Minimally Invasive or Minimally Effective? | Dr. Arthur L. Jenkins III

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I always tell my residents, it's a fine line between minimally invasive and minimally effective. And so you need to make sure that it's the least invasive that does the most effective.

Hi, I'm Dr. Jason Siefferman and welcome to Care Beyond the Pain. In each episode, I will sit down with a provider, a person with pain or a supporter to explore their experience and share their perspective on the pain journey. Together, we will navigate care beyond the pain.

Hi, I'm Dr. Arthur Jenkins, neurosurgeon, founder of Jenkins Neurospine uh and a spine innovator and cautious but caring uh minimally invasive spine surgeon.

Dr. Jenkins, thank you for joining us today.

My pleasure, Jason. Thank you for having me.

It's a pleasure to have you because you've done so much on the front of hypermobility spectrum disorders and just spine care in general. Can we start? We want to talk about the patient journey, specifically the the diagnostic portion. We both see a number of people who have been through the wringer. They they've seen more than 15 doctors. They've spent lots of money. They haven't gotten clear answers or maybe they've gotten clear answers that weren't the correct answers. Uh how do you begin when you meet these patients?

Honestly, the first step is often just acknowledging the journey that they've been through so far. It's There's been so much medical gaslighting on these patients that they don't even trust doctors. They don't trust They don't trust their family half the time because the family has heard from so many doctors that they are making it up, that it's not real, that there's nothing here. And so acknowledging that this journey can be a very frustrating one. I can using the word in many cases medical gaslighting where I'm like, "It's exactly what I'm feeling."

Post-traumatic stress disorder, it's medically induced PTSD is a real thing. And just being empathetic with them for that complicated course, um it it helps them to understand that they're going to be listened to instead of shunted to the side, which is what most of them have been used to. Um and I just to me just just getting past that first level of of "Is this going to be another doctor who doesn't listen to me?" is is huge. Once I get to that point, it's about listening.

And understanding what the problems are. So many patients will be will see a doctor who just wants to look at the films and say, "I can operate on that. So, tell me enough to justify me operating on that." And then they move on to the next patient. I need to really get to the bottom of what their problem is. And I definitely take a little more time than many of my colleagues do. I can afford to cuz I am at the top of the food chain in terms of being out of network, private practice doctor.

But that's also deliberate, very deliberate. I I don't want to be the, you know, 3 seconds and you're out kind of uh spine surgeon because I know that spines are the most complex joint in the body and they need a more thorough, nuanced understanding not just of what's wrong at one level, but what the consequences of treating one level will have on the adjacent levels. It's And and what all of this the impact all of this has on the patient. So, it's about their understanding their goals, their goals of treatment, and their goals of life, and how do I get them back to being a patient stopping a patient starting a person again.

So, that process in my mind as a scientist and as a researcher involves testing a hypothesis before acting on it. So, to me I I'll look at it and because I know there's so many different conditions out there that many of them overlap. They have the same symptoms. So, just because they have a disc herniation, doesn't mean the disc herniation is causing them pain. And so, we test the hypothesis, and I use esteemed colleagues like you to do diagnostic injections, or to sometimes just give me a second opinion on where that you think the pain is coming from for it to get convergence.

Yeah.

Um but if I test a diagnosis with an injection and it doesn't give relief, we got to look somewhere else. Not just, "Oh, well, if you didn't get better with this the injection, then surgery is the alternative." Well, no. It's actually if you didn't get better with the injection, the hypothesis is wrong, and we got to go back to the drawing board.

Yes.

And and as you know, frequently I'll send you a patient and I'll say, "I want you to do this injection, and then 2 weeks later this injection, and then this injection. And if one of those three is positive, let me know."

Yes.

And so, it's it's that scientific method of iteratively find a hypothesis, test the hypothesis, revise the hypothesis, make a new hypothesis.

Yeah.

Then once you've done that, and you've got enough evidence to support moving forward with a treatment strategy, well, then we offer the least invasive, but most effective surgery. Now, some of those surgeries are big, and some of them are small. And sometimes the smallest operation you can do isn't the most effective. One of the things I have found is that endoscopic surgery takes a lot longer to do the same operation that you could do microscopically. And even longer to do it microscopically in many cases than open.

Mhm.

So, you really have to weigh the And you have to know all of these techniques to know which one is right for which patient. Um I just saw a patient who came from another city who had been operate on by supposedly a very good guy who had done an endoscopic procedure on one of my patients. And guess what? They didn't actually address the underlying problem. I always tell my residents it's a fine line between minimally invasive and minimally effective. And so you need to make sure that it's the least invasive that does the most effective.

So sometimes the least the very least invasive isn't that effective.

Yeah, it's really about understanding the cascade, the biomechanical chain, not just what's hurting in the moment, but what happened that led that part part to hurt.

Exactly.

Getting to that that root anatomical reason.

Yeah.

If we can go back just a little bit, what you described is what we call the discovery phase. It's really that diagnostic process, which is the first part of the pain journey. The only way to get a solid answer and understanding for what's happening is to go through that iterative process. And you described it so beautifully, so thank you for that. It's it's core to our messaging that if we do not fully understand how, what, and why of the pain, we can't begin to propose a treatment that's potentially helpful.

We can guess, we can throw something at you like stem cells and you know, spin the dice, roll the dice, spin the wheel all at once. We could do two treatments at once, can't we?

