Podcast: Why would you ever need back surgery?

Podcast Transcript

Hello and welcome to The Bone and Joint Playbook with Dr. John Urse, Tips for Pain-free Aging. Today’s topic is Why Would I Ever Need Back Surgery? Let’s listen in.

Terry: Hey there listeners, welcome back to The Bone and Joint Playbook with Dr. John Urse. Dr. John what are we talking about today?

Dr. Urse: Well Terry, today’s topic is why would I ever need back surgery.

Terry: That’s a great question. What makes you qualified to talk about back surgery?

Dr. Urse: Well Terry, I’ve spent the last 35 years as an orthopedic surgeon in Dayton, Ohio. In my early days I did back surgeries when I thought they were indicated, so I think I have some qualifications knowing some of the contributing factors to back pain. We will include some of the issues in the neck and middle of the back and concentrate on some of the low back problems people get into.

Terry: So, tell us who else is joining us today for this conversation.

Dr. Urse: Well, today’s podcast has Dr. Brian Handal. He is a orthopedic surgery resident who is going to be doing specialty training in spine surgery, so I believe this will give us a perspective of some of the older and newer ideas that are influencing how we are dealing with back problems that affect many people.

Terry: Hey Dr. Brian, welcome to the show.

Dr. Handal: Hey, thanks for having me.

Terry: Do you want to tell us a little about yourself?

Dr. Handal: Yeah, so I am from Houston, Texas and went to school in Des Moines, Iowa at Des Moines University and am currently doing my orthopedic residency here in Dayton, Ohio. I plan on, like Dr. Urse said doing my spine fellowship soon.

Terry: So, I am going to open here with the first question. What makes back problems so common? What is it about a back problem that everyone seems to get them?

Dr. Urse: Well, I think this must go back a little further than we think. We evolve to be two legged animals that stand up right. When you think about how our walking is, we walk on two feet instead of our predecessors that may have been on four which puts a lot more pressure on our spine with an erect posture. We can also look at two things that are simple things that everyone can feel on their own bodies. We have a rib cage that is bony, we have a pelvis which is bony, but in between that we have this low back area that is muscle. Some of us have a few extra inches due to our recent COVID environment, and some of those support structures which are mostly muscular and help in between the bony areas can also fail to support us adequately when we do activities such as gardening, sports, lifting and twisting activities.

Terry: So, my first question is back a long time ago, and I won’t say how long ago it was. I was in so much pain laying on the floor they took me to the emergency room, and I thought I had a back problem, but it turned out it was a kidney stone. So, if someone is having aback problem what are simple things they can do to diagnosis a back problem between something else and what can they do to alleviate the pain if they come across some back issues?

Dr. Urse: Well, I think the simplest thing is how did it come about and if you were in the garden taking care of some of your spring planting issues and your back was sore by the end of the day. That is something we can attribute to the back as being a muscular problem from overuse, twisting, shovel, etc. I think we know that is an unlikely scenario for a kidney stone. On the other hand when you have intermittent pain that is out of proportion then you’re use to, and it may be on one side of the back, more on the flank or higher up in the middle back. This can sometimes be the kidneys or the pancreases, which is one of the internal organs in the belly and it’s far towards the back of the belly, so frequently those issues are felt in the back. Our esophagus, ulcers in the stomach and things that are in the abdomen can be considered, and also adjacent structures like things in the hip can cause referred pain to the back. As we go further up the spine the neck can be influenced by the shoulder or swallowing problems in the food tube or esophagus. The gallbladder and other issues that irritate the diaphragm even the heart can mimic the shoulder, back and neck pain. It’s the history that we have to ask ourselves, how bad is my problem? Is it from overuse and if it is then the short answer is lay down, bend your knees and put a heating pad on your back and try some anti inflammatory medicine or Tylenol. If it gets better in the next few hours or days then most of your problems will resolve. If your pain is intractable and more out of proportion than you would expect or wasn’t precipitated by something obvious, then you have to start thinking of a reason to seek medical attention to figure out what is the problem.

Terry: Dr. Brian, let me ask you a question because you’re a resident and have recently come out of medical school, are there things that maybe Dr. Urse wouldn’t know about from a treatment point of view from simple things you can do if you’re at home and your back starts to hurt you? What are some things that you would recommend being newer to the medical field.

