Neck Pain Explained: Disc Herniation, Posture & Treatments with Spinal Consultant Alexander Montgomery

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Welcome to another episode of Move Well, Live Well, Perform Well.
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I am excited to hear to be here today because we've got a return guest, Mr.
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Alex Montgomery, who is an amazing spinal surgeon.
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Alex is a consultant orthopedic spinal surgeon at the Cleveland Clinic in London's Neuroscience Institute and London Sports Orthopedics, and has previously worked as the lead for spinal surgery in Northeast London and Essex.
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As a Glasgow graduate, Alex completed his surgical training in London, followed by a spinal fellowship in New Zealand, where he gained experience treating elite athletes and developed his expertise in minimally invasive techniques.
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He in the past had established the spinal unit at Bard's Health and directed it for around a decade as it grew into quite a large multidisciplinary team, including major trauma, deformity, tumour, and determinative disorders.
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And he was the first in the UK to adopt robotic-assisted spinal surgery.
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Alex has treated a lot of athletes from Premier League footballers to rugby players, British Olympic athletes across cycling, sailing, athletics, boxing, hockey, throw in some professional cricket, ballet, maybe triathlon as well.
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Cirque.
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Sorry?
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And circ to sleigh.
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Yep.
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He's an honorary senior lecturer at Queen's Mary University of London and contributes to multi-center clinical trials.
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Despite being a surgeon, Alex is a really strong advocate of movement-based therapy, Pilates, rehab, and strength and conditioning, helping to reduce the need for surgery, which really is why we love working with him and why he's a great advocate to come and speak to us about neck pain today.
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So, Alex, welcome.
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Thanks for inviting me again.
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So your episode last time was on low back pain and it was very well received just because it was simplified and fairly straight to the point in terms of your approach on how you manage low back pain.
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So if we're looking at sort of neck and maybe a little bit of upper back or thoracic pain, do we feel that this is often hanging around a lot longer in patients?
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Is it that it's closer to the brain?
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So patients sort of report it as more problematic than low back pain.
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Is that ever been?
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I think that's fair.
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Yeah.
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I think people hang on to it for longer because it often presents, you know, especially if you're a desk worker with you know that kind of periscapular tightness, which we all think is all postural.
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You know, it's because we're leaning forward or whatever.
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But actually sometimes it is.
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Uh and then sometimes it's not.
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Yeah, sometimes it's not, as we know.
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One of the most common presentations of nerve compression is that is that periscapular medial scapular pain.
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Exactly, yeah, very common.
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Um, and then that fatigue in the neck, everyone associates with being normal with work.
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Uh so I think you hang on to it for a lot longer.
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And then it's when it maybe gets a bit worse or it interferes with your sport like tennis or you know, whatever you also you're doing that people present.
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Whereas I think low back, um, if if you've got back pain every day when you're sitting at work, then people generally, after a number of weeks, go, okay, I need to see someone generally a physician.
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Yeah.
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Um, so I think people hang on to it for longer.
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And so maybe they action the low back pain a little bit earlier.
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Yeah, yeah.
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There's greater load on the low back, as you know, you know, it's the more of your body, there's only five kilos in your head or whatever.
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You know, if you're in the right posture, something like six or seven times that.
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Um, if you're a if you're leaning forward and you you know you're putting more stress in that area when you're at you know on your laptop at work.
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But um, is it more complicated?
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It's closer to the brain.
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Uh, there are different aspects to it.
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You've got C1, C2, which have a different anatomy.
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Yep.
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Um, there's other associations like headaches, uh, and you know, you can get muscular tightness, which goes into your jaw, goes around your ear, and all sorts of things.
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So people can sometimes get all sorts of other symptoms.
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Yes.
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Uh, and there's a crossover with migraine.
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Yeah.
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And and people often get very alarmed by neck and and and neck pain because it can often produce those headaches, which people sometimes want that reassurance that actually then then they don't have a tumor.
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They don't have something sinister going on, and it's just something more mechanical.
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Is that a feature that you see fairly commonly in a lot of your neck presentations?
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Yeah, I think the thing to establish first is do they normally get migraines?
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You know, some people do get migraines, and yeah, neck pain I think can make it worse if you have migraines anyway.
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Uh, and if you've got neck pain, especially from facet joint or even nerve root irritation, you can get headaches primarily from that, especially in the upper cervical spine around C23, C12, the nerves go up into their head.
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And I think if they have pre-existing migraine, it's it's easier.
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You know that this is an exacerbation because of a bit of neck pain.
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Yeah, yep.
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Um, but if it's primary, it's slightly harder.
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You've got to establish it may be more unilateral.
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Uh it may be that it comes on with neck movement uh in certain positions.
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Um, so yeah, it's some sometimes it's quite difficult, and sometimes you just got to MRI scan the brain and send them to your neurologist as well.
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Yeah, yeah, to rule out.
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Yeah.
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So the anatomy of your cervical spine or your neck is somewhat different to your lumbar spine.
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And as you alluded to, that C1, C2 have you have sort of different anatomy.
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And then you've got your vertebral arteries and your carotid arteries and all sorts of features which add a little layer of complexity that you don't have in your lumbar spine necessarily.
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Yeah.
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So yeah, you've touched on the vertebral artery, so dizziness.
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Yep.
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Uh so some people present, they lift, you know, they extend their neck and then they have they're dizzy.
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Yep.
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You know, sometimes, sometimes that's just, you know, they've got some kind of vertigo, but actually you can get osteophytes or bone formation near the where the vertebral frame is, where the vertebral artery goes, and they actually can just block it off.
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Yep.
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Okay.
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Normally what happens is one side is dominant, as in you get a bigger vertebral artery on one side and a smaller one on the other side.
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If it happens to block off the more dominant one, then you could just pass out.
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Okay.
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So there's quite normal, that's a normal anatomical variation, is it that one side is larger than the other?
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Yeah, yeah.
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Not always there, but often you see when you do a scan, if you look at the axis, oh that one's big, that one's small.
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Yep, okay.
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Um, so uh, you know, fortunately most of the time I don't don't go near the vertebral artery, I don't do brain surgery.
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Yeah.
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But if you are going that way with your burr, which burrs bone, then you know that that's the dominant one.
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Definitely 100%.
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Don't go anywhere near that.
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Yeah, okay.
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And we'll touch on sort of treatments and how you'd you'd you you'd manage some of these necks in a little while.
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So neck pain often I just wonder whether it can feel more threatening some of the time because you you can get those headaches, you can get the dizziness, you can get sort of whether that's um, you know, the vestibular issues as as you also mentioned, but also you know, the visual disturbances that come with headaches or migraines.
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Is it harder to manage than low back pain?
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Yeah, in some ways, because you're thinking about all of those things.
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And I think it's quite the associated symptoms, I think, are more common than you see in the literature, in my opinion.
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Like they say 2.5% of people with neck pain have get headaches as well.
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I might I think your experience might be that it's more than that.
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Uh definitely, yeah.
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Yeah.
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Anecdotally, when we treat, yeah, I I I would assume I would have assumed the prevalence is quite a lot higher than that.
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Yeah, exactly.
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Uh although if you look at people who have pre-existing migraine, there's something like a 15 to 20% chance it'll increase it.
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Um so yeah, there is there is uh there are other things you've got to think about.
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Yep.
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Um and it's sometimes neck pain can be more resistant.
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Okay.
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Uh sometimes I find two treatments.
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It's yeah, it's it's certainly I I think from uh our physio perspective, uh it's often a little bit harder.
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You've got to get the whole balance of of probably quite a bit more tissue work some of the time to unload, but then also um reloading that neck, getting the neck strong again.
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And I this is a something I wanted to touch on with you um because there's this perception that okay, we get the core strong and stabilize that, and that's sort of an integral part of that lumbar spine and that spinal system, but we perhaps as a whole we don't strengthen the neck sufficiently because you know you look at the Formula One drivers or rugby players, and they go through an enormous amount of strength work around the neck to try to build that resilience in their system so they can tolerate loads.
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Yeah, yet we're probably never doing that with normal patients, yet maybe we're missing a trick with that.
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Yeah, I think uh education-wise, the general public know all about core strength.
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Yep.
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I always tell people like, you know, it's like a house.
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You wouldn't be able to build a house with just a a front wall.
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Yeah.
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You want you want to build a back wall, you want to build a roof, you want to build, you know, and a foundation.
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A foundation and a floor.
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Yeah for me, the core is you know, whatever core is, you know, is just the front.
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Yep.
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You've got you know, your foundation, your glutes, your hamstrings, your pelvic floor, you've got your roof, which is diaphragm, yep, and your muscles at the back.
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So it's just one thing.
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But education-wise, everyone knows you need to strengthen your core, but doesn't know that.
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Yeah, yeah.
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If you ask the average person who's never had neck pain, never been through rehab for their neck, you know, how are you gonna improve your neck?
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How are you gonna strengthen?
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They'll probably just say, Oh, you know, maybe some biceps or whatever.
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You know, when you mention the word deep neck flexes, people don't really know what you're talking about.
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Exactly.
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Yeah, when you talk about face pulls and pullbacks, yeah, they kind of know because some people do rowing and things like that.
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But and the effect of thoracic flexion and thoracic extension, lack of rotation.
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Yes, I mean something most people have thought about.
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Exactly.
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And I think that's the key thing for for me when I'm looking at a neck, I'm often looking at okay, right.
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Well, you need a stable base, which is your core, that area first.
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You need really good mobility through your thoracic spine.
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And without that thoracic mobility, you're you're either loading your lumbar spine or or often loading your cervical spine.
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And that cervical spine almost becomes that pivot point.
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Yeah, exactly.
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Um like your classic uh everything about being at a desk and a laptop is bad for your neck because you are flexing your thoracic spine.
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Yep.
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You try and explain to people actually, when you're flexing your thoracic spine throughout the day, your neck is in extension.
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So it's basically like you're looking at the ceiling all the time if you had normal thoracic flexion, because you haven't got normal thoracic flexion.
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Can we differentiate that there?
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We're probably looking at upper cervical flexion there, aren't we?
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Upper cervical extension there, aren't we?
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Yeah, yeah, exactly.
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And and almost lower cervical flexion when you're in that sort of position, aren't you?
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Yeah, exactly.
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So you're possibly hinging over your lower cervical spine, like C5, C6.
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Exactly, most common area.
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And then yeah, jamming up your C2, C three sort of area.
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Yeah, exactly.
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In the same way as you do when you get on a bike, like a you know, turbo trainer or you know, bike where you're super flexed.
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Yep, yep.
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You know, you're basically, I say to people, you're you're bent forward and you're looking straight ahead because you want you've got to look at the road.
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It's equivalent of actually of sitting like this the whole day or for one or two hours while you're on your bike.
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Yeah, yeah, yeah.
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Uh and people ride, don't you?
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Uh I yeah, cycle, not that regularly, but yeah.
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Yeah.
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But um, but yeah, it's it's it's just something people don't really think about.
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You know, people think about oh, you need to have upright posture, whatever, but with your neck, you know, it's it's harder to realize when your neck is hyperextended or forward flexed and extended.
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Yep.
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And there's a lot of static holes that we that we get into with with sort of postural positions and and with our neck.
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And without having that inbuilt resilience in the system and that's support structure, it's quite easy to overload that.
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No, exactly.
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Exactly.
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So I think there's quite a lot of things you have to do that you know people don't really realise.
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Whereas people seem a lot more educated about, oh, I need to get my hips moving, I need to do squats, I'm gonna make bridges.
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You know, they watch Pilates, they go to Pilates and they say they do bridges, single leg stuff.
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You know, people seem more educated in general about it.
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But all they know about posture and sitting is sit up straight.
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It's a lot more comp, you know, that's actually and often what they're doing is hyperextending their lumbar spine.
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Exactly.
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Yeah, yeah, yeah.
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Um, because there's this misnomer that posture, poor posture, and there's you know, a one-size sort of fits all for everyone.
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And actually, lots of the time now I'm actually telling people to slouch a little bit when it comes to their ther uh thoracic or lumberspine because they're hyperextending and they're hyperlow dosing a lot of the time and not actually using the right system to No, exactly.
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When I tell people to go on an exercise bike, you know, they they'll say, Oh what?
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And sit bolt off right.
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It's like, no, well, actually, you know, don't be right flexor as you're hyperextending, just so kind of, you know, don't be too flexed, too extended, just relax into it.
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But also move.
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Yeah.
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You know, not be stuck in that one position for for long periods of time.
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Yeah, yeah.
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You touched on headaches a little bit.
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And I know we're not sort of going down that sort of cervicogenic sort of or neurology with headaches, but what are the sort of structures that can refer into and give you headaches?
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Like your upper cervical facet joints can do.
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Yeah.
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And you can get quite a lot of myofascial pain that that gives you sort of occipital-based and or tension type headaches, can't you?
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Yeah, yeah.
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So so facet joint can give you classic C23, uh, the upper cervical nerve route, C1 to C3, obviously a lot, as you know, a lot less common than C56, C67, C4, five.
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So it kind of goes in order of C56, most common, then probably 6, 7, then 4, 5, then 3, 2, then 2, 1.
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Yep.
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So it's less common, but is that in terms of real structural change that you're seeing?
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Or because I think a lot of the time with these headaches, a lot of the time we're not seeing big structural change, but we might see that those facet joints are bloody stiff.
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And actually they're a culprit of some of the the pain sores, but actually if we scan them, they'd look normal.
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Yeah, no, exactly.
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Sometimes you do see uh like hypertrophic facet more on one side.
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In fact, I just saw one today and she's an EA executive assistant, okay, she's 57 years old.
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And I said, Have you been doing this all your life?
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And she went, Yeah, I have.
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I said, Did you at one point uh answer the phone like this?
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She went, Yeah, actually I did it all the time on the Yeah, yeah, yeah, yeah.
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And so that facet joint on that Okay, yeah, it was hypertrophic because she's been loading it.
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Yeah, yeah, and there's an osteophyte fragment is catching the C3 nervary.
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Okay.
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Uh so that's a classic example.
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But yeah, the my the fascial layer goes all the way up to the skull and down to the trapezial layer, so you can get like you know, that effect of uh the muscle spasm and pain that goes up.
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Yeah, okay.
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Um and you get funny symptoms, and I know this because that you can't really explain because you do injections and they just go away, and maybe it's just a general effect of steroids.
