Spinal Disc Replacement Surgery with Dr. Amir Vokshoor: Rational Wellness Podcast 443

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Dr. Amir Vokshoor discusses Spinal Disc Replacement Surgery with Dr. Ben Weitz.  

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Podcast Highlights

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Dr. Amir Vokshoor is a board-certified neurosurgeon with more than 20 years of experience and Chief of Surgery at Providence St. John’s Health Center in LA, Dr. Vokshoor is internationally recognized for advancing minimally invasive spine surgery, spinal disc replacement, and motion-preserving technologies. His website is DrVokshoor.com. His Instagram account is drvokshoor. Use the Discount code BEN for a discounted consulation and MRI with Dr. Vokshoor.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

 

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Podcast Transcript

Dr. Weitz:  Hey, this is Dr. Ben Weitz host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com.  Thanks for joining me, and let’s jump into the podcast.

Hello, Rational Wellness podcasters, on the Rational Wellness Podcast I generally speak about functional medicine topics, though I am both a functional medicine practitioner and a musculoskeletal chiropractic doctor. And today we’ll be speaking about back and neck surgery as an option for patients who fail conservative care, like chiropractic or physical therapy.  The most common forms of back surgery are microdiscectomy for disc herniations, laminectomy, spinal decompression, and spinal fusion, which is allowing to stabilize the vertebrae, but the newest procedure, spinal disc replacement surgery only accounts for a relatively small percentage of surgeries, only 1% of back surgeries and less than 14% of neck surgeries, suggesting that there’s been a very slow adoption of this procedure despite first being approved in the US in 2000.  Back and neck pain are very common, and while most cases of back pain will eventually resolve. Recurrence is common and a significant percentage of patients go on to have chronic pain.  Outside of traumatic injuries or conditions like cancer, most back and neck pain results from degenerative conditions and postural issues, including intervertebral discs that break down, tear or bulge or herniate out, spinal joints that become damaged, spinal nerves that become compressed or stretched, bone spurs, and shifts in spinal alignment. Surgery for patients with back or neck pain is particularly effective for radicular pain, which is when you have pain that radiates down an arm or a leg. But most patients who have back surgery will likely still have some future episodes of back pain, which is why surgeons like Dr. Vokshoor, who is our guest for today, have continued to search for better surgical methods since as minimally invasive surgical procedures and spinal disc replacement surgery.  Dr. Amir Vokshoor is a board certified neurosurgeon with more than 20 years of experience. He’s chief of surgery at Providence, St. John’s Health Center in Los Angeles. He’s internationally recognized for advancing minimally invasive spine surgery, spinal disc replacement and motion preserving technologies. In addition, he’s also the founder of the NeuroVella Brain Spa.

Dr. Weitz:  Dr. Vokshoor, thank you so much for joining us.

Dr. Vokshoor: Thank you, Dr. Weitz.  Thanks. Thanks for having me.

Dr. Weitz: So welcome to our podcast, and perhaps you can tell us about your journey and what made you decide to become a neurosurgeon.

Dr. Vokshoor: I love the name of the podcast, by the way, it really speaks to keeping a rational mind around health situations. Health events is extremely important and you know, I have a long journey, but basically it boiled down to I loved brain anatomy and neuroanatomy in medical school, and I loved the orthopedic aspects of bone and nerve health in the spine where they joined. So something about the segmentation of the spine, something about the way it was being treated really attracted me to learn as much about it as the [00:04:00] neuro and orthopedic structure and the function of the spine, but brain anatomy and how it connects to the spinal cord and how it’s like the central governor of all of our body energy really spoke to me. And, you know, we can go into details another time about exactly what led to becoming a neurosurgeon, but in a very short recap is I walked into the wrong operating room as a third year medical student, and there was a glistening white membrane, and it was the septum pellucidum of the third ventricle [of the brain].  And I, that week I had my first neurosurgical lecture by Dr. Paul Musilar about subarachnoid hemorrhage, and then we had another lecture about how drugs affected the brain. Right there, you know, walking in to the wrong operating room, looking at this white glistening membrane with a single vein behind it.  It looked like, oh, is that the eyeball? You know, and I was a student, so the nurse says, be very quiet. That’s the center of the brain. And right there I was like, oh wow. And something like came over me and I was like, you know, in the same week I’d heard about brain physiology, brain anatomy, here I was seeing brain surgery in person, and it really spoke to me.  And neurosurgery has really been a privilege in my life to be able to learn and practice and also try to see beyond its limits and where we go, where we fall short as neurosurgeons. So I have the, you know, utmost humility for the fact that, we have some very sobering conditions that we do not treat and we cannot treat yet very effectively.  Brain cancer being part of it, but even things like dementia, deep depression you know, there, there are chronic pain, there are things that we…

Dr. Weitz:  Yeah, a lot of neurogenerative conditions like Alzheimer’s and Parkinson’s… 

Dr. Vokshoor:  Exactly, precisely. So we haven’t made a meaningful dent in the treatment of those diseases.  And that’s why I want to continue to push the envelope forward in every way we can. And in the small way that I can, the NeuroVela brain spa is my answer to bringing you know, physiology and anatomy, which is our expertise, to psychospiritual levels and using meditation and frequency medicine and things of that sort in a way of biohacking affecting your nervous system in a positive way,

Dr. Weitz:  And we’ve been incorporating a functional medicine approach taught by Dr. Dale Bredesen, who’s been publishing about how that can sometimes be effective for patients with Alzheimer’s. 