Dr. Handal: Simply in orthopedics no matter if it is your shoulder, hip or back the most important thing is keeping range of motion. The last thing you want to do is be sedentary. It’s completely different if you functionally cannot move and that is the time to seek medical attention, but if you have some aches and pains you might want to start working out your core and do some abdominal strengthening like Dr. Urse was saying. The only thing that is supporting your back is the muscle structures in your abs. We have all different body shapes and sizes and for someone who is a little heavier set than they are probably going to have more back pain, because they are leaning more forward and the back is taking more of the brunt of the work and so you start getting some decompensation. If they were coming to see me I would talk to them about strengthening their abdominals and when they do therapy that is what they’re going to work on. It seems somewhat counter intuitive and people sometimes want a quick fix, but truly it is something that you have to work on and it’s not something that will go away in a day, sometimes it takes some work and grit to get through that.

Terry: What about all of these heat rubs and things like that? Are they really doing us any good or are they hurting us or just disguising the pain? What do we need to know about icy hot and things like that?

Dr Urse: For muscles in the back I think you’re ok using a lot of the over counter items, there certainly is no downside to them.

Terry: So, out of all of the patients that come and see you throughout a month or week and they come in with back pain, how many of those ever get recommended for surgery?

Dr. Urse: I would say 5% or less.

Terry: So, surgery is like the last case scenario here?

Dr. Urse: Yes, and that is why today we are going to list about five major areas where people might consider having spine surgery.

Terry: Ok, how about we go through the list right now. Give me the top of your list.

Dr. Urse: Well I think the intractable pain is the first topic. People frequently will get a ruptured disc or pinched nerves, but nerves have nerve endings and they hurt when they are unhappy. So, if you have a pinched nerve that is shooting from your back down your arm or down your leg, we talk about that nerve as being a body structure that allows us to feel things like warm, cold, sharp and dull. They have pain fibers and when pain fibers are irritated in a nerve, they cause significant pain, which people are extremely interested in relieving as soon as they can. 90% of people in their adult life will have some low back pain as they go through their normal activities of daily living. That has to do with moving furniture, work, activities and sports. The odds are in your favor that it is going to be fine though. In fact in Asia most people don’t even seek medical attention for back pain, because it’s expected you will get it and there are so many people that there are not enough doctors to deal with all of the issues that involve other body parts. When you then distill down the 90% that are going to get better with a few days rest, therapy modalities, over the counter medications or topical treatments, you’re left with a distinction of whether you have now lost some function from what the nerve is suppose to do. Some nerves in your low back help pull your foot up and down. If you have a foot drop and that intractable leg pain coming from your back is now caused by a pinched nerve from a ruptured disc. That disc is a spongy jelly type tissue between the back bones and when that herniates or ruptures, I tell people its like a piece of toothpaste that pops out of the tube, but now it is sitting on top of that nerve that is going down your leg. If you cannot pull your foot up and down all of a sudden, now you have a foot drop and you can’t lift your foot up and that effects function. Now you not only have a pain issue, but you have a function issue that is more urgent and in that case we want to give people the best option of getting better. Hopefully the little piece of toothpaste or disc will dry up, and not become a problem hat needs surgery, but occasionally it doesn’t find a way to get away from that nerve and it doesn’t get better. At this point when you have the intractable pain patient we get a lot more aggressive in our treatment plans and we say that we need a diagnosis. At that point we get MRI’s, imaging studies like a CAT Scan, Myelogram, or a nerve test called an EMG. We need to diagnosis the problem and make sure it’s a nerve, and find out which nerve it is so we know what we’re dealing with.

Terry: One of the questions that I have that is on the top of my mind right now is, twenty years ago how risky was a typical back surgery and are there things that we are doing today in modern medicine that is making back surgery more safe, simple and less evasive.

