A: I’m a general endocrinologist, a specialist in diagnosing and treating health conditions related to problems with the body’s hormones. I focus on obesity medicine, which is its own field of medicine now. It’s growing fast, and there is now a fellowship (specialized training) in this subspecialty. If someone has concerns about their weight, they can talk to a specialist about their concerns.

It’s important to discuss how we define and measure obesity in the medical field because it is complicated. Body composition is the percentage of fat, bone, and muscle in your body. The most accurate ways to measure body composition are complex, such as submerging someone in water and measuring how much water is pushed out of the way. We can use air rather than water to measure body composition in a process called air displacement plethysmography (ADP). We can measure human body composition with dual-energy x-ray absorptiometry (DXA scan) — commonly used to measure bone density. However, water displacement, ADP and DXA scans take a lot of time; we can’t do them in the office, and they’re not covered by insurance.

Healthcare providers most often use BMI or body mass index, which is a calculation that uses weight and height. You may have seen these charts. You may have also been told that you have a high BMI that indicates obesity. That’s not always true. There are people with high BMIs that are healthy and people with lower BMIs that are unhealthy. We define the term “obesity” as an increase in body fat that impairs health.

Fat mass, body composition and family history can all affect your health. So, I would like to look beyond body mass index. Because measuring obesity and fat mass is complicated in practical terms, we can instead measure the extent of obesity (called “staging”) the way we do other medical conditions. To do so, we ask: Are they experiencing complications related to high BMI?

We can assess somebody’s obesity by looking at existing medical and mental health issues, as well as their ability to perform daily activities. This method is called the Edmonton Obesity Staging System:

Stage 0: There are no medical, mental or functional health problems related to a high BMI.

Stage 1: Patients have mild health complications of high BMI, such as prediabetes, slightly high blood pressure, mild psychological distress about one’s weight or mild functional impairments, such as joint pain.

Stage 2: Patients have health complications related to high BMI, such as diabetes, high blood pressure, osteoarthritis, or back pain.

Stage 3:   Patients have organ damage due to health complications related to high BMI, such as kidney damage from diabetes and diabetic neuropathy. We may also see mental depression or the need for joint replacements.

Stage 4:   This is the end stage of the disease. Patients need to use wheelchairs, potentially have congestive heart failure or require dialysis due to complications of obesity and diabetes.

If you have any concerns about your weight and how it may be affecting your spine conditions, contact us. We are happy to help you find the best solutions available.

• Rekha Kumar, endocrinologist and weight management specialist at Weill Cornell Medicine

This question was answered during the episode of Spine Time called “Is Your Weight Hurting Your Back? How Your Daily Habits Affect Your Spine.” A recording of this webinar held on October 14, 2020, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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Q: I have back pain from scoliosis, but I also have a bleeding disorder. Is it safe to have radiofrequency ablation?

A: Back pain is a common symptom in patients with scoliosis. When pain is not effectively relieved by other treatments such as physical therapy and medication, your doctor may recommend radiofrequency ablation.

Radiofrequency ablation is generally at low risk for bleeding issues, but patients should disclose any history of bleeding disorders and anticoagulant use with their provider to develop an appropriate treatment plan.

Radiofrequency ablation is a minimally invasive procedure, which means it does not require a large incision (a cut in the skin made by a surgeon during an operation), is less invasive than other procedures (such as open surgery), and recovery time is much faster.

Patients taking anticoagulants (medicine to prevent harmful blood clots) or those with bleeding disorders, such as von Willebrand disease, are at higher risk for bleeding during some invasive procedures.

Blood clotting is necessary to stop bleeding from wounds and cuts. Some conditions, such as atrial fibrillation, can cause blood to thicken and clot too quickly. Anticoagulants help thin the blood, so it doesn’t clot as easily. Physicians will sometimes tell patients to stop taking anticoagulant medicine before surgery to prevent bleeding during or after an operation.