Dr. Vokshoor:  Indeed, I’m a huge fan of Dr. Dale Bredesen. And I’ve spoken with him specifically about his methods and, you know, it’s like a breath of fresh air to really be like, okay, can we actually in our lifetime make a dent in these devastating disorders?  I, we formed a nonprofit research organization after my father contracted Alzheimer’s. It was almost like my gut reaction to the [00:07:00] ineptitude that we had exercised with billions of dollars poured into research dollars, you know, chasing wrong wrong data and, you know, erroneous data formats and bad, badly done research.

Dr. Weitz: Unfortunately that’s still going on. We’re still looking at amyloid plaque as the cause of Alzheimer’s and trying to come up with another drug to remove it. And now some of the researchers have switched from amyloid to tau as if that’s going to be the magic answer. And unfortunately, they’re not really asking the question is, why is this amyloid and tau proteins present in the first place and addressing that is going to be a really important part, even if part of the answer is getting rid of it

Dr. Vokshoor: Exactly. Exactly. I a hundred percent on board with that. And I feel like the amyloid, you know, I tried to picture this as a neurosurgeon, as my father is undergoing this ravaging disease inside his brain that, okay, you know, he has these myelin sheath that are perfectly connected, and then they get little potholes inside them, and those are the amyloid plaques.  And what these drugs are doing is just filling the potholes without really treating the disease. So we don’t know what’s causing the potholes, we’re just kind of trying to clear ’em up and that’s, you know, that’s why we haven’t really made a dent in it. Yeah.

Dr. Weitz: We think that part of the problem is that the amyloid is protecting the brain against inflammation and toxins and even infections, because now that we know that the brain is, that the brain blood barrier is not as tight as we thought it was.

Dr. Vokshoor: Indeed and there’s, you know, there’s great theories on infectious ideology and there’s definitely in Parkinson’s there’s an intestinal component that’s being investigated.  So I definitely feel more excited than ever that we are going to see some drastic discoveries come to fruition.

Dr. Weitz: Yeah. So, we’re going to talk about spine surgery and a lot of it’s about the disc. Maybe you can explain to us what is the intervertebral disc, what’s its purpose, and then what can go wrong with the disc.

Dr. Vokshoor: Yeah, so the intervertebral disc my most favorite subject matter because it really affects our structure, our physiology, and our psychology so effectively when it’s not functioning well. And so it’s basically this very low vascularity or avascular shock absorbing structure that’s between our vertebra, which act like brick supporters here actually happen to have a model here. So, you know, this is a glass shaped model, but basically the vertebra act like the bricks and the discs are these shock observers between the vertebra. And and then in the back we have the spinal joints, which are two on either side. So we have, you know, 7 cervical, 12 thoracic, 5 lumbar that are illustrated here.  And then sacrum, which is really a unified bone of 5 segments. And then the coccyx, the tailbone, which is a unified bone of 4 segments, or somewhat unified bones of 4 segments, is absolutely fascinating the way these structures come together and between each of the disc. Especially the ones that move for us, there is a working functional disc and in the neck you can imagine the shock absorption that goes on the extreme dynamic movement that goes on is due to the, you know, just the magic of C1/C2, which by the way, C1/C2 don’t have an intervertebral disc because they’re really specialized. Interesting vertebra. And you know, I would say our super subspecialty is in neurosurgery is knowing C1/C2 anatomy, you know, better than any other, especially surgically. And and then between two to seven we have cervical intravertebral discs in the thoracic spine.

Those distal move a lot because there [00:11:00] is a rib cage, but they do move. And as you know, there’s definitely some dynasty to that system as well. And sometimes in the thoracic spine, like our scapula, our shoulder blade motion is dependent on how mobile your thoracic spine discs are. And this is where the dynamic part of the system becomes really useful for hacking into it and decreasing pain and suffering.  And in the lumbar spine, we have shock observers between L1/2 and S1. Those essential discs are not only giving us shock absorption and structural integrity, they’re also giving us our curvature. So in the lumbar spine and the cervical, as a matter of fact it’s this parenthesis appearance of the of the lumbar vertebra.

This lordotic appearance, we call this lordosis of the spine, and you may have explained this to, to your audience at other times, but this structure, the structure of the disc in the lumbar spine being [00:12:00] a little wed shaped or lordotic is essential for a sense of. Uprightness wellbeing and painless motion during physiologic loads and due to trauma, wear and tear or sometimes infection or other ideology, the disc loses its height, loses its structural integrity, and begins undergoing this four stage generation to being completely gone, being bone on bone, sometimes filled with a little air, air particles or air VAEs, which is usually interesting to my patients. My patients are like, how did air get in there doc? And I’m like, good question. We’re still investigating that. ’cause some people think it’s a bacterial source. Some people think it’s just part of the degeneration, kind of a grade 4 degeneration of the disc, but these shock absorbing discs when they herniate out of their usual area, they can hit a nerve. So the spine is supposed to protect our [00:13:00] nerves, but if the disc herniates out of its original place, when a nerve is exiting the spine, the, it can be pinched by a herniated disc or a ruptured disc.