Dr. Handal: So that is one of the big reasons why I am interested in doing spine surgery and why I plan on doing my fellowship in spine surgery is because of the rich history of it. Going as far back as Hippocrates when people were having tuberculosis that would go into their back, they would get these big curves so they use to use blood soaked leaves and cast people in these leaves to prevent the curves from getting worse. We don’t do that anymore, but we do use plaster paris and we still cast people for their curves in their back. So no matter how far we’ve come from that point we still use a lot of the same techniques from way back then. It wasn’t until someone named Paul Harrington out in Houston Texas saw these casting techniques and said it’s way too humid out here in Houston and we cannot get these kids to wear these casts. He then came up with Harrington Rods and that is where fusion techniques started coming in and then you started having people doing back surgeries and putting the rods in the back because of some guy in Houston who thought it was too humid to use casting techniques. We still do that, and that was back in the 1970’s and 1980’s and so although we still use those same techniques it’s more of our technologies that we are using now. We have navigation, robotics and different types of materials we are using in spine surgery to help us fuse and help correct curves. Overall, since more people are having more spine surgery over time we are getting bigger cohorts of people that we can do research on and see what works best for them. The whole history of spine and spine surgery is fairly new in the grand scheme of things, not much has changed, but more philosophies are starting to come out.

Terry: Ok Dr. Urse. Let’s keep going with your list, whats next?

Dr. Urse: Well this is going to segue us into deformity and curvature problems, but I wanted to summarize what Dr. Handal said. So, basically if we talk about a pinched nerve and a piece of toothpaste pushing on it, instead of opening the back with a big incision now, we use microscopic techniques that are less invasive and there are some through the skin called percutaneous techniques. We have robotics if you think augmented reality where you have seen kids play virtual reality games we have some of those techniques that allow us to see the bodies bony structures and help us place screws or rods or things that would help us do less invasive techniques. I think a lot of that is the cutting edge technology that is coming to some of the back issues. Deformity has to do with whether things are straight or crooked. Dr. Handal was talking about scoliosis, and now we are going to get very simple. We are going to take building blocks that you would see in a kids playroom and we are going to take a normal spine that is straight and the building blocks are the bones that go from the bottom called the lumbar vertebrae through the middle thoracic, and up to the cervical which is the neck vertebrae. When they are straight they’re great, but when they look like a dollar sign and have a curve like a “C” or an “S” that is what scoliosis is. Scoliosis is a sideways curvature of those building blocks and there is a certain amount of curve that is acceptable for normal function. If you’re under a certain number like 30-50 degrees that we measure with x-rays, then there are types of casting that we can use that are more tolerated with lighter braces that we use. Those braces are kept on in mostly adolescent children for a certain time to try and correct or slow down the curvature. When they reach above a certain degree of curvature that is when the rod or realignment to hold or improve the alignment would be considered by a pediatric or children’s orthopedic surgeon in that child with scoliosis. Those are big surgeries that someone would talk to you about if it ever got to that amount of curvature. The reason we talk about surgery in those cases are because it effects breathing and peoples ability to take a deep breath and exchange oxygen, because the amount of curvature starts to effect that organs around the spine. The second type of deformity that we talk about is a forward bending of the spine. So if you take the building blocks and lean then forward like the Leaning Tower of Pisa, and they started leaning forward. We have seen people walk like Groucho Marx leaning forward and we call that kyphosis, and when that is at a certain amount of forward bend it can affect the ability to breathe again and occasionally that is corrected by helping straighten the spine and that is a much bigger surgery, but they’re all big. The third type of deformity we see is called a slipped vertebrae. People might have heard of this but it’s like taking a building block and sliding it forward, it can be slid on the vertebrae below a fourth, a half or three fourths or all the way forward where it’s almost off the bone below it. That slipped vertebrae is called spondylolisthesis which means your spine is slipped forward. So, slipped vertebrae is an easy way to remember when a spine isn’t lined up right and that is why x-rays and imaging studies are important to diagnosis a problem. There are times that the slipping of a vertebra will then pull on some of the back nerves that will affect the spinal cord or function in the legs and therefore a corrective surgery might be needed for more severe slips.

Terry: So, let me ask Dr. Handal a question. Why when people get older, elderly people start to have the hunched over or bent over look? What is going on that creates that?

Dr. Handal: That is typically caused by usually by hip or knee problems and we compensate for that by using our backs. Typically, very arthritic knees or arthritic hips lead to a contracture of that joint, and so arthritis does not pick a certain joint it typically goes to other places. We have joints in our back, and I know we were only going to use one big word, but those joints are called facets. These facets are joints in your back and they get arthritic too. Once you have this certain posture for a long period of time and those joints develop arthritis you have now developed a fixed arthritis where you’re hunched over. Muscle weakness is another big thing, and you cannot physically lift your front side up to look forward, so you start to develop this posturing where you’re bent over.