When used for scoliosis, radiofrequency ablation works by cauterizing (burning) part of the nerve or nerves in the spine responsible for causing the pain. The physician first numbs the skin on the spine where the treatment will be done. Numbing the skin prevents the patient from feeling any pain in that area during the procedure. Next, a very small cannula (tube) is inserted through the skin and into the spine. A special type of x-ray (fluoroscopy) is used to help the physician see the area better. Heat is then sent through the cannula to burn part of the nerve.

Because the area of the spine treated with radiofrequency ablation is not near any major vessels, the risk of bleeding is low. Your physician will discuss any concerns you have during your evaluation.

The most common question we get asked about radiofrequency ablation is if burning the nerves can cause any side effects, such as problems with moving the legs. The nerves treated aren’t involved with movement; they are mostly responsible for controlling pain, which is why we can do this procedure.

After the procedure, patients experience about one to one and a half years of relief from spine pain. The nerves that cause pain do grow back, but they grow back slower and weaker. We can repeat the procedure for some candidates and provide longer pain relief.

Our experts can give you a complete evaluation. This means we consider all options that may help manage your scoliosis. You want to choose a medical center that will give you individualized care that meets your needs and provide many options so you can choose what is best for you.

Epidural steroid injection is another minimally invasive procedure for treating back pain. This procedure is done by the physician injecting steroid medicine into the joints of the spine. Steroids reduce swelling and help relieve pain caused by swelling. Patients having an epidural steroid injection are evaluated closely to make sure they are not at increased risk of bleeding into the spine.

If you have any concerns about scoliosis or other spine conditions, contact us here at the spine center. We are happy to help you find the best treatment available.

• Kai-Ming Fu, director of spinal conditions and scoliosis, and Dr. Daniel Pak, double-board-certified in anesthesiology and pain medicine

This question was answered during the episode of Spine Time called “Scoliosis: When Is Surgery an Option?” A recording of this webinar held on December 2, 2020, is available on YouTube.

The post Is It Safe to Have an Ablation for Back Pain If I Have a Bleeding Disorder? appeared first on Center for Comprehensive Spine Care.

Q: What happens next when I find out I need spine surgery? How should I prepare?

A: Coming to the decision to have surgery is very difficult for patients. We want to make sure our patients feel comfortable that we are taking really good care of them. Once it has been determined that surgery will benefit the patient and it has been agreed upon that surgery is going to happen, we want them to feel comfortable that we can guide them through the entire process. We want the patient to know what to expect before, during, and after surgery, so they are happy and comfortable afterward.

One of the most important considerations is the urgency of the surgery. The timing depends on how severe the pain is, whether symptoms get in the way of daily life activities and what will work best for the patient. You don’t want to wait too long, but you also don’t want to rush into surgery. Timing the surgery can be challenging because the patient may have other medical conditions that need to be considered.

Patients also need to be medically cleared for surgery. Medical clearance is important because it means the patient can safely undergo the type of surgery planned. The length of surgery is not as much of a concern as the impact the surgery will have on the patient’s body, such as their heart, lungs, and blood pressure.

Part of preparing patients for surgery includes talking about pain management and recovery. We want to talk about the whole process of surgery including post-operative pain (pain after surgery) and what to expect. Pain experienced after surgery is different than the pain before surgery. A lot of surgeries that we do require only a small incision (cut), which generally have less pain than more invasive surgeries with large incisions.

Depending on the surgery, the pain may not be completely gone afterward but may take some time. We help the patient understand what to expect in terms of immediate pain relief and pain that may take time to relieve. Muscle spasms (involuntary tightening of muscles) usually occur two or three days after surgery. These spasms may cause mild discomfort or more intense pain. When patients know what to expect, they are not surprised.

We use a protocol called ERAS (enhanced recovery after surgery), which is based on scientific evidence that minimizes the pain throughout the surgical experience. ERAS helps the recovery go as smoothly and comfortably as possible. We explain what the patient can expect to happen after surgery. Pain is managed during the recovery period with medication and physical therapy.

