For more detailed information on spine medicine or if you have specific questions, please contact us at 716-247-5320.
Since the vast majority of spine problems in the back and neck can be treated medically without the need for surgery, it makes sense to start the healing process by seeing a physician who is a Medical Spine Specialist. So when a medical expert is needed to diagnose and treat your spine problem, it is important to see the physician who not only has extensive experience but also continues to learn, teach and network nationally bringing back to WNY the most current treatments. Diagnosing and treating spine problems is what Dr. Geraci has been doing in Buffalo for 35 years. As the pre-eminent expert in Spine Medicine, Dr. Geraci has gained a national reputation in research, teaching and training other medical professionals. Dr. Geraci was the first physician in his field, to focus his practice on medical spine care in the Western New York area.
Getting to the root of your spine problem, in my opinion, involves no short cuts. You should expect to fill out a pain diagram, a complete spine and medical history, get into a gown, (yes, the physician should LOOK at your back!) and have a comprehensive physical examination. Let’s start with a generic question: Where does it hurt? Some answers may surprise you. A patient may say that their tailbone hurts yet are actually referring to their lower back when asked to point to the area that hurts. Where is your tailbone? Where are your hips? How far up and how far down does the spine go? While these may seem like obvious questions, patients, especially pediatric patients, may give a variety of interesting answers since they may not know anatomy. When a patient tells a doctor, they hurt their tailbone (or another specific part of their body), it is ALWAYS helpful to make sure the physician and patient are talking about the same thing. It is important that the patient points to the place on their body where they feel pain or have been injured. Pain drawings are especially helpful as well. They illustrate what the patient feels and where on the body he feels it. There may be numerous imaging studies that may not be helpful or even indicated if the correct body part is not identified. Excess radiation can be harmful! Besides unnecessary x-rays, focusing on the wrong body part can delay treatment, send you to the wrong specialist and cost the patient time and money. Insurance costs will also be adversely affected. Patients – point to where you hurt! Your health could depend on it!
Then and only then, should your imaging be reviewed by your spine specialist. After that, the radiologist’s reports should be read. If any of these steps are skipped, or if any short cuts are taken, you are likely to be seeing a spine specialist who will be influenced before they see you. In general, we do not treat imaging, we treat patients. The history and exam will tell the treating physician how each patient is affected by their spine problem.
During the history we should focus on which body positions (i.e. sitting, standing, etc.) cause your symptoms to worsen or improve. This is helpful because you may have multiple imaging findings (i.e., disc herniations, stenosis, disc degeneration, and normal wear and tear). The only way to know what is symptomatic is to know which body positions cause your symptoms to worsen or improve.
Using cutting edge approaches he has pioneered, Dr. Geraci works to pinpoint the actual source of the problem. Is it an injury? Maybe the way you lift? You could be bending or twisting incorrectly 3,000 – 5,000 times a day without realizing it. Could it be postural? Sitting jobs are just as detrimental to your spine health as jobs which involve lifting and twisting all day long. Could exercise be the problem? Do you leave your seated job and go into a gym and train using seated weight machines? If you do, you need to know that a seated position increases the pressure on your disc more than 50% compared to standing. Using a seated weight machine increases disc pressure 100 – 150% over standing.
By the end of your first visit Dr. Geraci will work with you to identify the cause of your problem and the factors that contribute to it. Through his expert diagnosis and experience as a spine specialist, a long-term treatment plan can be formulated that actually works to improve your health, start you on the road to recovery and reduce the chance for recurrent episodes. Set up an appointment at Geraci’s Williamsville office to begin your road to recovery.
The physical exam should reassure the patient that there are no neurologic deficits, such as weakness, loss of reflex or sensation. Fortunately, only about 3-5% of patients with low back pain and sciatica will present with neurologic deficits. Another important part of the exam is to determine if the patient has a directional preference to movement. What this simply means is, if you present with low back and leg pain, can we find a direction of motion that reduces your leg symptoms toward your back or so called “Centralizing” the pain. Usually the patient will feel worse sitting and bending forward at the waist while standing and better when they bend backward. This is a typical presentation when a disc herniation is present, one of the most common causes of low back pain and sciatica. The most effective medical treatments include exercises that centralize your leg pain toward your back. Bridges and planks that build strength and endurance while not placing a high load on the injured tissues. Mobilizations and manipulations have been shown to be most effective in the first month from onset of symptoms and when symptoms are not below the knee level. Other commonly used treatments, but that carry a low success rate, are traction, acupuncture and massage.
If imaging is not done when you see your spine specialist then there are very specific indications when this should be ordered. If there is any weakness, in particular, progressive weakness, loss of bowel and/or bladder function or any “red flags” or a reasonable period of time for medical treatments to have been tried, then imaging is indicated. These so-called “red flags” include a history of cancer, unexplained weight loss as well as urinary retention, weakness or loss of bowel and/or bladder function.