Terry: So, what would you do if my 90-year-old mother-in-law showed up to you and she has this bent over look. What are some things that you would do to correct that or at least give them a little straighter back?

Dr. Handal: A lot of the spine surgeons that I have worked with always tell me there are about five things you can do for a back. You can do nothing, obviously she has lived to 90 years old, and she has done nothing up to this point. You can ask her what her biggest complaint today? Is it pain? Can you not go to the restroom correctly? Are your feet and hands working? Honestly, they have low complaints and usually it’s because someone else was concerned for me and so they brought me in. There is not much to do at that point. Other things like physical therapy are always a great modality. Anti-inflammatories and pain medications

Terry: Is there an anti-inflammatory medicine that you prefer over another?

Dr. Handal: Yeah, I think keeping it simple is the best thing, so taking a one a day type like Mobic instead of popping Ibuprofen all day long which can hurt your stomach. It’s not something you want to continue to do for a long period of time without seeing a doctor, because you can get ulcers and things like that. You don’t want to overuse anti-inflammatories, but you want someone to walk that path with you as it is an important thing to seek out that attention if it’s something that is becoming a repetitive thing.

Terry: Dr. Urse, back to you.

Dr. Urse: I will give you one more thing on that lady who is leaning over. They have upright walkers that hold their posture better and it comes from the word ortho which means straighten. Orthopedics came from the Greek word meaning to straighten the child, we have talked about scoliosis and an orthodontist who straightens teeth. We tell people ortheous meaning stand up right which is a Greek word for holding your posture up, so a walker will let you lean forward to waist level and an upright walker will hold the spine straighter and will hold them upright with a platform attachment for your forearms and you can walk and see people better. I will tiptoe into one other reason why people could have a forward bend to their back and that is a spine fracture. There are compression fractures that we frequently see with osteoporosis as we get older the bones do not have the mineral content and they get fragile. Osteoporosis means soft or porous bones and as people lose their bone structure, we can see fragility fractures. Some people break a hip bone or wrist, but the spine and a compression fracture that is where a square block turns into a pie shape, where it bends forward like an accordion and smashes forward and then leaves the building blocks above to lean forward as well. This not only causes potential deformity, but it hurts because it is a fracture. There are newer techniques for dealing with that and I will let Brian Handal explain a little bit about a kyphoplasty or vertebroplasty which is a good way to put something in a crumbled bone to stabilize it and decrease the pain. So how would we do that Brian?

Dr. Handal: If you have a vertebral fracture that doesn’t mean you automatically get surgery. The biggest thing is how stable it is and getting that person back to function. Most of the time we can get away with just bracing. We can put a brace on someone and give them pain medication and say this is going to heal predictably on its own and see you in two to four weeks and get an x-ray to make sure nothing is progressing on this fracture. Now, say that doesn’t happen or mom or dad are in so much pain that they can no longer get out of bed due to the pain. Then it is something at that point you start to talk about something minimally invasive and low risk of this type of surgical procedure that is most commonly done as a kyphoplasty. That is simply when under x-ray we go in with a little needle and put it into the bone and blow up this little balloon that acts like a jack for your car and lifts up that bone and then you inject some cement or grout into the bone. You let it set up and then that bone is sitting up right and it heals like that. There is another procedure called a vertebroplasty which is very similar, but you don’t use the balloon. That procedure has gone back and forth on whether or not we should be doing those, because sometimes you inject too much grout, but that is neither here nor there. It’s really for pain relief at that point and those are great. Other things you can do are injections. Sometimes maybe mom or dad are not healthy enough to have that procedure done. There are injections you can do to block the nerves in the back that are causing the pain and will give you pain relief. We utilize some of our spine surgeons that are trained in that or our anesthesia colleagues to help us do that as well.

Terry: If I had a procedure like that, how long am I out? How long until I walk or have a normal life?

Dr. Handal: Typically you can get back to doing whatever you want right away. Now am I going to council you and say you can go ahead and hit the gym again or go back to your labor type job lifting 50 pounds overhead? I am going to say no, because I want the best outcome for you. I will tell you to take it easy, but keep moving because you will be able to walk immediately after the surgery and you can pretty much live your normal life. I just suggest you take it easy for the first four to six weeks and let that bone set in and start to heal a little bit.

Terry: Ok, Dr. Urse what else do we have there?