The type of pain medication is based on the pain and the type of surgical procedure. We usually use several kinds of medication. Patients who go home the same day may only need high-dose ibuprofen or acetaminophen. Usually, they will also have medication for muscle spasms. Patients may also need a neuropathic medication, which is for nerve pain. If needed, we will order low-dose narcotics for more severe pain. After surgery, the patient will be encouraged to sit up, get out of bed and go for a short walk in the hallway with one of the nurses or doctors. Again, depending on the surgery, outpatient physical therapy may be recommended to increase strength and endurance. Patients will receive instructions about activity restrictions, any equipment needed, such as a brace, and when to contact the doctor or surgeon after they are discharged. The goal is to adapt the surgical experience to the patient’s needs based on their individual situation.

When patients are preparing for spine surgery, we will help them learn what to expect from a physical as well as an emotional standpoint, so they are well prepared, and their questions and concerns have been addressed.

– Dr. Roger Härtl, chief of spine surgery, and Dr. Mohammad Piracha, inpatient pain management program director

This question was answered during the episode of Spine Time called “Preparing for Surgery (and Recovering from It.” A recording of this webinar held on September 30, 2020, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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Q: When is a patient a good candidate for a CT scan instead of an MRI?

A: There are several scenarios in which a CT scan would be needed instead of, or in addition to, an MRI.

Often, arthritis or another abnormality is found on an x-ray, and further evaluation with higher-level imaging is called for. CT imaging shows many aspects of osseous (bony) detail better than an MRI.

CT imaging is often the most appropriate first choice in the case of a trauma. A CT is quick; it may take less than two or three minutes to obtain all the images. In comparison, an MRI can take 15 to 45 minutes.

Additionally, CT allows for assessment of spinal hardware integrity, including hardware positioning and loosening. Although most spinal hardware is safe for MR imaging, the metal creates significant artifact (misrepresentations) on MR images, and adequate hardware assessment is nearly precluded.

Some patients experience claustrophobia or have difficulty staying still in an MR machine. While there are many methods we can use to help patients better tolerate the MR experience, such as music, MRI goggles for viewing movies, relaxation techniques, and even anti-anxiety medications, some patients cannot tolerate the time or environment of an MRI scanner. These patients would benefit from getting a CT instead.

Additionally, patients with certain types of implanted medical devices cannot be exposed to the magnetism of an MRI scanner. As a patient, it is especially important to mention to the technologist or radiologist if you have any implanted devices as there are a few circumstances in which a patient cannot get an MR examination. A CT scan can be more appropriate for these patients.

MRIs are much less restricted than they were years 20-30 years ago. For example, many years ago, everyone who had a pacemaker was told they could not go near an MRI scanner. With pacemaker evolution and research, we now know that many pacemaker devices are completely safe for MRIs with proper monitoring. Patients with a pacemaker should only have an MRI in a facility where cardiologists (doctors specializing in the heart) can monitor them. This would typically be at a university-based health care center.

Radiologists (doctors who specialize in imaging) are experts in interpreting medical imaging. They are also trained to help healthcare providers, and patients determine whether an MRI or CT imaging is best. Never hesitate to call the imaging center ahead of time and ask to speak to a radiologist or chief technologist when you have any questions about imaging safety.

– Dr. Gayle Salama, Neuroradiologist and Director of Spine Imaging

This question was answered during the episode of Spine Time called “Neuroradiology: The Marriage of Diagnostics and Intervention.” A recording of this webinar held on September 22, 2021, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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Q: What Are the Connections Between Exercise, Nutrition, and Spine-Related Disease?

A: The main connection is weight. Every extra pound in your belly is equal to almost 7 to 10 pounds of pressure on each of the discs (bones) in your spine. So, if you have even 5 to 10 pounds to lose, that’s 50 to 100 extra pounds of pressure on your spine. Losing that weight will have a direct benefit on your back.

When we talk about disc degeneration and facet joints (the small joints of your spine) having inflammation (swelling and pain), it’s a balance between anabolism and catabolism. Anabolism is cell growth and repair, and catabolism is cell destruction. We know that if you have a lot of inflammation, you have inflammatory cells moving in your body. These inflammatory cells are going to degenerate your discs. This is why we get shorter over time, from degeneration of the discs in the spine.

By reducing inflammation in your body, you will probably prevent some degeneration. Not all degeneration can be cured with diet and may require other interventions, like therapy or surgery. Overall, decreasing inflammation will help improve your spine function.

