Dr. Benjamin Cohen: Welcome to get your life back. I'm your host, Dr. Benjamin Cohen. I'm a neurosurgeon who specializes in spinal surgery. Today, we're going to be talking about back pain. We have as our guest Dr. Barry Fabrikant, who is a chiropractor. Most of his patients I think refer to him as Dr. Barry, so can we call you Dr. Barry?
Dr. Barry Fabrikant: I'd like that very much.
Dr. Cohen: Great. Back pain is obviously a very common problem. It's probably the second most common reason why patients visit a physician, but the good news is that 80% of patients with back pain will just have a single episode and very few patients go on to have a chronic pain issue. Most interesting, even though this is a show hosted by a surgeon, less than 1% will actually need surgery. Therefore, most back pain is treated medically. One of the doctors and specialists that treat back pain are chiropractors. Certainly along with physical therapy, pain management, acupuncture and various others, I think that chiropractors tend to be at the forefront of the medical treatment of spinal pain.
One of the things I wanted to mention right up front is it's 2018 and I have patients ask me all the time, "Doctor, I can't believe you're referring me to a chiropractor. I didn't think surgeons liked chiropractors, or that they endorse them." It's interesting, with me, I have a long history of working with chiropractors. During my fellowship a number of years ago, we actually had a chiropractor on our staff at the University of Alabama in the neurosurgeon department. He would basically manage all the non-surgical back pain patients, so, we almost exclusively referred to him.
Then when I came to New York, I immediately started meeting chiropractors and felt very comfortable. I've had a lot of experience with referring to chiropractors back and forth. They refer patients to me and vice versa. Not to say anything against physical therapist because I work with them as well and there's a lot of overlap between the two fields. Perhaps I'll just ask Dr. Barry what chiropractors do and how your field overlaps or differs a little bit from physical therapy, and what unique things you bring to the treatment of spinal pain and back pain.
Dr. Barry: Chiropractic in practice, this is my 38th year in practice. I have practiced so many different techniques and methodologies. I would say that at this point in practice, our focus is herniated disc. Our focus is people who are suffering with psychotic pain, pins, needles, tingling, discomfort, continued discomfort. Our practice has moved from what we did 38 years ago into a practice that is very highly technology-based as well. We have brought in some decompression tables, spinal decompression tables for cervical herniated disc and lumbar herniated disc.
We're getting some tremendous results, very happy with the technology. We've also broadened some technology to help people that are fearful of the older version of chiropractic which is the twist and turn chiropractic.
Dr. Cohen: Cracking your back.
Dr. Barry: Cracking your back chiropractic. Some people find it very satisfying and of course, 38 years of practice we've refined our technique to deliver that in a very effective way but we brought a technology designed to analyze motion in the spine. It's called Sigma instruments, and to make corrections in the spine without any of that twist and turn. It does it with an oscillating precaution.
Dr. Cohen: Everything is so physiological, it's a very-- I've been to your office, I've seen a lot of the sophisticated equipment that you have. When patients basically say, "Look, I don't want them cracking my back or manipulating my back." That's a little bit of an old-school mentality, right?
Dr. Barry: There's fear with it and the older the clientele comes in, the more adverse they are to it.
Dr. Cohen: Right. Let's talk specifically a little bit about back pain. Obviously, there's many causes of back pain. We have mechanical back pain which is mostly related to trauma, closely related to degenerative or arthritic causes of back pain. Then obviously we have things like infections and tumors and things like that; but the more common causes of back pain tend to be musculoskeletal, benign, self limiting. I would assume that most patients that come to see you have some element of that. What's your initial approach? How do you approach back pain?
Dr. Barry: I love that question. My approach is a very posture-based approach. One of the first things we do with clientele is to assess posture. The flow chart I would use in my mind is that the purpose of your skeletal system is to distribute force. When you've lost that center, when you've lost that postural center balance and alignment, then muscles take over but muscles were never designed for that purpose.
People are starting to feel continued muscle stress, muscle strain. Sitting at computers, driving their cars, living the 2018 lifestyle is very stressful on people's skeletal system which is posture-based. If they continue with that and just live with it, it's just a matter of time before it will create a degenerative change at the level of the spine. Disks will start to bulge and herniate, and then you're looking at neurological consequences.
Dr. Cohen: Right. One of the things that I was always taught in spine training was humans want to have their head balanced over their pelvis. That is what we're all sort of struggling to do and we’re probably there when we're 10 or 12 years old, and then as we age we slowly kind of fall forward. We've all seen patients in their 70s and 80s who are quite pitched forward and that hurts, that's difficult to support the body in that posture.
What about imaging? You can look at someone's posture but getting X-rays, MRIs, things like that. At one point when someone comes to you with back pain, do you get imaging right away? Does it depend? Do you treat them for a little while and then get other imaging?
Dr. Barry: First level imaging for us is X-ray. We do something called Motion X-ray in the office whether it's for cervical, neck, spine, or lower back. For us, all of our imaging is standing in the erect posture because so often you get sent out for imaging where you're lying down and you're out of the stress position so you can't visualize some of the real issues people have when they're sitting and standing.
Then we do motion film to see what segments of their spine may be restricted, blocked, not motioning properly. That leads us to our diagnosis and our treatment protocols. If we discover that patients are having neurological symptoms: tingling, numbness, weakness down an arm or a leg then we will probably move up the scale, up the diagnostic scale to the imaging of MRI or CAT scan.
Dr. Cohen: Okay. Most patients that will come to see me will usually have at least an X-ray and often an MRI. What I usually say to patients is there are certain red flags that we'll see in terms of back pain. If somebody has for example fever and severe back pain, we worry about things like an infection in the spine which is called osteomyelitis or Discitis and that could be a serious thing. Sometimes leading to an epidural abscess which can be life or limb threatening.
Those are obviously reasons to immediately refer someone to someone like myself to a spine surgeon. Then also other red flags could be in patients with a history of cancer, because some tumors tend to metastasize the spine. If you have a patient with breast cancer or prostate cancer who suddenly has horrible back pain, then that may be a reason to get urgent imaging and potentially refer for spine surgery. Well, I'm getting the cue that we're almost out of time. This was a great session. Thank you, Dr. Barry and I hope you'll join us again on a future episode.
Dr. Barry: Thank you, Dr. Cohen.
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Scoliosis Research Society American College of Surgeons American Association of Neurological Surgeons Long Island Board of the American Heart Association Section (AANS/CNS) of Disorders of the Spine & Peripheral Nerves
North American Spine SocietyNassau County Medical SocietyNassau County Surgical SocietyAmerican Medical AssociationCongress of Neurological Surgeons