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Join us in this enlightening episode as we welcome orthopedic surgeon and author Yoshihiro Katsuura, who sheds light on the process of spinal degeneration and the secrets to aging gracefully. With a focus on back and neck pain, Yoshihiro shares insights on how some individuals continue to lead active lifestyles despite degeneration, while others experience pain and disability.

We discuss the importance of non-surgical interventions, such as a healthy diet, smoking cessation, osteoporosis treatment, and balanced exercise regimens, in extending the lifespan of our spines. Yoshihiro shares practical tips and strategies to ensure our backs work for us, rather than the other way around.

With Yoshihiro’s expertise and comprehensive knowledge from his book, The Spine Encyclopedia, this episode unveils the keys to maintaining a healthy spine as we age. Don’t miss this engaging conversation that explores the intersection of aging, spine health, and overall well-being.

Yoshihiro Katsuura is an orthopedic surgeon.

He shares his story and discusses his book, The Spine Encyclopedia: Everything You’ve Wanted to Know about Back and Neck Pain but Were Too Afraid to Ask.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Yoshi Katsuura. He’s an orthopedic spine surgeon, and he’s the author of the book “The Spine Encyclopedia: Everything You Wanted to Know About Back and Neck Pain but Were Too Afraid to Ask.” Yoshi, welcome to the show.

Yoshihiro Katsuura: Hi, Kevin. Thanks for having me on the show.

Kevin Pho: We’ll get into your book in a little bit. First off, briefly share your story and journey to where you are today.

Yoshihiro Katsuura: OK, no problem. I’m an orthopedic surgeon. I started my practice at the Hospital for Special Surgery in New York City, where I also trained in spine surgery, but now I practice in Northern California, which is my home.

Kevin Pho: All right. I understand you’re a rural spine surgeon. Tell me some of the challenges of practicing in a rural area as an orthopedic surgeon.

Yoshihiro Katsuura: It’s the challenges that I think you would imagine: mainly lack of resources, lack of hospital beds, lack of other consulting physicians. I practice in a fairly complex specialty that requires a lot of collaboration, and so some of those things can be challenging, but they can also add to the joy of medicine, in that I have to be independent for a lot of different things and think on my feet quite regularly. So that’s why I like it.

Kevin Pho: So give us a story or example of some of those resource challenge scenarios that you would typically face as an orthopedic surgeon.

Yoshihiro Katsuura: Well, one of the very simple ones that we face very commonly is dealing with patients in renal failure, or patients who require dialysis or consultation with a nephrologist, both of which we don’t have at my hospital. But we frequently have people who are on dialysis who come in for orthopedic problems, and we have a lot of challenges dealing with those and getting them transferred to other facilities.

Kevin Pho: All right, let’s talk about your book now, “The Spine Encyclopedia: Everything You Wanted to Know About Back and Neck Pain but Were Too Afraid to Ask.” Now, how did your book come together? Why did you decide to write it?

Yoshihiro Katsuura: Well, I found that I was writing a lot of patient education materials just to give out to my patients in clinic, and it evolved from that writing. I’ve always been interested in writing, so it was an amalgamation of wanting to create a resource for patients that was honest, easy to read, informative, and full of pictures. I’m also an artist, and I illustrated the entire book myself as well. So it was a combination of those things.

Kevin Pho: All right, tell us some of the main points readers can come away with from reading the book.

Yoshihiro Katsuura: I think there are several main take-home messages. The first is that I think the spine is a very beautiful organ system, and it functions in the background of your life and allows you to have this upright life and get around, and everyone, almost 100 percent of us, takes it for granted until it stops working properly. And then when it stops working properly, it goes from this silent thing that is working in the background that you never noticed to being your worst nightmare.

Spinal conditions are extremely debilitating. Even benign conditions that don’t require surgery can have this profound impact on your life. They can turn you from being a mobile, active individual into someone who is bedridden and can’t move easily. This is something I see in my clinic commonly, and that can be from a simple back strain, or it can be from a condition that actually does require surgery. So one of the main take-home messages of the book is that just like most health-conscious people brush their teeth twice a day, it’s also important to think about your spine and think about your body mechanics every day and to do something to try to proactively take care of it.