We could do a many many of your colleagues, I use that term very loosely, will do three or four injections for different regions. They'll they'll inject everything they can think of at the same time. Which the downside of that is you don't know which one helped.

Yeah. Yeah. So, lots of challenges with the diagnostic process. I think we share an approach where it's essential that we understand why something is hurting. Not just what's hurting, but why it's hurting. Because that's where the treatment is. So, when we meet these patients, we go through this process, how do you engage with them about treatment options? How do you open the discussion and talk about the breadth of treatment options? Well,

My as I said, it goes back to what's the least invasive that gets the most benefit and and it helps to know what you do and what you bring to the table cuz I don't bring everything to the table. And so I have a to my philosophy is if somebody comes to me and I just get them to the right person, if it's not me, I win cuz my patient is now happy. They're they trust that I have done what's in their best interest, not mine.

I mean, sadly, there are a few of my colleagues out there who will operate on everybody who walks in their office if they can talk them into the surgery whether they need it or not. And so if if I have helped somebody by just getting them the right epidural and they feel better and they don't need surgery, that's a win. But it also you have to know who to go to because there are plenty of people out there who throw up a shingle and they throw in a needle and they bill as much as they can and then the next thing you know, they've used up all of their benefits and the patient is no better.

Well, now what? So now they've actually bled them dry financially without actually making them better medically. And so it you need to make sure that you you fully un comprehend the full treatment range and that's why working with people like you is so helpful to me because once I know what you can do, it's easier to weigh well, wow, this doesn't make sense to even think about surgery for this cuz you're this is a problem that's limiting you in the following ways and surgery will do this and it has the following consequences but an injection has a 70% chance of making you feel better without it requires Hello.

Uh let me introduce you to my good friend, Dr. Seafroman will fix this up and and if he can't then we'll talk about what the next steps are.

Yeah.

But it's always about having a treatment strategy.

Yes.

It's about having an escalating process and always doing the least invasive that has a like a high likelihood of of yield. Um So, if you don't know those, how can you even have an informed consent discussion?

Yeah.

Informed consent requires discussion of the risks of the procedure, and that includes not just what rarely happens, but if it happens, it's really bad, but also the known consequences. The things we know happen all the time. Like, it's going to hurt. It's going to take an incision. The incision has to heal. Um the benefits, and you have to have a reasonable projection of what the benefits are. Anybody who says it's going to be like this never happened isn't giving you the straight story.

You have to be able to tell them that, you know, 90% of people get better with a discectomy with a discectomy as well as with conservative management at 6 months. What what does that look like? Well, what's what's what's the trajectory of pain relief with each and having that discussion of the potential benefits. And then, if you don't actually know the alternatives, which is the third of the big three of consent, if I don't know what you do, and I don't know what other people do, I'm just kind of talking I'm selling you a car, not explaining what car would be right for you.

And that to me is the critical part of that discussion.

Yeah. I I think another thing worth mentioning, and you touched on it, is not all surgical procedures are the same. Not all epidurals are the same. I compare it to chefs. You may not like my apple pie. You might like his apple pie better. You know, I use more cinnamon in mine, something like that. Uh can you

I love cinnamon, by the way.

Great, I do, too. So, I I don't I don't think most patients appreciate the variance in the application of these tools. Uh so, can you speak a little bit about the variety you see within the scope of neurosurgery. Or or even within the scope of pain management of how certain procedures are done and how they can be done. Well, so first of all, 50% of every specialty are by definition below average. Okay? So, you really everybody thinks they're the best person in the world and everybody's mother will agree with that particular surgeon that they are the best, but the reality is many of them are not as good as others.

And so, you really have to get sometimes it's hard to tell cuz everybody advertises well and some of the people who present the best may actually be the least competent or the least thoughtful about what they do. In fact, it it anyway, my point being you really have to do your due diligence and find out not just does is he is he a friend of somebody, but is he also uh does he actually do what he says he's going to do and in a careful and thoughtful way.

Now, on top of that, there's some people just don't know certain techniques. I was having a LinkedIn conversation with a surgeon who or I was asked him, "Did you consider a laminoplasty instead of doing this laminectomy and fusion?" And he said to me, "I don't believe in laminoplasty." Well, how can you not believe in a procedure? Procedures have the things that they're better for and worse for. You just So, if there are procedures that they don't do, suddenly that procedure can't have any value if you're asking them.

So, you have to make sure that you you go to somebody who has a very deep toolbox, will pull out the right tool right size tool for the tool for the job needed, and isn't going to treat, you know, your your Phillips head screwdriver with a giant sledgehammer.

And how can a patient possibly know?

And that the answer is they they really have to ask their doctor, their any friends they have in the business to dig deeper than just well, who do you usually send to? But ask ask the anesthesiologist at this hospital. Ask the pain management doctors who treat patients from multiple people. Ask people who have in-depth experience taking care of the patients. You know, they're definitely that you know, there's your friend and then there's the guy that if they were operating on you, you'd have them do it.

Um and not everybody will tell you the whole story because they may be afraid of hurting somebody's feelings, they may be afraid of being sued. You know, that this doctor in another city has a reputation for suing people who tell their patients that they he did the wrong thing. Fascinating. So, that there's there's complexities to informing patients of what to expect when you're expecting surgery. It's hard to always know you're getting the right answer. Um but one of the ways that people often know is once they've had a surgery with somebody, they get a sense of what kind of surgeon they are and they can go back to them.