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But I have had people where I've done injections around C3 area and they've got rid of their tinnitus, they've got rid of pain around the ear, they've got rid of pain going up the head.
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You know, like it is funny what and but I always tell them look, I I you know this may well not be associated, and I can't guarantee that particular aspect of your symptoms is going to go away, but it's an amazing amount of time.
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Because I often think about your trigeminal nucleus is associated with with upper cervical stuff.
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Yeah, see one to three.
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Yeah, and you've got this sensory branch which runs sort of to supply.
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So a lot of the time, you know, that upper cervical spine can be a driver of quite a lot of those symptoms.
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Yeah.
00:16:13.950 --> 00:16:16.830
So the nucleus uh it yeah, it links to the trigeminal nerve.
00:16:16.910 --> 00:16:21.389
So often your brain doesn't um trigeminal nerve and you know, obviously from the brain.
00:16:21.470 --> 00:16:25.470
So sometimes your brain can't tell whether that pain is coming from the brain or coming from the C spine.
00:16:25.550 --> 00:16:25.790
Yeah.
00:16:26.030 --> 00:16:29.150
Um, so yeah, it's it's a funny corridor around that.
00:16:29.389 --> 00:16:30.110
Yeah, okay.
00:16:30.350 --> 00:16:33.710
You know, but for us, I think as we always do, keep it simple.
00:16:33.950 --> 00:16:34.269
Yep.
00:16:34.430 --> 00:16:35.470
You know, keep moving.
00:16:35.550 --> 00:16:36.830
You know, what's the best posture?
00:16:36.990 --> 00:16:38.910
Best posture when you're sitting down is the next one, change it.
00:16:39.070 --> 00:16:39.629
Yeah, yeah, yeah.
00:16:39.870 --> 00:16:45.629
You know, 70% of people um, you know, will get better if they just get up and start moving around on a regular basis.
00:16:45.950 --> 00:16:53.070
Get moving, deep flexors, exercise to open your shoulders up, thoracic mobility, you know, let the rest take care of itself.
00:16:53.150 --> 00:16:57.470
Yeah, and if you've still got stuff left over after that, then maybe you need other kinds of treatment, you know.
00:16:57.710 --> 00:16:58.750
Yeah, okay, cool.
00:16:58.990 --> 00:17:02.670
So you've just cracked cracked it on its head just right there.
00:17:02.750 --> 00:17:07.710
So thoracic mobility, deep neck flexor work, some shoulder girdle stuff, and move a lot.
00:17:07.869 --> 00:17:08.190
Yeah.
00:17:08.829 --> 00:17:21.629
Um okay, so in terms of looking at sort of neck pain, we often see lots of quite specific neck pain and people sort of being blocked.
00:17:21.789 --> 00:17:25.069
You know, a common presentation might be a rye neck.
00:17:25.230 --> 00:17:27.069
People wake up and they just can't move their neck.
00:17:27.230 --> 00:17:30.670
That's usually a fairly short resolving thing.
00:17:31.230 --> 00:17:41.470
But when people start getting sort of radiating pain down their arms, we're talking, you know, some nerve root irritation or ridiculopathy.
00:17:42.590 --> 00:17:44.110
Is that most common?
00:17:44.350 --> 00:17:45.950
You mentioned at C56.
00:17:46.350 --> 00:17:48.190
Yeah, C56 is probably the most common.
00:17:48.350 --> 00:17:48.430
Yeah.
00:17:48.670 --> 00:17:50.350
Followed closely by C67.
00:17:50.990 --> 00:17:58.829
Do you think that those levels are most common because so much of our movement tends to hinge over those lower segments?
00:17:59.069 --> 00:17:59.549
Yeah, yeah.
00:17:59.710 --> 00:18:04.670
So just natural shape of the cervical spine, I think most of the force or stress goes through that apex.
00:18:04.750 --> 00:18:04.910
Yep.
00:18:05.069 --> 00:18:06.029
They're at C56.
00:18:06.269 --> 00:18:06.750
Yep, okay.
00:18:06.910 --> 00:18:09.789
Um, unless you have some kind of feature about your anatomy.
00:18:09.950 --> 00:18:10.110
Okay.
00:18:10.430 --> 00:18:15.470
Or or you've, you know, you've held your, like I mentioned that EA who's been like that.
00:18:15.789 --> 00:18:18.750
So over a period of time you've you've loaded yourself in a specific way.
00:18:18.910 --> 00:18:18.990
Yeah.
00:18:19.150 --> 00:18:19.630
Yep.
00:18:20.110 --> 00:18:28.670
And what are the the sort of yellow or red flags that you're thinking about in those sort of presentations?
00:18:29.470 --> 00:18:39.069
Yeah, so um, as you know, um, you know, nerve compression symptoms, whether it's just pain to the shoulder blade or into the shoulder or down the arm or into the hand, pretty common.
00:18:39.309 --> 00:18:39.390
Yep.
00:18:39.870 --> 00:18:43.150
85-90% of people get better after a six to eight week period of time.
00:18:43.309 --> 00:18:43.549
Yep.
00:18:43.710 --> 00:18:47.710
Uh so I wouldn't say that's a panic, but just do the right things for it, anti-inflammatories, yeah.
00:18:47.950 --> 00:18:51.710
Find a physio, keep it moving, you know, keep yourself moving, all that kind of stuff.
00:18:51.950 --> 00:18:56.670
So the kind of things we look for are power loss, weakness, yeah, obviously.
00:18:57.150 --> 00:18:57.309
Yep.
00:18:57.549 --> 00:19:00.509
Uh it's not a dire emergency weakness.
00:19:00.910 --> 00:19:06.509
You know, you've got a we can come on to that in a second, but you've got, you know, kind of four to six weeks to track that.
00:19:07.069 --> 00:19:07.630
To track that.
00:19:07.710 --> 00:19:10.110
And you know, the decent amount of them do get better on their own.
00:19:10.190 --> 00:19:10.430
Yep.
00:19:10.670 --> 00:19:12.670
But it's best being in the system while that's happening.
00:19:12.829 --> 00:19:12.990
Yes.
00:19:13.309 --> 00:19:14.430
Don't sit on it at home.
00:19:14.509 --> 00:19:14.829
Yep.
00:19:14.990 --> 00:19:18.350
Uh see the physio immediately and if he thinks it's significant enough.
00:19:18.590 --> 00:19:21.950
Triceps is quite a sensitive one, and people often don't notice that, as you know.
00:19:22.029 --> 00:19:22.190
Yep.
00:19:22.350 --> 00:19:24.670
Because unless you go to the gym regularly, you don't notice your triceps.
00:19:24.910 --> 00:19:25.069
Yeah, yeah.
00:19:25.710 --> 00:19:29.230
Yeah, because you don't do that on a regular basis at home very much.
00:19:29.470 --> 00:19:33.069
Um, so weakness is then the level of weakness is obviously important.
00:19:33.549 --> 00:19:40.190
If the patient hasn't noticed the weakness and you have, then that's a little bit less important because it's functionally not important for their day-to-day life.
00:19:40.350 --> 00:19:43.950
Because it's it's a bit different to a foot drop almost, because that's really quite noticeable.
00:19:44.190 --> 00:19:44.829
Yeah, yeah.
00:19:45.069 --> 00:19:49.630
And with unless you're a gym goer, yeah, some of the time this is quite subtle.
00:19:49.950 --> 00:19:50.750
Yeah, yeah, yeah.
00:19:50.910 --> 00:19:55.470
I think the important one is is you know, obviously biceps is people will notice that straight away.
00:19:55.950 --> 00:19:58.430
Um and the wrist, I think, is the most important.
00:19:58.590 --> 00:19:59.789
People notice hand function.
00:19:59.950 --> 00:20:00.269
Yeah, yeah.
00:20:00.430 --> 00:20:04.910
You know, you're dropping things, you know, things slipping through your hands, finding typing difficult.
00:20:05.069 --> 00:20:05.230
Yeah.
00:20:05.549 --> 00:20:08.269
Um you know, especially with the numbness and feeling.
00:20:08.750 --> 00:20:11.870
Um so that's um so I think the weakness is important.
00:20:12.190 --> 00:20:12.350
Okay.
00:20:12.829 --> 00:20:19.870
You know, there's good data, uh, you know, particularly in the lumbar spine to show that actually a decent amount of those do get better over a six-week period.
00:20:20.190 --> 00:20:27.150
And the data also shows that if you're gonna do an intervention such as surgery for it, the best time to do it is you know, around that six-week mark.
00:20:27.309 --> 00:20:35.069
Because it outcomes from surgery in terms of improving the weakness, although never guaranteed, starts declining after that sixty-week period.
00:20:35.630 --> 00:20:36.430
Reasonably quickly.
00:20:36.590 --> 00:20:38.350
There are other factors that are involved in that.
00:20:38.430 --> 00:20:41.789
The denser the weakness, the more likely you you're gonna go earlier.
00:20:42.110 --> 00:20:42.430
Yep.
00:20:42.670 --> 00:20:42.990
Okay.
00:20:43.150 --> 00:20:59.950
And how often are you seeing that being driven, say a disc pro an acute sort of disc prolapse versus you know, that hypertrophic facet joint or narrowing, stenotic sort of um area that that is more bony over growth?
00:21:00.269 --> 00:21:06.029
Yeah, I'd be interested to ask other spine surgeons that, because I you probably know I see uh probably a disproportionate amount of younger people.
00:21:06.269 --> 00:21:06.590
Yep.
00:21:06.750 --> 00:21:09.390
Uh, but I also that also see a lot of rugby players.
00:21:09.630 --> 00:21:09.950
Okay.
00:21:10.190 --> 00:21:16.190
Um so I think obviously in the middle-aged older population it tends to be more, you know, stenosis.
00:21:16.509 --> 00:21:18.350
That stenosis, that bony change, yeah.
00:21:18.670 --> 00:21:21.150
Or a chronic degenerate dysbulge in general.
00:21:21.230 --> 00:21:23.390
In the younger population, it tends to be a disc prolapse.
00:21:23.549 --> 00:21:23.710
Yep.
00:21:23.950 --> 00:21:34.670
Except if you're a rugby player, when especially a forward, where even by the age in your late 20s, early thirties, you can get that foramenal stenosis from facet hypotrophy, you know, chronic degenerate dys bulge.
00:21:34.910 --> 00:21:36.829
I mean, they have such enormous loads through the back.
00:21:37.230 --> 00:21:37.390
Exactly.
00:21:37.870 --> 00:21:38.110
Yeah.
00:21:38.269 --> 00:21:47.150
So you can get both, but I think like in general, I would say still So a younger population we're probably thinking more disk-y as a generalization.
00:21:47.390 --> 00:21:55.710
And an older population we're thinking you know, more degenerative change, foramenal knowing narrowing, stenotic type pattern.
00:21:55.950 --> 00:21:58.750
Yeah, I'll tell you even older being like even in your forties, you know.
00:21:58.910 --> 00:21:59.230
Yep, okay.
00:21:59.470 --> 00:22:01.870
In mid-40s is probably more likely to be that.
00:22:02.029 --> 00:22:02.190
Yep.
00:22:02.350 --> 00:22:08.509
Uh, but you know, I've seen I've saw a 70-some-year-old that had chronic genitive disc and a and a acute disc prolapse.
00:22:08.670 --> 00:22:08.910
Oh, really?
00:22:09.390 --> 00:22:09.470
Yes.
00:22:09.789 --> 00:22:09.950
Okay.
00:22:10.110 --> 00:22:11.549
So either either can happen.
00:22:11.710 --> 00:22:11.870
Yeah.
00:22:12.029 --> 00:22:19.470
I think seeing a foramenal stenosis in a non-uh collision sport player who's twenty in his twenties is pretty would be rare.
00:22:19.549 --> 00:22:19.789
Yeah.
00:22:19.950 --> 00:22:20.110
Okay.
00:22:20.430 --> 00:22:28.110
And so with the with the acute dis discs, you're generally giving them time to try and settle because often they do settle in that sort of presentation, don't they?
00:22:28.350 --> 00:22:28.750
Yeah, yeah.
00:22:28.910 --> 00:22:33.150
Eighty five, ninety percent of about eighty five, eighty, eighty five percent will settle within six weeks.
00:22:33.230 --> 00:22:33.470
Yep.
00:22:33.630 --> 00:22:35.470
Uh probably eighty five, ninety percent by four or five.
00:22:35.950 --> 00:22:36.190
Months.
00:22:36.269 --> 00:22:36.430
Okay.
00:22:36.590 --> 00:22:40.350
And then after that, there's still a chance it can settle, but obviously your chances start dwindling.
00:22:40.430 --> 00:22:40.670
Yep.
00:22:41.309 --> 00:22:55.710
And that your uh the way that you would approach management would be okay, pain you manage with with anti-inflamms, meds, physio, appropriate sort of management.
00:22:55.870 --> 00:22:56.029
Yeah.
00:22:56.190 --> 00:22:58.910
And then if there's power loss, you're watching them much closer.
00:22:59.069 --> 00:22:59.230
Yeah.
00:22:59.390 --> 00:23:10.110
And then would it be injections first port of call to see if that restores, or are you talking some surgical intervention possibilities?
00:23:10.590 --> 00:23:12.509
I I most likely wouldn't do an injection.
00:23:12.750 --> 00:23:12.990
Yep.
00:23:13.069 --> 00:23:13.230
Okay.
00:23:13.549 --> 00:23:22.350
Um because you're you're planning for surgery and you know there's Yeah, you don't want to you generally don't want to inject them in that kind of month before surgery.
00:23:22.430 --> 00:23:24.509
You know, if you can really How long do you want to leave that?
00:23:24.750 --> 00:23:25.950
Six ish weeks?
00:23:26.350 --> 00:23:27.390
The weakness, yeah.
00:23:27.630 --> 00:23:34.110
So if let's say someone comes to me at one week and it's three plus out of five, or you know, or four out of five, but functionally weak.
00:23:34.269 --> 00:23:39.230
Um So that's based on the Oxford scale we're talking about here, if was MRC grade.
00:23:39.390 --> 00:23:39.470
Yeah.
00:23:39.630 --> 00:23:39.950
Yeah.
00:23:40.269 --> 00:23:50.990
So if let's say it's one week, I'll get them back to the physio, just say, okay, you can carry on doing your exercises, and then I'll probably see them at four, four weeks, four and a half weeks, five weeks, something like that.
00:23:51.150 --> 00:23:51.470
Yep.
00:23:51.630 --> 00:23:55.069
Um, and if it's improving, it doesn't have to completely improve by that chance.
00:23:55.150 --> 00:23:58.829
But there's but if the trajectory is right, right trajectory, then keep an eye on it.
00:23:58.910 --> 00:24:04.190
Yeah, buying time, you know, tells you that you know there isn't that you know, nerve cell degeneration.
00:24:04.350 --> 00:24:09.390
Um, if it's static or getting worse, then you shouldn't really make a decision at five weeks.
00:24:09.470 --> 00:24:15.789
But I always tell people look, if at any point the next few weeks um it starts improving, then just let us know.
00:24:15.950 --> 00:24:16.190
Yep.
00:24:16.350 --> 00:24:19.390
You know, because it is we are drawing an arbitrary cutoff, yeah.
00:24:19.549 --> 00:24:21.390
Uh depending on how weak it is.
00:24:21.470 --> 00:24:26.430
So if it's you know, if it's three out of five, then I probably would hit it on five weeks.
00:24:26.670 --> 00:24:26.990
Okay.
00:24:27.150 --> 00:24:29.549
Uh, you know, if it's less than that, I'd probably do it sooner.
00:24:29.710 --> 00:24:35.150
If it's three plus four out of five, it's weak, but you know, there is something there, then I'd probably wait the full six weeks.
00:24:35.309 --> 00:24:35.470
Yep.
00:24:35.789 --> 00:24:38.590
After five hundred recovers, it does it after the third week.
00:24:38.829 --> 00:24:39.069
Okay.
00:24:39.309 --> 00:24:44.430
So you've got a window between like three and a half weeks and six and a half weeks where you're watching it.
00:24:45.069 --> 00:24:54.029
But you're saying okay, you don't want steroid injection in those patients that you might need to consider some surgical intervention.
00:24:54.990 --> 00:24:56.829
You want the steroid to wash out of the system.
00:24:56.910 --> 00:24:59.309
Is that a six-week period that you need to wait?
00:24:59.470 --> 00:25:03.630
If if someone's seen someone else and done done a steroid injection beforehand?
00:25:03.870 --> 00:25:04.670
Yeah, it's a good question.
00:25:04.750 --> 00:25:06.670
I don't think there's really any strong evidence on that.
00:25:06.829 --> 00:25:20.829
But if we go back to the vax, you know, when we uh when we were all getting COVID vaccines, um, the the advice based on whatever guide you know evidence there was was an absolute minimum of three weeks in terms of if it's of its immune effect on your body.
00:25:21.069 --> 00:25:25.390
So um I would definitely not do it before three weeks, probably four weeks.
00:25:25.630 --> 00:25:26.190
Yep, okay.
00:25:26.829 --> 00:25:55.069
And you're doing in terms of how you'd manage these type of patients, your treatment approach would be okay, meds, physio, or appropriate sort of treatment, simple offloading exercises, and then as you can, you you start sort of trying to deep neck flexor, reload them, mobilize the thoracic spine, um, activate the muscles to help to provide a bit of support.
00:25:55.150 --> 00:25:55.470
Yeah.
00:25:56.110 --> 00:26:03.150
If that's not effective, you'd then if it's pain, consider it set of injections.
00:26:03.950 --> 00:26:07.710
And you'd be doing what nerve root block most of the time.
00:26:07.950 --> 00:26:08.269
Yeah.
00:26:08.509 --> 00:26:14.430
So it's I think the my first emphasis is always you need to reduce the inflammation and pain, like you said.
00:26:14.750 --> 00:26:22.670
And you know, either with time, because sometimes it just gets better on its own, or with anti-inflammatories, or with a steroid injection, if there's no weakness that you're monitoring.
00:26:22.829 --> 00:26:22.990
Yep.
00:26:23.150 --> 00:26:31.309
Uh the reason for that, as you know, is that A, it's painful, B, you can't activate muscles properly while you know you uh everything's inflamed, the joints inflamed.
00:26:31.870 --> 00:26:34.269
Um and and also the joints stiffen up.
00:26:34.430 --> 00:26:34.670
Yep.
00:26:34.990 --> 00:26:42.990
So in order to make progress, you've got to reduce inflammation so you can mobilize joints and activate muscles, which then gets you on to the next stage, which is activate the muscles.
00:26:43.069 --> 00:26:43.309
Yeah.
00:26:43.549 --> 00:26:48.430
And that, like you said, we said thoracic mobility, deep neck flexes, shoulder girdle work.
00:26:48.829 --> 00:26:56.110
And you know, if they're progressing and pain is improving, then you can move on from bands to like weights and then monitor them from there.
00:26:56.269 --> 00:27:00.029
If the pain's not settling, and it depends on the pain level how long you wait.
00:27:00.190 --> 00:27:05.309
Uh, but let's say for argument's sake, it's they've had it for now, eight weeks, ten weeks, and things aren't settling.
00:27:05.390 --> 00:27:11.630
Um, then yeah, the injection is there to reduce inflammation, swelling on the nerve, try and reduce sensitivity.
00:27:11.870 --> 00:27:15.069
And uh yeah, it's a nerve root block or for raminal epidural.
00:27:15.309 --> 00:27:19.630
And that would be more for your ridicular or arm sort of symptoms.
00:27:19.789 --> 00:27:19.950
Yeah.
00:27:20.029 --> 00:27:20.190
Yeah.
00:27:20.509 --> 00:27:21.230
More so.
00:27:22.110 --> 00:27:30.190
Do you you then consider maybe facet joint injections if it was more neck pain was the feature that just wasn't settling?
00:27:30.430 --> 00:27:30.829
Yeah.
00:27:31.069 --> 00:27:36.750
So yeah, they've got obvious facet pain, which classy presents in extension, and you know, when you palpate it, it's sore.
00:27:36.829 --> 00:27:36.990
Yep.
00:27:37.150 --> 00:27:41.150
And some people just say, look, it's really sore there, and it just goes down the arm.
00:27:41.230 --> 00:27:43.870
And you know, then I'd probably inject the facet joint as well.
00:27:43.950 --> 00:27:44.029
Okay.
00:27:44.350 --> 00:27:50.190
Now, in the way I do that in a kind of oblique position in the theater, it's literally, you know, they're millimeters away from each other.
00:27:50.269 --> 00:27:51.630
So you may as well.
00:27:51.789 --> 00:27:52.029
Yep.
00:27:52.430 --> 00:27:58.990
Um, but yeah, so for aminal lepidril, which is the same as nerve root injection uh and facet block if you need to.
00:27:59.230 --> 00:28:01.150
And then these things can take time, as you know.
00:28:01.230 --> 00:28:05.150
Sometimes it's four or five days, sometimes it's ten days, sometimes it's longer three weeks.
00:28:05.390 --> 00:28:05.630
Yeah, yeah.
00:28:06.029 --> 00:28:10.110
Um, and having done thousands of these injections, there's there's kind of two things you look for.
00:28:10.269 --> 00:28:12.829
It's not just about, oh, has it worked or has it not?
00:28:12.990 --> 00:28:16.990
Uh, because sometimes you get a low flancet effect, which uh gives you pain relief stowed away.
00:28:17.069 --> 00:28:17.309
Yep.
00:28:17.470 --> 00:28:20.190
Then you get an increase in pain, then hopefully a reduction in the pain.
00:28:20.269 --> 00:28:20.590
Yep.
00:28:20.750 --> 00:28:24.670
It's not just about that initial pain relief because sometimes people say, Yeah, it's a bit better.
00:28:24.750 --> 00:28:27.710
But then I started physio and suddenly I could do all these things I couldn't do before.
00:28:27.789 --> 00:28:27.950
Yeah.
00:28:28.110 --> 00:28:30.190
Uh and my physio said, Oh, you couldn't do that before.
00:28:30.350 --> 00:28:31.630
Now you can activate this muscle.
00:28:31.710 --> 00:28:35.870
Now your hips moving better, you know, if you're doing a lumber one or your neck's got better range.
00:28:36.110 --> 00:28:38.110
So it's kind of opening the door for something.
00:28:38.509 --> 00:28:40.029
Yeah, for that rehab pathway.
00:28:40.190 --> 00:28:40.590
Yeah.
00:28:40.910 --> 00:28:51.150
Often because often I will find that okay, patients haven't made a big improvement within the first 10 days, two weeks when we start seeing them.
00:28:51.230 --> 00:29:08.110
And and then as soon as we start getting them moving and and mobile again, whether that just switches on your your active system a little bit better, it starts mobilizing and the computer sort of lets go of that guarding and and and a little bit of sort of protective spasm.
00:29:08.190 --> 00:29:18.190
And you we often see that good improvement from that period of time, whether that's just time, but it seems to correlate with them starting moving appropriately again.
00:29:18.430 --> 00:29:18.910
Yeah, yeah.
00:29:18.990 --> 00:29:20.350
It's around that same time.
00:29:20.590 --> 00:29:26.670
So it's hard to know which one, but all I know is that sometimes obviously they do get quite a significant effect, dramatic effect.
00:29:26.829 --> 00:29:31.950
Sometimes they don't, and actually you need to start the physio and then realize, ah, okay, now this is working.
00:29:32.110 --> 00:29:32.590
Yeah, yeah.
00:29:32.829 --> 00:29:34.670
It's it's the kind of combination, yeah.
00:29:34.990 --> 00:29:36.029
Combination of the two.
00:29:36.670 --> 00:29:56.590
How when when you're talking about um if the if the injections haven't worked for pain, um, because you've then got okay, some power issues in one cohort that okay, might need intervention, and that's probably a separate a separate cohort.
00:29:56.750 --> 00:30:03.230
If if someone's just got persistent pain and you're not able to quieten it down, what are your options then?
00:30:04.190 --> 00:30:06.190
So in terms of ridicular pain, yeah.
00:30:06.509 --> 00:30:07.950
Yeah, I'd go for a second injection.
00:30:08.190 --> 00:30:08.430
Okay.
00:30:08.590 --> 00:30:11.789
Uh and for whatever reason, sometimes a second one just can work better.
00:30:11.950 --> 00:30:12.190
Yep.
00:30:12.350 --> 00:30:15.390
Uh is that just topping up the system a little bit?
00:30:15.870 --> 00:30:19.710
It just needed a bit more anti-inflammatory in the system to quieten it down.
00:30:19.950 --> 00:30:25.950
I don't think there's any evidence of why that might be, but it's almost like if someone's been chronically inflamed for some time, you've taken off the top.
00:30:26.190 --> 00:30:26.430
Yep.
00:30:26.509 --> 00:30:34.990
You know, I don't have any evidence for this, but taken off the top level of chronic inflammation, the next one just gets more rid of the acute inflammation, or sometimes it just works like that.
00:30:35.150 --> 00:30:35.630
Yeah, okay.
00:30:35.870 --> 00:30:37.950
Um and so it's always worth trying a second one.
00:30:38.110 --> 00:30:38.190
Yeah.
00:30:38.350 --> 00:30:44.110
There are lots of people walking around that have no root compression or foramenal stenosis that have absolutely no symptoms.
00:30:44.190 --> 00:30:44.350
Yeah.
00:30:44.590 --> 00:30:46.829
So people say, look, the you the injections are not doing anything.
00:30:46.910 --> 00:30:56.269
You're not taking away the the bony compression, you're not taking away the disc prolapse, you're not, but there are loads of people wandering around who have the same thing as you who have have absolutely no whatsoever.
00:30:56.829 --> 00:31:04.430
Are we talking about sort of 50 to 70 percent of people will have pathology on their MRIs of the neck?
00:31:04.670 --> 00:31:05.549
Yeah, yeah, absolutely.
00:31:05.710 --> 00:31:07.150
I'd say more than that.
00:31:07.309 --> 00:31:12.509
If you're taking 25 to 50 year olds or 70 year old 25 to 70 year old.
00:31:12.829 --> 00:31:16.430
Which sort of suggests that actually you can have a lot of pathology and not necessarily have pain.
00:31:16.750 --> 00:31:17.470
No, exactly.
00:31:17.789 --> 00:31:26.110
And what you're doing with the injections, not changing the structure, but you're changing the inflammatory process around that that area so that you're just dampening that down.
00:31:26.350 --> 00:31:41.950
Because some of the time that's been there, but it there's been a trigger or an event, or your system has just had enough, and that deck of cards has sort of been pulled out, and and that kick starts that sort of cascade of inflammation.
00:31:42.269 --> 00:31:42.430
Yeah.
00:31:42.509 --> 00:31:46.110
And often often it is your immune system that takes takes it over.
00:31:46.269 --> 00:31:56.029
If the scan is exactly the same as it was before, look at again, I talk about COVID, the amount of people that started getting ridicular and back pain and neck pain when they have exactly the same scan.
00:31:56.190 --> 00:31:56.750
Yeah, yeah, yeah.
00:31:56.990 --> 00:31:57.150
Yeah.
00:31:57.390 --> 00:32:05.309
You know, you go through a stressful period at work, you're not sleeping properly, sleep is a massive thing with necks, um, almost more so than low back pain.
00:32:05.390 --> 00:32:08.430
Uh, you know, your diet's rubbish, stress at home, whatever.
00:32:08.590 --> 00:32:10.910
And then suddenly you've got your rip-roaring arm pain.
00:32:10.990 --> 00:32:13.309
And the scan's exactly the same as what it was before.
00:32:13.390 --> 00:32:15.549
I'm not but yeah, structure hasn't changed.
00:32:15.870 --> 00:32:21.069
Structure hasn't changed, and I'm not saying it's in your head either, like psychological, but actually your immune system does.
00:32:21.150 --> 00:32:24.190
Uh your inflammation does increase in certain scenarios, you know.
00:32:24.430 --> 00:32:24.590
Yep.
00:32:24.670 --> 00:32:39.069
And but then, okay, we can often have things like the myofascial system you can't pick up on a scan, but you can assess that, or the joints have stiffened up, or you're not moving as effectively, or you've just had these layers of stress which have which have which have loaded the system.
00:32:39.309 --> 00:32:39.549
Yeah.
00:32:39.789 --> 00:32:59.630
And I think it's important to differentiate between uh someone who is psychologically perceiving pain more, uh, and that's why the pain is more versus physiologically, they've had a lot of stress at home, they're not sleeping, or they've had a lot of stress at work, their diet's been rubbish, they put on a bit of weight, they're not moving.
00:32:59.789 --> 00:33:00.029
Yep.
00:33:00.190 --> 00:33:04.190
That is a different level of that's physiological stress that raises inflammation.
00:33:04.430 --> 00:33:04.750
Yes.
00:33:04.829 --> 00:33:06.029
You know, yeah, yeah, yep, yep.
00:33:06.110 --> 00:33:06.670
And we know that.
00:33:06.750 --> 00:33:08.910
And there's a load of evidence for that.
00:33:09.150 --> 00:33:09.950
Yeah, yeah.
00:33:10.269 --> 00:33:13.150
So sleep is an interesting one.
00:33:13.309 --> 00:33:15.870
We'll come back to that if we can.
00:33:16.350 --> 00:33:21.630
Um so, in terms of okay, another another set of injections for those ridiculous symptoms.
00:33:21.789 --> 00:33:23.470
Okay, that helps great.
00:33:23.789 --> 00:33:26.590
That person sort of pushed into that rehab process.
00:33:26.750 --> 00:33:28.430
We're trying to get them stronger.
00:33:28.670 --> 00:33:42.590
I sort of look at, okay, also lots of isometric neck holds in various positions, you know, a front neck hold, a back neck hold, sort of back uh cervical extension, side flexion, doing lots of that work.
00:33:42.750 --> 00:33:50.110
Because I I've really over the years pushed lots more load into the neck than what I used to.
00:33:50.350 --> 00:33:59.789
We used to do basic deep neck flexes and then some simple scap stuff, but I would sort of recognize that we're actually just not strengthening the neck in the way that we need to for daily life.
00:34:00.190 --> 00:34:11.549
And so if that doesn't settle things, uh then are we talking then about a possible sort of surgical intervention?
00:34:11.869 --> 00:34:17.389
Yeah, so you know, it depends on how you know how severe it is and and how long it's been going on for.
00:34:17.630 --> 00:34:17.949
Okay.
00:34:18.190 --> 00:34:29.389
So um, you know, I think it's quite reasonable if you've had, let's say, six months of moderate to significant pain and you've had a couple of injections and good five and a half months of physio, that's a reasonable time to start it.
00:34:29.469 --> 00:34:29.710
Yeah, yeah.
00:34:29.869 --> 00:34:36.110
I would discuss the fact that you have the option of continuing with the rehab for longer, or even a third injection, you've got to give them that option.
00:34:36.190 --> 00:34:36.590
Yep.
00:34:36.750 --> 00:34:38.429
Uh they'll ask, what's the chance?
00:34:38.509 --> 00:34:42.349
Well, it's a low chance, but there is a chance if we just left it alone, yeah.
00:34:42.509 --> 00:34:44.429
Or or just continued that it might get better.
00:34:44.510 --> 00:34:47.230
Most people have significant pain for six months, that's a long time.
00:34:47.869 --> 00:34:53.070
Yeah, that's that's a fairly long time to have fairly debilitating sort of arm symptoms and neck pain.
00:34:53.309 --> 00:34:53.789
Yeah, exactly.
00:34:53.869 --> 00:34:56.269
And certainly by nine months, most people are kind of switched.
00:34:56.349 --> 00:34:59.470
I'd say six months for me, unless there was another factor involved.
00:34:59.550 --> 00:34:59.630
Yeah.
00:34:59.789 --> 00:35:00.510
It's probably early.
00:35:00.829 --> 00:35:00.990
Okay.
00:35:01.550 --> 00:35:02.349
And then going longer.
00:35:02.829 --> 00:35:22.429
What are you looking at depending on is that uh a debridement, if it's a bony sort of overgrowth, or are you having to look at um effusion in in some of these so there's uh neck operations broadly uh categorized into anterior and posterior?
00:35:22.510 --> 00:35:22.750
Yep.
00:35:22.829 --> 00:35:25.710
Um so an anterior approach and a posterior approach.
00:35:25.789 --> 00:35:26.030
Yeah, yeah.
00:35:26.190 --> 00:35:26.349
Yeah.
00:35:26.429 --> 00:35:28.030
So the more common is the anterior approach.
00:35:28.110 --> 00:35:28.269
Yep.
00:35:28.429 --> 00:35:30.590
It's been going since about 1968, the approach.
00:35:30.670 --> 00:35:32.590
So it's extremely popular, used all around the world.
00:35:32.670 --> 00:35:33.710
It's a one approach.
00:35:33.869 --> 00:35:36.429
Everywhere in the world, people do it because it's such an excellent approach.
00:35:36.590 --> 00:35:37.949
Probably my favorite operation.
00:35:38.190 --> 00:35:38.510
Okay.
00:35:38.670 --> 00:35:40.349
Um so it's a kind of horizontal.
00:35:41.470 --> 00:35:42.670
Because it just works well?
00:35:42.909 --> 00:35:44.030
Uh oh, many reasons.
00:35:44.190 --> 00:35:46.429
So it's uh it's beautiful anatomy.
00:35:46.590 --> 00:35:51.710
Like so you basically you can do it right, right or left, but for anatomical technical reasons.
00:35:51.949 --> 00:35:58.110
Most people, modern uh sort of uh this my generation of surgeons, go from the right-hand side.
00:35:58.190 --> 00:36:01.389
Actually, the guys who are older, a lot of them used to go from the left-hand side.
00:36:01.470 --> 00:36:02.990
There's you know, there's why is that?
00:36:03.230 --> 00:36:10.829
Oh, it's to do with um, you know, so uh the recurrent they they would say the recurrent laryngeal nerve is more predictable on one side, but actually you've got thoracic duct.
00:36:10.909 --> 00:36:13.230
But actually a lot of us trained are right-sided.
00:36:13.389 --> 00:36:13.869
Yep, okay.
00:36:14.030 --> 00:36:15.470
Uh so and you know, yeah.
00:36:15.869 --> 00:36:24.110
And would that determine okay, if you had uh left arm symptoms and you're would you be more inclined to change that?
00:36:24.269 --> 00:36:24.349
No.
00:36:24.750 --> 00:36:25.150
It doesn't matter.
00:36:25.309 --> 00:36:29.070
So that bit you have to explain to patients is that it doesn't matter, I always do it from the right hand side.
00:36:29.309 --> 00:36:37.710
And then, you know, at the beginning of the operation you check the levels with a with a marker, so it could be up here, it could be lower, could could be in the middle, could be in the lower.
00:36:37.789 --> 00:36:39.230
Uh so you only have to cut the skin.
00:36:39.309 --> 00:36:40.510
That's the great thing about this operation.
00:36:40.590 --> 00:36:44.909
You just cut the skin and you part the platisma, which is because you can just part the platisma.
00:36:45.070 --> 00:36:46.269
Yeah, you can just part the platisma.
00:36:46.590 --> 00:36:51.630
So you're not cutting through muscle like you like you have to for say other spinal operations.
00:36:52.030 --> 00:36:52.349
Exactly.
00:36:52.510 --> 00:36:54.990
And actually, in a lot of people, platisma is very thin.
00:36:55.070 --> 00:36:56.829
Some people is virtually non-existent.
00:36:56.909 --> 00:36:57.070
Yep.
00:36:57.230 --> 00:36:59.309
Um, you get a rugby player, it will be there.
00:36:59.470 --> 00:37:03.470
Um, and then after that, it's all retraction, it's all dissection and retraction.
00:37:03.789 --> 00:37:06.750
And you've got the uh carotid artery there.
00:37:06.909 --> 00:37:08.269
Uh you've got your sternocleid.
00:37:08.590 --> 00:37:21.230
You first find your sternocleidomastoid, you find that medial border of the sternocleidomasto mastoid, and then you're just dissecting down, you find the carotid artery, and you just gently take that laterally, and then that opens up the plane to go behind the esophagus.
00:37:21.309 --> 00:37:21.470
Yep.
00:37:21.630 --> 00:37:23.710
And then you gently try and retract the esophagus.
00:37:23.789 --> 00:37:25.309
Some people have quite a mobile esophagus.
00:37:25.389 --> 00:37:25.470
Okay.
00:37:25.710 --> 00:37:28.269
Some people it's uh it's not so mobile.
00:37:28.429 --> 00:37:31.550
Um, and then you check what level you're in with an x-ray.
00:37:31.710 --> 00:37:32.110
Yep.
00:37:32.269 --> 00:37:34.670
And then you put your nice retractors in.
00:37:34.829 --> 00:37:37.150
Some are nice, some are very nice, some are not so nice.
00:37:37.630 --> 00:37:49.710
Um, and then and then you get the microscope with this big six-foot microscope out, and you've you're, you know, you're going, you're taking the disc out, and you're taking the pressure off the nerve either by removing bits of disc or shaving bits of bone.
00:37:49.789 --> 00:37:49.949
Yep.
00:37:50.110 --> 00:37:52.909
So you're taking pressure off the nerve or spinal cord.
00:37:52.990 --> 00:37:53.710
We haven't come onto that.
00:37:53.949 --> 00:37:57.869
If there's spinal cord compression, you'd yes take the pressure on that off that as well.
00:37:57.949 --> 00:38:05.789
Then you have two choices of implants uh an anterior cervical cage, which is essentially a fusion or a disc replacement.
00:38:06.190 --> 00:38:12.030
The problem here is that, and you'll hear if you had six spine surgeons come here and talk, you're gonna hear something slightly different from each one.
00:38:12.510 --> 00:38:19.630
Um, is that fusion sounds awful and disc replacement sounds really cool uh and modern and everything like that.
00:38:19.949 --> 00:38:23.710
Yeah, it's not so the reality is the reality is they're very close together.
00:38:23.789 --> 00:38:24.030
Yeah.
00:38:24.269 --> 00:38:27.150
Um, and that you can do a fusion on pretty much everyone.
00:38:27.309 --> 00:38:30.190
Disc replacement can only be done in certain category of people.
00:38:30.829 --> 00:38:37.789
So if you've got significant facet degeneration, for instance, uh you wouldn't advise doing a disc replacement if you get neck pain.
00:38:38.030 --> 00:38:44.590
If you've got a deformity or a sponge, you know, a slip or anteriolistesis or anything like that, you wouldn't do it.
00:38:44.670 --> 00:38:46.510
It's basically got to be good.
00:38:46.750 --> 00:38:50.190
Um it's got to be that there's relatively normal anatomy apart from that.
00:38:50.269 --> 00:38:51.949
Yeah, but disc prolapse or that kind of thing.
00:38:52.190 --> 00:38:55.230
And would you consider doing that in a younger cohort?
00:38:55.470 --> 00:39:00.429
Yeah, so generally younger, but then you know, as we said, some younger people have advanced degeneration.
00:39:00.590 --> 00:39:00.670
Yeah.
00:39:00.829 --> 00:39:04.349
Uh so I'd I'd, you know, rather than the age obviously makes you think of it.
00:39:04.429 --> 00:39:07.070
Like if it was a 65-year-old, I wouldn't think of it really.
00:39:07.389 --> 00:39:14.349
But if they're in there, if they're 34, I would certainly think, okay, my first question is would they be suitable for a disc replacement?
00:39:14.429 --> 00:39:14.590
Yep.
00:39:14.750 --> 00:39:18.590
I'd do a flexion extension x-ray to see if there's any instability, do a CD scan.
00:39:18.909 --> 00:39:23.070
How m how often do you see instability with those sort of flexion extension?
00:39:23.710 --> 00:39:24.510
Yeah, not that often.
00:39:24.990 --> 00:39:25.949
Yeah, it's a good point.
00:39:26.190 --> 00:39:29.070
But yeah, you you have to do that if you're considering a disc replacement.
00:39:29.389 --> 00:39:29.630
Okay.
00:39:29.869 --> 00:39:36.110
Um because if that segment is unstable already, then the disc replacement's not going to be a viable option.
00:39:36.429 --> 00:39:36.990
Yeah, exactly.
00:39:37.150 --> 00:39:41.389
So I'll stress at this point that people, spine surgeons around the country have different views on this.
00:39:41.470 --> 00:39:41.630
Yeah.
00:39:41.869 --> 00:39:45.550
Some people don't think we should be putting them at all because they are more expensive.
00:39:45.710 --> 00:39:48.510
Uh some of the early data from some of the implants wasn't great.
00:39:48.590 --> 00:39:50.349
It's very, very implant specific.
00:39:50.590 --> 00:39:50.670
Okay.
00:39:50.829 --> 00:39:55.869
I know bad workmen blamed us to all, but in terms of disc replacement, it's very implant specific.
00:39:56.110 --> 00:40:03.630
In terms of how well they do in terms of rates of heterotopic ossification, okay, extra bone formation, uh, in terms of loosening.
00:40:03.710 --> 00:40:04.750
So that's become a big thing.
00:40:04.829 --> 00:40:10.110
One of the implant uh implants that is used was used by a lot of prominent people, especially in sport.
00:40:10.269 --> 00:40:10.429
Okay.
00:40:10.670 --> 00:40:22.349
Uh some good Australian studies on this um from rugby players actually have shown that it it loosened actually to a point where they're they're now there's now like a guideline that's gone out to recall people that have had it.
00:40:22.510 --> 00:40:22.909
Oh really?
00:40:22.990 --> 00:40:28.829
And so they can then convert to a fusion, but it's probably a harder, a harder operation.
00:40:29.150 --> 00:40:33.789
Uh no, not I've I've done, yeah, there's different ways of trying to trying to fuse it.
00:40:33.869 --> 00:40:37.949
You know, that's a so I guess separate question, but it doesn't necessarily have to be difficult.
00:40:38.110 --> 00:40:38.429
Yeah.
00:40:38.670 --> 00:40:41.150
Um but yeah, it's very implant specific.
00:40:41.230 --> 00:40:44.670
And the problem is you don't really find out how good that implant is for great.
00:40:45.150 --> 00:40:47.470
For 10 years, 10 years down the line.
00:40:47.630 --> 00:40:47.789
Okay.
00:40:48.269 --> 00:40:57.470
Um and so you know, at some point in your life you're always going to be um you know, always gonna be looking back at the ones you've you've done before.
00:40:57.710 --> 00:40:57.869
Yeah.
00:40:58.030 --> 00:41:05.550
Um yeah, and there are leading guys who lead on research and disk replacements who put in disk replacements that have loosened in, you know, hundreds of people.
00:41:05.789 --> 00:41:06.269
Yeah, yeah, yeah.
00:41:06.429 --> 00:41:09.389
Uh so there is that uncertainty and it's more expensive.
00:41:09.710 --> 00:41:15.389
But the the key thing about it is there is a certain amount of force going through your neck every day.
00:41:15.470 --> 00:41:20.429
And if you fuse off one level, it's gonna be shared between all the other levels, not just that level.
00:41:20.510 --> 00:41:24.990
So each level, especially the adjacent ones, are gonna have a greater stress on them.
00:41:26.030 --> 00:41:34.590
And you know, there's various studies on it, but I at a rough uh estimation, 2.5 to 3% rate of adja adjacent dis segment degeneration per year.
00:41:34.670 --> 00:41:36.190
So maybe at 10 years it'd be 25%.
00:41:36.670 --> 00:41:36.829
Okay.
00:41:37.150 --> 00:41:39.309
There might need something done at the adjacent levels.
00:41:39.389 --> 00:41:44.110
And it in some disk replacements, uh in the more successful ones, it's lower.
00:41:44.429 --> 00:41:44.670
Yep.
00:41:44.990 --> 00:41:53.389
Uh but then in in the batch of ones that weren't as successful, the rate of reoperation at the same level uh was greater.
00:41:53.789 --> 00:41:54.030
Okay.
00:41:54.269 --> 00:41:54.670
Interesting.
00:41:54.909 --> 00:41:55.230
Yeah.
00:41:55.550 --> 00:41:58.829
And so we're talking about the this anterior approach.
00:41:58.990 --> 00:42:07.949
How often would you be needing to do this in like is this a couple of percent of your population that you're you're needing to operate on?
00:42:08.030 --> 00:42:11.630
Do you think uh so I probably do one I have to probably do about three a month now.
00:42:11.869 --> 00:42:12.190
Okay.
00:42:12.349 --> 00:42:13.470
Yeah, at the moment.
00:42:13.710 --> 00:42:15.470
Uh so qu quite a lot of people.
00:42:15.550 --> 00:42:22.990
Um, you know, is so in other words, I'll probably list um, you know, yeah, for say three people every four weeks.
00:42:23.230 --> 00:42:23.470
Okay.
00:42:23.710 --> 00:42:23.869
Yeah.
00:42:24.269 --> 00:42:27.869
So for that kind of procedure, I do a lot of cervical injections.
00:42:28.190 --> 00:42:28.510
Yes.
00:42:29.070 --> 00:42:41.710
Um, and I think going back to that concept, I think if you've done everything you can in terms of rehab, injection, inflammation, and everything, and that smaller percentage of people who are left over having operations, I think they do better.
00:42:41.949 --> 00:42:42.190
Okay.
00:42:42.590 --> 00:42:44.190
You know, because of everything you've done for them.
00:42:44.349 --> 00:42:44.829
Yeah, yeah, yeah.
00:42:44.909 --> 00:42:45.150
Yeah.
00:42:45.389 --> 00:42:50.110
Um so it it's uh in general, it's a very common operation done all around the world.
00:42:50.349 --> 00:42:51.630
Yeah, I mean I've seen loads.
00:42:51.789 --> 00:42:54.990
Um more fusions than disc replacements, though.
00:42:55.389 --> 00:42:58.110
Um and then there's another approach, the posterior posterior.
00:42:58.349 --> 00:42:59.470
Posterior approach, yeah.
00:42:59.789 --> 00:43:02.750
So uh there are different operations you can do from posterior.
00:43:02.829 --> 00:43:05.869
Yeah, the most common in this country is uh foramenotomy.
00:43:05.949 --> 00:43:10.670
Okay, where you're basically uh shaving bone at the back to create more space for them.
00:43:11.630 --> 00:43:13.710
And uh that's another way of doing it.
00:43:13.789 --> 00:43:15.710
Some people have a philosophy that's better now.
00:43:15.869 --> 00:43:20.750
The And that's really creating more space for that nerve to and blood vessels to run out of.
00:43:21.070 --> 00:43:21.630
Yeah, exactly.
00:43:21.710 --> 00:43:27.869
So obviously the advantage of the the front is that you're just cutting the skin, you're not cutting anything else.
00:43:28.030 --> 00:43:34.829
Everyone's always really surprised because you say you get up the same day, you know, some could even potentially go home the same day, definitely the next morning.
00:43:34.990 --> 00:43:35.150
Yeah.
00:43:35.309 --> 00:43:42.190
And I say, well, you know, it's operation on your neck, and the only thing we're cutting is that I'm not touching your abdomen, your hips, your knees, your foot, yeah, yeah.
00:43:42.349 --> 00:43:42.750
Anything else.
00:43:42.990 --> 00:43:44.510
There's no reason why you can't just walk.
00:43:44.750 --> 00:43:51.869
Um, you know, so it's very good from that point of view, and you're you're only cutting that that skin at the beginning, the disadvantages and the midline structures.
00:43:52.030 --> 00:43:52.269
Yep.
00:43:52.429 --> 00:43:57.789
You know, you could quote one in 400, one in five hundred risk of a significant issue with the esophagus.
00:43:58.750 --> 00:43:59.869
Yeah, those kind of things.
00:44:00.190 --> 00:44:07.070
From the back, obviously, you don't have any of those important structures, but you've got a, as you know, thick load of muscle there.
00:44:08.030 --> 00:44:23.470
And uh the if you're doing an open operation in the neck, uh at the back of the neck, the that has the highest rate, that area has a highest rate of infection or wound breakdown of pretty much any orthopedic operation because of the tension on the even the Achilles?
00:44:23.710 --> 00:44:24.909
Achilles is pretty high, isn't it?
00:44:25.150 --> 00:44:25.949
Yeah, it's pretty high.
00:44:26.110 --> 00:44:26.269
Yeah.
00:44:26.510 --> 00:44:32.510
Um so it's because of the tension on the wound, whereas this has it has less a bit less blood supply at the back.
00:44:32.670 --> 00:44:34.829
Uh here, this has an excellent blood supply.
00:44:34.909 --> 00:44:35.389
Yeah, yeah, yeah.
00:44:35.789 --> 00:44:37.869
Okay, when you slash someone's neck, it bleeds like mad.
00:44:38.030 --> 00:44:38.349
Yes, yeah.
00:44:38.590 --> 00:44:42.590
Excellent blood supply and it's very loose, whereas that's very tight in some people, it's extremely tight.
00:44:42.750 --> 00:44:43.230
Yep, okay.
00:44:43.389 --> 00:44:48.190
So infection rates are higher, wind breakdown weights are higher, pain levels are obviously higher.
00:44:48.429 --> 00:44:48.670
Yeah.
00:44:48.909 --> 00:44:49.150
Okay.
00:44:49.550 --> 00:44:50.030
In general.
00:44:50.429 --> 00:44:53.230
And a longer, longer recovery process.
00:44:53.470 --> 00:44:54.750
Yeah, uh more pain in the beginning.
00:44:54.829 --> 00:44:58.829
So let's say you're a rugby player, and the World Cup's in three months.
00:44:58.990 --> 00:45:03.550
I've had this situation, and you've got a choice between anterior and posterior.
00:45:03.710 --> 00:45:08.190
Uh the anterior gets rid of the disc bulge and the you know, whatever bit of information.
00:45:08.349 --> 00:45:09.389
Yeah, it addresses the structure, yeah.
00:45:09.630 --> 00:45:16.909
Whereas the posterior foramenotomy doesn't get rid of the disc bulge or the disc osteophyte complex, but it shaves some bone to create more space.
00:45:17.070 --> 00:45:17.869
More space, yep.
00:45:18.110 --> 00:45:22.190
Um, so they're they're most likely not going to make the world cup if you do an anterior approach.
00:45:22.269 --> 00:45:22.510
Yep.
00:45:22.670 --> 00:45:26.429
Uh you do a posterior foramenotomy, they most likely will make it.
00:45:26.750 --> 00:45:34.990
Um so if you've got uh some people favor that approach anyway, uh, but if you've got like targets, yeah, you know, that's why some people do it more often.
00:45:35.070 --> 00:45:35.550
I think so.
00:45:35.630 --> 00:45:37.869
A sporting population you need to consider, yeah.
00:45:38.110 --> 00:45:38.429
Yeah.
00:45:38.670 --> 00:45:45.710
Um there's also you can do fusions from the back, but that's generally in the older population with cord compression, myelophy or trauma.
00:45:46.269 --> 00:45:46.829
Yep, okay.
00:45:47.470 --> 00:45:51.550
And then there's a a kind an operation which we don't do that commonly in this operation.
00:45:51.630 --> 00:45:56.429
It's very common in um Australia and New Zealand, especially New Zealand and Japan.
00:45:56.590 --> 00:45:58.429
The what they call a laminoplasty.
00:45:58.670 --> 00:45:58.829
Okay.
00:45:59.230 --> 00:46:05.949
Where it's uh like an open door, it's hard to explain without showing, but you basically shave the l all the way down one lamina, yep.
00:46:06.190 --> 00:46:08.909
Uh, and then half on the other side of the lamina.
00:46:09.070 --> 00:46:11.710
So you're like opening the spinal canal like a door.
00:46:11.869 --> 00:46:12.110
Okay.
00:46:12.269 --> 00:46:14.190
And you keep it open with this little plate.
00:46:14.590 --> 00:46:25.949
Um when I was in New Zealand, we did absolutely tons of them because you know, the Pacific Islanders, they a lot a lot of them uh they're more susceptible to congenital narrowing of the cervical spine.
00:46:26.190 --> 00:46:26.590
Oh really?
00:46:26.750 --> 00:46:27.630
So yeah, yeah.
00:46:28.110 --> 00:46:32.510
So it's even in young people, you know, they go into a rugby tackle and then they just get arm drop.
00:46:32.750 --> 00:46:33.230
Yeah, okay.
00:46:33.470 --> 00:46:36.110
Um because they've got congenital narrow canal.
00:46:36.190 --> 00:46:39.389
So you the operation that's favored there is an open door laminoplasty region.
00:46:39.630 --> 00:46:41.150
Okay, so that widens it all for them.
00:46:41.389 --> 00:46:41.630
Yeah.
00:46:42.190 --> 00:46:42.909
Yeah, okay.
00:46:43.150 --> 00:46:43.789
Interesting.
00:46:44.670 --> 00:46:52.030
Okay, so defin definitely sort of different options from a surgical perspective.
00:46:52.590 --> 00:47:05.789
Um recovery from that, we're talking, you know, the f the the fusion, we're talking sort of six to nine months, probably full recovery from uh uh one level.
00:47:06.190 --> 00:47:06.829
Anterior, yeah.
00:47:07.070 --> 00:47:11.309
Yeah, so I guess the the thing we didn't talk about is there's a big difference between one, two, and three levels.
00:47:11.389 --> 00:47:11.630
Yeah.
00:47:11.869 --> 00:47:12.190
Yeah.
00:47:12.429 --> 00:47:18.110
So one level you can pretty if it all goes well and everything, you can pretty much go back to everything.
00:47:18.750 --> 00:47:24.190
Um and that's are you would a rugby player be able to go back with that?
00:47:24.429 --> 00:47:24.670
Yep.
00:47:24.909 --> 00:47:26.269
I've got loads of being back.
00:47:26.590 --> 00:47:32.510
Okay, and how long do you want to wait till full contact for something like that?
00:47:32.829 --> 00:47:33.070
Yeah.
00:47:33.230 --> 00:47:35.470
So of course everyone's trying to push the boundaries all the time.
00:47:35.550 --> 00:47:35.789
Yeah.
00:47:35.949 --> 00:47:41.150
And you know, it's like everyone's trying to push the boundaries with you, obviously, because they've got responsibilities, yeah, yeah.
00:47:41.470 --> 00:47:42.030
Coaches.
00:47:42.590 --> 00:47:52.190
So yeah, there's a very, very common conversation I have um at all levels, like England down to, you know, um down to Second League or whatever county.
00:47:52.510 --> 00:47:58.030
Um so generally what we do is um just gentle range of movement three weeks, yeah.
00:47:58.190 --> 00:48:03.550
Um, and then normally get start the physio we talked about already, uh, at three, four weeks.
00:48:03.630 --> 00:48:08.030
Uh, then you can start using bands at five weeks and weights and progress onto there.
00:48:08.429 --> 00:48:14.349
And then from three months you can start, you know, properly trying to load and progressively strengthen.
00:48:14.590 --> 00:48:20.510
I do a CT scan if all's going well, they've got a good range of movement, uh, pain's gone, or pretty much gone.
00:48:20.670 --> 00:48:22.510
Uh so I do a CT scan at four months.
00:48:22.670 --> 00:48:22.909
Okay.
00:48:22.990 --> 00:48:23.309
Yep.
00:48:23.470 --> 00:48:25.869
And that shows you the sort of the bony healing.
00:48:25.949 --> 00:48:26.030
Yeah.
00:48:26.269 --> 00:48:26.429
Yeah.
00:48:26.510 --> 00:48:32.990
There's a difference now though, because the implants, the one thing that's really the operation's been going, the approach has been going since 1968 or whatever.
00:48:33.150 --> 00:48:36.110
But what's really changed in the last 15 years is the quality of the implants.
00:48:36.190 --> 00:48:36.349
Okay.
00:48:36.670 --> 00:48:39.230
And they've got this coating on it which grips onto the bone.
00:48:39.389 --> 00:48:39.550
Okay.
00:48:39.789 --> 00:48:46.590
So much more nowadays we're we're we're looking at its position rather than having to see a fusion block of bone all the way through.
00:48:46.909 --> 00:48:46.990
Okay.
00:48:47.070 --> 00:48:52.030
So you're not worried, you're worried less about that there hasn't been any give or movement in it.
00:48:53.550 --> 00:48:59.869
Sorry, you're worried you're worrying less about you know seeing that bony fusion and you you wanted to see that it's nice and stable.
00:49:00.110 --> 00:49:00.269
Yeah.
00:49:00.429 --> 00:49:06.670
And normally in a young because uh generally rugby players are younger people, you'll see like you know, that link of bone going across it.
00:49:06.829 --> 00:49:07.150
Yep.
00:49:07.389 --> 00:49:17.949
And so if now we've pushed to four months, if the CT scans fine, pain free range movement, neuro in neurologically intact, and everything, then they can start going into general contact.
00:49:18.030 --> 00:49:27.150
So start with the bag and then into tackles and before scrums, because they tend to be forwards uh one-on-ones, uh, and then into a full scrum after that.