And we can certainly go through that terminology. But, that by itself usually causes arm pain or leg pain pretty severe. If it’s extruded and large, it causes massive pain. But if it’s, if it separates itself from the body completely and it’s just sitting there, this free fragment, what we call a free fragment, sometimes the body can chop that up really quickly.  And there’s always this controversy like, should we do early surgery, no surgery. Or wait and do surgery. And it’s a, it’s always a little bit touch and go. And, you know, I have a lot of conversations with the patient’s primary care or chiropractor or whoever referred ’em to me. And we always go through this workup of saying, okay, is there any nerve damage?

Is there a foot drop or is there [00:14:00] something that’s. Causing potentially permanent damage, and those cases were very interventional. Being a neurosurgeon gives you this immediacy to your mindset that, okay, nerve is under compression. We have to go take care of it. But if the weakness is mild or absent and there’s just a lot of pain, sometimes the body completely takes care of it.

You can avoid surgery, and it’s a, it is, it was antithetical to the size of the disc and the a disc fragment that could occur. But we see that in my 20 plus year career, I’ve seen that a lot. So being a conservative surgeon, my favorite thing to tell those people is, you’re probably going to pass this episode just fine with a steroid pack and maybe an injection and maybe some other types of medications and ice, et cetera.  But in your lifetime, if this shock observer becomes incompetent, means becomes bone on bone, then you may benefit from a disc replacement. And [00:15:00] I can get one of those models as well to show you guys. So, basically it’s an implant that then tries to replace the disc completely with. A, a metallic on plastic implant that moves, like the original disc does not absorb shock as much, at least this generation of the implants.  And it it doesn’t have I would say. Always the ability to give you the complete motion and flexibility back. Right. Especially in shock absorption.

Dr. Weitz: Okay. Before we go on to explaining the artificial disc, I want to make a couple of comments that I think are, yeah, you talked about the posture and the fact that we normally have this backwards curve in the lower back and the discs are aligned for that.  So the disc actually encouraged that backwards curvature, and I think one of the, problems leading to back problems that is often unrecognized is posture because we sit in chairs and people often sit with their [00:16:00] lordosis reversed. In other words, your chairs are soft. Your back actually curves the opposite way and studies have shown that sitting with your back slouch for as little as 20 minutes can cause the distal bulge or posterior ligaments to loosen up. And so I think one of the prevent preventative things is really important for people to be aware of that and to use some sort of lumbar curve. I specifically use these lumbar pillows that go directly.

To support that curve, and I think that’s super important for us to be aware of that if we want to keep those discs healthy and in the right place, we need to support that lumbar curve while we’re sitting. When you stand your back automatically arches and then precise. Second point I’d like to make is when patients have these discs that become damaged and bulge or herniate, what happens is that the immune [00:17:00] system attacks these discs because it’s seeing this piece of the disc in a place that’s not supposed to be, basically sees it as a foreign body like a bacteria or a virus and it attacks it, it sends these types of immune cells to gobble it up. It sends chemicals that create pain and. So a lot of the pain related to these disc problems is really just related to that immune process. And even without changing what’s happening with the disc, if you get that chemical process, that immune process, to calm down, then you’re, a lot of times the pain will go away.

Dr. Vokshoor: Indeed. No, I’m glad you mentioned those things because yeah, we didn’t go over the other things that happened. The chemical milieu of inflammation and then the macrophages actually coming and chopping up the fragment. Both of those being painful processes you’re absolutely correct.

Dr. Weitz: And over time, you know, [00:18:00] one of the thoughts is that the macrophages can come in and gobble up that part of the desk. It might actually resolve itself. The problem is how long is it going to take and can you withstand the pain till that happens, because it can be a long process?

Dr. Vokshoor: Yep. Yeah. We’ve, you know, we’ve seen trial after trials showing that, you know, surgical arms and non-surgical arms can be equivalent, but the surgical arms had like faster patient satisfaction scores and things of that sort because they get out of pain a little easier and they can go back to work and become functional a little faster.

Dr. Weitz: And there was a time that a procedure was being done to try to enhance the ability to gobble up those discs. They were injecting papaya enzymes into the spine, and that would dissolve the disc. Unfortunately, sometimes it would dissolve some of the nerves as well. Yes.

Dr. Vokshoor: Indeed. Thankfully those days are over.  We have a lot better tools. But that’s that, that’s an era from the past where we’re [00:19:00] experimenting with how do we change the chemical milieu there. Now we do numbing medicine shots or corticosteroid shots. And there are other techniques to, for the peripheral nerves to feel a little bit better.  I’ve even seen some chiropractors do like hydro dissection and things of that sort to just make the final pathway of the nerve feel a little better. All these things are meant to try to decrease the inflammation and make the nerves feel better while that actual healing goes on. Right.

