MedStar Health Neurosurgeon Dr. Zeena Dorai on the Latest Treatment for Neck Pain


(upbeat bright music) – [Jamie] Let’s start with neck pain. – [Zeena] Sure. – Neck pain right away and
all of a sudden, what happens, when they come to see a doctor? – Well, I think it’s
important to recognize that most neck pain results
from activities that we do that strain our neck. And some of the more common causes, including like the gentleman mentioned, sleeping the wrong way, poor posture, sometimes if you’re at a desk for hours and you’re starring at a computer and you don’t change the
position of your neck, if you injure your neck, some of you in the
audience may be familiar with the term text neck, the position that we put our neck in when we are on our
mobile devices for hours, which we’re all a little guilty of, puts a tremendous amount of strain on, not just our neck, but our
shoulders and our arms. And so, as a consequence, the vast majority of neck pain
is treated non-operatively. It responds well to muscle relaxants, physical therapy, and then certainly, trying to avoid those stressful positions for the neck in the first place. – [Jamie] Text neck? – Text neck. – [Jamie] Wow, that is something. – You just always want to
maintain a good posture whether you’re working at your desk, whether you’re sleeping at night, you never want to sleep on your stomach ’cause your neck is going
to be in that awkward almost 90 degree position. So things like that can be helpful. – And when does it lead to surgery then? – You’ve probably heard of sciatica. Sciatica refers to pain
or numbness or weakness that goes down the leg generally as a result
of a lower back issue. Well, in the neck, it’s the same. If someone has a pinched
nerve in the neck, they develop pain, numbness, and tingling that travels down the arm. But even if you have that, the majority of people respond well with physical therapy,
especially traction. Steroids are great, either oral steroids or cortisone injections given and so about 70% of people,
even with nerve issues, get better without surgery. But, if someone presents to me
with a neurological problem, weakness, persistent numbness, tingling– – [Jamie] Headaches? – Headaches can be a referred pain center for neck pain, sure. And so if the pain is so intractable and nothing else has
worked, then you should consider a consultation with the spine specialist and you may be a surgical candidate. – [Jamie] Tell us about the
disc replacement surgery you do. – Well, I think before we go there, let me talk about the
more common operation and kind of lead into that because it makes more sense that way. Because the main part of the operation, which we do, hasn’t
changed in in many years. So technology has evolved but the main part of the
operation hasn’t changed. And I think the most important
part of being a neurosurgeon or I would argue a surgeon in general, is patient selection. Who’s gonna make a good
surgical candidate? And, so I mentioned if they
have a neurological deficit or if nothing else worked, then surgery is a consideration. For spine disease, we look
very carefully at an MRI. And when I look at an
imaging study of the spine, I think of two questions: Number one, does this
person need a decompression, are the nerves pinched or
is the spinal cord squeezed, does it need to be un-pinched? And then number two, does the
spine need to be stabilized, does this patient need a fusion, where the bones have to be knit together or instrumentation placed. Now we don’t treat an imaging study, but we certainly evaluate
the imaging study in the context of what
someone comes to see us with. And when this patient’s symptoms correlate with an imaging study, we can generally offer them surgery. So the most common procedure
we do is a cervical fusion. It’s called an ACDF. And that stands for Anterior
Cervical Discectomy and Fusion. It’s a very routine operation, where we expose the spine
through the front of the neck, remove the disc herniation
or the bone spur, most people have a combination of both, and where that disc was we replaced with a graft of some sort and a plate usually to
hold everything together. I use the operating
microscope as you can see for the procedure, we have a state-of-the-art
operating microscope at MedStar Union Memorial Hospital. It affords us, just
excellent, visualization of a very very small area
no more than an inch. The microscope is connected to a screen, as you can see there, so
those who are assisting us can see what we’re doing
and better help us. And these days, some of
the microscopes are even synced with navigation systems that you can sort of use as a GPS for brain and spine surgery. – And how do patients
know that the injections into the neck aren’t working and that surgery is next, how does that come to be? – So, we usually send people to our pain management specialist, who are outstanding for
cortisone injections, and it’s generally a trial of
three injections to the neck, specifically targeted at
the area that’s pinched, and if after the first two injections, there’s no improvement, then generally, surgery
is a treatment option. But if there’s consecutive improvement, we go through all of the injections. – All right, anybody
with pain in the neck? Out there? Anybody want to ask a
question to Dr. Dorai? – [Dr. Dorai] I think we
have a microscopic part of the procedure I can show as well. This is the actual procedure. So what we’re looking at is
what I see under the microscope. Start by cutting into the disc, and this is a very small space. This is about three
quarters on an inch wide. And then the disc gets removed
with these small rongeurs and the metal you’re seeing
are these distracting pins, which are used to pull the bones apart, which gives me a little
more space to work in. And then, these are bone spurs. Almost everyone above the age of 30 develops bone spurs in the neck and probably most other joints. So, we start by removing the bone spurs, getting more space into the disc, and then I cure out the rest of the disc. This is a three millimeter diameter drill that’s used to remove the
remainder of the disc, and even out the end plates. And then now, I’m drilling
those deep bone spurs and these are the bone spurs that cause problems for patients. These bone spurs are the ones that are actually
compressing the spinal cord. So, they’re carefully
drilled off, layer by layer, until the ligament is visualized and now we’re looking
directly at the spinal cord. And I’m just removing a piece of ligament which can get thicker as we age until the spinal cord is
completely un-pinched. So, this whole procedure,
a one level procedure, takes about 45 minutes to an hour. This microscopic part of the procedure takes about 20 minutes, 20 to 25 minutes and now I’m just making sure that the spinal cord is free, nothing is compressing it anymore. Then we have to fill in that space. So that’s the graft we use, we pluck that right into
the disc space void, and we tamp that in gently. And once that’s in place,
that’s what it looks like. So you have the bone above and below, and the graft is where the disc was. And then to secure everything, we use a plate to hold
everything together. – How long did you say this is? A 40 minute operation? – [Dr. Dorai] Yeah, it’s incredible! A one level surgery
takes about 45 minutes. It’s an outpatient procedure,
like a lot of what we do. So most patients either
go home the same day, or elect to stay
overnight in the hospital. It’s pretty well tolerated. – Incredible. And they spend overnight and then they’re good to go the next day? – [Dr. Dorai] They’re good
to go home the next day. We put them in a soft cervical collar for about six to eight
weeks after surgery. – Outstanding. – But this is what the graft looks like. One thing about the fusion
surgery is the plate doesn’t allow that part of
the spine to move right? So, we can do the surgery for
up to four levels in the neck. And the more levels you do, the more rigid the spine becomes. It also is sort of a fulcrum. So when you have a fused
segment in the cervical spine, it can put pressure on
those adjacent levels and accelerate degeneration. So in some patients, like
you mentioned earlier, they’re candidates for
disc replacement surgery. And this is what the disc
replacement looks like. It’s a small graft between the two bones and this graft actually moves
like a normal disc space. So it preserves mobility at the segment and it’s just recently been approved for one and two level procedures. So in some patients who
are candidates for this, it’s a great option. (applause) (soft music)

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