Once imaging has been ordered, it should confirm what our history and physical exam has already told us – the most likely diagnosis. This information will help to guide the patient’s best options for treatment. Failure to respond to the most effective medical treatments such as exercise, mobilizations and manipulations then imaging and more invasive treatments may be indicated. Epidural steroid injections performed under fluoroscopic (x-ray) guidance with contrast (x-ray dye) enhancement should be considered. Blinded injections without these benefits carry a much lower success rate and should not be done any longer now that this simple and safe technology is readily available. A trial of oral anti-inflammatories, oral steroids as well as pain medications and muscle relaxants have a limited role and often help temporarily when exercises are not enough. A recent study from the Netherlands stated that after 1-3 Epidural Steroid Injections 78% of patients then benefited from exercise avoiding surgery.
The indications for surgery are very clear. If the patient presents with progressive weakness, loss of bowel and/or bladder function or failure to respond to medical treatments such that your lifestyle and work status is unacceptable to you then surgery should be considered. Surgery, when indicated, is only one step in the rehabilitation process. Studies now confirm that patients who receive physical therapy after surgery will do better in the long run than those that do not. Interestingly less than 10% of spine problems require surgery. In my practice only 2% required surgery. Surgery for a disc herniation carries a high success rate and with microdiscectomies available, much of the normal anatomy of the spine is preserved. When fusions are considered or artificial disc replacements are offered, the indications and results are much less predictive with a higher complication rate as well. Lumbar Disc Replacements are no longer recommended by the North American Spine Society Guidelines for Treating Lumbar Spine Disorders.
A step-wise approach is always prudent. It is generally thought that medical treatments may take a little longer to improve your disc herniation but will still restore you to function within a reasonable period of time.
Why in medicine do we have so many terms to describe the same thing? Is it frustrating as a patient to hear that you don’t have a “disc herniation” you have a “disc bulge” from 2 different clinicians while the radiologist’s report called it a “disc protrusion or extrusion”?
Not uncommonly treatment is diverted by clinicians based on the confusion, lack of understanding or just plain misunderstanding of this medical terminology. I will give you my humble simplification of these terms:
A normal physiologic or age-related rounding or flattening of the disc cartilage. Capable of causing some mild numbness, tingling or pin and needles but no pain.
A pathologic condition where the center nuclear material migrates through the cartilage seen most commonly over a prolonged period of repeated flexion and/or rotation movements. Capable of causing back and/or leg pain. This occurs as enzymes are released from this center nuclear material and less commonly, in fewer than 5% of patients, weakness. An estimated 40% of people who never had back or leg pain will have a disc herniation on an MRI scan. Types of disc herniations:
All 3 of these above terms are forms of herniations whether the term herniation appears or not on a radiology report.
The following terms in spine care are misleading and do not describe how discs herniate: Disc Rupture and Slipped Disc.
First, discs do not rupture nor slip. When a disc herniates the nucleus (inner 2/3) it has to “worm” its way through the cartilage (outer 1/3 of the disc that is called the anulus) most commonly from repeated flexion and/or rotational movements.In fact, it takes about 25,000 repeated flexion movements to herniate a normal disc. So why does it seem that you have symptoms of low back pain after a simple movement of bending forward (flexion)?As the nucleus worms its way through the anular fibers that overlap at about 30 degrees with each of the thousand flexion movements we make every day you don’t feel or know this process is happening. Only the outermost fibers have a nerve supply, so you don’t feel it till it is too late and the nucleus has herniated through the anulus.
Now for the good news. This process, oftentimes, can be reversed by certain exercises. Most commonly with press-ups and standing end range extension. If done correctly at about 10-15 reps every 2 hours while you are awake some studies, by McGill, and others have shown this to be true in both cadaver and human research. Almost all physical therapists, some physicians as well as chiropractors know them well and will give you these exercises as the first line of treatment when you herniate a disc.
This term applied to tears in the cartilage portion of the disc which in some cases is and in other cases is not painful.
A term applied to a narrowing of the spinal canal. When symptomatic, the patient typically will say they are worse with standing and walking and relieved with sitting or forward bending. Don’t be confused if a radiology report fails to contain this term and you see narrowing of the central or nerve canal. This narrowing is another way to say stenosis. Interestingly, by the time we are in our nineties we will all have stenosis on an MRI scan but not all will be symptomatic.
This is a term that will no longer be used in the future as it implies a disease process is present. Most of the time this is thinning of the disc and is a normal process of wear and tear as we age.
Spondylosis (Spondylosis Deformans) is best thought of as normal wear and tear that eventually all of us will have after our 20’s. Not to be confused with arthritis (it does not end in itis). It ends in 'osis' arthritis = spondylitis. With spondylosis there are also reactive bone spurs that help stabilize the bones above and below the disc that is going through the wear and tear. So these spurs, often thought of as a negative, are actually necessary for stability, and not a painful process.
Spondylolysis refers to a fracture of the spine that occurs between a process that goes up and one that goes down on each side at the back of the spine making up the Facet Joints.
Three stages exist:
Spondylolisthesis is a slip of one vertebrae on the one below. Most commonly seen at L5-S1, the lowest level. Multiple types are seen but the 2 most common are:
There are 5 grades of spondylolisthesis based on the percent of slippage: