It's my absolute pleasure to introduce Dr. Aruna Ganju. I have known Aruna since she was a little baby resident at Henry Ford Hospital in Detroit, and now she's a big grown-up spine surgeon. She's at Northwestern University where she is a complex spine surgeon. She's going to talk to us today about diagnosis of back pain and when it's not always your back. So, Aruna, thank you. Awesome. Thank you, Marianne, for inviting me to speak today. We're going to do some A.V. things. But really, a shout-out to everybody in the room. As Marianne said, you know, when I started out as a resident, you know, first year, we're good? First year resident and everything else. I'll be honest with you, it was the nurses who taught me what I needed to know, whether it was in the ICU, whether it was in the OR. You know, back in the day, we were working with RNs, you know, Marianne's the PA. We didn't have any APNs, as I recall, back then. But really, these were the people, the professionals who kept me out of trouble when I was clueless and didn't know anything. And certainly in the OR, you know, the nurses in the OR, they knew how to do the case better than we did. So they handed you the instrument you needed. You didn't know. You didn't know what you needed, but, you know, the old-timers, for sure, knew what you needed, and they handed you the right instrument and made sure you stayed out of trouble. So, you know, once again, you may not always get the thanks from us, but believe me, most of us have a lot of nurses to thank in our education and training. And then even afterwards, keeping us out of trouble, but we'll get into that. So I was asked to speak about hip versus spine. In this business, when your patient comes in with back pain, where is the pain coming from? I have nothing to disclose, except for the fact that, obviously, as a neurosurgeon, and as somebody who specializes in spine, I'm probably gonna be looking at everything as having a spinal etiology, right? It's kind of like having the, what do you call it, the handyman that only has one tool and he's gonna hit everything with that hammer and so on and so forth. But in any case, hopefully by the end of this, we'll have a better understanding as to what causes back pain and when is it related to the hip pathology, the hip versus pathology of the spinal column. How many people in here have had back pain? Anyone? Oh my God, so I'll ask the reverse. Who hasn't had back pain? Aye, aye, aye. Okay, all right, well. So we'll start with an index case. This was a patient of mine, a retired professor. He presented with a history of back pain dating back about five years. Obviously he comes to us with some diagnostic films and specifically this lateral radiograph of the lumbar spine. And what do you think? Do we have a cause for his back pain? Yeah, we could, right? Absolutely we could. Certainly, do we have a pointer? Or should I just use it? Use my mouse, okay. There we go, okay. So certainly he has evidence of spondylosis or degenerative changes, right? With like, for instance, loss of disc height over here at four or five, yeah. Osteophyte formation, some straightening. I think there is some, or loss of lordosis. There is some minor misalignment, spondylolisthesis. But certainly this is a ratty looking spine, right? We all agree with that. Now what if I told you this was also him? So what do we see there? Bilateral hips, right? I mean, could that be a cause of back pain? Could be, right? How about this? This is also him. Right, I can only laugh because what else are you gonna do, right? He, you know, internal fixation here of his left femur. Right knee replacement. And this is his lateral scoliosis film, right? And so certainly when you take this 3,000 foot view, right, that lumbar spondylosis doesn't look as impressive, right? Kind of what strikes me the most about this film is really kind of this, he's a little bit, you know, pitched forward, what we call positive sagittal balance, but really he's ramrod straight, right? He doesn't have the thoracic kyphosis, lumbar lordosis. He does have antiversion of his, you know, ilium, and also the hip replacement. So all of these things could be causing back pain. And so this is his expanded history. He had a number of medical comorbidities, diabetes, hypertension, CAD, had undergone the left femur fracture, or rather internal fixation. And then consequently or subsequently in two years underwent one hip replacement, then the other one, and then most recently a knee replacement. And in spite of, or despite all of this, he continued to have complaints of back pain and gait difficulties. And this is why he was sent to us. All right, so that brings us to the topic today. How do we go about sorting out where this gentleman's pain is coming from? And what