Remember, not all inflammation is cause for concern. When you have an injury, the acute (short-term) inflammatory response protects the body. It sends cells to where healing needs to occur. Sometimes, inflammation becomes chronic (long-lasting). This happens when the body continues to send inflammatory cells; these cells not only help heal injured tissue but also destroy or damage healthy organs and healthy cells. Inflammatory damage can lead to many chronic diseases that people, especially in America, experience. These include heart disease, cancer, gastrointestinal disturbances, arthritis and spine pain.

Eating a more anti-inflammatory diet tends to provide some protection against back pain. If you eat an inflammatory diet, you are 42 times more likely to have back pain in your lifetime. The difference between an anti-inflammatory and an inflammatory diet is that the inflammatory diet is consistent with what we eat in America, sadly. It’s called the Standard American Diet (SAD). This diet is high in sodas, fruit juices and trans fats.

The anti-inflammatory diet is what we tell our kids to eat. Eat the rainbow, all the colorful fruits and vegetables, and legumes (beans), as well as healthy fats, omega-3s versus omega-6s. Anti-inflammatory diets have been shown to help with neurodegenerative conditions, Alzheimer’s disease, Parkinson’s disease, heart disease and joint inflammation.

Losing extra weight and eating a nutritious diet can help keep your spine healthy.

– Dr. Jaspal Ricky Singh, co-director of the Comprehensive Center for Spine Care

This question was answered during the episode of Spine Time called “What’s Eating at Your Back: How Nutrition Affects Your Spine’s Health.” A recording of this webinar held on January 12, 2022, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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Q: How Do You Diagnose Peripheral Neuropathy?

A: Neuropathy means a disorder of the nerves. Peripheral nerves are found all over the body and down through the arms and legs. When something affects the peripheral nervous system, there could be hundreds of causes.

The most common cause of peripheral neuropathy is diabetes.

Nerves have tiny blood vessels wrapped around them. These vessels supply the nerves with blood. Diabetes can damage these blood vessels. When the vessels are damaged, the nerves don’t get as much blood as they need, causing a variety of symptoms.

These symptoms may include numbness (lack of sensation) or tingling (often called “pins and needles), pain (often a burning sensation) or weakness in the muscles.” These symptoms occur most often in the hands and feet.

When we diagnose peripheral neuropathy, we use a lot of tools. Sometimes, the diagnosis is obvious. Sometimes, the diagnosis is more complicated.

We start by getting the patient’s medical history. Then we complete a physical exam. We check their sensation to touch and temperature. We check muscle strength and evaluate reflexes. These are all ways the nerves send messages to the brain.

When we think someone has peripheral neuropathy we use electromyography (electrical stimulation) to look at how the nerves are working. This way we can see if nerves are damaged, and if so, what parts of the nerves and how badly the nerves are damaged.

Once we have a better idea of what kind of neuropathy is going on, then we often do blood tests. That is when we check for diabetes, thyroid problems, kidney issues, vitamin levels and other tests. We do blood tests to see if there is anything we can treat right away.

The Weill Cornell Medicine Center for Comprehensive Spine Care has experts from many different specialties. We work together to diagnose and treat many disorders of the spine and nerves.

– Dr. Joshua Weaver, neurologist and co-director of the WCM Center for Comprehensive Spine Care

This question was answered during the episode of Spine Time called “Neuropathy: Diagnosing and Managing Nerve Pain.” A recording of this webinar held on January 26, 2022, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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A: Diet is an important part of health, including spine health. Diet and nutrition are also an important part of integrative medicine. When talking about diet and nutrition, the integrative medicine approach begins by asking about goals: How would eating the best diet meet your goals?

Talking about goals changes how you look at your weight or health or whatever issue you’re dealing with.

Integrative medicine approaches diet from a holistic perspective. This means that we look at all parts of your life, whether it’s sleep, stressors, emotional well-being, your physical symptoms, medication you’re taking. We look at everything together. This allows us to focus on your overall health and well-being.