00:49:27.389 --> 00:49:28.909
So a lot of them are expecting.
00:49:28.990 --> 00:49:34.349
I never say expect, but I say this is the best case to start pool playing at four and a half months.
00:49:34.590 --> 00:49:37.710
Okay, that's that that that's yeah, fairly punchy.
00:49:37.789 --> 00:49:39.070
That's very punchy, yeah.
00:49:39.150 --> 00:49:43.869
So I'd say in I've done I mean these are well-trained individuals initially, so you're starting from a pretty good base.
00:49:44.349 --> 00:49:46.190
Good base, and they've obviously got physio every day.
00:49:46.349 --> 00:49:46.750
Yes.
00:49:46.909 --> 00:49:51.550
Um, and a lot of these physios have seen this operation um or dealt with it at some point.
00:49:51.710 --> 00:49:52.110
Yep, yeah.
00:49:52.269 --> 00:49:57.070
I'd say that's been my approach for about five years, and I'm yet to have anyone come back from that.
00:49:57.389 --> 00:49:58.349
Yep, okay, okay.
00:49:58.750 --> 00:49:59.309
So yeah.
00:49:59.710 --> 00:50:00.750
Okay, cool.
00:50:01.070 --> 00:50:05.389
So okay, so single level people can get back to pretty much everything.
00:50:06.110 --> 00:50:09.150
Multi-level fusions, different it's different.
00:50:09.789 --> 00:50:17.150
So I guess one of the other false concepts about the uh fusion is that I'll, you know, I'll be fused as an I'll be stiff.
00:50:17.389 --> 00:50:24.590
Because of the block to rotation that people with hypertrophic facet and phrammals they naturally they naturally have that anyway.
00:50:24.829 --> 00:50:25.710
They have a block anyway.
00:50:25.869 --> 00:50:25.949
Yeah.
00:50:26.110 --> 00:50:34.190
So with one level fusion, I try not to promise it, they more often than not they have a greater range of movement post-surgery, even though it's a fusion.
00:50:34.429 --> 00:50:34.750
Okay.
00:50:34.829 --> 00:50:37.710
Uh I mean, I can't remember last time there wasn't.
00:50:37.949 --> 00:50:41.710
But yeah, you know, three months down the line, that's normally what I'd expect.
00:50:41.869 --> 00:50:42.110
Yep.
00:50:42.269 --> 00:50:50.909
Uh with a two-level, I'd say uh you obviously a bit stiffer to begin with, um, but hope to get the same range of movement you had before the two-level fusion, which is still surprising.
00:50:51.070 --> 00:50:51.470
Yeah, yeah, yeah.
00:50:51.710 --> 00:50:53.230
And with three level, you will be stiffer.
00:50:53.309 --> 00:50:53.550
Yep.
00:50:53.630 --> 00:50:53.789
Okay.
00:50:54.030 --> 00:50:59.949
Um, so one level all goes well, heals well, CG scans fine, you can get even get back to collision sport.
00:51:00.269 --> 00:51:00.510
Yep.
00:51:00.670 --> 00:51:03.230
Two level you can go to everything but non-collision.
00:51:03.470 --> 00:51:03.710
Okay.
00:51:03.949 --> 00:51:04.829
But not collision.
00:51:05.070 --> 00:51:06.909
And then three level you're quite restricted.
00:51:07.070 --> 00:51:10.110
So at two level you can get on a bike, you can swim, you can ski.
00:51:10.349 --> 00:51:19.710
Um and the levels that you're usually doing these fusions at are you sort of four, five, five, six, six, seven?
00:51:20.269 --> 00:51:21.230
Those are the three most common.
00:51:21.389 --> 00:51:21.470
Yeah.
00:51:21.630 --> 00:51:22.909
Five, six, and six, seven, especially.
00:51:23.150 --> 00:51:23.230
Yeah.
00:51:23.470 --> 00:51:23.630
Yeah.
00:51:23.710 --> 00:51:23.869
Okay.
00:51:24.829 --> 00:51:25.789
Okay, interesting.
00:51:26.030 --> 00:51:32.269
So we've talked about okay, injections, surgery.
00:51:32.429 --> 00:51:37.150
Now, the vast majority of time people are not heading down that surgical pathway.
00:51:37.389 --> 00:51:37.789
That's right.
00:51:37.949 --> 00:51:38.349
Yeah, yeah.
00:51:39.070 --> 00:51:41.630
So how much more than ninety percent won't end up.
00:51:42.110 --> 00:51:42.349
Okay.
00:51:42.510 --> 00:51:44.829
Yeah, probably yeah, something in order.
00:51:44.990 --> 00:51:47.630
92 to 95% of people just won't end up in that.
00:51:47.869 --> 00:51:48.670
Yeah, okay, cool.
00:51:48.990 --> 00:51:52.990
So, how much do you place on, you know, a phone use?
00:51:53.230 --> 00:51:57.470
Emphasis do you place on phone use, postural, iPads?
00:51:58.429 --> 00:52:05.789
Do you think that drives quite a lot of that sort of shearing force that loads next over a period of time?
00:52:06.110 --> 00:52:09.710
I don't believe, you know, I honestly don't believe there's any proper strong evidence for that.
00:52:09.869 --> 00:52:18.190
So I I go by the thousands of people I've seen in the city over the last like 15 years, whatever, that you you there's a certain it's like rugby players.
00:52:18.269 --> 00:52:22.269
Like I can almost tell someone's a rugby player before they walk in if I have their scan.
00:52:22.349 --> 00:52:23.710
Uh, the tech neck.
00:52:23.869 --> 00:52:24.269
Yep, yeah.
00:52:24.510 --> 00:52:32.349
You can kind of see it as it's like an upper cervical kind of reversal of lauridosis, and you can kind of see they've almost been doing that for a long period of time.
00:52:32.429 --> 00:52:32.829
Yeah.
00:52:33.070 --> 00:52:40.590
Um, and do do I think that those that category of people have a greater tendency to fatigue and neck discomfort?
00:52:40.670 --> 00:52:41.230
Yes, I do.
00:52:41.309 --> 00:52:41.710
Yep.
00:52:41.869 --> 00:52:43.630
Uh I don't think anyone's ever proven that.
00:52:43.710 --> 00:52:50.590
In fact, I think the only study that I rem recall has been done on that showed that there was no difference between the tech neck and normal circulation.
00:52:50.990 --> 00:53:08.429
Um we hear a lot about that, you know, phone news well, phone news from a social media perspective, but but phone news from a neck perspective and looking down that sort of uh upper cervical extension some of the time and and but also that lower cervical sort of flexion.
00:53:08.670 --> 00:53:09.309
Yeah, yeah.
00:53:09.470 --> 00:53:15.309
I I am pretty sure 10 years, 15, 20 years down the line, we're looking back and going, oh my god, I can't believe we all did that.
00:53:15.470 --> 00:53:15.869
Yeah, yeah.
00:53:16.030 --> 00:53:23.710
Uh because it's gonna have an impact over, you know, I didn't I didn't have a phone or a uh uh you know, I didn't have a phone till I was 25 years old.
00:53:23.869 --> 00:53:24.429
Yeah, yeah, yeah.
00:53:24.510 --> 00:53:30.030
You know, because we you generally didn't most of the time then and then didn't have an iPad or whatever till whenever, who knows?
00:53:30.190 --> 00:53:33.070
Now they've all got iPads at age 10 completely or younger.
00:53:33.309 --> 00:53:42.349
And yeah, I I always wonder whether it's a little bit of that sort of postural pattern, but it's a lot of that people just not exercising enough.
00:53:42.510 --> 00:53:45.630
Yeah, we're not we're not keeping sufficient strength in the system.
00:53:45.789 --> 00:53:46.190
Yeah, yeah.
00:53:46.349 --> 00:53:50.590
You know, kids aren't aren't running around and playing outside anymore.
00:53:50.670 --> 00:54:03.070
They're playing on screens, they're playing in indoors, unless and I know your kids are sporty as as as are mine, but you know, my childhood was was I left home at 9 a.m.
00:54:03.309 --> 00:54:06.190
I was in the street with all the the neighbour's kids.
00:54:06.269 --> 00:54:10.349
Yeah, yeah football, cricket, skateboarding, bike riding.
00:54:10.670 --> 00:54:13.150
We don't seem to have adult weather though.
00:54:13.470 --> 00:54:14.190
We did, yeah, yeah, yeah.
00:54:14.269 --> 00:54:14.909
So that definitely helps.
00:54:15.150 --> 00:54:15.789
That's no excuse.
00:54:15.949 --> 00:54:16.269
Yeah.
00:54:16.510 --> 00:54:24.909
Um, I mean, I I can't I can understand, but I can't understand really when people say to me, I don't have time to exercise.
00:54:25.070 --> 00:54:25.309
Yeah.
00:54:25.550 --> 00:54:27.389
We're both busy, we do it.
00:54:27.630 --> 00:54:27.949
Yeah.
00:54:28.269 --> 00:54:41.070
Um and maybe because we're it's we're right at the cold face of seeing the effects of of these things on your body in so many different ways, is that you know, after sleep, exercise is the the most important thing in your life.
00:54:41.150 --> 00:54:45.630
It doesn't matter what else you're doing, um, movement is the most important thing.
00:54:45.949 --> 00:54:49.150
And I think uh it's probably just not prioritized enough now.
00:54:49.309 --> 00:54:53.150
Even when people do it, it's often people are going for goal setting.
00:54:53.230 --> 00:54:59.150
You know, I'm doing exercise because I'm running the marathon, I'm doing exercise because I want to get to 150 on a deadlift.
00:54:59.470 --> 00:55:04.670
And that goal setting by nature means that you're going against listening to your body, I think.
00:55:04.990 --> 00:55:07.949
You know, you you are setting your goal by April.
00:55:08.030 --> 00:55:09.230
I need to be able to do this.
00:55:09.550 --> 00:55:13.389
Actually, you need to wake up in the morning and see how just like see how your body feels.
00:55:13.630 --> 00:55:14.110
Yeah, yeah.
00:55:14.190 --> 00:55:20.110
I think I I I like I like people using goals because it helps to orient them a little bit.
00:55:20.670 --> 00:55:28.670
But actually, you you need to actually have that interpretation with within the body as well, and go, okay, right, well, this isn't smart.
00:55:28.829 --> 00:55:30.909
Okay, I've got to back off, I've got to listen to my body.
00:55:31.070 --> 00:55:33.230
But I think it's to having the right balance of exercise.
00:55:33.309 --> 00:55:38.590
I mean, you're a big advocate for Pilates rehab um with with spinal things.
00:55:38.670 --> 00:55:49.389
And I, you know, for all of our athletes, I like having some form of mobility, Pilates in the mix as well as all their other training.
00:55:49.470 --> 00:55:49.710
Yeah.
00:55:49.869 --> 00:55:52.110
Because I think it helps to keep a balance in the system.
00:55:52.349 --> 00:55:52.909
Yeah, yeah.
00:55:53.150 --> 00:55:59.710
It's just being able to being able to move in in ways that is really effective for your body without injuring yourself.
00:55:59.869 --> 00:56:00.190
Yeah.
00:56:00.349 --> 00:56:00.829
You know.
00:56:01.070 --> 00:56:06.829
Um, you know, most we talk about deadlifts, you know, most things are good for you up to a certain dose.
00:56:06.990 --> 00:56:07.309
Yeah.
00:56:07.470 --> 00:56:07.710
You know.
00:56:07.869 --> 00:56:08.269
Yeah, yeah.
00:56:08.429 --> 00:56:10.030
And as long as you're doing it correctly.
00:56:10.110 --> 00:56:10.429
Yeah.
00:56:10.590 --> 00:56:16.110
You know, I I remember sitting, you know, I grew up in Singapore and walking to school, I'd see people doing tai chi.
00:56:16.349 --> 00:56:16.590
Yeah.
00:56:16.750 --> 00:56:18.670
And I'd think, they are doing nothing.
00:56:18.829 --> 00:56:19.389
What are they doing?
00:56:19.470 --> 00:56:20.269
They're doing nothing.
00:56:20.429 --> 00:56:23.070
They're just moving their leg around and arm around.
00:56:23.150 --> 00:56:24.190
How amazing is that?
00:56:24.349 --> 00:56:24.670
Yeah.
00:56:24.909 --> 00:56:27.470
Now I realize how good why the Chinese do Tai Chi.
00:56:27.710 --> 00:56:27.949
Yeah.
00:56:28.030 --> 00:56:33.550
Look, it's it's incredible for you, but also just yeah, what it does for the whole system as well.
00:56:33.710 --> 00:56:34.030
Yeah.
00:56:34.190 --> 00:56:36.110
As, you know, yeah, no, exactly.
00:56:36.429 --> 00:56:42.750
That stability, that you're moving and your breathing, and your and your in fact meditating because you've forgotten about everything else.
00:56:42.990 --> 00:56:43.470
Yeah, yeah.
00:56:43.710 --> 00:56:46.269
Which which has a big role, definitely.
00:56:46.590 --> 00:56:48.909
I think you you touched earlier on sleep.
00:56:50.429 --> 00:56:55.630
We have so many questions about what pillow should I get?
00:56:55.869 --> 00:56:56.829
How do I sleep?
00:56:56.990 --> 00:57:01.789
What's the best position to try and get comfortable in with neck pain?
00:57:02.030 --> 00:57:16.349
And I think you can probably get low back pain and people a bit comfortable, you know, pad out with pillows underneath their knees, or you know, feet up on a sofa or when they're lying on the floor.
00:57:16.670 --> 00:57:18.750
There's ways to get them comfortable.
00:57:18.990 --> 00:57:21.309
But necks are much, much harder.
00:57:22.829 --> 00:57:34.190
I mean, I'm banning front sleeping for necks, or for people generally, actually, because you know, you you can't be in a neutral position because your your head's sort of rotated to one side.
00:57:36.030 --> 00:57:37.070
What are you?
00:57:37.309 --> 00:57:39.630
Do you have these questions that patients will ask?
00:57:39.949 --> 00:57:40.269
Yeah.
00:57:40.510 --> 00:57:41.389
All of those.
00:57:41.550 --> 00:57:45.550
Um, so on neck position, it's very difficult because your neck position moves all the time.
00:57:45.710 --> 00:57:45.949
Yep.
00:57:46.110 --> 00:57:50.110
Um, but try and make them realize that actually what you're aiming for is a neutral position.