Dr. Weitz: And so, the disc replacement is a replacement for fusion surgery, which is done much more commonly.  Can you explain what is fusion surgery, when is it indicated, whether the pros and cons of it? And then after that let’s get into the artificial disc.

Dr. Vokshoor: So, yeah, so discogenic pain is a huge participator in our overall disability score all across the United States and the world. So discogenic back and neck pain take away more productive hours of our [00:20:00] workforce than almost anything else.  And when you have disc pain, you just don’t feel well because the foundation of your body is unable to hold you up and have you doing most of your daily activities without pain. So in those cases, when the quality of life is so severely affected, then we actually contemplate, okay, what if we change the shock observer out for a new one?  And traditionally. We have had to put a, basically a bone wedge inside the area of the disc, the defect that’s caused by the disc being gone. This was initially done in the cervical spine successfully for by Dr. Klau and Dr. Smith Robertson Robinson. And those were little tiny dowels that they would put inside the neck discs.  Those were pretty successful, except we realized that a percentage of those patients continue to have problems at the adjacent level discs. So because the fusion did [00:21:00] such a good job eliminating motion, then the other disc would work harder and presumably wear out a little faster.

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Dr. Weitz:  Let me just jump in real quick, so, yeah, whenever you’re going to bend or rotate you, each of your vertebrae are going to participate in bending a certain amount. And so if you talk, think about the five lumbar vertebrae and now you fuse L4/L5, you’re still gonna bend over to tie your shoes. And now the disc at L5/S1 below the area that was fused, or the disc above it, is going to be under a lot more stress because instead of say each of those levels participating five or 10 degrees some of the other levels have to move more to allow you to still be able to tie your shoes.

Dr. Vokshoor: Precisely and so if you think about how the spine was designed originally. It’s supposed to give you coupled motion. So at each segment you have a disc between two vertebra and two joints in the back, but they’re also talking to their buddies and they’re sharing the load. So if there are five of them sharing the load, it’s less load on each one of them than on one.  So if one of them checks out. There’s more load on the other four if two of them are fused. There’s mo more load on the other three, and this happens in the lower back, happens in the mid back, [00:24:00] happens in the neck. And that phenomenon of adjacent level degeneration has been well, well studied. So thankfully in the recent years, I would say at least 10 years, we have the advent of being able to replace the discs.

With mobile discs. With mobile devices, not just fusing them with a wedge of bone or a wedge plastic or a titanium implant. And in the lumbar spine, we went through this tiny little hiccup where the initial disc implants didn’t work that well. They would move too much, they would move too little, they would spit out, they would do they were hypermobile, et cetera.  And sort of very first generation implants. I mean, we can go way back. But there they were, thought they were thought of as these little balls first, and then the early two thousands we had, 

Dr. Weitz:  They were like metal ball bearings?

Dr. Vokshoor: Right, right. That was the original thought. And you know, they actually did okay for a while, but they weren’t studied very well.  We didn’t have this incredible system of doing very good [00:25:00] randomized controlled trials. So in the early two thousands I believe Johnson and Johnson actually put a very good effort in creating the cite disc and teaching everyone how to do it, et cetera. But the device was just not that good. It was a little hypermobile.  It was a French device company that initially came up with it from CTE Hospital in France. It just it just didn’t work out. So again, the fusion bandwagon, which is sort of like the equivalent of, you know, big pharma in our industry they were like, see, like this stuff doesn’t work.  And we were so hopeful. We were so hopeful that we can finally do what orthopedic surgeons do on the hips and knees every day. They say, here is your hip back, you know, with motion. Thank you so much. I brought you some models just in case we wanna review them. Thank you. Okay. So, so in, in essence, you know, the first generation lum artist that didn’t work gave rise to much better engineering, much better design.  So finally we have an implant now called the pro disc l that has been [00:26:00] approved for up to two levels in the lumbar spine and it’s a very stable device and it moves. And it gives you your curvature back. And so it’s the best device we have in order to replace the discs that are abnormally degenerated in the lower back.

Dr. Weitz: And what is that made of? And then how does it allow motion? And then how do you keep it in place?

Dr. Vokshoor: So it has these, so here’s the device. I hope we can zoom in on it to see it. So this is the actual device, okay. And it has these little fields that go into the vertebrae to keep it in place. Okay? But center, the center of it is indeed a polypropylene or plastic.  And the end plates, the ends of it are metallic, so the ends of it me mend with the bone, almost like fused to the bone above and below, and then the plastic part moves in the center, which is, you know, for the first time we’ve been able to mimic some of the physiologic motion surgically, [00:27:00] which is so exciting.

Dr. Weitz: And does that plastic wear out over time?

Dr. Vokshoor: No. So these are high grade polypropylene that have withstood 20 million cycles of fatigue. So they’re like medical grade plastic, so they don’t wear out in a human lifetime. Interesting. Yeah. Yeah. And the part of the body that has had a really good blessing from artificial disc replacement is the neck that didn’t even go through that hiccup from the very first generation of artificial discs, the neck.  Reacted much easier, and it’s a very natural area to restore motion. And I would say we’re probably the most frontier arthroplasty surgeon as far as disc replacement in the neck because every time you’re putting a disc replacement in the neck, you have to make sure that the joints in the back of the neck are not too arthritic.  And the neck has really interesting. This is a model of the cervical spine, another glass model. [00:28:00] And this is an example. A disc in the cervical spine.