Dr. Urse: Well we talked about a type of pathologic fracture, the bone broke because it was soft as it had osteoporosis. We would then tell you to get treatment with your doctor to prevent other fragility fractures. You can take Vitamin D, calcium and get a thing called a dexascan where they look at your bone density. There are other types of fractures. You have seen people get in car wrecks, skiing accidents, or football injuries. You can actually break a spinal vertebrae or bone with a bad injury. In those cases that is another indication for surgery to stabilize the spine or prevent it from causing the bone to be deformed or pushing against the spinal cord or nerve. A lot of times it doesn’t have to be through an incision or an invasive procedure. You have seen people wear those halo jackets on their neck and head, they are a little invasive because they have to go into the side of your head. They mount to a vertical bar that looks like a frame around your neck and that allows a certain neck fracture to heal while it’s in this external device called a halo jacket. There are reasons fractures cause a need to consider surgery like bad motor vehicle accidents, an unstable spinal bone that is going to allow the bone to settle near a vital structure like the spinal cord, a nerve or nerves that control your bladder or bowel. That leads us into the next category which is neurological compromise. That means the nerve is now not working the way you want it too. You can’t squeeze with your right hand because one of the neck nerves have been pinched or injured at the spinal cord level. If that nerve test that we spoke about, an EMG as well as an MRI all match that would then lead a doctor to discuss options to restore function, because of neurologic compromise. One of the most important things in medicine is to not get an MRI and say look at all of the things wrong here, the answer is to take the MRI and see what is shows and if it matches your symptoms. So, if you have a ruptured disc at the C6-7 level on the left part of your neck, but your right arm is burning then those don’t match. A good doctor will look at your test and look at you and put everything together and see how you are doing without surgery. If you’re not getting any better or have a foot drop or losing bowel and bladder control then those are more critical issues and you’re now losing function and neurological compromise is one of the most absolute reasons to consider surgery for a spine problem.

Terry: As we are talking I’m starting to think if I walked into an orthopedic doctor, what are the three, four or five questions I should be asking that guy before I let him do any surgery or procedure on me? Should I also get a second opinion before I go through with that?

Dr. Urse: Both good questions. The first thing is are you sure that whatever you think is wrong is the problem? Does the test match your symptoms from your understanding of what the test shows. So, a neurological test like an MRI, EMG, CT Scan, or Myelogram that shows where the problem is and that it correlates with your findings of numbness in that nerve distribution. Each nerve in the neck and low back go to a certain body part. One goes to the inside of your arm down to your thumb, another goes to the little finger side, another nerve in the leg goes to the little toe side, the top of your foot and the bottom of your foot. All of those things your doctor should be looking at and then examine you to check your strength, reflexes, and feeling. They can then check your test and see if this is your problem that is number one, you have a neurological deficit that matches the test. The number two thing is have you had adequate conservative therapy. We know that 90-95% of these will get better within three months. Our job, and I hate to say this on the air, but the role of the physician is to sufficiently entertain the patient long enough to allow nature to effect a cure. So you can be entertained by physical therapy, an epidural block, or nerve block from a pain doctor. You can say to that doctor can I try some other things or is my foot drop going to be bad in three months and I won’t be able to move my foot ever again, and then there is a more relative urgency. I think the earliest most people would work on something for intractable pain or neurological issue would be three to six weeks, we would like to go twelve weeks because it may start getting better with some of those options we just discussed. The other thing I would ask the physician is if they feel qualified to do and if they have done a number of these and if this is the least invasive way to do it. You don’t want to do things that are so minimally invasive that the doctor cannot see what he is doing. We see that with hip replacements when people do them with a two inch incision and the implants are put in wrong, because the doctor couldn’t see because the patient wanted a small incision. There is a balance between minimally invasive and cutting edge and established technology. As Dr. Handal said as we look at evidence based outcomes we want to know if these newer modalities are working. I think the most important thing is a second opinion is always a good idea and a doctor that hesitates to tell you that I think is insecure with his diagnosis or what he has told you. If you see me for a problem I am going to tell you that you could go see someone else, here is what I think you need and if that other doctor disagrees then I would see a third doctor and break the tie. Maybe one of us is wrong or you may like him more than me and then you can let him take care of it. I would never have a problem telling you to see someone else as it is a big surgery and a big step for you.

Terry: So what I am hearing from Dr. Urse is not to be afraid to get a second opinion. My thought as a patient would be that I would make the doctor mad at me. Dr. Handal, let me ask you a question as you are newer into the field. How do you feel about someone asking for a second opinion. Do you take that as an offensive thing?

Dr. Handal: No, absolutely not. It’s the patient taking ownership of their own diagnosis which is really important. Not only do we have to entertain these ideals and things like that, we have to give them some ownership. I think having a patient go see another physician for an opinion, maybe I missed something, we are only human. The spine and medicine in general is very complex and getting other peoples opinion is very important and I would never take offense to that.

Terry: We are coming to the end of this podcast. Dr Urse is there anything you would like to express before we wrap this up?

Dr. Urse: I have one more thing on my list. To review there are five major reasons to have back surgery. Intractable pain that isn’t getting better with conservative treatment that matches a test. Two, a fracture from osteoporosis or trauma. Three, would be a deformity like scoliosis. Four, is what we talked about with neurological problems and the final thing is post spine issue. Which is you had surgery or you have an infection that came through the blood stream into the spinal disc spaces or into the bone. A blood collection called a hematoma, a infection in the spine, broken hardware, an area where a spine fusion at one level has caused more force at the level above or below it. You may have to consider another surgery, because you have had one already that may have caused an issue down the road. Those may never happen, but there certainly are times where another surgery would be needed after an initial surgery. The final thing I want to let Dr. Brian Handal talk about are the newer cutting edge technologies for avoiding surgery perhaps. We had a podcast about PRP and stem cells so some of the newer advances in spine pain management and dealing with patients issues. I will go back to one story when Jack Nicolas had some of the low back joints called the facet joints, and had some arthritis in those joints. This was in the newspaper so this isn’t a HIPPA violation. He went to Munich Germany to get a stem cell injection performed at different levels in his back. They said he was back playing tennis the next day, but I thought he was a golfer. We are using imaging guidance to place platelet rich plasma called PRP for some mild problems in the SI joint called the sacroiliac or some of the small facet joints. There are some other uses for stem cells in those areas for more severe problems and less invasive ways to use them. So, Brian what have you seen on some of the trends on that?

Dr. Handal: Some of the new things we are starting to talk about are stem cells in the discs. So the disc is kind of like the toothpaste or jelly analogy, as you get older it kind of dries up over time. Just like with any other joint in your back the cartilage wears out, the disc can wear out. So the thought process is if we can start injecting stem cells into the disc, does it regenerate? Well, we’re not there yet. Typically what we are seeing right now is that it may cause the disc to wear out faster. It doesn’t mean that we are going to abandon that whole realm yet, but we are just now getting into the whole new field of medicine. We can inject into a disc, but now we are doing it into the facet joints to help rejuvenate and keep the motion there. Like when we went back and talked about fusions, that’s a fusion there is no going back from that because the joint is now fused and so we are trying o the keep the motion. So that is what we are seeing is that people are happier with more options with stem cells and PRP.

Terry: As we end this segment, by the way this has been fantastic. I have learned so much by listening to you guys talk. Do you want to leave the listeners with a thought about back pain if they were to come see you. Should they not come to you right away and kind of let it go for a couple of days?

Dr. Urse: I would try some simple things first, again there are lots of ways to help back pain issues. If you cannot get rid of it yourself certainly chiropractors help and family doctors and as osteopaths such as D.O.s learn manual medicine techniques. There are simple things that you can even get started before you see an orthopedic surgeon such as physical therapy modalities, recommendations from a trainer, pilates, yoga, or swimming. Most of these things are going to take care of themselves. There is another adage in medicine, may you never know what you prevent. I think people need to make lifestyle changes and choices and I think if you say I want to work on my core or an exercise program and try to prevent a problem, I feel that is the best way to attack it.

Terry: Thank you guys for helping us out today and learning more about this. Again, please join us for the next episode of The Bone and Joint Playbook with Dr. John Urse. Brian, thank you for coming in today.

Dr. Handal: Thanks for having me.

Dr. Urse: Just finally, these podcasts are able to be heard on Spodify, Apple or on my website DrJohnUrse.com.

Thank you for joining us today on this episode of The Bone and Joint Playbook with Dr. John Urse, Tip for Pain-free Aging. Please join us again for another episode. This has been an episode of Doctors Unmasked, produced by Terry O’Brein.