are we gonna do about it, okay? So on one hand, you could look at this as being hip versus spine. Well, you know what, this is musculoskeletal system versus neuro, or neurogenic causes of pain. And certainly these days, there aren't as many operations being done, let's say spinal fusions for axial low back pain in the absence of neurologic symptoms. Back in the day, maybe 1990s, early 2000s, there was a lot of that going on. If you've looked at any of those statistics, and I think more recently it has either plateaued or perhaps come down as the guidelines and whatever have become stricter. So once again, in the very simplest sort of terms, you could think of this as being disorders of the musculoskeletal system versus disorders of the spinal column and associated neuro elements, whether it's spinal cord or nerves. Is this really about ortho versus neuro? I guess you could kind of look at it that way. And what I'll tell you is in medicine, we always talk about certain personality types going into different areas of medicine, right? I know we do that on the MD side, and I've come to believe it also exists on the nursing side, right? Not every nurse goes to become a neuro nurse, right? Of course not, why would they? But this is one, I don't know if you all have seen this or not, and hopefully it will work. Let's see. But, yeah, awesome. Let's see. No, no, not airplay. Shoot, full screen. Let's see. Sure. Huh? What's the story? There is a fracture. Oh, how can we turn it up? Okay, tell me more. You think we can turn this up? There is a fracture. I need to fix it. Phone check. Okay. If not, has anyone seen this? No, it's so good. Oh yeah, it's historical. If we can turn up the volume some more. I did it on this. Yeah, you can do it. Can you tell me more? The fracture is very displaced. No? I need to fix it. Okay, let's start from the basics. Where is the fracture? The fracture is. Can you put the microphone, do you have a long microphone? Yeah, we could. Do you want to try that? So this is an encounter between an orthopedic surgeon and the anesthesiologist. Let's see. It's on, is it on mute? Oh, there you go. And then turn it off. Yeah. Hang on, I'm sorry, guys. Well, all right, we won't be. Can we escape out of it and go to your system? Okay, sorry. We'll just give it a second. If it doesn't work, we'll leave it alone. What do you want to do? Go back to the presentation. That's all right, all right. Well, nevertheless, it's okay, don't worry about it. In dealing with the orthopedic surgeon, right, the orthopedic surgeon approaches the anesthesiologist stating that he has a fracture and he needs to fix it. And he kind of perseverates despite the anesthesiologist's questions. Like, for instance, well, where is the fracture? And he's like, it's in a bone. What is the patient's medical profile? And he'll be like, well, I don't know, has a broken bone, I need to fix it. And then the anesthesiologist says, or rather the orthopedic surgeon says, well, you know what, actually the patient has a condition I've never heard of. And the anesthesiologist says, well, what is that condition? And the orthopedic surgeon says, asystole. And, you know, there won't be, right, there won't be much bleeding and so on and so forth. So it's pretty funny. So I will encourage you to go look on YouTube. It's pretty hysterical. And certainly we in neuro, right, we tend to think of ourselves as being a little bit smarter than some of the others. And we certainly always do this business of kind of dumbing down the orthopedic people, guys and girls. But I will tell you, I mean, as you probably know, people who go into ortho are always at the top of their class. So they are, you know, super intelligent, super bright. And certainly in putting this talk together, I really developed an appreciation for what they do in terms of all of the joints of the body and how they all articulate to allow us to walk and move and do everything. So it's pretty awesome. All right, so what is back pain? So when somebody comes in and complains of back pain, what do you make of it? Has anyone ever had a patient come in and they're complaining of back pain and then you ask them, I always ask them, where is it, where is it located? Can you show me? Either on yourself or on me, put a hand on it. Has anyone ever had a patient put their hand like on the back of their neck or like upper thoracic? I mean, I guess technically it is the back, but I always kind of think of lumbar spine as being the low back, if you will. So I think it's very important to ask them to show you where the pain is. You wanna know the nature of the pain, the quality of the pain. Is it sharp? Is it stabbing? Is it a dull ache? Is it a deep ache? Does it radiate anywhere? Okay, typically nerve pain or associated nerve pain, it involves some radiation, right? And it may feel like electricity or an electric shock. There may be paresthesias, weakness. You wanna know, was there some sort of event associated with it, right? Like, you know, traumatic event. Were they skiing? Did they fall? So on and so forth. And certainly what makes it better and also what makes it worse, okay? So extremely important to get this history. And back pain is really a big problem, right, in our society. I mean, as we saw, everybody in this room has had back pain. You know, what I didn't ask you is how many people have actually missed days of work because of it. So it's a number one cause for people missing days of work. Number one cause of visits to the primary care physician. So it's not, you know, it's not a small problem. And it certainly has resulted in loss of revenue annually. So it's a big deal. And part of the problem is there are a lot of things that can cause back pain, right? You can have a UTI and have back pain. You can have renal stones, muscle strain, fibromyalgia. There could be a spinal etiology or a hip-related etiology. So let's start with the hip. As you know, the hip is a ball and socket joint, right? And it consists of the femoral head and the acetabulum. It has six planes of motion. And this is really the link between the upper body and the lower body, okay? And so orthopedic surgeons kind of refer to this as really the most important joint in what they call the kinematic chain. And it's kind of crazy. I mean, once again, as I say, I didn't do ortho. So I really, you know, didn't have much of an understanding of this. Certainly for spine, we need to. We've had to learn, but we don't get the same training that the orthopedic surgeons do. And if you look at the anatomy, here is the femoral head, acetabulum on the other side. And there are a number of muscular and ligamentous attachments. And so the six degrees or planes of motion include flexion, extension, abduction, adduction, both internal and external rotation. This is a busy chart, but I mean, look at all of the muscles that kind of affect and attach onto the hip joint, okay? I mean, it's crazy. And so it's pretty complex, if you will. And so once again, there is probably about, actually, depending upon the position of the patient and the position of the knee joint and also the hip joint, there are different degrees of motion, if you will. So all of these impact the mobility of the hip joint. In the upright erect extended position, you have about 45 degrees of abduction, 30 degrees of adduction. With the knee flexed, internal and external rotation about 40 degrees in each direction. And this is supine, greater range of motion, 120. You know, the other thing is that there is, you know, there's a differential in terms of active versus passive motion. And with passive motion, there's a greater degree of range of motion. But with active, whether the hip is flexed or extended, you have about 90 to 120 degrees. Hip extension, less at 10 to 20. Abduction, once again, it's probably about 40 in each direction, but 50 for abduction, 30 for adduction. And then internal, external rotation can vary zero to 70, zero to 90 degrees. Now, if we switch gears and think about the spinal column and the low back, as you know, it extends all the way from the skull down to the sacroiliac ilium, if you will. We often joke about the skull being C0. I don't know if any of your practitioners say that, but over at our place, we joke about it. And it's a very complex sort of thing because you can think of the spinal column as plugging into the pelvis, if you will. And so that's a big deal. And here we have the, and there are a number of not only muscles, but also ligamentous attachments. We have the SI joint and the ilium here, and so on and so forth. Now, if you look at the spinal column from a global perspective, right, you know that in the lateral view, it consists of those alternating curves, right? And so the human column has this form because evolutionarily, this is what was created. If you think about it in utero, right, what does the fetus look like? It looks like a kidney bean, right? Because at that time, it only consists of kyphoses, the thoracic and sacral kyphoses. And so those are what we call the primary curves. The secondary curves are the cervical and the lumbar lordosis. And this develops when the baby, after birth, when the baby develops the ability to lift up its head and also to sit and then to stand, okay? And this form allows human beings to be bipedal versus walking on all fours. And it allows for protection, right, of the nervous system, spinal cord and nerve roots. For both conditions, history and physical are key to making the diagnosis. And then you will get radiographic studies to support your diagnosis. But just like as is the case with spine, with hip, you have to correlate the radiographic pictures with the clinical pictures. So the average population, if you get, you know, let's say adult population gets hip X-rays on them, they're going to have degenerative changes, just as is the case with getting plain films of the spine on the adult population, okay? Typically for the hip pathology, obviously pain is going to be unilateral, right? And sometimes this pain may radiate into the groin. It may be laterally located. It may be associated with certain motions, right? Internal, external rotation, whatever. For spine, I think it's a little bit easier. Yeah, typically we want to know, once again, where the pain is located. We make this distinction between axial low back pain and a more musculoskeletal cause, if you will. So axial low back pain is something that is midline. And typically you may elicit it on palpation, whether soft or pounding on them, right? Certainly in the setting of like tumor and also trauma, right, patients may have axial low back pain, where you touch in the midline and they're hurting. Once again, paraspinous pain, if you will, is to the sides. And I think of that as being more, or we think of that as being more musculoskeletal, if you will. But typically for the neurosurgeon, to be evaluating low back pain, we always have this question, right? Is there neuroinvolvement? So involvement of the spinal cord, the nerve roots. And certainly if you have compression of a nerve root, right, that's lumbar radiculopathy, versus if you have canal stenosis, lumbar stenosis, you have neurogenic claudication, okay? And I'll talk a little bit about that. Now, if we move to the examination of the hip, it's pretty involved, okay, 21 steps. And if you read the orthopedic literature, you know, they kind of laugh about this. They're like, hey, you know what, the hip examination is not a big deal because the knee has 33 steps, you know? So once again, you know, for the ortho guys, it's always, they gotta kind of reduce it to terms that they can all kind of understand. And the hip exam, they do this in the upright position, supine prone. So it's pretty involved. And then once again, they do this business of keeping the knee flexed, keeping it extended to remove that element from the exam. And so these are the 21 tests they do. There are a number of tests here that have acronyms, whatnot. I will tell you, this is the test that I do, is the FABER test. I don't know if anybody is familiar with this or does it. Otherwise known as the Patrick's Maneuver. I don't do this whole thing. And I'll kind of go through that a little bit. So in terms of examination, it doesn't matter if you do it at the beginning of your physical exam or at whatever point. But I do think that this gross inspection and examination is extremely important. So there's a business here on the far left. You wanna look at the shoulder height. Is there some discrepancy? This could indicate perhaps hip issues or hip asymmetry or scoliosis. You wanna look at the iliac crest in the middle picture here. And whoops, and do the two of them line up. Then also there's a business of having the patient bend forwards. And certainly you palpate the spine and this is a rough sort of screen for scoliosis. It's interesting. And you see the asymmetry there, this rib hump, if you will. But you know, the ortho guys, they do a lot of this. I don't know that we do it in neurosurgery, but a lot of this business of assessing the general health, flexibility, mobility, physical health of the patient. So if you kind of read their literature, it's kind of interesting. You know, once again, I think a lot of orthopedic surgeons come from a background of having been athletes themselves. And so perhaps this is why, but it's really very interesting. I mean, I think we in neuro don't do that as much. But it is important, right? It's important, it has an impact. Certainly with the patient lying down, you know, you wanna check for is there pain? And then also what is the motion like? You know, it might flex the hip. For the Faber test, I will actually put that ankle, you know, over the contralateral knee and then kind of gently, you know, push that joint out, you know, externally rotate, if you will. And typically, if there is hip pathology, they will complain of pain localized right there, laterally. I don't check this on everybody, but certainly if there's any question that the hip might be involved, I'll absolutely put the patient on the table and check for this. You know, and especially if the patient will say things like, well, you know, my back is hurting, but also my hip is hurting. I'll say, all right, just get on the table, let's check it out. It's a rough screen. But I think for us, it works. It works perfectly fine. Obviously, in that first patient that I showed you, he is somebody I might send to orthopedics, right? Because I have no expertise in commenting on his hip replacements or his knee or what's going on. Also, abduction, in this, you know, here he's abducting that left leg and actually also the symptomatic one is the right one. He's palpating for any crepitus or any pain with this. And here, more of the same, okay, external rotation. Actually, this is kind of what I use for the Patrick's maneuver. For the spine, same sort of thing. You want to start with this gross examination. So I'll have the patient get up. I will eyeball them from the side and kind of get a sense, you know, are they pitched forward? Are they standing upright? And I don't want them to do anything for, you know, I want them to assume their normal posture. So I always tell them this, just stand like you normally do. Don't do anything that you think I want to see. And also paying attention, you know, are they flexing at the hip? Are they flexing at the knee? This can be compensatory mechanisms. I will palpate the spinal column and then really do an abbreviated neuro exam, right? So this is motor exam, primarily. Reflexes, I think, are important. You know, sometimes you can use them. They're the only objective part of the exam. Most patients don't fake it. So that's the value of doing the motor exam. Typically, I'm checking patella and the ankles, right? And so the patella is L234, ankles S1. Gait, I think, is extremely important. And I will, I'll get back to that. So once again, I don't have the patient's, you know, disrobe, no, but, you know, we should be able to kind of palpate the spinous processes. In the lateral view here, just rough, rough guide. The EAM, external auditory meatus, should be above the shoulders over the hips if you have this ideal sagittal alignment. There are five muscles I check on the motor exam of the lower extremities. So, and they cover all the major nerve roots. So iliopsoas, which is like L1, L2, L3. Quadriceps, 234. Hamstrings, four, five, and one. Dorsiflexion, four and five. Plantar flexion, S1. Okay, reflexes we talked about. Gait, you know, you may not be able to pick up subtle weakness when a patient is seated. So I kind of get everybody up and I have them walk. The other thing is there are a number of things that enable us to walk, right? Like the cerebellar input, the sensory input. If you have a peripheral neuropathy, it's gonna cause a problem. And there are very characteristic types of gait abnormalities. So I like to have people walk on their heels, walk on their toes, right? To bring out subtle L5 or S1 weakness. Tandem gait is great, right? Especially if somebody has spinal cord compression or myelopathy, they're gonna have trouble doing the tandem gait testing. And you would be surprised how many of our, you know, the percentage of our patients that have lumbar spondylosis that also have issues elsewhere. Cervical and thoracic, okay? But if you don't know or don't look for it, you won't find it. Diagnostic testing, plain radiographs. You can get MR to look at the nerves, the soft tissues. Once again, there's a high incidence of fall positives, so you wanna correlate the radiographs with the clinical picture, okay? And this is an example. Actually, there are lots of hip views that can be taken. I just, you know, show you the simplest one, the AP view. Spine films, obviously. AP lateral of the lumbar spine, okay? Flexion and extension to look for occult instability. And then the scoliosis views, right? This gives you the 3,000 foot view, the global spinal alignment, AP and lateral. And, you know, in very broad terms, once again, on the AP, you know, you should be able to draw a line, drop a plumb line down, bisecting C2, and it should bisect every spinous process. And then in the lateral view, if you drop a plumb line from C7 straight down, it should come within five centimeters of that posterior superior corner of the sacrum. Sometimes we include the leg lengths, and this way you can pick up leg length discrepancies that may be accounting for a curvature or other asymmetry. Okay. Typically when, you know, the degenerative changes related to spine disease, once again, collapsed disc space, osteophytes, CT is better for demonstrating those things, the bony anatomy, yeah, and certainly we see some loss of disc height here. But MR is the gold standard, right? And here we see multilevel spondylotic changes and stenosis, okay? And so some of the things that we see, we may see thickened ligaments, dorsal compression, if you will, ventral compression from a herniated disc. And so sometimes a nerve root can be impinged upon, and a patient may not only have back pain, but also lumbar radic, okay? And so typically I describe this to patients as a nerve kind of being sandwiched, right? There may be a disc bulge or herniation ventrally, and then dorsally you'll have thickened ligament and bone, right? So the point of surgery or whatever is to kind of decompress that nerve root. And remember, typically, you know, the L4-5 herniated disc is gonna give rise to an L5 radic, right? It hits a nerve root that is exiting. And similarly, the L5-S1 herniated disc will cause an S1 radic. This is pretty busy, but the 4-5 and the 5-1 discs are the most commonly ones to herniate, probably about 40 to 45% on each. 3-4 is less common, okay? But there's a characteristic distribution of sensory pain and motor symptoms that go along with each one of those. Now, in lumbar stenosis, right, there is narrowing of the canal, and so patients present with symptoms of neurogenic claudication, right? And I would think of it as being a multifactorial thing where you kind of have this circumferential narrowing of the canal, okay? So ventrally you may have disc bulges and osteophytes. Dorsally here, like C and D. Hypertrophied, and E rather, hypertrophied facets. C represents thickened ligamentum flavam, and these things just reduce the room for the nerves. And patients typically present with pain that is greater when they are walking, and when they bend forwards, right, the pain is less, right? And that's because the ligaments, when in the flexed position, all of that stuff kind of buckles outwardly of the canal, so relieving the compression. Either which way, regardless of the etiology, the back pain, first line treatment is gonna be symptomatic relief, right? So NSAIDs, oral steroids, injections, physical therapy actually is huge. And if these things don't work, then you look at surgical. After diagnostic studies that back up the diagnosis, you can consider surgical intervention. So if we return to the index case, what I didn't tell you was that this gentleman also had bilateral lower extremity pain. Consistent with neurogenic claudication. He had undergone medical management, hadn't gotten better. And once again, this was his MR. And he had multilevel spondylosis. He had loss of lordosis. And actually, this is a guy who in a perfect world would have undergone a spinal reconstruction as well as decompression. But nevertheless, he required surgical treatment. And I'm sure this isn't gonna work, but do you guys know this song? Anybody know this song? Yeah, yeah, yeah. Right, okay, so it's great. If you, yeah, you want to sing it? ♪ Down, down, down the drive, oh, down the drive ♪ Right, right, right, right. And so it starts out with, right, like the foot bone's connected to the ankle bone, the ankle bone's connected to the knee bone, and so on and so forth. And you know what? This is really important, right? And I think I've come to appreciate this even more. All of the parts of the body are connected and they all impact one another, right? So when you have pain in one area, you either consciously or unconsciously shield that area. You compensate with other areas, which then throws them off. And so this cycle gets set up of pain and inflammation. And if you don't break it, it becomes a problem, right? So I stress this to all of my patients, absolutely. So let's see. So this is what I would say in conclusion. I've come to appreciate over the years, you know what, it is so complex, the human body, and it's pretty amazing what we can do. And for any of you who have had pain, you know, it stinks, right? Absolutely, when you cannot go about your life and do the things that make it a life worth living. You all in this room, you know what? You are the experts of the nervous system and the protector, right? So you have to be alert, you have to know what to look out for. Rehab is key. It doesn't matter where the problem is. If it isn't addressed, it's going to impact other parts of the body and then causes an even bigger problem. And then always remember this, the hip bone, right? Actually, the video is pretty nice because it shows all the, you know, things marching up because the hip bone, you know, is connected to what they call the backbone and then the neck bone, so on and so forth. But in any case, just a brief shout out to our team. You know, at Northwestern, we have the doctors, we have the APNs, the RNs, the MAs, the people in the OR. I mean, it's kind of crazy, right? But it's a huge team that makes it all work. And so it's pretty fun, yeah? And I think that's it. Happy to take any questions, thank you. Thank you. Can you talk a little bit about sacroiliitis? Damn good question. All right, well certainly, so this is inflammation of the SI joint, which, you know, as you know, there are two of them, one on either side. And certainly, there can be many etiologies of it, including repeated use or muscular strain, if you will. You're not necessarily, you may or may not pick up pain on palpation, yeah? But certainly an injection, a steroid injection, can both be, what do you call it, diagnostic as well as therapeutic, okay? Along similar or different lines is the business of piriformis syndrome, which, you know, it's 50-50, people who believe in it versus don't believe in it. But once again, piriformis syndrome can cause pain in that area. And it won't necessarily be something that can be palpated on exam. I kind of tend to think of piriformis as really being structural compression of the sciatic nerve there at that inferior end of the muscle. A very sort of specific thing, but in any case. But yeah, I would certainly, you know, if you have a good, whether it's an anesthesiologist or even physiatrist who is willing to do diagnostic and therapeutic injections, this can be helpful, very helpful, yeah. I know that some of the ortho guys will do, you know, like SI fusions for this. But, you know, there are all sorts of implications. Yeah. I thought that was getting big in the spine world now. Yeah, no, it is, but I think, yeah, but I think, you know, I think it's like other things that have kind of come into vogue. And I think the test of time will tell, we'll see. Yeah. What do you mean to the problem of getting SI fusions covered unless the patient has had previous. Spinal fusion? Yeah, right. You know, so super briefly, you know, what I will tell you is, you know, certainly in my career, like our understanding of things has evolved. So let's say late 1990s, you know, when I was training, you know, the typical operation, so this is when spinal fusions, at least in neuro, people started to first start doing them, you know, lumbar fusions. And so the typical operation was like, like an L2 to L5 spinal fusion, or L3 to S1, something like this. And then probably in the early 2000s, you know, our understanding of things kind of evolved to say, well, okay, you know what? We shouldn't just be looking at a restricted segment of lumbar spine. We should be looking at, you know, L1 to S1 sort of thing. And then, you know, we started looking at the lower thoracic, you know, people would come in with, let's say, junctional kyphosis or adjacent segment degeneration and disease, and so then we started doing, let's say, you know, lower thoracic to sacrum. Then there were issues with pseudoarthrosis, and we started going to the ilium. Then there was an understanding of, you know, global balance, sagittal balance, which is so important, right? But even today, I mean, not all spine surgeons are doing scoliosis films and looking at the overall, you know, overall alignment. And I think probably in the past maybe eight years, this business of the spinal column's relationship to the pelvis, you know, we understand this even more. But I think a lot of what has gone on, I don't want to call it iatrogenic, even though it is, but I think our understanding has evolved. Ignorance is bliss, right? Yeah. So. Thank you so much. Any final questions? Next, we have a beverage. Oh, one more question. Go ahead. Thank you for your talk. About the, if you have a old disc, or a herniated disc, lower disc, does it contribute, does it lead to a particular pain, or does it have some sort of contribution to back pain as well? Right, tough question, right? You know, I think the easy answer, there's no way to prove or disprove it. That's what I will tell you. I think the only way you could prove or disprove it would be, let's say you had a before and after MRI, the first one demonstrating no herniated disc, the second one demonstrating a herniated disc, and in between the two, you had new back pain. You get what I'm saying? But back in the old days, once again, 1990s, early 2000s, we used to do discograms. You know, it was not uncommon. And basically, this was like a provocative sort of injection into the disc space. So you would have somebody come in, let's say with multilevel spondylosis, right? Let's say from L2 to L5, with loss of disc height and disc bulges at every single level, and the neurosurgeon would send the patient to the radiologist or the anesthesiologist to inject each disc to selectively determine which one was accounting for the back pain. You know what, this is totally not in vogue. You know, I don't know that anyone is doing discograms anymore, but back then, I mean, this was kind of the thought. So once again, the scenario I described to you would be the only way that I would buy it, if you will. Yeah. That's it, great. Thanks. Thank you so much. Thank you. Quick break.

back pain

diagnosis

physical examination

hip pathology

spine pathology

treatment options

multidisciplinary approach