gratitude approach to life, you will alter the activity levels in your hypothalamus in a positive way. This also illustrates how improvements in gratitude could have a wide ranging effect from increased exercise and improve sleep to decrease in depression and fewer aches and pains. So it really ties in.
Sanjiv Lakhia: 23:20 And lastly, when you walk around feeling good about life and feeling appreciative, it can affect your neurotransmitter levels, particularly the neurotransmitter dopamine. Most of you may know that dopamine is kind of your feel-good reward neurotransmitter. But what you may not know is that elevated levels of dopamine correlate with initiating action. So that means that increases in dopamine make you more likely to do the thing that you just did or to follow through on healthy habits. So there you go. This is not voodoo science folks, it's real neurobiology and real neuroscience that a simple act such as daily journaling or keeping a positive outlook on life can affect how you feel physically and help you at least cope with your back pain if not reduce it.
Sanjiv Lakhia: 24:07 So how do you do this on a day-to-day basis? I'll share with you two tips. One, there is an app, the Five Minute Journal app, and we'll put a link to that in the show notes that you should download. It's only a few dollars and it walks you through listing about two or three items that you're appreciative for that day and some things that you're looking forward to that day. And then you can even add in a photograph of a loved one. And that's kind of your daily journal entry and that's a simple health habit. It takes about one to two minutes that you can do on a daily basis.
Sanjiv Lakhia: 24:37 If you want to get more involved, I personally like to practice the 6-Phase Meditation and this is a meditation program that has been developed by Vishen Lakhiani of MindValley. And it walks you through almost a guided process for covering topics such as gratitude, forgiveness, and visualization. I'll put a link to his meditation that he has posted on YouTube. It only takes about 20 minutes and it's something that I highly encourage you to look at. So as you approach Thanksgiving this year, I hope you find at least one or two things to be grateful for. I myself am quite grateful that you've taken the time to listen to our podcast and I hope you found this health matters segment to be useful.
Sanjiv Lakhia: 25:23 All right, let's move on into the next set of questions. If you're just joining us, we have a interview today with Dr. Joe Cheatle, a neurosurgeon with Carolina Neurosurgery & Spine Associates, and we're covering the topic of lumbar spinal stenosis from top to bottom. And our initial set of questions so far, we've kind of set the table for our listeners, put out some definitions on what stenosis is, just kind of described how it presents. But now I really want to get into some questions that I get in the office and from friends and family that are very important to them. Number one here at this point, what are your top recommendations to help patients treat their symptoms and avoid or postpone surgery?
Joe Cheatle: 26:02 In general, I think a good working team is what's most important. So having a team of physicians, physical therapists, physiatrists, the surgeon that all worked together to help try to avoid surgery if at all possible. So oftentimes, there's a lot of things that go into making the decision for surgery. And the first thing is have we tried everything that's not surgical. So we can do physical therapy, you can do acupuncture, you can do chiropractic manipulations, you can do injections, you can do medicines. There are so many things to do before surgery becomes an option or something that's even required that oftentimes help avoid surgery and having a surgeon that sits and says, "Wait, there are other things we haven't tried yet. Let's try those first," is often the most important step in avoiding surgery.
Sanjiv Lakhia: 26:51 Can you counsel the listeners on what you think would be a reasonable time frame for a trial of nonsurgical care? Assuming they don't have an acute neurologic issue, a foot drop, something emergent. If it's mostly kind of pain and numbness and decreased functional activity, what do you think is a reasonable time frame? Are we talking about in four weeks, three months, six months?
Joe Cheatle: 27:13 It really depends on the patient and it depends on kind of their personalities. So some patients literally go crazy if they're less active in six days. And so they'll come into your office and they're like, "Doc, I've been down in the couch for like four days. I'm dying," and so sometimes it takes a lot of effort to say, "Wait, wait, let's rethink this. We're not dying. This is not a life threatening situation."
Joe Cheatle: 27:38 In general, I try to go three to six months if at all possible. If they have no neurologic deficit, we have plenty of time. We try to do everything we can. Now, like you said, if they have a neurologic deficit, completely different game, completely different situation. We may try some conservative therapy, but we're much more aggressive on if they have a weakness or if they have significant numbness or if they're having problems with gait or are at risk because of their injury. But in general, for pain only, I try to push it off if at all possible for as long as possible.
Sanjiv Lakhia: 28:11 Dr. Cheatle covered numerous treatment options there that if you're not familiar with them, stay tuned. We're going to have future episodes where we go into things like acupuncture, the research on injections, more information on exercise, approaches to spine conditions because there is a lot of misunderstanding and misinformation and we'll be clarifying that in future episodes. But what he just described is a real comprehensive approach where oftentimes patience pays off. You certainly can improve your quality of life with non-operative care in many situations. But after you've tried that and if things haven't gone your way as a neurosurgeon, what are the indications that you're looking for that really tell you this individual's going to need surgery to address their pain and function from spinal stenosis?
Joe Cheatle: 28:57 That's a good question. Like we said a little bit ago, if they have a neurologic deficit, surgery becomes a much higher and a much quicker option that we're going to.
