In this short talk, neurosurgeon Irene Say, MD, discusses neck pain, one of the leading causes of disability, delineating the range of age-related degenerative issues that MRI reports typically sum up as “cervical spondylosis.” She clarifies the signs or factors in a patient's history that warrant a workup or a surgical consult, and offers a look at cutting-edge surgical techniques that are providing patients with alternatives to fusion and achieving remarkable outcomes.
Hi, thank you. Thank you to um the entire UCSF Med connection team for um for allowing me the opportunity to speak today. Uh Good afternoon. My name is Irene say, and I'm an assistant professor in the Department of Neurosurgery at UCSF. And I just wanted to take this opportunity to really introduce myself and my practice to you guys. And once again, thank you everyone for your time for taking a part of your day to, to meet me and to learn and review about a topic that can be a major source of, of frustration for patients and and, and for you. And so today's topic is that we'll be talking about about neck pain, neck pain and arm pain. And so its title of pain in the neck modern approaches to cervical spine disease. I don't have any disclosures and just want to take an opportunity to set the stage and to introduce myself and what my general philosophy is. Um and how I approach neurosurgery and patients. And my approach really is focused on the patient and how we can provide the most cutting edge personalized types of surgery to treat spinal conditions and to really help patients restore them to what their definition of an active lifestyle and that can be different for every patient. Um I have patients who range from aspiring or even professional athletes to weekend warriors to even patients who are on the more sanitary side. But for them, their definition of a happy satisfied lifestyle, maybe something different. And the reality is that there's no one size fits all for any patient. And how can we and how can we use the full gamut of the latest surgical technology to provide options to people that maybe maybe not have had options in the past. We all know there's a growing population of um of that baby boomer, even retired retired retirees that maybe now have the time and the resources but feel held back from because of their spine because of their neck or their low back. And so by complex spine surgery, this means a lot of different things. This can range from what we call minimally invasive spine surgery. So how do we accomplish the same goals but minimize blood loss, pain, um need for pain medication. And how do we do that in a minimally way? And that requires different techniques, different tools, things like neuro navigation or computer assisted spine surgery or robotic spine surgery. That is a burgeoning new area of growth where we're using robots to help increase the accuracy, the precision and really ultimately the safety and the chance of a good outcome for patients and things like microsurgery using the microscope. The way I view spine care is that it's really a team sport. Um, neurosurgeons are one part of it, but we all take care of spine patients. We all either know someone who has had a neck or back problem or maybe a patient ourselves and we all work together. And that involves of course, neurosurgeons, orthopedic surgeon's primary care doctors. You guys are on the frontlines, seeing these patients, er doctors, pain management, radiology, neurology, and the list goes on and on to really our, our therapists are nursing physician assistants and we all take care of these patients together. And so the term that really is probably the most common that we hear a lot or read a lot in M R I reports is something called cervical spagnolo sis. And that's really an umbrella term for degenerative hate using that word, but degenerative spine disease or arthritis in her neck. And this can range from anything from an irritated cervical nerve root, almost like c atocha in the neck that can cause very bad arm pain, shooting arm pain, even numbness or tingling, even weakness in the arm. And this can vary on a spectrum between this kind of pain to what we call myeloma Kathy or spinal cord dysfunction. And that's really a more intense kind of almost on the mild form of spinal cord injury where the signals from the brain do not transmit to the, to the rest of the body and that can cause um more detrimental, really life threatening things like the ability to walk and can even paralyze you. This is a cartoon right here of how we really evolved and how we use our neck. And most of us fall on the right hand side of the screen here where many of us who work certain kinds of jobs may not be heavy labor anymore. But we are using stressing our neck in different ways than we used to. And the main goal that I'm just gonna outline here is how do we adapt and how do we treat that? And so really, this ranges from anything from conservative management. So this would be things like physical therapy, medications, activity modification, maybe doing less of a certain activity, you know, massage, ice heat, um, medication, ranging from muscle relaxants to even opioid medications, which we all know is a growing epidemic or even holistic treatments. This can be things like acupuncture cupping. And then on the more intervention on the more, um on the more interventional side, this would be things like selective nerve root blocks. These are things done typically by anesthesia, pain management or physical medicine and rehab. And then on, on my end on the surgery and as, as I kind of see all the different treatments that lead to an appointment with me, um is or things like surgery. And so the most traditional kinds of surgery may involve things like fusions and it's those get a reputation almost like it's the dreaded F word because those can limit motion in your neck by allowing bones in the spine to fuse together. But the technology has significantly evolved over the last decade to even two decades where not all patients have to have these kinds of surgeries where their bones have to fuse together with rods and screws