Of course, this takes time. Rather than coming in for a 15-minute appointment to discuss the best diet and sending you home with basic information, we have a longer visit. We talk about your whole life. We get to know our patients on a personal level. We create individualized treatment plans with the help of many specialists — in nutrition, acupuncture, psychotherapy, massage, Pilates, yoga and mind and body.

From an integrative medicine approach, the question “what’s the best diet?” is really a question about how diet impacts your life and how life impacts your diet. Once we understand that, we can then build a plan that will meet your goals.

There are so many diets out there, it can be overwhelming. People try new diets all the time and many fail. There’s really not one diet or one treatment that is going to fix everything for everyone. Diet needs to be personalized to fit with your preferences and your specific culture.

In integrative medicine, we highly recommend an anti-inflammatory diet (similar to a Mediterranean diet). Research shows this diet has the most health benefits and allows more food choices than more restrictive diets. We can apply the basic principles of an anti-inflammatory diet to many different diets, which makes it easy to individualize.

Everything we do is based on evidence and research. We will work with you to develop a personalized plan that will meet your needs.

– Dr. Juveria Abdullah, assistant professor of clinical medicine

This question was answered during the episode of Spine Time called “Integrative Medicine: What Is It and How Can It Help My Back?” A recording of this webinar held on October 6, 2021, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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Q:  Does exercise improve bone quality?

A: Exercise does not improve bone quality, but it does help slow down the rate of bone loss that happens as you age. Exercise also helps strengthen your muscles and improve your balance. The stronger and more balanced you are, the less likely you are to fall and break a bone.

When bones become weak and brittle, it’s called osteoporosis. Osteoporosis leads to a higher risk of a bone fracture (break or crack). It’s a serious public health concern that affects many people, not just those who are older.

Osteoporosis is very common. More than 14 million Americans over age 50, about 80 percent of whom are women, are affected by osteoporosis. More than two million fractures occur every year in the U.S. That’s more than 5,000 fractures a day.

Half of women over age 50 and one in four men will have a fragility fracture in their lifetime. A fragility fracture is a crack in the bone caused by osteoporosis. The most common fractures occur in the spine. Wrist and hip fractures are the next most common types.

Fragility fractures can be serious, and people who get these fractures are likely to get more fractures. When bones are brittle or thin, our own weight or a simple movement like bending can lead to cracked vertebrae (bones in the spine). Once you get one, you’re at high risk of getting another one.

More than 50 percent of people who get fragility fractures do not get back to their daily activities. They often have complications from the fracture that can increase the risk of death. Complications include infections such as pneumonia and blood clots from inactivity or surgery. People who have a vertebral (spine) fracture have a 15 percent higher risk of death in the first six months after the fracture. After a hip fracture, 20 percent of people die within a year.

Unfortunately, exercise is not enough to improve bone quality and significantly reduce the risk of fractures. Improving bone quality requires medication usually prescribed by an endocrinologist (a specialist in endocrine disorders, such as thyroid disease and diabetes). Benefits of exercise include slowing down the rate of bone loss and improving muscle strength and overall health.

At the Center for Comprehensive Spine Care, we are here to answer any questions you have about your spine or bone health. We value you as a patient and will design treatment that meets your needs.

– Dr. Panagiota Andreopoulou, Weill Cornell Medicine endocrinologist

This question was answered during the episode of Spine Time called “Healthy Bones, Healthy Spine.” A recording of this webinar held on November 17, 2021, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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A:  Why is my sacroiliac joint pain worse at night?

The sacroiliac (SI) joint is the joint that connects the hip bone with the sacrum at the base of the spinal column and lies between the large bones of the pelvis. (The pelvis is the group of bones that connects the trunk and the legs.) The SI joint is the largest joint in the body. Strong ligaments around the joint help stabilize it, supporting the weight of the upper body and transferring the load between the spine and the legs. Because its primary function is stability, it’s a very stiff joint and has minimal ability to move. About 15 to 30% of low back pain can be attributed to dysfunction of the SI joint.

Your SI joint can be injured or degenerate as you age and cause low back or spine, pelvic, leg, or buttock pain.