Sanjiv Lakhia: 29:06 All right, let's clarify that for the listeners. What is a neurologic deficit?
Joe Cheatle: 29:10 Good question. So neurologic deficit usually means weakness and that usually is weakness in a certain muscle group that's traceable back to our nerve root that's injured. And so sometimes it'll be what's called a foot drop, which is weakness of the foot, and you'll see people walking around the mall; if you go to the mall any day of the week, there's at least one person you see that flops their foot down and they usually had weakness secondary to disc herniation.
Joe Cheatle: 29:35 There's other causes. You can have weakness in the hip or weakness in the arm and oftentimes that does require surgery. Now, that being said, my mentor had weakness in his hand and he couldn't operate and he didn't need surgery and ended up doing physical therapy. So sometimes even weakness can result in nonsurgical treatment, but it's something that you need to look at and have surgery as an option if therapy doesn't work or if the injections don't work. But a neurologic deficit basically is usually weakness, numbness or bowel or bladder problems. Now, bowel or bladder problems are one that require usually surgery right away.
Sanjiv Lakhia: 30:13 Pain brings people in to see us and what Dr. Cheatle just elaborated on, emphasizing weakness as a criteria for surgery. And just to clarify for the listeners, we look at weakness on a higher level of importance simply because if it develops and becomes permanent, weakness can translate into permanent functional disability, which no one wants to see happen. So thanks for that clarification, therefore, as Dr. Cheatle.
Sanjiv Lakhia: 30:40 All right, moving forward now. Here we go. We're going to get right into your wheelhouse. Can you break down, in simplistic terms, what are the common neurosurgical approaches to treating lumbar stenosis? And I want you to cover the top risks associated with a surgery and just help listeners understand how risky is surgery and these different approaches.
Joe Cheatle: 31:01 In general, the way I talk to patients about it is we start from the least invasive to most invasive, so the smallest incision to the biggest incision. And sometimes small incisions can be pretty invasive. So the smallest surgery is a microdiscectomy, which that is, is a small little incision on the back. It's a small little opening in the bone of the back called the lamina or the roof of the spine. You move the nerve root out of the way, you take the disc out and you close up. That can be done either through a tube or through small little micro instruments and that's usually a very simple surgery, 45 minutes, home the same day. That has a risk; everything we do has risks. The main risks are going to be spinal fluid leaks and infections. Very, very rarely could you damage the nerve root.
Joe Cheatle: 31:46 And then last but not least the disc could re-herniate out again. A little bit more aggressive would be a laminectomy. So like we said, the lamina is the roof of the spine, so to take off that roof you take out the thickened ligament, you open up the nerve roots a little bit wider, you free up nerve roots on both sides and again that can be done either through a small incision or through a tube. Same risks; bleeding, infection and spinal fluid leak and usually still patients go home that same day or maybe the next morning. Pretty simple surgery, pretty quick recovery as well.
Joe Cheatle: 32:19 Then we talk about doing more complex surgeries; surgeries that include fusions. And so fusions can be done from the front, the side or the back. Every patient is different. Some patients require both. Some patients require rods and screws, some patients don't, and that's a decision that's much more complex to make.
Sanjiv Lakhia: 32:38 Sure. Yeah.
Joe Cheatle: 32:39 Now, those surgeries can be actually really quick recoveries as well, sometimes home that day even. So they can be really good surgeries and even though patients get really scared when you say, "I'm going to need a fusion," in general, those surgeries have much better recoveries than they used to. That being said, again, we do a lot of minimally invasive through small little stab incisions to put in the rods and screws nowadays and patients oftentimes do much better. The difference between those first two surgeries and then the fusion surgery really is going to be instability. And that is where that decision tree is branched, where if you have instability, then you need something to stabilize you and those are where you put in hardware. If you don't have instability, oftentimes you can get away with a smaller surgeries. So instability, the medical term you'll see on your MRI report when you read it at home is called spondylolisthesis. Huge term, but basically it means the bones have started to slip. In other words, the bones are unstable and that requires a more aggressive surgery, but not necessarily a harder surgery for the patient.
Sanjiv Lakhia: 33:44 All right, so Thanksgiving is coming up and you're home talking with one of your family members and they just heard our podcast and they still have questions. So let's drill this down even into more simplistic understanding about risk. So on a scale of 1 to 10 if 10 was the most risk you could have in a surgery and one was virtually no risk, give me the rating for those three surgeries. So first of all, for microdiscectomy, what number would you give it?
Joe Cheatle: 34:17 So for a microdiscectomy, I would say is a two.
Sanjiv Lakhia: 34:19 A two, okay.
Joe Cheatle: 34:20 Very low risk.
Sanjiv Lakhia: 34:21 And then for a lumbar laminectomy?
Joe Cheatle: 34:22 2.5.
Sanjiv Lakhia: 34:24 And then for, now, I know there's multiple different approaches for fusions, but in general a lumbar fusion.
Joe Cheatle: 34:29 So a lumbar fusion, you're talking there's a lot more risk. Probably a five or a six. It's not a 10, which would be open-heart surgery or brain surgery.