And I think the other take-home message from my book is that there are some very stark realities about what spine surgery can and cannot do, and I think there’s a lot of confusion about that, both in the media and in people’s impressions of spine surgery. Now, there has been a lot of progress in what spine surgery can do, and I find that a lot of patients think, “Well, if I go in for spine surgery, I’m going to come out paralyzed,” or they just imagine the worst-case scenarios, which is not true. But on the other hand, there are certainly things that spine surgery cannot treat and that won’t benefit from spine surgery. So in the book, I try to flesh out the differences between those two things and really let patients learn more about their conditions and specific procedures.

I called it an encyclopedia, and it’s a book, but some might refer to it as a textbook. It’s not really a book that’s meant to be read from cover to cover, but you can pick and choose the sections that are of interest to you. If you’re going in for a specific spine procedure, or you have a patient who has a specific spine problem and you want to learn a little bit more about the procedure, you can pick those chapters, read those, and learn a little bit about it.

Kevin Pho: So let’s go a little bit deeper on each of those two points. You mentioned that there are some proactive things that we could do to take care of our spine. So what are some examples of what we can do?

Yoshihiro Katsuura: Well, I think the most basic thing that most people can do is just be mindful of it. Like I said, I think the spine operates in the background, and you don’t really think about it as you go throughout your day-to-day life. You can go years without even realizing that you have a spine. You just use it every day, and it takes care of you. It’s a very resilient structure, and as you age, that resilience and the tolerances of the tissues start to degrade slowly, and what happens is that smaller, more trivial injuries can cause harm to your spine and tears and wear in the tissue. So one of the things is just being mindful of your back: that you have one, your posture, and that the forces that you put across your back can have an impact on those tissues. And there are certain things that you can do to proactively prevent injury.

One of the most common things, and one of the things I spend a lot of time talking about with my patients in my clinic, is abdominal bracing, so that when you go to lift something heavy off the ground, you’re activating your core musculature, which supports your spine, and you’re just being mindful of how you use your back, and you’re not unconsciously lifting something heavy off the ground in an awkward fashion. I think most people don’t have that awareness.

Kevin Pho: I see, just like you, people who are in their 60s, 70s, 80s, and we always say, “Exercise more to help protect that spine.” So give us more specifics. What are some recommendations we can give to that demographic in terms of exercise to help prevent injury?

Yoshihiro Katsuura: So exercise is really important. I recommend a combination of exercise for all my elderly patients, and the combination includes working on flexibility, strength, and cardiovascular training. I generally recommend about 150 minutes of moderately strenuous exercise per week, and you can divide that up into three to five sessions, or 75 minutes of more vigorous activity. I do think that the higher the intensity of the workouts, the more bang for your buck you’re going to get, and so some people may prefer to do less overall activity but at a higher intensity, and I think that that’s fine.

And we know that the tissues respond very well to exercise, especially for elderly individuals, where you’re really dealing with two main issues, and those issues are, as you know, osteoporosis, which is a slow degradation of the strength and quality of your bones, as well as sarcopenia, which is the degradation of the muscles. Those two things happen very slowly and insidiously as you get older, so the strength training and the flexibility and cardiovascular training really work to fight against those things, which I think is really important in longevity and having a healthy spine.

Another important thing is that the spine is somewhat of a passive structure. Your discs, the intervertebral discs that sit between the vertebral bones, don’t have a tremendous amount of blood supply, which means they don’t get good oxygen and good nutrition as some of your other, more well-fed tissues do. So motion is actually a really important part of feeding those tissues. They get fed through osmosis and diffusion, and so moving around and actually getting exercise and having the discs move a little bit is really helpful for their overall metabolism.

Kevin Pho: So let’s talk about the second thing that you previously mentioned, about what spine surgery can and can’t do. Talk more about that.

Yoshihiro Katsuura: Well, I think a lot of patients have this impression that their back hurts and so they need spine surgery, or they’re living with chronic back pain and the only option for them is some sort of intervention, that medicine is going to save them, which in most cases, unfortunately, is not true. I wish it were. I wish I could take everyone with back pain and do an operation on them and cure their back pain and be the hero, but unfortunately, that’s not the case.

What I spend most of my time in clinic doing, I would say 99 percent of the time, is counseling patients about how they can modify their pain and how they can deal with degenerative disc disease without surgery, because the tools that we have in spine surgery are still pretty limited. We have spinal decompression and spinal fusion, sometimes we can do disc arthroplasty, and there are other smaller, more specific procedures, but we have certain tools that we can use, and we use them to treat a diverse array of pathologies, and so it’s not going to work for every single case.

Specifically, in bread-and-butter degeneration, where patients decompensate, they may have a little bit of degenerative disc disease but not necessarily any specific neural impingement or anything that could be relieved by decompressing the spine, and they are unlikely to benefit from spine surgery. So in those cases, really, the patients are on a self-driven, self-motivated rehabilitation program, and that’s what I try to instruct my patients on: how to develop a program that gets them moving more and gets them to be more active. And then a lot of times, it’s altering lifestyles that are unhealthy, such as being obese, smoking, and drinking alcohol.

Kevin Pho: So, as you know, I do internal medicine, primary care. If I see someone in their 50s, 60s, 70s with back pain, what kind of questions should I ask? What kind of things should I look out for if I’m to consider, say, referring that patient to someone like you?

Yoshihiro Katsuura: I think with someone who’s getting a little bit older, you have to be a little bit more cautious as to your workup. With a younger person, you can maybe get away with, “OK, try some physical therapy, try some exercise. If that’s not working, come back and see me.” With elderly patients, the chances of having a meaningful pathology go up the older that you get. The more common things that I see are spinal canal stenosis in the lumbar spine and, even more troubling, spinal canal stenosis in the cervical spine. So one of the common things that I see that’s overlooked, particularly by primary care, is cervical myelopathy and cervical stenosis.

The typical story is a patient will come in and they say, “Well, I just feel like I’m getting older. My balance is no good. My body is not working as well. My hands are dropping things. I feel clumsy. It’s just old age. I feel like I’m just getting old.” That usually is not the case. I mean, you do have a slow, progressive loss in motor function as you age, but sudden declines are not what we would expect, and that can often be caused by cervical stenosis. That’s a painless condition, so you don’t even know that you have it. You may not have any neck pain; you may not have any other red flags. But if someone’s losing the capacity to sign their name or button up their shirts, or just their basic balance, it’s a red flag for me to look for cervical stenosis.

Kevin Pho: So that story that you just mentioned is fairly common in the primary care world. So if we see patients like that in the exam room, what’s the next step?

Yoshihiro Katsuura: I think it’s all about the exam. For me, it’s all about the exam, and I look for signs of hyperreflexia, which I do all the time, and I’m good at looking for that, but that’s one thing that will cue me to order advanced imaging in almost every single case as a screening. It’s not that that is definitely going to be confirming your diagnosis, but I certainly look for that, and if I see it in combination with the clinical symptoms, then I go for the advanced imaging just to rule it out.

I’m also very mindful that if a patient comes to see me for low back problems, they come to see me for spinal canal stenosis, and they have these other signs, I wouldn’t want to take them to surgery with unknown spinal canal stenosis in the cervical spine, because during the intubation, they could have a catastrophic neurologic injury. So it’s one thing that I’m mindful of.

Kevin Pho: And by advanced imaging, do you mean MRI?

Yoshihiro Katsuura: I do.

Kevin Pho: So let’s talk about another patient, let’s say a younger patient with low back pain, which is another common primary care scenario. What are some red flags to look for there, and at what point should we consult a spine surgeon like yourself?