or need more surgery in the future. And so we'll talk a little bit about those techniques today about what are the options? Are there different options and other options of which patients aren't necessarily uh in the hospital for weeks and, and in rehab for weeks, that's probably the most common question that I get is how, how long is the recovery, how disabling the spine surgery? And that's really with the technology and the technique has evolved to allow us to provide those same things, but with less impact, less damage, less side effects to the patient. And so just a little bit about numbers for, for neck pain and, and it's really one of the leading causes of disability. It's hard to separate out between neck and back pain because they're often group together. But combined with back pain can be actually the leading cause of disability claims in America. It is responsible for a lot of this is seems like common knowledge. So I won't belabor this but um it is an expensive expensive diagnosis and has been associated especially chronic neck pain with things like headaches, with things like mental health and, and pain is pain can affect all of those things that affect it. And I don't have that something that everyone knows, everyone experiences personally, that pain really limits your ability to enjoy life and um and be able to carry out in your daily life. So by the numbers just can, um there are a couple of levels that tend to be more effective than others and that C C 56 and C 67. Now there is a growing body of literature that suggests that women tend to have a higher reported incidents of neck pain. Now, that doesn't mean that men don't have neck pain, but at least women are more willing to their reporting it more often and this occurs most frequently, at least by the first time a presentation in our mid forties. This is a pretty, this is a dramatic polarizing picture, but it really shows us how we've used our neck and how it can change. And on the left hand side is probably how most of us in the western hemisphere tend to use our neck. Uh We are with the advent of the smartphone, we are using our neck um in ways and stressing it in ways that may not be as obvious. But over time, you can tell this is a picture here in your upper left hand corner. Using smartphones, patients are coming in with more neck pain for those who are um in a bent posture. And then on the right hand side is a picture of women in the South Sudan. And if you look at a global perspective, patients who live in Africa have a lower reported incidence of neck pain. Now, that may be confounded because of disparity and access to health care. So I would take that with a grain of salt. But just as an example of people have been using their neck clearly, putting a lot of weight on their neck and they're stressing it in different ways. And yet we're seeing in the highest incidence of neck pain in the western hemisphere. This is just an example. This reminds me of uh of a, of a magazine of a celebrity magazine that celebrities really are just like us. Uh And on the left hand side, you may recognize this picture as Peyton Manning. Uh and he famously has had at least two separate neck surgeries that we know of. It's we don't, obviously, I'm not his treating physician, but it has been published that he has had different next surgeon in surgeries. And this is someone who really does need to have on an elite professional athlete level function of his arm and neck. And on the right hand side, a little bit more of a recent picture, you may know this is Katherine Hagel and actress and she's had a cervical disc replacement for, um, for severe neck and arm pain. And so this is a picture of her in a cervical collar, um, after surgery. So, truly, this is something that is not a, it's not a population that only affects one person. This is, this is a very common condition. This is a picture that is, this is not a picture of me and this is not a picture of what I do in surgery, but this is one of the more ancient this is in the level of Hippocrates and the use of traction to correct deformity or abnormal alignments in the spine. And this is not how we treat spine surgery in 2023, but it has just shown how far we have come in understanding what we do. In fact, modern surgical techniques, the most traditional is probably something called a decompression and fusion. And so fusion, like I mentioned is using rods and screws or spacers to help realign the spine and have those, those bones fuse and heal together. Some of the more newer techniques involve moving away from fusion such as motion preservation. And these are things like a cervical disc replacement, something called a laminar plasticity that allows to recreate that, that post your laminate or the roof of the spine. And of course, things like computers and robotics, Cervical disc, Arthur Plasticky. This is an example here where on the left hand side, you'll see an MRI of the cervical spine. And this arrow actually points to a herniated disc at cervical 6 7. And this is a patient, a young patient who worked at a donut shop who had severe pain shooting down the left arm. And it was really disabling her. And to the point where she failed all medical management and that pain was just limiting her ability to eat sleep and, and walk. And this is an example of a patient who she had a cervical disc replacement. And she was a great candidate for that. Because if she had a fusion, there are a lot of studies that show that when patients have fusions that in the future, it can affect the levels above or below that fusion and they may need more surgery in the future. And so this is how the technology has evolved where, where we have been able to provide a surgery that helps to restore that same motion. So people don't lose that motion in their spine and hope and that it won't affect their other levels in the future. This is an in comprehensive list, but really just to give you an idea of the kinds of different devices that have come out in terms of technology, surgical technology, of how we can try to, we're trying to engineer different employees are all implants