Sanjiv Lakhia: 34:36 There we go.
Joe Cheatle: 34:37 But it's definitely more risk because you're doing much more work. You're putting in hardware and so although risks are still incredibly rare, there's a lot more opportunity for risk.
Sanjiv Lakhia: 34:50 You mentioned earlier, there's a risk of the disc re-herniating. Is there documented literature that gives you a percentage risk that we can reference?
Joe Cheatle: 34:59 Unfortunately, the literature is all over the map on that. And the way I describe that is a disc is a jelly doughnut, right? So you've got your doughnut, everybody knows jelly doughnuts, they're amazing and that little area on the back where they put the jelly in the doughnut, you always start eating there. Unfortunately what happens with the disc herniation is you have a weakening of the outside of the disc and then that jelly squirts out. We take out just the squirted out jelly when you do a microdiscectomy, you don't take out everything. The rest of the disc is there. Unfortunately, until that heals up, which can take weeks or even months, there's a risk of that jelly squirts back out. So it really depends on the individual human and what they do. That's why we make you be a little less active to help prevent that.
Joe Cheatle: 35:42 The rate of disc re-herniation can be up to 20% after these surgeries. But again, it depends on the surgeon, it depends on the patient. So it can be as low as three to 5% and as high as 20.
Sanjiv Lakhia: 35:54 3 to 5% is about what I've observed in my patient population that I refer out for surgery. So I appreciate that clarification. Now, moving on, what are some of the rehab or recovery times? Again, let's just use those three types of surgical approaches you mentioned. So for a microdisc surgery, is there a recovery time and do they typically need to miss work?
Joe Cheatle: 36:14 So for microdisc, in general, you go home the same day and most people, depending on what they do for work can go back pretty quickly. Now, again, so my laborers, so a patient that does heavy lifting may be out for even up to three months depending on how bad the disc herniation was and how aggressive of a job they have. But if you have a desk job, oftentimes if you had surgery on Thursday, you're recovering ready to go back on Monday.
Sanjiv Lakhia: 36:41 Awesome. So it's really dependent upon the type of work you're looking at going back to. Is there a longer rehab recovery time for a lumbar fusion?
Joe Cheatle: 36:50 For a lumbar fusion, for sure. And that takes quite a bit longer to repair from because you're trying to get the bones to fuse. From that standpoint, recovery is pretty similar at the beginning where you start increasing activity at a pretty similar rate, increasing walking and being more active. But to go back to this long work, so sitting in a chair can be really uncomfortable for long hours of the day or labor. So oftentimes patients are out for six to eight weeks, even after a big surgery. Again, it depends on the patient and it really depends on their recovery. Some patients are super strong and some patients just require more time to get better because their muscles hurt worse.
Sanjiv Lakhia: 37:27 And I think, some of the points that Dr. Cheatle made earlier about staying fit, eating healthy, those are factors that can play a major role in how long it takes you to recover from surgery. So if you go into a surgery already in really good shape, having good nutritional habits in place, good exercise routine in place, your typical recovery time would be much less than if you had those other challenges to begin with. All right, we're coming towards the end of our interview here with Dr. Joe Cheatle where he's been giving us the lowdown on lumbar spinal stenosis. Joe, are there any new innovative surgical techniques on the horizon for treating spinal stenosis that you can share?
Joe Cheatle: 38:02 The biggest new technique that's really coming out there is robotic surgery. So robotic surgery is just in its infancy in neurosurgery. It's much more well-defined in general surgery and in GYN surgery. But for neurosurgery, robotic surgery is just starting to take off. It looks like robotic surgery is going to help make surgery safer, make surgery smaller, make surgery more efficient for the patients, which is important and it's going to hopefully standardized surgery a little bit more so that every surgeon is able to do exactly what they intended to do, even though there's variations in the patients. So I think in the next five to 10 years, we're really going to see a renaissance in that.
Sanjiv Lakhia: 38:43 That sounds very exciting. Looking forward to learning more about that. And on future episodes, we may have a few other people on who can elaborate on robotics in surgery. And our final question for you today, Dr. Cheatle, do you have any specific take-home tips or helpful tools to recommend to our listeners who may be suffering with lumbar stenosis? Can you give them a little bit of hope?
Joe Cheatle: 39:02 So in general, lumbar stenosis can be quite debilitating, but the vast majority of patients, 95% of patients that undergo treatment, oftentimes nonsurgical treatment can get better and live a normal, happy, productive, aggressively energetic life. It just takes some time and to be patient, do your therapy, and really kind of go through that recovery and most people do awesome.
Sanjiv Lakhia: 39:30 Thank you so much for that. I really appreciate your time today. I know this was a topic that comes up almost daily in our offices and I think you did a tremendous job clarifying in simplistic terms for our listeners, what is spinal stenosis and really how can it be treated from both a surgical and nonsurgical perspective. So I really appreciate your time, Joe.
Joe Cheatle: 39:50 Thank you.
Outro: 39:52 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 carolinaneurosurgery.com.