Other times you'll have people say, oh, I you have to go to so-and-so, he's the best. And there's a certain if they've had a surgery with this person and they don't know anybody else, they they feel they're they owe that person a debt because they had a good outcome and therefore he's the best and so and they don't want to be wrong for having picked that person. It's it's just hard. You really need to make sure that you find somebody whose philosophy aligns with yours, who's going to take the time and the care to choose the right strategy, the right treatment options and give you the right care post-op because it's it does surgery doesn't end when they roll out of the OR.

Surgery ends when they're done recovering.

Yeah. I can tell you from my perspective as the pain doctor, it's the aftercare that's the most telling.

Yeah.

Uh when I have a patient that has a surgical complication and I reach out to the surgeon and they don't respond, that's concerning. Uh you know, especially with more concerning complications. So, the these are things that happen over time over multiple patients. Um you start to get a picture of it from the provider's perspective. For patients, of course, it's very difficult. You know, they'll use support groups and call aches and things like that, which can be helpful, but um

Yeah.

we are here to support to the degree that we can.

Yeah.

Uh I'm very curious. Most spine surgeons aren't tremendously informed on hypermobility spectrum disorders.

Oh, wow, yeah.

How did you get into this?

Um by listening. Honestly, just listening to my patients and hearing them describing these problems. It's It's not taught in medical schools. It's not taught in residencies. It's not part of any core curriculum. Although, I will say that in the last 5 years, there have been more and more centers for hypermobility conditions that have been set up around the country. They're I was just talking with one of my colleagues who also treats hypermobility, and he was saying there are there is more awareness, but it's still massively under aware.

And but by listening to my patients and thinking, well, that shouldn't be. Nobody should, every time they stand up, get dizzy. Nobody should, every time they raise their arms above their head, get numb and and and weak and and in some cases change color in their arms. That can't be normal. And, you know, if they turn their head to look to the side and all of a sudden they're getting dizzy or visual changes or auditory change That's not normal. There must be something structural cuz it happens every time they do this.

You stand up every a lot of times and it you get dizzy and feel like you're going to pass out or worse. Um or if you're having problems that are mechanical in nature, there should be a mechanical solution. And so, we looked into it. There's a lot of There's a fair amount of research and a number of people, whether it's Fraser Henderson or Paula Polonaise or some other people who have been doing research on this. It's great. We learn from them.

And then, I work with people who can help me to manage some of these conditions, whether it be rheumatology, pain management, allergy immunology. You know, these are people who overlap with us and can help us provide the the whole blanket, not just a couple of threads, but to provide the weave the whole blanket that we can wrap around these patients cuz they require a lot of different care. Some very simple and some require immuno modulation therapy and and extensive other thing and sometimes they just need good psychological support.

So, you need to have a deep team that are on the same page, that this is not just functional, it's just a it's not just something they're making up, that they actually have real problems.

Yeah. And and it's never one fix.

And it's never one fix because we can't yet Yet's most powerful word in English language cuz it gets you from no to yes. We can't yet cure the problem that's causing craniocervical instability, thoracic outlet syndrome, hypermobility induced, you know, entrapment neuropathies and all these other, whether it's mass, mals, Bertolotti syndrome, May-Thurner All of these happen in hypermobile patients who develop dysautonomia and other forms and until we can cure that, until there's a drug treatment, something that makes that better, we have to treat the individual components and frequently they get more than one.

Yeah. Can we talk about craniocervical instability for a bit?

Absolutely.

It's one of the most debilitating pieces with with EDS. Can you tell us about your approach both for diagnosis and then going into treatment?

Sure. So, uh for those of you who don't know, craniocervical instability means that somewhere between where the head is screwed on to the cervical spine, it's not screwed on tight enough. And this is a ligamentous problem. We think that at least part of this is immunologic. Part of this may be inherited. Um and part Sometimes it's traumatic. I have patients who have none of those other things. Nobody in the family and and never had any real inflammatory issues.

And then now they they got whacked in the head and now they're Every time they turn their head, they got a problem. And so, there are different ways they get there. But when they have it, the head is kind of sliding around or rotating around. You're stretching the vagus nerve, the sympathetic chain, compressing the jugular. Sometimes that you're even compressing the carotid and vertebral arteries. So, if you're hitting all the vessels that go in and out of the brain and and I suspect it's also causing torsion on those other the venous uh anastomoses that come out through the foramen magnum as well.

And so, all of these vascular in and outflows, if they're getting compressed, how can that be good? And it's not. So, they develop brain fog, they develop uh memory problems, they other cognitive problems, visual problems, auditory hearing things like they've got horrible tinnitus or other problems that frequently come and go when they turn their head or move tip their head forward or backwards or something like that. Um and so, if it's a dynamic problem, there is a hypodynamic solution. We immobilize the levels where the worst compression, the worst distraction, the worst irritation is is taking place.

And we try to minimize the how much we do. But sometimes we have to go bigger because the problem is more extensive. I had one patient recently who came to me. She had clearly craniocervical instability, but she also had myelopathy from her spine at multiple levels, sliding back and forth cuz all of her ligaments were And so we but she did very well, but we had to fuse her spine all the way down to her just just below right around where her shoulder blades were because that was the it was that or or not treat her enough and have her have spinal cord compression and have other spinal cord dysfunction.

Yeah.