Dr. Weitz: Okay.

Dr. Vokshoor: Where it’s also has the metallic end plates and the plastic in the center. And what’s fascinating about the cervical spine is that it’s a five joint complex.  It’s a disc in the front, two little UNC or vertebral joints on either side, and then two facet joints in the back. Huh. So that’s what really gives us all of this dynamic motion is an absolute. Fascinating structure to study from a design standpoint. And so the disc replacement in the neck can be used to reanimate three of those five complexes.  Huh? So, so if the joints in the back of the neck are not. Fused on their own or severely arthritic in a way that the neck just doesn’t move correctly, which we can check with x-rays and CAT scans. If it hasn’t fused or if it’s just a little bit arthritic, you can still get a disc replacement in the neck.

[00:29:00] And even if you have abnormalities of the, those two other side joints called the unco-vertebral joints, which are right on either side of the disc right there. So it’s really fascinating. So in, in my practice, we’ve been able to reanimate motion segments that, you know, in the in early arthroplasty days would be deemed impossible to give someone motion back.

And it’s absolutely fascinating to see how life wears out something and how you can reverse that. I call it the the spine rejuvenation surgery because you literally get years of life back after your spine has decided to, you know, look this way because of a degenerative cascade or trauma or car accident or playing football as in high school, like, being a truck driver.  I mean, I’ve seen it all. Some of it is. Cumulative trauma of life, and some of it is acute trauma due to an accident or something of that sort. Both of those can lead [00:30:00] to the same place, and this replacement has been our mainstay of giving people motion back, which is so extremely exciting.

Dr. Weitz: What do the studies show about this success rate?

Dr. Vokshoor: So we now have seven and even 10 year data from the cervical disc replacement. It shows not just equivalence, it shows superiority to the art of to the previous fusion, especially more than one level. So, if you imagine the cervical spine is supposed to move, let’s say you have three levels that are.  Abnormal and de herniated and degenerated yet, let’s say you need a three level disc replacement. Can you imagine what a three level fusion would do to the moment arm of a flexible neck? Sure. So, so as you get more into, you know, like higher age groups and more levels, degenerated. We need even better technology.  ’cause like currently, FDA is o only approved up to two level disc replacements. And some of that is because [00:31:00] the research studies are expensive and the companies that make these discs don’t have the bandwidth to put yet another randomized controlled trial to get a three level approval or four level approval.  So unfortunately we get into a sticky situation where. The insurance doctor is telling me, no, you can’t do more than two levels artificial discs. And we have to either do a hybrid construct, use a fusion, or simply tell the patient we can only do two at a time because of your insurance. Which is an absolute travesty in my humble opinion, that American healthcare has to even go there, you know?

Dr. Weitz:  So yeah.  Unfortunately this topic comes up a lot. Yeah, and I think so many consumers don’t realize that insurance companies really call the shots in the healthcare system in our country.

Dr. Vokshoor: And so, we need to really band together and get the FDA to study multilevel disc replacement as an option.  And I think that will happen. But currently, you know, even though our practice is known for. Even three or [00:32:00] four level disc replacement in the lower back and the neck. Currently we, based on FDA guidelines, we stick to one to two levels in most circumstances, unless it’s an extreme circumstance. And we’ve seen incredible results.  So compared to fusions, the cervical disc replacements are not just equivalent, but superior. The lumbar spine data is a little bit more. Dicey. I wouldn’t say it’s as clear cut. Most of the reason for that is the initial hiccups in lumbar disc replacement are also included in that data. So, you know, I, a lot of my colleagues say disc replacement just doesn’t work that well in the lumbar spine, and that’s just not true.  In my experience, that’s absolutely not true.

Dr. Weitz: So what are the after, let’s say a patient has disc replacement in the lumbar, what are the limitations? Can a patient go back to sporting activities? Can they do heavy weight lifting?

Dr. Vokshoor: So I would say my goal is to [00:33:00] have you at a hundred percent by three months.  If you know, kind of extrapolate, that means 50% in six to eight weeks. That means 25% in, you know, two to four weeks. So it’s like we do want this gradual increase of your activity. At the same time, depending on how long your symptoms were going on, how tight your muscles got as a result of your disc degeneration, how much of intervention we have to do to restore the height and the lordosis of each disc.  There can be longer. Recovery periods, and we have to be very realistic about that. I feel like, you know, you have to form a bond with your patient. You have to say, this is a marathon that we’re gonna traverse and you’re gonna be happier as a result of doing it in the long run, but we have to respect your physiology.  Some people he’ll super fast and are lifting Weitz and one week in the gym, that’s usually they’re younger, their muscles are more, more able to adapt, they recalibrate easier. Some people are, you know, a [00:34:00] month out and they’re still having some stretch nerve sensation in the back because we have stretched the spine to give it your original height.  You do get taller as a result of the operation most of the time.