that go in replacement of your cervical disc. And these try to mimic the disc by really giving us that same stability, but also that same motion. This is a common question that I get in terms of when, when is the right time? What a red flag symptoms for someone who has neck pain and arm pain? Very common question I get from my primary care colleagues and, and really the time to call someone or, or to get studies and investigate this or when p patients have progressive or worsening neck pain, arm or leg pain problems, walking, no new numbness or tingling. And really any history of, let's say cancer, bad trauma or any kind of um any kind of immuno compromised state. So these would be patients who do have cancer um or on chronic steroids and those are patients that could be at higher risk of, of spinal pathology when they say that they complained of neck pain. This is an example of that here. Uh This is a patient, a young patient I have who unfortunately, you know, was an admit was admittedly a drug user and I V drug user and he woke up and had severe weakness in his arms and legs. I'm gonna point out to you if you see my pointer here on the cat scan of the cervical spine that you may notice that two of the bones here. Um So this is a side view. So this is a cervical five and cervical six vertebral bodies that normally look like a square that are destroyed and their, their destroyed and they're putting pressure on the spinal cord. This is an M R I that different kind of study that really shows how much it's putting pressure on the spinal cord itself. And then you'll see that in this picture here. This is a cat scan showing how we were able to reconstruct and restore the normal alignment to the spine. So this is a, an example of a more complex spine surgery in a patient who did have risk factors, red flag symptoms. And thankfully, this patient was able to, he came in almost totally paralyzed. And thanks, thanks because we're able to get him, we were able to get to him so quickly. He is able to walk now and he is almost completely recovered and sober. I had never just one more quick example of a quote red flag symptom of a patient who again, a young patient who came to me for about for a few months telling her primary care doctor that she was having a lot of acting um really feeling off balance, gait, imbalance and pain and numbness and tingling. Sometimes her, her left arm and sometimes even her right leg. And that didn't quite make sense. And so she got an M R E for cervical spine and you'll show here there. Um This is again a side view of her M R I and this right here, if you see my mouse here, you can see this is the spinal cord and this is a problem here. This is a massive, very inside and even outside the spinal cord. And this is a different kind of M R E that shows that really enhancement, avid enhancement right there. And it's on more on the left side. And so you'll see a picture here is an inter operative photo. And this, if you see my mouse here is the mass, what we call it a type of primary tumor called the swan oma. It's inside and outside the spinal cord, probably on the more probably one of the most complex cases that we do in spine surgery that puts a lot of pressure on that spinal cord. And she was also a really great outcome, you know, she recovered a lot of her function and she actually did need a instrumented fusion surgery because of the really the the destruction from this kind of tumor. And then this is a video that I'll briefly kind of show this is a different kind of tumor. And this is a tumor that is involving the inside of the spinal cord itself. Again, one of the probably most delicate complex surgeries we do. This is under the microscope. This is a tumor here being peeled away from the spinal cord. This has to, this takes painstaking really delicate micro dissection. And this is something that, you know, we know can be a different set of driven kinds of tumors. But the more we're able to take out safely. It involves a lot of different services. Um And, and thankfully, this patient also had a really a really great outcome. Okay. And then just to close out in terms of the different kinds of when do you need to contact, when should I contact a spine surgeon? And I just want to preface this by saying that my personal approach is I don't feel bothered and I don't feel bothered when someone calls me about a potential problem with the patient because I know that this is what we're here for. We're here to help you. And if you have a patient that you're worried about that has neck pain or arm pain or losing function in their arm or difficulty walking, I think that that's your calling me. And I don't feel bothered by that you're calling me because you need help. And some of the highest yield studies are usually an M R I of the cervical spine. But even in X ray sometimes can be very helpful to, to see if there's any what we call abnormal motion in the spine. But an M R I S fine without gadolinium. So without contrast is probably the most, the most helpful for most patients. If they have a history of tumor or they have a history or possible of possible infection, then those patients would benefit from having what we call gadolinium. So M R I C spine with or without gadolinium, if they have those um those potential issues and just a plug for I am based in San. I'm a neurosurgeon here at UCSF and I am based out in the South Bay in San Jose. I also see patients at our main campus in Parnassus in San Francisco. And part of my team in San Jose involves both um a brain tumor specials. That's Doctor Toyota and my vascular neurosurgery neurosurgery colleague, Dr Daniel Raper who covers things like aneurysms and stroke and arteriovenous malformations. And we are building out a practice there on behalf of UCSF and this is a bit of my contact information here. I'm gonna show it to you in a bigger format. Just one in the next slide. This is my contact information for San Jose and I have clinic every week there. And below is my, the best, my best clinic information. And then in San Francisco, I'm have a clinic at the Spotting Center at Parnassus.