About SI joint pain and sleep, many patients say that it hurts when they move or change positions in bed. Why does that happen, and what are the best sleeping positions to avoid pain?

Motions such as getting up or turning over too quickly may irritate and compress the joint space to cause more pain. To reduce nighttime pain:

• The most important thing you can do is to avoid lying on the side of the affected SI joint. When lying on the painful side, you’re increasing the stress through that joint. Try sleeping with the painful side facing up.
• When sleeping on your side, people often like putting a pillow between their legs to get the body in a more anatomical position (keeping your hips, pelvis, and spine aligned.)
• Lying on your back can be helpful because this reduces the pressure through the SI joint. Placing a pillow underneath your legs can also help relieve some of the pressure on the SI joint.
• Sleep on a supportive mattress that isn’t too soft or too hard. Many patients prefer flexible foam mattresses over coil mattresses and medium-firm or firmer mattresses. Softer mattresses do not provide you with the stability and support your body needs while you’re sleeping.

If you have any concerns about back pain or other spine conditions, contact The Spine Center at Weill Cornell Medicine. We are happy to help you find the best treatment available.

• Jennifer Soo Hoo, physical medicine and rehabilitation specialist

This question was answered during the episode of Spine Time called “Sacroiliac Joint Pain — Getting to the Root of the Problem.” A recording of this webinar, held on December 1, 2021, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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A: Spondylosis is common in young athletes and a common cause of lower back pain in children and adolescents. It is a crack or stress fracture (weakness) in one of the vertebrae, the small bones that make up the spinal column. Spondylosis can occur when there is repeated stress on the lower back, such as a lot of repetitive arching (bending) motions or twisting. Having a background in gymnastics, I had one of these injuries and know how it feels and how frustrating the recovery can be.

Although it can happen among young athletes of any age, we often see these injuries in teens. There are certain sports where it occurs more frequently, such as gymnastics and dance. But we also see them in sports like soccer, where athletes twist to kick the ball and volleyball, where athletes jump and twist to spike the ball. Those are just a few of the sports where spondylosis tends to be common. It’s something that physicians, coaches and parents should keep in mind. So, if a child is having back pain for longer than a month, it’s important to get them checked out for a spinal stress fracture.

For those patients who come to us and their (MRI) diagnostic imaging indicates they’ve got either the beginnings of or advanced spondylosis, treatment depends on the severity of the condition. Treatment differs mainly in the amount of time we spend allowing this part of the body to heal. It’s important to rest the back from repetitive arching or bending, as well as jumping and landing, which also puts strain on the back. You should rest it for a minimum of two to three months, even for a mild case; if it’s a more severe case, possibly closer to six months.

I have found that you do not necessarily have to brace the spine to allow it to rest. However, we sometimes see faster recovery with a brace because it limits mobility. Kids adapt very well to the brace. They find comfort in it, knowing that it will help them heal. They also appreciate that it clearly indicates to their coaches and teammates that they are injured. It’s a good reminder to their coaches to not push them and allow them to rest.

It’s important to catch this kind of injury early and treat it before the child develops a full fracture line. If we diagnose it when the bone is swollen, we can rest it and let it heal without ever breaking fully. This leaves the spine completely intact and less likely to cause issues later as an adult.

If a young athlete comes to us with the beginnings of spondylosis and wants to continue to compete as an athlete, we can get them started in physical therapy and core strengthening right away while they’re resting. We try to develop the muscles around the spine, including the trunk (shoulders, chest, lower abdomen, back and buttocks) muscles. In addition to general strengthening, we also look at form — the specific motions that the athlete might be doing that caused this injury. We want to improve their form so that the back doesn’t keep getting stressed.

If you have any concerns about back pain or other spine conditions, contact The Spine Center at Weill Cornell Medicine. We are happy to help you find the best treatment available.

• Katherine Yao, sports medicine specialist

This question was answered during the episode of Spine Time called “Back and Neck Conditions in Kids and Teens.” A recording of this webinar, held on December 15, 2021, is available on YouTube. To sign up for future episodes of Spine Time, where you can ask questions of our spine specialists, subscribe here.

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