And she gratefully traded range of motion for elimination or profound reduction in her symptoms.

Yeah.

And that distinction between elimination and profound reduction is critical because I always tell patients I don't have a magic wand. My wand is still at Ollivander's waiting for a new phoenix feather, but in the meantime this is this surgery is the science I have to offer until there's magic. And I can't do everything and there is sometimes there's permanent damage that's already been done. But sometimes there's a lot of things that are just getting repetitively distracted.

Yeah.

And so managing and mitigating their expectations. I don't want somebody coming out saying, "I'm 90% better. How dare you not make me 100?" Funny story. Twice I had patients where that was a problem. So one time I had patient who was going to do a pretty run-of-the-mill spinal fusion. And I was explaining to them statistically speaking I'm going to make them 80 to 90% better. And he was like, "Why aren't you going to make me 100% better?"

And I'm like, "Okay, this sounds more like a you problem than a me problem, but listen, I'm going to try. Some of my patients do, but I don't want to raise your expectations too much. I just I just want you to visualize 80% as being a win, not not not a loss. And and he was but he finally agreed to do the surgery cuz I told I told him, you know, just trust him. He's He's got your back. 6 months after surgery, he comes back in for his 6-month post-op.

"You have to change how you talk to patients." And I'm like, "Okay." He's like, "You told me I wouldn't be 100%. I'm 100%. You have to change how you talk to patients." And I was like, "So, that's your take-home from you being 100% better. Not, thank you, Dr. Jenkins, but you have to change like

[clears throat]

okay." Now, on a sadder note, I had a patient who had been paralyzed from the neck down, horrible accident, at another hospital. Terrible things were happening to him at the other hospital. We brought him over. We We I patched him up. I worked with my team. It took a week. He was so sick. It took a week before he was healthy enough for me to take him to the OR. And cuz I knew that although he had fractures in his neck and it looked terrible and his function was absolutely nonexistent.

All he could do was blink. He had no other neurologic function. I said, "I just know there's what I'm seeing here, there are things we could do. We just need to do all of these things to this this spine at this problem at this time." And we did it. And after a week, he started being able to feel. And after 2 weeks, he started being able to wiggle his hand and and breathe over the ventilator. And a year after the surgery, he walked into my office and my nurse practitioner could not tell that he'd ever been weak.

He was skinny, he'd lost some weight, but he was neurologically non-focal. It was honestly, that was one of my most gratifying patients. I mean, obviously I still talk about it. Gives me goosebumps to think about it. A relative of his called up one time one day. Dr. Jenkins, I need your help. My husband, you fixed You fixed my cousin. I now need you to fix my husband. I'm like, well, hold on. I don't know what I can do, but tell me the story.

He just had a massive heart attack. He's in another hospital. He He I need you to fix him. I was like, well, I don't do heart attacks, but let me at least call and find out what the story is. And they called and they said She said, well, he's got brain swelling and you're a neurosurgeon, can you fix that? So, I I called the doctors treating him and I said, well, he asked me to. They said, well, you know, here's the story.

They sent me the images. He had a massive bihemispheric stroke. He had had 45 minutes of arrest time. He had a Basically, he had all his vessels were occluded and they brought him back with chest compressions, but he was brain dead. He was already brain dead. There was nothing that I could do to fix him. And she literally screamed at me and I just listened. She Look, she went through the one worst moments of her life. I'm not going to argue with her.

I just listened. I let her let her vent. Why you no Why you no fix my husband? You fix him. You no fix Why you no fix my husband? You miracle worker. And I'm like, I'm not a miracle worker. But I have a pretty good idea of the things I can do. And I do my best to do the safest, most effective treatments of fixing things, but I This would have I'm not God. I'm not Jesus Christ.

I can't raise the dead. And I I wish I could, but and I wish there were somebody else out there I could send you to who would.

Yeah.

And so sometimes having those that reputation that you could be a little bit of a miracle worker works against you. Um but, you know, at least I was able to tell her definitively that there's literally nothing else that can be done and help her get eventually come to peace with the fact that there was it was time to let go. But that's a conversation you never want to have. I mean it's just there's no there's no way that that ends well other than helping them to come to peace.

You've created a number of new techniques for a spine surgery.

Yes.

Can you start at the top

Sure.

down?

Sure. So, um I invented a minimally invasive way of getting to the odontoid process. So, the normal surgical approach to the odontoid process is going through the mouth because the odontoid process is here and the spinal cord is here. So, going through the spinal cord, especially the most vital part of the spinal cord, it doesn't even like to be pulled on, let alone pushed to the side. So, you can't get to it from the straight on from the back. So, the only other way to get there because there's so many other structures on either side of it is really to come through the front.

They then it's called an open mouth.

Mhm.

Sometimes they'll do through the nose endoscopically, but either way you're coming through the front. And so, you're going through the oropharynx, you're going through the the you got to you got to cut through dirty tissue to get to this. Well, I realized that as long as certain ligaments were intact, you could change the position of the neck. And and from having done a lot of surgeries in that area, I know how big those windows are.

Mhm.

And so, I realized that if you actually bent, rotated, and then uh turned, you could create a wide enough window to get all the way back, coming just take shaving about 3 mm of the medial lateral mass of C1,

Mhm.

opening up the C1-2 interspace, you can drill right down and drill the you could get the entire odontoid process off without putting any pressure on the spinal cord. And we did it, we published it, um it worked. Um and in fact, but before we did it, I went up to the cadaver lab and I went up with one of my residents, um and we just we practiced it. And we made sure it would work. I had a patient who needed it, and I was like, "There's no way I'm getting through her mouth."