00:57:50.190 --> 00:57:50.590
Yep.
00:57:50.829 --> 00:57:56.909
You know, try and make sure, like, if you've got one pillow that you're not hyperextended or you're not hyper, it's not a thick pillow that's flexed.
00:57:57.070 --> 00:57:59.150
If you're going on your side, you're not boom, yeah.
00:57:59.309 --> 00:58:04.990
Like lateral flex, or but of course your position changes, and if you end up prone on your front, then you are hyperextended.
00:58:06.030 --> 00:58:08.510
Yeah, and and you're rotating your neck as well.
00:58:08.909 --> 00:58:09.470
To one side.
00:58:09.550 --> 00:58:11.389
So, and then there's other factors with sleep.
00:58:11.470 --> 00:58:14.990
Some people have, you know, you know, get sleep apnea in certain positions.
00:58:15.070 --> 00:58:19.550
Some people, when they're in neutral, they you know, they have to hyperextend their neck a bit when they have that.
00:58:19.789 --> 00:58:20.829
Um, so it's difficult.
00:58:20.990 --> 00:58:21.949
Pillows, yeah.
00:58:22.030 --> 00:58:22.909
Another tricky one.
00:58:22.990 --> 00:58:28.510
So, you know, I don't think there's any validated randomized control trial on pillows, right?
00:58:28.670 --> 00:58:35.309
People, you know, cause certain companies will advertise these are our results, but they're kind I think they're just comparing their pillow to top.
00:58:35.389 --> 00:58:38.670
Yeah, and they're probably internal sort of internal sort of studies.
00:58:38.990 --> 00:58:40.030
Yeah, exactly.
00:58:40.190 --> 00:58:41.710
So I think that's difficult.
00:58:41.789 --> 00:58:43.389
I I mean I have my own way of doing it.
00:58:43.470 --> 00:58:46.590
I have I know someone that seems to know a lot more than me about it.
00:58:46.670 --> 00:58:48.349
Yeah, so I tend to send them to him.
00:58:48.510 --> 00:58:48.829
Yep.
00:58:48.990 --> 00:58:59.550
Um, so uh I think as a clinician, uh whether you're physio osteopath or you're a um surgeon, you've got to have the right people around you to answer the questions you can't answer.
00:58:59.630 --> 00:58:59.869
Yep.
00:59:00.030 --> 00:59:01.710
Uh same with mattresses.
00:59:02.030 --> 00:59:02.349
Yeah.
00:59:02.670 --> 00:59:16.590
And and it's uh I I think with sleep and with regards to sort of neck position, if you're a side sleeper, you need a different level of support than a back sleeper because you've got, you know, you you've got to keep your neck in that neutral position.
00:59:16.670 --> 00:59:19.710
You've got all this space from from your neck to your shoulder.
00:59:20.190 --> 00:59:26.750
And so that's where sometimes the temperature style pillows can be a little bit better.
00:59:26.829 --> 00:59:26.990
Yeah.
00:59:27.150 --> 00:59:30.909
But actually, then you roll onto your back and they're too big for you.
00:59:30.990 --> 00:59:31.150
Yeah.
00:59:31.309 --> 00:59:38.750
They're sort of forcing you up into quite a hyperflex sort of position, and you need less support when you're on your back.
00:59:39.630 --> 00:59:42.110
You then you have to you only have to try it yourself to realise that.
00:59:42.349 --> 00:59:42.909
Yeah, yeah.
00:59:43.150 --> 00:59:58.030
So there's a few brands that we do use um with with pillows, but it is about sort of educating the patient and ensuring that they, you know, I like patients to ultimately get to a stage where actually they can sleep in any position.
00:59:58.349 --> 01:00:02.269
And their neck has the the the resilience to be able to cope with that.
01:00:02.349 --> 01:00:02.510
Yeah.
01:00:02.590 --> 01:00:06.349
But when they're super acute, um that can be tricky.
01:00:06.429 --> 01:00:09.070
And I think it's educating about those different positions.
01:00:09.150 --> 01:00:18.510
And sometimes we'll get a patient to wrap a really small towel underneath their neck to just try and provide that little bit of support so it's almost keeping their neck long.
01:00:18.829 --> 01:00:19.789
Yeah, yeah, exactly.
01:00:19.869 --> 01:00:21.309
Yeah, that that's quite a good idea.
01:00:21.470 --> 01:00:24.349
Yeah, it's difficult because you there's some of it you can't control.
01:00:24.670 --> 01:00:28.510
But you know, for me, just making them realize actually that sleep is important, yeah.
01:00:28.750 --> 01:00:30.909
Uh, and get more of it.
01:00:31.070 --> 01:00:31.470
Yes.
01:00:31.630 --> 01:00:37.389
And, you know, don't be working late if you've got reprowing arm pain and you're working late at work every day.
01:00:37.630 --> 01:00:41.230
Yeah, so that stress and sleep cycle.
01:00:41.470 --> 01:00:48.030
Yeah, you know, it I I probably hold tension in my neck and shoulder girdle.
01:00:48.750 --> 01:00:54.190
I know people hold tension in different places, but that's a pretty common area to sort of hold a lot of tension.
01:00:54.269 --> 01:00:56.829
And particularly if you're stressed, you tend not to breathe well.
01:00:56.990 --> 01:00:57.150
Yeah.
01:00:57.309 --> 01:01:01.869
So you're using all your other accessory muscles for breathing, which which load up your neck.
01:01:03.309 --> 01:01:09.710
The lack of stress, sorry, the lack of sleep massively impacts how your body can function, doesn't it?
01:01:09.869 --> 01:01:10.030
Yeah.
01:01:10.349 --> 01:01:14.590
And it won't allow a normal healing pathway when you're in sort of acute pain.
01:01:14.909 --> 01:01:15.470
Yeah, exactly.
01:01:15.630 --> 01:01:19.470
So you you're kind of your par, you know, your sympathetic system goes into overdrive.
01:01:19.550 --> 01:01:19.710
Yep.
01:01:19.869 --> 01:01:21.630
You're you're gonna get inflamed more.
01:01:21.789 --> 01:01:22.030
Yep.
01:01:22.190 --> 01:01:26.750
Um, and it's really over a longer period of time, it's not so much over one night that you're inflammation.
01:01:27.150 --> 01:01:30.829
It's that chronic stress thing where you're, you know, cortisol reduces inflammation.
01:01:31.230 --> 01:01:34.269
We use cortisol as a generic thing for reducing inflammation.
01:01:34.429 --> 01:01:40.750
We have our own body cortisol uh from our adrenal glands, but eventually those receptors become less receptive.
01:01:40.909 --> 01:01:41.230
Yeah.
01:01:41.389 --> 01:01:44.829
Uh, you know, when you're going through a chronic period of stress at work.
01:01:45.150 --> 01:01:50.750
Uh and you and then you combine it with, you know, the fact that you're on a computer for like 14 hours a day or something.
01:01:50.990 --> 01:02:01.869
And, you know, uh, as you probably have found, like when your shoulders are flexed like that, that can often make it worse, which is why sometimes when you uh when you take people back, sometimes their pain just goes.
01:02:02.110 --> 01:02:02.670
Yeah, yeah, yeah.
01:02:02.829 --> 01:02:03.630
You know, yeah.
01:02:03.789 --> 01:02:13.230
I mean just uh just changing people's you know awareness and and opening them up can make a really big difference to um to their pain.
01:02:13.550 --> 01:02:22.269
So you'll often sort of be talking to people about just making sure that they're minimizing stress as much as possible, but sleeping very, very well.
01:02:22.510 --> 01:02:22.829
Yeah.
01:02:23.070 --> 01:02:25.949
Um, because without that sleep, you're not getting into a healing state.
01:02:26.190 --> 01:02:27.070
Yeah, no, exactly.
01:02:27.150 --> 01:02:28.670
I mean that's where the body repairs itself.
01:02:28.750 --> 01:02:30.110
So it's very hard.
01:02:30.190 --> 01:02:35.630
There are two two situations when it's really hard for back or neck issues to to try and make someone better.
01:02:35.789 --> 01:02:40.110
One if they're not sleeping, secondly if they're just sitting at their desk and just not moving all day long.
01:02:40.269 --> 01:02:40.429
Yeah.
01:02:40.670 --> 01:02:46.429
I often say to them, I you know, I don't think I or your physio or your osteopath can help you in that situation.
01:02:46.990 --> 01:02:48.190
Yeah, you've got to change your lifestyle.
01:02:48.510 --> 01:02:49.869
Yeah, I I don't think we can help you.
01:02:50.190 --> 01:02:51.309
Even if I do an operation.
01:02:51.470 --> 01:02:51.630
Yeah.
01:02:51.789 --> 01:02:54.190
And and you're back at the desk and not sleeping.
01:02:54.349 --> 01:02:56.190
It's it's just something something else is gonna happen.
01:02:56.510 --> 01:02:57.789
Something, something's going to give.
01:02:58.030 --> 01:02:58.269
Yeah.
01:02:58.990 --> 01:03:12.990
So what's i uh if we're just thinking about okay, neck pain, are there any sort of real misconceptions about neck pain that we haven't discussed today?
01:03:14.190 --> 01:03:15.309
I think we touched on it.
01:03:15.389 --> 01:03:18.110
Like, you know, you talked about the myofascial aspect of it.
01:03:18.909 --> 01:03:25.630
And um, you know, a classic I think lady before I just came here has just had this kind of pain here.
01:03:25.789 --> 01:03:25.949
Okay.
01:03:26.750 --> 01:03:28.670
Like a periscapular sort of region or medial.
01:03:30.510 --> 01:03:36.829
And um she's uh she's been to see a physio before, has actually teach seen two shoulder specialists.
01:03:36.909 --> 01:03:37.230
Yep.
01:03:37.470 --> 01:03:40.590
Um, and I think you know, that was a classic example.
01:03:40.670 --> 01:03:43.230
She's got actually a C4 nerve impingement.
01:03:43.389 --> 01:03:47.070
Um, you know, and the same we taught touched on with periscapular pain.
01:03:47.150 --> 01:03:47.309
Yep.
01:03:47.470 --> 01:03:53.389
And sometimes same with, you know, numbness in the hands or whatever, you know, doesn't and your neck won't won't always be hurting.
01:03:53.470 --> 01:03:54.110
They won't always be.
01:03:54.349 --> 01:03:54.909
Yeah, yeah, yeah.
01:03:54.990 --> 01:03:55.309
Yeah.
01:03:55.550 --> 01:04:00.030
Um so I think sometimes that's why I think people hang on to neck symptoms for longer.
01:04:00.190 --> 01:04:01.230
You don't kind of realize all the things.
01:04:01.389 --> 01:04:06.829
Because it's a low-level grumbliness at times, and then it can slowly escalate over a period.
01:04:07.070 --> 01:04:14.349
Yeah, and I think you know, it's I think it's harder to differentiate with sh when shoulder and neck symptoms sometimes than it is lower down the body.
01:04:14.510 --> 01:04:14.909
Yeah.
01:04:15.150 --> 01:04:19.630
Um so I think I think that that makes it a bit trickier for people.
01:04:19.789 --> 01:04:25.070
And it's sometimes just having that awareness of by the way, actually, even pain under there could be nerve-related.
01:04:25.389 --> 01:04:26.269
Yes, yeah, yeah, completely.
01:04:26.429 --> 01:04:26.909
You know.
01:04:27.070 --> 01:04:36.829
Um and how often do you pick up you know, a lot of patients will come in and and sort of point, oh my my shoulders really sore, but they're sort of pointing here.
01:04:36.990 --> 01:04:37.230
Yeah.
01:04:37.389 --> 01:04:41.470
And a lot of the time it's the neck.
01:04:41.710 --> 01:04:42.750
The neck is driving it.
01:04:42.829 --> 01:04:50.110
But how often do you see that there's sort of a lot of coexisting sort of pathologies between the shoulder girdle and the neck?
01:04:50.429 --> 01:04:51.150
Yeah, absolutely.
01:04:51.309 --> 01:04:55.789
I guess you only have to look at what interactions I have with other specialities.
01:04:56.429 --> 01:04:58.909
So I have a lot of interactions with shoulder surgeons.
01:04:58.990 --> 01:04:59.309
Yeah.
01:04:59.470 --> 01:05:00.990
You know, and and likewise.
01:05:01.150 --> 01:05:01.630
Yep, yep, yep.
01:05:02.030 --> 01:05:04.110
Hip surgeons and lower back, much less so.
01:05:04.349 --> 01:05:04.670
Okay.
01:05:04.990 --> 01:05:12.349
Uh so, but like knees, for instance, uh, you know, uh knee replacement surgeons, this they're often 70-odd-year-old.
01:05:12.429 --> 01:05:16.269
How many of those have degenerative lumbar spines and potentially some L3 nerve root?
01:05:16.349 --> 01:05:16.510
Yep.
01:05:16.670 --> 01:05:17.630
You know, that's another one.
01:05:17.710 --> 01:05:21.869
But yeah, I have a lot of interactions with shoulder surgeons because one can drive the other, as you know.
01:05:22.030 --> 01:05:37.710
Like you can have kind of C56 issue, kind of low-level nerve irritation or grumbling, or C67, and then you'll get a bit of shoulder muscle dysfunction, you'll get a shoulder muscle patterning issue, and then suddenly you've got a bit of instability in your shoulder, and you've got then suddenly your AC joints hurting.
01:05:37.789 --> 01:05:38.110
Yeah.
01:05:38.269 --> 01:05:40.670
And they present a shoulder guy with AC joint pain.
01:05:40.750 --> 01:05:40.909
Yeah.
01:05:41.070 --> 01:05:42.590
Which, as you know, can be really painful.
01:05:42.909 --> 01:05:50.429
But a lot of the time that sort of shoulder dysfunction leads to weak huff, poor scapula stabilizers, then you get overload through the neck as well.
01:05:50.670 --> 01:05:50.990
Yeah, yeah.
01:05:51.070 --> 01:05:51.949
And then it goes back again.
01:05:52.030 --> 01:05:52.190
Yeah.
01:05:52.429 --> 01:05:52.750
Yes.
01:05:52.909 --> 01:06:00.429
And without then addressing that scapula glinohumeral position, yeah, you're g you you you're you're overloading the whole system.
01:06:00.510 --> 01:06:05.230
And so the neck is is is impacted in that in that sort of situation.
01:06:05.630 --> 01:06:06.030
No, exactly.