Dr. Weitz: So, it may take some time, but they can go back to. Playing tennis, playing golf, lifting weights? They don’t have to worry about this thing coming loose or moving?

Dr. Vokshoor: We have professional athletes that are doing the highest level intensity.

Dr. Weitz: You can go back to professional athletics?

Dr. Vokshoor:  Yes, absolutely.

Dr. Weitz:  Can they go back to football?

Dr. Vokshoor: Yeah, I mean in the cervical spine there’s some recommendations as to what levels and for what cause you had it. So the cervical spine you’re protecting the spinal cord at all costs and spinal cord events, especially with settings of high head contact sports, are something that the physician has to consider I’m very sensitive to. Brain and spinal cord injury. So those are a bit [00:35:00] individualized, but in a lumbar lower back disc replacement, going back to any level of high intensity activity is definitely doable.

Dr. Weitz: Cool. Yeah, I think I remember one of the professionals, I think it was Darrell Johnston, he was like, a fullback for Dallas and I think he had a cervical fusion and went back to playing

Dr. Vokshoor: exactly. Exactly. And we always hear about the ones that, you know, that had a difficult time, you know, like had redos Yeah. And like Peyton Mannings of the world, et cetera. But no. Clearly I think the dynamics have changed and I think now we can finally restore spinal motion.  Yeah. To way it was supposed to be.

Dr. Weitz: Yeah. I think Tiger just had to have another fusion surgery.

Dr. Vokshoor: Yes, I did. I did hear that as well. And I think you know, it’s that’s why your index surgery matters so very much your index surgery,

Dr. Weitz: meaning, meaning if you get a fusion, you’re not then gonna be able to get a disc replacement.  Once you get that, you’re pretty much at the end of the line, right? 

Dr. Vokshoor: You can get a, you can get a fusion if it’s absolutely indicated due to instability or just severe arthropathy, or things that are, things that make a fusion absolutely necessary are gross spinal instability like a fracture, dislocation.  Sure, you know, but you can get a disc replacement above that fusion in the future. That needs to be considered. Right. But I think the, in by index surgery, I mean, no bridge is burned, so you can’t unuse a spine. Right. Right. But you can always go to a fusion from a disc replacement. 

Dr. Weitz:  Yeah. That’s what I was, that’s what I was trying to say.  Yeah. Exactly. So why isn’t this procedure being done more frequently?

Dr. Vokshoor: Yeah, so in the lumbar spine you do need access to a surgeon. So in Los Angeles, we enjoy having like the best of the best in class access surgeons, which are vascular surgeons that help get to the spine, to a minimalistic approach from the, from a belly incision, you know, very small belly [00:37:00] incision.  That’s, you know, done very routinely in LA, New York, other parts, but not, and not all throughout the country. And and in the cervical spine. I think it is being adopted more and more. There is insurance blocks and there’s also this like, learning curve of the surgeon’s comfort level. What I was talking about, reanimating different parts of the cervical spine.  I think that by itself, you know, I am now, I would say at this sweet spot of. Calling myself, you know, a masterclass competent surgeon. But that takes a while to develop and you have to be honest with your abilities. And I think every surgeon should be honest with telling the patient in my hands, this is the safest procedure for you.  And I think that’s the most important thing. So I think there’s an evolution of understanding. The pathoanatomy and the structural characteristics of each disc, each bone end plate, and then making the intraoperative decision to correct the [00:38:00] anatomy perfectly. And this is where I think the cervical spine is like a Swiss watch.  You’re, you know, you’re the more gentle but methodical you are with your methods, the better chance you have of restoring emotion with a cervical disc replacement.

Dr. Weitz: There’s one more set of joints we haven’t mentioned, a set of spinal joints that I want to ask about. What about the sacral lilac joints?  Is there a way to surgically repair a sacro lilac joint and still preserve motion?

Dr. Vokshoor: That’s a fantastic question. You know, the sacroiliac joint is a very important joint because it transfers the. All the load of the lumbar spine to your hip joints, right? So it’s like this, it’s like this interface joint that’s ever so important.  And even though it doesn’t move much, it moves in a very certain way. It’s actually that. 

Dr. Weitz:  And as a chiropractor, we [00:39:00] move it all the time.