Um but we did it, and she actually did well with what we had to do. And then we published the So, that's kind of fun. You know, it's like finding a better way of doing things using the body's natural windows. So, whether that's uh developing, you know, novel ways to take out cervical ribs for thoracic outlet syndrome, first ribs, first thoracic outlet syndrome, um the I've been doing thoracic discectomies minimally invasively for about 22 years. I actually went to France to first learn how to do thoracoscopic.

And then I realized we could do them microscopic using almost the same technique. Instead of four portals, we could do it through one. Um and then uh I took some of those lessons, and that's how I learned how to do my first rib resections. Um one of my vascular surgeon said, "I would love to have you scrub with me on doing these operations." And he showed me how they do them, and they had an operation that was about that big. And I was like, "I think we have an opportunity here to do the exact same operation through an incision this big."

And if you take an incision this big from an incision this big, the recovery is profoundly better. It's an outpatient procedure. It's It's like It's a completely different animal. Um but it took bringing a bunch of different technologies that he wasn't used to using. And nobody else was using. Uh but we could we were able to convert what's known to be the safest approach to this into now the smallest. Um minimally invasive uh lumbar procedures got, you know, whether it's um doing the cross-court pass for far lateral discectomies at 05 S1, which most people take so much of the facet joint that it they make it unstable, to all the different minimally invasive techniques for treating Bertolotti's syndrome, which you're well aware of, to having two different coccygectomy techniques, one with an incision this big and one with an incision this big.

And once again, depends on what the patient's needs are, which is the right one for them.

Yeah.

Um that The reason that's so critical is that the normal complications from doing a coccygectomy are due to the fact that the way most people do that procedure is through an incision this big instead of one this big. And they do it on the midline, which tends to fall apart because it's an area that tends to be a little dirty, right? It's down near the bottom.

And there's a lot of pressure.

And there's a lot of pressure. So, instead, I take the incision, I put it off to the side. We go through at an angle, so it's all through very well-vascularized tissue, and it's through a minimally invasive approach, so there's much less wound to heal in the first place. And so, once again, outpatient procedure, low complication rates, patients love it. It's just it's listening and figuring out a better way of doing things.

So, you're always looking at each patient as an individual, understanding the cascade of issues affecting them mechanically, and looking for the least invasive, most effective option for that patient, even if it means designing a new procedure.

Correct. Actually, I developed a minimally invasive way of taking out spine tumors. Partly because back in the day, um I was the director of the spine tumor program at Mount Sinai. I had trained under one of the big old-school spine tumor surgeons um up in Boston. And we did operations that were this big. We would you would call them big back wax, you know, and that was the classic way of treating spine tumors. You got to put in a lot of hardware cuz you're taking a lot of bone out to get to the tumor.

Well, I I had one patient that actually did I had a beautiful operation. He didn't do well. I said, "There's got to be a better way than this." This is what I've been taught. This is what we do. And most people accept that 40% of spine tumor patients get major complication. 40% That's huge. So, I said, "There's got to be a better way." Went to the lab, figured it out. And we start we turned it from an incision this big to an incision this big.

And I realized that most of what we were doing in the spine tumor operation was replacing the normal tissue I had to take out to get to the tumor that was in the middle of the spine. And so, if I didn't have to go through it, I didn't have to take normal stuff out, I just went past it, I could get there, shell it out, just put a little cement in where the tumor used to be to keep it let it have stability, but leave all the normal structures intact, leave the ligaments, leave the muscle, leave the the normal bones, and just take out the tumor.

You make it sound so obvious.

Well, we wrote it up. The outcomes are actually better than big classic clunky old-school spine tumor surgery. But we get pushback. You get spine surgeons who are used to doing big, clunky, old school surgery. They don't want to hear there's a minimally invasive approach. They In fact, they used to get up on podium and I heard this many times at national meetings. There's no place in spine tumor surgery for minimally invasive approaches. Well, not if you don't know them.

But if you're willing to try and you follow the patients and you take the data and you honestly look at it and you see it actually is better, well, how can you argue with that?

Yeah, I I I think that's the key. I mean, we both see innovation in medicine in both directions.

Right.

Uh a lot of what we do in regenerative medicine is practiced very differently. You know, prolotherapy specifically.

We see that.

It's applied many different ways.

Stem cells.

Exactly.

There are people who use pen stem cells as panacea and then there are people who understand what stem cells can and cannot do

Yeah.

in in our current iteration. Do I believe stem cells are going to be the the greatest thing since sliced bread at some point? Yeah, I do. I think the the potential biology biologic solutions to many of our problems. But we ain't there yet.

Yeah, and it has to be rooted in understanding what you're actually fixing.

Yes.

Like what is it that you need to fix? Why? And are stem cells the best option for that? And if so, how do you apply them so they will actually get the job done? I mean, just to go off on a little tangent, we see hypermobility with meniscal tears, we see hypermobile hips with labral tears. And can PRP and stem cells heal labral tear? Absolutely. But why is that labral tear in the first place? Why is the meniscal tear in the first place?

If there's an unstable joint, that labrum's never really going to repair. And even if it does, it's going to re-tear. If there's a bony impingement, you're going to wear that labrum away right again. And you see it in the spine all the time, undiagnosed hip problems causing back pain.