01:06:06.110 --> 01:06:10.349
And quite often people do go to the shoulder guys with, you know, proper AC joint pain, yeah.
01:06:10.510 --> 01:06:19.869
Or cuff tendinopathy or whatever, and they go, Wow, and they look at they do a C spine MRI because they said there's a bit of neck pain, and then there's severe C five, six for amino stenosis.
01:06:20.030 --> 01:06:20.269
Yep.
01:06:20.429 --> 01:06:27.789
When they see that, they often send it to me because they they kind of think, Well, actually, I don't even want to think about going further if that C six never is not working properly.
01:06:27.949 --> 01:06:28.269
Yeah.
01:06:28.429 --> 01:06:35.470
Uh, because if it is if it isn't working properly, let's say you do a great op shoulder athroscopy and then you're still gonna have then you're gonna have a rehab issue.
01:06:36.030 --> 01:06:36.510
You know.
01:06:36.750 --> 01:06:41.150
Um, so there's a bit of toing and froing with that, and you know, sometimes people have all of those.
01:06:41.309 --> 01:06:43.949
Same with nerve and carpal tunnel syndrome.
01:06:44.030 --> 01:06:44.269
Yep.
01:06:44.510 --> 01:06:51.949
You know, sometimes people have C56, nerve root issues, um, and conclementant uh carpal tunnel syndrome.
01:06:52.429 --> 01:06:54.510
And how are you differentiating those?
01:06:54.670 --> 01:06:58.909
I mean, clearly you've got sort of local sort of the tinnel sign for carpal tunnel test.
01:06:58.990 --> 01:07:03.309
And are you sending these patients off for a nerve conduction study very often anymore?
01:07:03.550 --> 01:07:10.190
Um, yeah, so I'd send people for nerve conduction studies in general, yeah, a fair amount for all sorts of different reasons.
01:07:10.349 --> 01:07:12.510
So I think you've got to look at the history really.
01:07:12.829 --> 01:07:22.269
So if someone's you know just got symptoms in the hand and the signs are positive, then I probably will do uh and uh you know, send them off.
01:07:22.349 --> 01:07:28.110
Um if they've got you know neck pain radiating down the arm into that territory, I'm not gonna do a nerve conduction study every single time.
01:07:28.190 --> 01:07:28.429
Yep.
01:07:28.590 --> 01:07:35.470
You know, because if they have got a nerve compression there, you know, that's gonna need to be, you know, dealt with addressed with physio injections.
01:07:35.630 --> 01:07:41.869
If it does come down to surgery and and I I'm suspicious of carpal and I'll do a bit of stuff.
01:07:42.190 --> 01:07:42.349
Yeah.
01:07:42.590 --> 01:07:46.750
And I'll I might say to them, it's not causing your arm pain, but it might be causing some of that.
01:07:46.829 --> 01:07:47.070
Yep.
01:07:47.230 --> 01:07:52.190
And then you try and work, you you work it through as to which might be worse best dealt with first.
01:07:53.470 --> 01:08:06.110
Is do you have a bit of a general rule that if the shoulders coexisting with the neck that you want to address one before the other, or it just depends on what you feel is the biggest driver?
01:08:06.349 --> 01:08:07.389
Yeah, not general rule.
01:08:07.470 --> 01:08:20.029
Just uh definitely driver, and sometimes there's a bit of tennis between the shoulder and you know, and you know, I've got great colleagues, and nobody, you know, fortunately, um no one's saying, Oh, I want to do my operation.
01:08:20.349 --> 01:08:21.789
It's often actually the other way around.
01:08:21.949 --> 01:08:22.109
Yeah.
01:08:22.269 --> 01:08:25.550
Yeah, yeah, you know, because I think everyone wants the ideal outcome.
01:08:25.710 --> 01:08:26.029
Yeah.
01:08:26.269 --> 01:08:31.630
And if there's something else going on, perhaps that's going to limit the the ultimate outcome.
01:08:31.949 --> 01:08:32.750
Yeah, exactly.
01:08:32.909 --> 01:08:41.949
So, you know, if someone's got pain on shoulder abduction, but a rip-roaring sciatic uh, you know, a C56 or whatever, nerve compression post-opits can be hard.
01:08:42.109 --> 01:08:42.349
Yeah.
01:08:42.510 --> 01:08:43.069
Yeah, yeah.
01:08:43.149 --> 01:08:44.029
Okay, that makes sense.
01:08:44.429 --> 01:08:45.789
But same for them as well.
01:08:46.189 --> 01:08:46.670
Yes.
01:08:46.989 --> 01:08:52.350
So what you do is you then do an injection and hope that that calms down, then they can do their shoulder rehearing.
01:08:52.430 --> 01:08:52.909
Yeah, yeah, yeah.
01:08:53.149 --> 01:08:54.430
So that's why it's easier doing that.
01:08:54.590 --> 01:08:55.710
Yeah, okay, cool.
01:08:56.350 --> 01:08:59.869
So final little question.
01:09:00.029 --> 01:09:07.550
Do we think that spinal health should be something almost considered in schools and taught in schools?
01:09:07.789 --> 01:09:07.869
Yeah.
01:09:08.109 --> 01:09:17.230
You know, that sort of movement awareness of what's good exercise, what's healthy exercise, and how to move effectively.
01:09:17.869 --> 01:09:20.829
Well, I think musculoskeletal health in general should be taught better.
01:09:20.909 --> 01:09:21.149
Yeah.
01:09:21.310 --> 01:09:24.270
Uh, not just do sports here, this is your warm-up.
01:09:24.590 --> 01:09:27.630
Uh, you know, because that's that evolves all the time anyway.
01:09:27.789 --> 01:09:30.909
Um, but actual formal teaching on musculoskeletal health.
01:09:30.989 --> 01:09:40.430
And yeah, for me, spine health, because it's one of the most common ailments that people get in terms of understanding what we mean by posture, what why do your parents tell you not to slouch?
01:09:40.670 --> 01:09:40.989
Yeah.
01:09:41.230 --> 01:09:42.029
Classic thing.
01:09:42.270 --> 01:09:44.350
Uh why do we why do we say warm up?
01:09:44.430 --> 01:09:48.350
You know, you just you get kids on the rugby pitch, people why do we need to warm up?
01:09:48.510 --> 01:09:48.590
Yeah.
01:09:48.750 --> 01:09:51.390
You know, it's like, you know, actually, this is why you need to warm up.
01:09:51.630 --> 01:09:51.789
Yeah.
01:09:51.949 --> 01:09:57.149
So educating them about the the processes and and their and their body and you know, what's going to happen.
01:09:57.310 --> 01:10:12.590
I you know, I suppose when you're that young, you don't you you sort of feel pretty resilient, yeah, and don't think that you're you know, you're you're bulletproof and don't think that some of these things are going to happen to you, which is perhaps why you know we only start paying attention to this when when we're a little bit older.
01:10:12.909 --> 01:10:24.750
Yeah, but you know, the the kids uh injuries like are not just fractures, but you know, whether it's spine or uh Oshgrid slats, you know, like uh you know, I had two parents come up to me at the weekend, you know, um uh for one kid.
01:10:24.989 --> 01:10:25.949
On the rugby pitch or something.
01:10:26.109 --> 01:10:30.989
Yeah, they just said like uh said, Oh do you I know your spine, but can we ask you about Oscar Slatters?
01:10:31.149 --> 01:10:31.470
Yeah.
01:10:31.630 --> 01:10:34.189
Um and it's an amazing amount of kids that have that.
01:10:34.430 --> 01:10:35.710
Uh it's uh yeah.
01:10:35.949 --> 01:10:36.270
Yeah.
01:10:36.590 --> 01:10:38.989
Severs, Oshgrid's ladders, yeah.
01:10:39.230 --> 01:10:41.630
And these growth growth sort of disorders.
01:10:41.869 --> 01:10:42.350
Yeah, exactly.
01:10:42.430 --> 01:10:45.310
And then and the data on uh past stress injuries.
01:10:45.390 --> 01:10:45.470
Yeah.
01:10:45.710 --> 01:10:46.189
Unbelievable.
01:10:46.350 --> 01:10:46.510
Yeah.
01:10:46.909 --> 01:10:52.350
Like it's actually quite a significant amount of kids or have that or even disc related issues.
01:10:52.430 --> 01:10:54.989
And I and I'm pretty sure that that that data is.
01:10:55.230 --> 01:10:58.029
It definitely feels like that's increasing across the board.
01:10:58.189 --> 01:10:58.590
Yeah.
01:10:58.750 --> 01:11:05.630
Um and so it's understanding making them understand at an early time there is a reason why we say go to sleep.
01:11:05.789 --> 01:11:07.069
I keep going back to sleep.
01:11:07.149 --> 01:11:15.230
Uh there was a reason why we say eat healthy, with the reason why we say um, you know, you need to do these warm-ups or these muscle activation exercises.
01:11:15.310 --> 01:11:15.470
Yep.
01:11:15.630 --> 01:11:17.710
And this is what you do to prevent injury.
01:11:17.789 --> 01:11:20.350
We're good at that at rugby, you know, youth rugby.
01:11:20.510 --> 01:11:25.949
You've got to teach them certain positions and there's yeah, certain ways of training uh of training, tackling.
01:11:26.029 --> 01:11:32.430
Yeah, you can't tackle with back flexion and you know, not you know, uh hip and knee flexion.
01:11:32.510 --> 01:11:33.310
You know, why is that?
01:11:33.390 --> 01:11:37.310
You try and explain to them, you look around next week, you ask them the same question, they still don't need to.
01:11:38.270 --> 01:11:41.310
Uh but yeah, I think an education on it is essential.
01:11:41.470 --> 01:11:45.789
Yeah, like it's it's something we've got to try and do because we're now doing sport more intensely.
01:11:45.949 --> 01:11:50.189
Kids are now uh well, most importantly, kids are now going to the gym at 40, you know.
01:11:50.430 --> 01:11:52.510
Yeah, kids are getting much, much younger.
01:11:52.670 --> 01:11:52.829
Yeah.
01:11:52.989 --> 01:11:54.029
And they're lifting heavy.
01:11:54.430 --> 01:12:10.590
Lifting heavy by the by the time they're 16, 17, you know, I saw a 17, 18-year-old critic who looks apparently he's you know, he's tall and lanky, and apparently he's he's like you know, really rated, and he's got a disc injury and a past stress injury, but it's actually the disc issue that's a problem right now.
01:12:10.670 --> 01:12:11.310
Yep.
01:12:11.710 --> 01:12:14.670
And I assumed he was a fast, I said you were bowling?
01:12:14.829 --> 01:12:18.750
He said, Yeah, and I said, So you did, you know, what were you playing a match when you did it?
01:12:18.909 --> 01:12:19.310
Were you warming up?
01:12:19.390 --> 01:12:20.109
I said, No, no, I didn't.
01:12:20.270 --> 01:12:20.989
The gym lifting.
01:12:21.149 --> 01:12:21.710
Yeah.
01:12:22.029 --> 01:12:23.470
Um, what were you lifting?
01:12:23.550 --> 01:12:26.829
It was something like 160, 17 years old.
01:12:27.069 --> 01:12:27.230
Yeah.
01:12:27.390 --> 01:12:32.829
I mean, these are big loads, and their movement patterns generally when we see them are not great at all.
01:12:33.069 --> 01:12:39.550
Yeah, you know, the ballet dancers, most of them are uh they do it in training in the okay.
01:12:39.789 --> 01:12:44.270
So that's been super interesting uh today, Alex.
01:12:44.350 --> 01:12:45.869
So thank you for that.
01:12:46.109 --> 01:12:51.390
I think the things that you know going back to okay, we all need to sleep.
01:12:51.550 --> 01:12:52.189
Yeah.
01:12:52.510 --> 01:12:58.829
Manage our stress, but exercise is key, keeping neck strong, keeping shoulder girdles strong.
01:12:58.989 --> 01:13:13.069
Do all those pulls, banded stuff, cable stuff, making sure your cuff is strong, making sure you're opening your chest out, making sure you've got good thoracic mobility, and that you're just not static all the time.
01:13:13.470 --> 01:13:14.029
I think so.
01:13:14.270 --> 01:13:26.189
And I think yeah, I think that it you kind of hit the nail on the head because we're all very educated in mobility for the lower back and the legs and doing things like bridges and muscle activation exercise and everything.
01:13:26.430 --> 01:13:29.630
You ask the average person what to do we we really don't do much.
01:13:29.789 --> 01:13:38.430
Yeah, they'll oh people just do shoulder press, which is a or just stretch the neck, which is a strength exercise, it's not you know uh rehab or training or anything like that.
01:13:38.670 --> 01:13:43.069
Um, but yeah, I think a greater education into that and more neck mobility.
01:13:43.149 --> 01:13:45.710
I think you know our necks are designed designed to be loaded.
01:13:45.789 --> 01:13:46.029
Yeah.
01:13:46.189 --> 01:13:48.750
Not in a massive way, but they're designed to be moved and loaded.
01:13:48.909 --> 01:13:49.230
Yeah.
01:13:49.470 --> 01:13:52.189
And I think we underload as physios.
01:13:52.670 --> 01:13:54.510
Um, I think we've done that.
01:13:55.069 --> 01:14:15.310
You know whether that's because we're cautious or we haven't known, but hopefully we're moving in the right direction where we're, you know, we're putting I'm certainly putting a hell of a lot more load into the neck than what I used to, you know, with banded work, different strength work, different isometric stuff, holes, um, and then combining that with sort of neck and short of shoulder girdle work as well.
01:14:15.710 --> 01:14:15.949
Exactly.
01:14:16.029 --> 01:14:17.710
And that that's loading in a sensible way.
01:14:17.789 --> 01:14:19.710
That's not even, you know, yeah.
01:14:19.869 --> 01:14:22.510
That isn't like you know, you're not lifting weights with your teeth or anything.
01:14:22.750 --> 01:14:23.310
No, no, no, no.
01:14:23.710 --> 01:14:25.149
No, we haven't got there yet.
01:14:25.550 --> 01:14:27.310
Um, but excellent, Alex.
01:14:27.390 --> 01:14:28.750
That was super interesting.
01:14:28.829 --> 01:14:29.470
So thank you again.
01:14:29.789 --> 01:14:30.189
Thanks very much.
01:14:30.430 --> 01:14:31.069
Nice to chat.
01:14:31.310 --> 01:14:31.789
Cool.