I'm Dr. Robert Watkins IV, I went to Vanderbilt for college, came back to Los Angeles, went to USC for medical school and orthopedic residency, I spent nine years at USC at county hospital. And then I spent a year in England training and doing spine surgery in England, a fellowship in spinal deformity, big scoliosis and corrections in England, which was a wonderful experience.
Back pain is a huge problem in America. Everybody has back pain at some point in their lives. Usually it goes away after a week or two, but sometimes it continues to happen and occurs more and more often and really is debilitating, it affects every aspect of a person's life. Part of the fundamental problem is that we're all so healthy now. Human life expectancy used to be age 50. Nowadays we're so healthy that our heart and our lungs last longer, we live until we're 80,90, 100 years old which is great. The problem is our back and our joints start fallin' apart around age 30. So it's this race between how to keep our joints and our back healthy and non-painful while we're living so much longer.
Part of the fundamental problem of the spine is there's so many moveable parts. In your neck you have seven moveable discs, thoracic spine 12, lumbar spine five, and then you have facet joints, for each disc in the front, two facet joints in the back. The spine is a very complex structure, you can see this is a lumbar spine, between here and here this is a real life size model. The disc is a source of pain. The disc is a woven basket that provides stability between the bone so every time you move and bend and twist, motion goes through the disc. 80 percent of all your weight goes through the disc. So, when people get back pain, a flare up of back pain, and they say oh I threw my back out, it's usually because they get a tear in the disc and it hurts just like tearing a muscle or a ligament in your body and then it actually releases acidic chemicals that irritate the nerves. Then you can get sciatica, and get nerve pain. The muscles will clamp down to stop any motion, then you get muscle spasms and everything locks down. But for each disc in the front, you also have two facet joints in the back. And that's where the motion occurs in the back, and this is a joint just like a knee joint or a finger joint, it's where motion occurs, it's innervated.
So if you get an injury to the joint, it'll hurt just like you sprained your knee. You sprained one of these joints and then on top of that you have nerves that come out between, these yellow tube structures of the nerves coming out. So you can injure a disc that then can irritate the nerve, the facet joint can get overgrown and then pinch the nerve and then you can get nerve pain. So between here and here in the human body, you have about 20 structures that all can be a source of significant pain. One of the fundamental parts of my job as a spine surgeon is to identify what exactly is the source of pain. Especially if we're going to do surgery, the outcome of the surgery depends on our ability to know what's causing the pain.
When a patient first comes to see me in the office, the first thing we do is take a history. I talk to the person and find out what's their primary complaint, what's bothering them and then how is it affecting their life, what do they want to be able to do that they can't do because of the pain. And then we also get some signs as to they get more pain standing, or sitting, or walking, what provokes the pain gives us some ideas to what is causing the pain. When you flex forward and rotate, you load the discs more, and so that can provoke disc pain. When you lean back, you load the facet joint, so that may provoke facet joint pain more, or a stress fracture in the back if you lean back it can provoke pain from stress fractures which a lot of young athletes get. If they get pain while they sit and it goes down the leg, it's more typical for nerve pain. The next thing we do is the physical exam, it helps us determine what is their deficit, do they have a neurologic deficit, do they have weakness or numbness. It also tells us do they have nerve tension.
So diagnostic studies in our business are very important because we have to identify what's the source of the pain? The first study we get is a plain x-ray, and we shoot an A/P lateral and flexion extension typically. So plain X-rays tell us about the bone anatomy, the alignment, is there any collapse of the disc spaces, is there any shifting of the bones in relation to each other. When you get degeneration, it can develop instability 'cause the disc and the joints aren't holding the bones in proper alignment which can pinch the nerves more. We shoot flexion/extension x-rays to see if there's any dynamic motion occurring in between the segments. When you get significant degeneration, you get sloppiness of the disc which can allow the bones to shift in relation to each other and that tells us a lot about what's the underlying problem and is it potentially the source of pain.
An MRI's the most common test ordered all over the world. The MRI is a non-invasive test, you get no radiation from an MRI, or extremely little and it moves around your body and it shows the doctor what is going on inside your body. It's an amazing test, probably the greatest invention in the past 100 years. An MRI shows the soft tissue. So an MRI shows us the disc is soft tissue, it shows us the joints, because the joints have a soft tissue capsule, we can see is it overgrown and hitting a nerve. And the MRI shows us the nerves which are soft tissue. So we can actually see the nerves going through the spinal canal and we can see is there any pressure on the nerve, is there anything pinching the nerve or squeezing it.
A bone scan is a test where they inject a marker into your blood that marks osteoblasts which are bone making cells. And so if you have a crack in the bone or an area of increased stress on the bones from a degenerated joint or a degenerated disc that then is loading the bones. The bone scan will light up this area with increased metabolic activity because the body is trying to heal that area. So the bone scan is a really good screening test to see if you have anything going on in any joint or bone in your body.
From your spine, to your hips to your SI joint, any joint in the body can light up on a bone scan if there's pathology in it.
The EMG or nerve conduction study is a nerve test where they put little needles in your legs or your arms to test the muscles. And it tests the electric signal across the muscles and it tells us what’s the status of the nerves. Are the nerves sending an electric signal down to the muscle and firing the muscle. Sometimes the test can be a bit painful, but it really depends on whose doing the test, and but the test can be extremely helpful to determine which nerve is being effected that's going from your spine down into your leg and it can also tell us do you have peripheral neuropathy. Which is dysfunction of the nerves in your legs themselves that has nothing to do with your back.
The number one thing we're treating is pain. And we can't measure pain, so we get different diagnostic studies such as the X-rays, the MRI, the CT scan, the nerve test, and none of those tests are 100 percent, but they overlap. The more those tests overlap and point to one source of pain, the m-higher the odds are that we know what the source of the pain is and the better the chance the surgery will help that pain.