Absolutely.

You know, I could do epidurals on those patients every 3 months for the rest of their life cuz they would need them if I don't treat their hips first.

Correct.

So, um yeah, understanding. So, if if we're looking at innovation in medicine and we're looking cuz anyone who treats hypermobility is on the edge of medicine. It's a little bit of the wild west. And there are a number of spine surgeons who each have their own recipe for tethered cord, for craniocervical instability, for uh a number of different issues. Um so, for patients, how can they know who's really on the right path? Who has the best idea?

Well, I think in in some ways you mentioned it earlier, there are support groups, right? There are So, for example, I actually participate. I don't advertise, but I do participate in a number of different patient support groups in Facebook. And probably I should get into Reddit, but I don't have I haven't done it yet. Um I don't get on TikTok. I'm barely on on Instagram.

We'll fix that.

But but I do spend a moderate amount of time on Facebook and and I'm primarily just in the support groups. Why am I there? Primarily to listen

Yeah.

and occasionally to give general advice. You'll never see me say, "Come to me, I can fix your problem." You'll hear me say, "You should find a surgeon who understands your problem. Sounds like you have XYZ problem, but you need to get a good workup to really understand it." I never say, but and and I think that has gives people the sense that I'm not advertising cuz I think that's tacky. I think that's wrong. And but I I do try to offer my advice and just help them to understand what choices they need to make.

And and many of them will look for somebody, just like I said, in their home network. And if they can find somebody in their home network, I get it. Not everybody wants to fly to New York to get a treatment. Yeah, they should, but they don't. Um

But so, looking for the approach to the solution rather than a direct solution.

So, partly it's looking for the approach, but also to a certain extent, they talk about the docs on these these networks. They hear about the problems they're having. I've heard about problems in my own office. I heard through some of these groups and and people who came to me privately after private conversations telling me when, you know, I was having, you know, problems with one of my administrative assistants or or something, that they weren't getting through, they weren't getting a This is great.

Thank you for letting me know. I don't I don't want that to be my representation. That's something we can fix. And by the same token, they hear about, you know, this is Dr. So-and-so, he completely gaslit me. This is Dr. So-and-so, he actually listened to me and even if he didn't understand the problem, he at least sent me to someone else who did. And so, you get a sense of who's who. Um but you also just have to always make sure that some of this is not bot-driven because there are also people who have their employees go on and and they're they're trying to feed a practice instead of feed the knowledge base.

So, for doctors who are innovative in medicine, how can the patient know if it's actually rigorous research or if it's just self-published, self-promoting uh middle of the New York uh post

Yeah.

style.

I I think to a certain extent, you want to look for who is viewed as the thought leader, but also who's actually doing the due diligence. So, case in point, I have my own research team. I've been doing research for years. I did it when I was full-time faculty at Mount Sinai. It was one of the reasons I loved being there as long as I was. But when it was no longer in my best interest to stay there, I brought I made my own research team and I've been doing continuous research ever since.

I have five summer interns this year who are helping me to collate and and process some of this data. If you don't have good data, you can't draw good conclusions. Whether that's a good exam, whether it's a good history, or whether it's having understanding what statistical test to do on the data you generated. And that's why everything I do I publish in PubMed you know, we've been PubMed peer-reviewed journals. We do all And so, you want to find somebody who's not just talking the talk, but actually walking the walk.

Um IMHO.

We appreciate that.

I think so.

Can you tell us about Bertolotti's syndrome?

I can. Poor Mario Bertolotti. Mario Bertolotti, he was an Italian anatomist and he made the first known association in 1917 between a congenital anomaly and patients with back pain. And it and it was well understood that these two were related, that you could get back pain from these Now, granted in the early 1900s, in the mid-1900s, they didn't have a lot of solutions for it, but they at least knew it was a real condition. In 1984, an article came out published by what was then a very junior inexperienced orthopedic surgeon wanted to get research he had done during his fellowship in the 70s published.

He didn't have any publications prior to that point and he wanted to get something published. He did publish a few things later on and he was generally well well believed to be a careful, thoughtful spine surgeon. And so, he published an article that said these congenital anomalies rarely have discarnations. He didn't call it discarnations, he called it epidural defects on myelography. And the reason he did the research was in the 70s, we didn't have MRI's. We couldn't look for discarnations.

So, they had to do a very painful, high-risk procedure called myelography. And they would put a needle into do a spinal tap. They would inject dye into the spine and most of that dye didn't go away ever. It stayed around forever. That was called Pantopaque. That's what they had in the 70s. And it stayed with you forever and it caused other problems. So, finding a way not to have to do that sounded like a good idea. And so, he did his study and he found that most patients who had transitional anatomy, which is what Bertolotti's syndrome is associated with, it's where the lumbar spine and the sacrum have a hybrid anatomy.

Most of the time lumbar spine five mobile vertebrae that all look pretty similar. Sacrum five vertebrae that all fuse together into a big triangle. All right? That's the cornerstone of the pelvis. Totally biomechanically different than the lumbar. And the transition is supposed to be very sharp. Lumbar vertebrae, sacral vertebrae. The two sit One sits on top of the other. In up to maybe a third of patients, that transition's a little bit hybridized. You might have one bone coming down, you might have one bone coming up.