Dr. Vokshoor: Exactly. So I love the term nutation, which right is what it does. And you know, lately there’s been this surgical procedure called sacro, sacroiliac joint fusion for the treatment.  Let me just stick it like a rod in there. For the treatment of atypical sciatica. I’ve been studying this procedure for some time. I spent time with some of some pelvic surgeons during fellowship and early years post training to really figure out whether sacroiliac joint is the way to go in those atypical sciatic patients.  And I remain skeptical as to the surgical fusion ability to eliminate that. Pain and I may be in a minority in spine surgeons and I certainly have a lot of respect for the data that’s come out in randomized controlled trials that show some benefit to sacroiliac joint fusion. But I would actually rather go the chiropractic route for a pure isolated sacroiliac joint problem rather than a surgical route, and this is coming from a surgeon that loves doing surgery. You know, and I love, you know, getting people out of pain and decompressing nerves. I think diagnostic injections in a sacroiliac joint are very nuanced and where you can get the injection or some people try different ablation maneuvers.  I think all of those things are of value. I do think in certain deformities and scoliosis cases, et cetera, when you’re having to fuse the spine, then the sacroiliac joint needs to be considered as going bad next. If you haven’t included it in your construct, it could go bad really rapidly.  There’s also conditions like ankylosing spondylitis and other conditions like that where the sacro ileitis is so severe that any motion of it is gonna hurt. In those cases, I think there is surgical solutions such as SI joint [00:41:00] fusion, but in most normal, atypical sciatica cases that I see. I send them to a soft tissue specialist rather than a surgeon to treat those pains.  And, you know, and this is an ongoing debate that I’m happy to expand to, you know, people that may disagree with me. ’cause I think one of the most important things we need to. B, as you know, clinicians slash scientists is honest with our outcomes, our real world outcomes, and in my practice I haven’t seen that much benefit from treating atypical sciatica with an SI joint fusion.

Dr. Weitz: How important is rehab and prehab if possible?

Dr. Vokshoor: So, so glad you mentioned that. Yeah. I would say both prehab and rehab are ex almost as important as the surgery and you know, like hip mobility, if you’re gonna do something to the lumbar spine at L five, S one, L four five. Regaining hip mobility, assessing hip mobility, even [00:42:00] having, even knowing about how the word a patient’s hips are in relation to the lumbar spine during standing, during sitting using dynamic x-rays and scoliosis.  X-rays is really important. Rehab should be multifaceted. Multimodal, so mentation, nutrition, exercise program, sleep hygiene, pain control. And the flexibility of the spine all need to be assessed and optimized prior to surgery.

Dr. Weitz: How important are pre and post surgical nutrition to ensure proper repair and recovery?

Dr. Vokshoor: Yeah, I mean we’ve had, so one of the, one of the only things that in artificial disc has been very challenging is patients that are older and have osteoporosis. So if you have osteoporosis, even if you’re on supplements you may have defects in your bone or weaknesses in your bone that may surprise your surgeon during surgery or afterwards.  There can be settling [00:43:00] of the implants, et cetera. So it’s really important to have good bone and nerve health. Both preoperatively and then continue that postoperatively. And there are some of the hardest tissues in the body to heal is your bone and your nerves. So I think to have a good grasp of that, to get hormonal control, physiologic control of your bone and nerves health.  Prior to surgery is absolutely essential. And, you know, we can go into a whole didactic about the microbiome and what your intestinal flora are you know, essential for, and your healing, your mood how the brain connects with it. So, yeah, absolutely. It’s a huge part of my practice is to figure out.  Where the weaknesses of someone’s entire physiologic picture is, and then using best in class experts to optimize those prior to an intervention.

Dr. Weitz: Yeah, I know all about bone healing. I actually had a traumatic femur fracture at the end of 2023. Had surgery [00:44:00] at St. John’s and afterwards ended up having a non-union.  And, was facing recommendations for additional surgery, but found a way to get it to heal without that. Wow. In my case, that’s surprising. I used the combin. Yeah. For some reason after the surgery, there was a gap. And how did you heal it? I used the combination of, well, first of all, high dose vitamin D, MK four.  I used Forteo injections daily for five months. Human growth hormone two IUs, five days a week, and a bone stimulator.

Dr. Vokshoor:  Wow. Excellent.

Dr. Weitz:  I did that for five months and now I’m a hundred percent. 

Dr. Vokshoor: I love it. I love it. That’s, you know, that’s a fantastic example that Yeah. You know, physiology, there’s structure, there’s function, and there’s psychology.  All three have to go well together for a spine surgery to, to succeed. Yeah. So, yeah. Glad you healed up.

Dr. Weitz: Thanks. How [00:45:00] is AI playing a role in your care?

Dr. Vokshoor: Yeah, it’s actually you know, I use an AI assistant almost daily now for almost every visit that I do as well as every note that goes into the chart.  There’s an AI way of making sure that the note contains the essential format. But what’s what I, where I’m really excited about AI is. You know, the outcome from spine surgery has been quite variable. And sometimes a study comes out that’s done under perfect conditions. ’cause those conditions are so controlled that, you know, they’re like, this device works because under these perfect conditions, we got it.

You know, 90%. Positive outcome, but in the real world that is not observed all the time. So one of the best services of AI in research engines and registries is actually putting all that data together and telling us accurately how successful intervention can be so we can inform the patients. [00:46:00] That’s occurring in deformity surgery right now, where, you know, Medtronic and a couple other major vendors and have come up with innovative ways of saying if we give someone spine criteria, their curvature, their height, weight, bone density, et cetera, all this information through X-rays and other imaging modalities to an AI engine, can they recommend to us the best intervention.