Yoshihiro Katsuura: I think you have to look out for the common red flags that we all know about, which are fevers, chills, and a history of IV drug abuse, which is actually very common in the area that I practice, and those things can lead to infection, and those things are very, very easily missed. So you have a patient who comes in to see you for back pain, you say, “OK, go have physical therapy, here’s some NSAIDs,” and then they could be slowly developing an epidural abscess or some sort of infection in their spine. That’s something that I’ve definitely been consulted on multiple times. So look out for other symptoms, red flags, just using a little bit of basic clinical judgment. If you’re unsure, getting labs and looking for a white cell count or any inflammatory markers, I think, is a useful thing.

And then other things I always look out for, which are pretty common, are just neurologic symptoms. So is the patient having sciatica, radiculopathy? Do they have numbness or weakness? Again, relying on your physical exam and using that to guide the use of advanced imaging, I think, is really important. If they’ve had sudden weight loss or any other systemic symptoms that could indicate a cancer or malignancy, I think that’s also useful to pay attention to.

And then, of course, if they’ve been involved in an accident, something that’s a high-energy mechanism, in a young person you’d want to be concerned about a fracture, and in an elderly patient, small, trivial injuries can lead to fractures. As you know, you could cough and you could cause a compression fracture; you could turn around in bed and have a compression fracture if you have osteoporosis. So it’s just a little bit of knowing the differences between the different age groups and what they present with.

Kevin Pho: Yoshi Katsuura, he’s an orthopedic spine surgeon. His book is titled “The Spine Encyclopedia: Everything You Wanted to Know About Back and Neck Pain but Were Too Afraid to Ask.” Yoshi, what are some back pearls that you could share with other clinicians, either in primary care or the urgent care setting?

Yoshihiro Katsuura: I would say one of the things that I would share with primary care physicians is don’t be afraid to order advanced imaging. I don’t see any patients in my clinic that don’t have imaging. They always come in and they get an X-ray as part of their clinical exam, and nowadays, for me, an MRI is part of the clinical exam. So I would encourage primary care physicians to use imaging according to their clinical judgment and not be afraid to do that. I think there’s a lot of reluctance to use it, whether they’ll be responsible for the impact of the report or the interpretation of the results. I think that you can use your orthopedic resources in the community and your colleagues and discuss these things, but don’t be afraid to order advanced imaging.

Kevin Pho: What about the specter of pre-authorization? Because I think that for a lot of primary care doctors, it’s not so much a fear of ordering, but there are just a lot of obstacles when it comes to ordering advanced imaging. You order an MRI for a younger patient without a lot of red flags, and you’re going to get a lot of pushback from a pre-authorization standpoint, and even from the patient, from a cost standpoint. So what are some responses that we could use when we encounter those obstacles?

Yoshihiro Katsuura: I think it comes back to doing the thorough clinical analysis and clinical documentation, and these things can be justified. There are certain rules and regulations that you just have to be aware of. If you need to get an MRI and the patient is a young, active person who is athletic, you know immediately that they’ve failed exercise for greater than six weeks, and you can use that to justify your MRI. And then if they have neurologic symptoms, that justifies the use of the MRI immediately. So I just think it comes back to using your clinical judgment and documenting things.

Kevin Pho: And my final question: Yoshi, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Yoshihiro Katsuura: I think my take-home message for the clinician audience, as well as the patient audience, is that the body is flesh and bone, and it needs good maintenance. Again, most people spend a lot of time thinking about certain aspects of their health, like their teeth. Everyone brushes their teeth twice a day, but you spend no time taking care of your spine, and I think it’s a really critical structure for your overall happiness as you get older, and you will miss it when it’s gone. So having a program that you develop just to maintain your spine, taking good care of it, having good nutrition, and having a good balance of exercise and physical activity, I think, is really important as you get older.

One final message: I know there’s a lot of difficulty being a surgeon and being in medicine, practicing medicine in this day and age, but I think everyone has to find a way to truly enjoy the practice of medicine. It’s an honor to be a doctor, and it’s an honor to care for patients, and so you just have to find a way that works for you.

Kevin Pho: Yoshi, thank you so much for sharing your time and insight. Thanks again for being on the show.

Yoshihiro Katsuura: Thanks, Kevin. I really appreciate it.