They might meet in the middle. They might be rubbing against each other. That's Bertolotti's syndrome. When those the proximity. His anatomy was he just was measuring he wouldn't do something simple. He just measured the size of the transverse processes. And that was his only measurement. Did they touch? And if they didn't touch, how big were the transverse processes of of L5? What he wasn't looking at was how many times did S1 reach up? What was the size of the discs in all of these?

What were other changes that were associated with it? He didn't look at any of that. He was just looking at this one one anatomic feature. And he published an article saying most of them don't get these epidural defects, disc herniations. And that's not surprising because when you have bone rubbing against bone, there's not a lot of wear and tear. There's no reason to get a disc herniation. But because he did that and another orthopedic spine surgeon was on a personal vendetta to say that only disc herniations cause back pain, he took that article, told people disc herniations are the only cause of back pain and this congenital anomaly doesn't get disc herniations, therefore this doesn't cause back pain.

Now, we know there's a long list. You and I could sit down for a while and come up with that whole list of all the things that can cause back pain and disc herniations is only one of them. But he said no, just disc herniations cause back pain because I'm doing research on disc herniations, therefore what I'm doing is the most important thing. He never said it quite like that, but that's read between the lines, that's what it was.

get to review that article.

20 No, it was never published. 20 years later he finally admitted publicly we thought we knew what caused back pain. We were wrong. We didn't know then what we thought we knew and we don't know now. It was his mea culpa. It was his way of saying I'm sorry. I was wrong. But that I'm sorry I was wrong didn't get widely As as you know, accusations are on page one, retractions are on page 17. This was a page 17 kind of response.

And so literally 40 years of trainees have been told with no evidence whatsoever that congenital anomalies can't cause back pain because they had it their whole life. How could it cause back pain? But it's not that they had it their whole life. It's that it they had it and it was sort of stable. The scar was holding it together until something happened and it wasn't. And so Bertolotti's syndrome is where either the proximity is bumping bone against bone or bumping against bone and causing chemical irritation that irritates the nerve.

That's right. Or sometimes even pinching the nerve.

And so Bertolotti's syndrome is the is the congenital anomaly causing back pain, leg pain, groin pain, hip pain, or sacroiliac region pain. And I don't know how many patients have come to me with their SI joint fused, with their hip replaced, with their their L4-5 spine fused. And their symptoms never got better because nobody ever looked at because a bunch of people incorrectly told them or what I call the rogma, the wrong dogma of congenital anomalies can't cause back pain. Therefore, this isn't your pain generator.

We're not going to look at it. Well, we started looking at it. I listened to my patients. I said, "That doesn't make sense. Let's inject right there. Let's see what happens." And they're like, "I've had 15 injections. This is the first one that helped and it helped amazingly. Didn't last long. Can you make that permanent?" I'm like, "I think we can." And so that started our whole process and we we have a research protocol and we published multiple articles on the subject and I think I have two or three interns working on Bertolotti's alone just this summer.

On top of all the other projects that we have working on. One of my medical students won one of the awards at one of the recent big spine meetings for his work on the injection part of the diagnostic workup. Um it's really it's been very gratifying and the number of patients who we've been able to help who were gaslit, who were told there's nothing wrong with your back and sent to we fix it and they're like, well, actually I mean, seeing kids go off to actually play college uh sports who were sidelined, completely sidelined.

Seeing people get back on to becoming caregivers instead of being taken care of. Um, I mean, it's it's amazing to be able to see that and it's sad that 40 [snorts] years of roagma prevented that.

Yeah. Can you tell us about your surgical approach?

Oh, sure. So, I initially I did what most spine surgeons who were presented with this and are what we call Bertolotti curious. I I said, well, if the two bones are so close together, why don't we just shave them down? And we did that. Some patients did well. Some patients didn't do great. They may have done well and then their pain came back. They may have just never gotten better. And I went back and I looked at the data and we said, well, let's look at this.

It turns out that type two LSTVs and I reclassified them to talk about the proximity instead of just the Castellvi classification cuz it just didn't work. We actually published an article showing it doesn't work. You miss 70% of type ones and, you know, and there's two classifications that we created that were didn't even exist in his. So, we reclassified it using our our technique we realized the type ones do well with resection. The type twos they did better if you fuse them.

And and people said, well, fusion's bad. Fusion's bad. Don't do fusion. Well, that's what certain people will tell you, but as you know, fusion is not bad. Fusion is a tool. And a tool used for the wrong reason will be bad. A tool used for the right reason will be good.

Yeah.

If the Bertolotti's pain comes from bone-on-bone motion and they have this anomaly and they barely move. So, the type 2s, we've looked at this, they have 1 degree at most range of motion at that level, if that. And normal is 10 degrees in each direction. So, if they're not moving to begin with, doing a fusion at that level doesn't take away any range of motion, doesn't do anything but take away most of their pain and will give back the most. Never promise anybody all but takes away most of their pain without a significant increase in the risk of adjacent segment disease.

Cuz everybody says you do fusion, oh, the next level's going to break down. And so, we've actually looked at my series, I'm going to take it back for 1 second to get to the punchline. If I do a spinal fusion on a patient with otherwise normal, non-congenital, and uh weird anatomy, we do a one-level fusion on them, they have a 20% incidence of breaking down at the adjacent level and needing surgery of some kind at that next level. 20%. When we look and we didn't do this, other people in Europe did this, two large series of like 4,000 patients, there's about a 40% incidence of having a problem at the level above.