So the first generation of those things are about. As you guessed it, spinal fusion surgery. But I look forward to that being applied to every spinal intervention, including soft tissue care, chiropractic care, injections micro endoscopic approaches and things that are much less invasive. And of course, disc replacement.  So. Our measurements of X-rays have been static in the spine for too long. With ai, we could make those measurements, real world measurements, and there’s a DY dynamic portion of the spinal [00:47:00] motion that will be studied better with AI because there’s a lot more information going into it. You can get a static lordosis.  Or you can say you’re this degree of lordosis and sitting, this degree of lordosis standing, this degree of lordosis and running, this is what the hips are doing. All of that information could be in, in a very smart AI engine, and then inform the patient and the practitioner to make the best decision.

Dr. Weitz: Is AI gonna take your job anytime soon?

Dr. Vokshoor: As a neurosurgeon, I’m not that worried, but I have seen it do some amazing things in I work with some urologists in our hospital where we do tumor work. You know, getting the tumor in the, in retroperitoneal areas. I’m only there to protect the nerves and get it off the nerves.  But the robot is pretty amazing and I think in neurosurgery within our lifetime. I mean, you know, in, in Neuralink it’s already able to create a bur hole. But it’s not able to do other little finer [00:48:00] things yet. I don’t, you know, I don’t quite know, but I’m not as scared of some other people are.  I think I, I’m a believer that we need to use technology for good use. Just like what happened to radiation therapy. What happens to almost every great innovation? I mean, every great innovation has pros and cons. And in the right hands it will be used for improving people’s health, and that’s truly my belief.

Dr. Weitz: Great. Did you want to talk a few minutes about your brain health centers?

Dr. Vokshoor: Of course. Yeah. I really appreciate the opportunity to talk about NeuroVella Brain Spa, which was my sort of. My answer in saying, okay, how? How are we not providing a comprehensive care for some of our patients, especially chronic pain patients?  So we have this traumatic event called surgery. We know that it’s going to happen on this date. Why aren’t we not studying the effects of this trauma on the nervous system pre and post to improve the entire [00:49:00] ritual, the entire journey, so to speak. So the surgical journey, is being studied very intensely at the NeuroVella brain spa.  And then, you know, I also thought about the vacuum that happens with patients that are suffering from concussion, depression, dementia, even early dementia, that they have nowhere to go. Literally, there’s a vacuum in healthcare. And so the thought was, I think humanity is gonna need deans. Brain centers where they have a responsible neuroscientist, neurosurgeon, or a team of experts that say these are technology biohacks that work such as certain frequencies sound light.

We have so much now at the brain spa, we have, you know, we’ve dabbled into the world of neurofeedback to try to really re rewire the brain through the way that the network can relearn there. They’re sort of habits and there’s some incredible [00:50:00] frequencies of vibration and sound and light that work on the nervous system.  So that’s in a nutshell what the Brain Spa is doing. Very non-invasive neurotech with a meditative. Component that doesn’t doesn’t have to get, you know, super spiritual, but it definitely borders on the psychospiritual health as well. And there’s a whole other, you know, wing of it that’s being developed, including psychedelic research, psychedelic assisted therapy.  And that’s where, you know, that’s most likely where we’ll be going in the next few years under some regulatory control and research.

Dr. Weitz: You want to get even better results. We’ll put the patient through a full breent type functional medicine protocol, get rid of, you know, balance out their nutrients or hormones, get rid of the various inputs into neural inflammation and then put ’em through the various inputs into promoting a healthier [00:51:00] brain, and you’ll get even better results. 

Dr. Vokshoor:  A hundred percent

Dr. Weitz: agree with you.

Dr. Vokshoor: I think that’s the brain spa is it is based on electricity, chemistry, and plasticity. Right. And you just mentioned the chemistry part of it, you know, that it what are the markers of neuroinflammation?  Where is your PTA, where’s your, you know, other markers that we could potentially, you know, improve? So a hundred percent.

Dr. Weitz: How can listeners and viewers get in touch with you? What’s your contact information?

Dr. Vokshoor: Yeah. So our I, you know, I love input from the audience and please do follow us and subscribe.  And I love this, the Rational Wellness podcast, and I think, you know, you’re bringing a very important service to the audience. Thank you. I’m at dr vhi.com. D-R-V-O-K-S-H-O-O r.com. I’m also at Dr. Vhi at Dr R-V-O-K-S-H-O-R on Instagram, Facebook, LinkedIn. And our office number [00:52:00] is 808 9 9 0 1 0 1.  And yeah, I look forward to hearing from the audience and being of service and your audience can, plug in a discount code for our yeah, I was just gonna

Dr. Weitz: mention that if you use the code BEN my first name and you get a consultation and an MRI with Dr. Vokshoor, you’ll get 20% off the fee. Indeed.

Dr. Vokshoor: Yes. Code BEN

Dr. Weitz: code, Ben,

Dr. Vokshoor: use it. That’s great. Thanks. And we’ll get a discount. Hey, thank you so much for having me.

Dr. Weitz: Yeah, very nice to meet you.

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Dr. Weitz:  Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star readings and review.  As you may know. I continue to accept a limited number of new patients per month for Functional Medicine. If you would like help overcoming a gut or other chronic health condition and want to prevent chronic problems and want to promote longevity. Please call my Santa Monica Weitz Sports chiropractic and nutrition office at 310-395-3111 and we can set you up for a consultation for functional medicine and I will talk to everybody next week.