Just with that congenital number, not treatment designed, just they have a 40% probability of having that problem. So, if they're already predestined to have a problem at that level, you'd think that they would have an even higher risk of breaking down after a Bertolotti's fusion, it's like 5%. So, that you go from a 20% risk of fusing a normal level down to about a 5% of fusing a Bertolotti level. It tells me that that's really and I don't do prophylactic extra surgery on people for only a 5% risk of needing it.

Same thing with my arc with my thoracic disc series. So, there's a very special surgery location, you know, not using capital S's there, but a very special hospital published an article saying it was safe to do spinal fusions on thoracic disc patients. Now, most people in doing a lumbar disc take the disc out and they don't fuse. But, they started doing fusions routinely on thoracic disc because they showed it was pretty safe. There was about a 5% complication rate. In my series, we in all the many probably hundred plus thoracic discs I've done, there's only about a 5% incidence of needing to do a fusion.

So, that means 95% of my patients, if they went to somebody else, would have gotten a spinal fusion instead of just a discectomy. So, 100% of patients are getting a big operation and in my book, only 5% are getting a big operation and one 95% are getting small operation. Both of them have the same outcome. That assumes that they have the same outcome. They didn't talk about outcomes, they only talked about safety.

Yeah.

So, it is what it is. We were talking earlier about the challenges we face being on the cutting edge of medicine. And just today, I had a challenge. Not mentioning any names, but it was at a hospital that I treat and then work at fairly regularly. I had a patient come from out of state to get treated for crazy cervical instability and related complications. And there were people there who said, "Well, I don't understand this." So, I'm questioning the indication for this surgery.

So, actually, this patient came all the way up from Georgia

[clears throat]

and isn't getting her surgery because the hospital's questioning the indications without even actually speaking to me directly. This happened indirectly. So, when and I'm sure we see this with insurance companies, we see this with when they go get a second opinion from another doctor who doesn't understand this, that people who aren't keeping up with the latest in this particular field. I don't know whether it's they feel threatened by it or whether they just don't understand it and don't feel they need to try to understand it, but I don't like it when I see my patients care being delayed or redirected.

But I'm hopeful, not mentioning any names cuz I'm optimistic we'll get to a an equitable solution of this in in in due time, but I hate even delaying care for patients who are seriously ill and struggling and in many cases already being gaslit by other doctors. Now, it feels like I'm doing it to them even though my hands are literally tied because I'm not even allowed to put it on the OR schedule.

Yeah.

Just because somebody wants to have a discussion instead of saying, "Well, this Dr. Jenkins, he's been at this hospital for a long time. He's got great results. He's takes great care of people. He's got a great reputation.

And the credentials to do the procedure in question.

And have all the credentials to do the procedure in question. I'm sure we'll get there eventually, but right now it's just be it's frustrating being in that in-between.

Yeah. Any advice you have for patients?

Don't give up. Don't give up on yourself. It's um advocate. Um find somebody who will listen and will take care of you and will make sure that they are with you on the journey. It is a journey. And nobody has ever said that the the ideal journey is a straight narrow arrow. Sometimes it's the waviness of the journey that you learn things about yourself and other people, but as long as you get to your destination in the end, you just want to make sure somebody's going to help you get there.

Yeah, I say pain's like the stock market.

Mhm.

Ups and downs, but trends up.

If if you're in the right hands, trend is up. If you're not in the right hands, you you could be in a in a bear market and and and not see where the end is. But, you can at least get better advice and reposition your stock portfolio to then see some gains again.

We all learn from the journey.

We do.

I tell patients that if they want the most thorough workup, if they want every stone overturned, you're the best one to go to for that. Can you tell patients what you do offer in that respect?

Yeah, so we do telemedicine. I patients come to me from around the world. Obviously, this one came up from Georgia. I patients come from other countries cuz they can't get the care that they need locally. In some cases, we had Kaiser was actually ordered by the courts to pay my fee for one patient from out on the towards the left coast

Mhm.

[clears throat]

because nobody in their network could treat them. And it's we we spend time. I have a PA who often does the initial intake to make sure that all the data is there, orders the additional tests that I need at least to do my first initial consultation. Then we dive deep into the problems. We typically take about a half an hour for a for an initial consult. Sometimes we run over. I apologize if you're waiting for me to come on because I'm delayed by somebody else, but I always say, "I hope you'll forgive me and I will give you the same attention I gave the person before you."

And it's it's not it's not just talk. I I try to treat patients the way I want to be treated if the roles were reversed. Yeah. And so that's kind of been my guiding force and sometimes they can't get in to meet see me in person. I know some hospitals won't let their doctors do out of state telecom because they are afraid of the consequences. I do my best to provide care to every patient who wants to see me. Um there may be a fee involved in that, but I do think my time is worth paying for.

If you think my time's not worth paying for, well, then why would you want it in the first place?

Anything else you want to talk about?

No, I I just want to say um not only is it a pleasure to be here with you on this, but it has been a true pleasure interacting with you as a colleague, um as a trusted co-caregiver uh in the patients that we take care of, um and a co-investigator in the science of how do we provide the best care for our patients. So, um certainly I uh I'm I'm pleased to be part of this process here, but also pleased to be part of your network of treating doctors that you use to try to make all of our patients better.

I I could say the exact same. Thank you for joining us today. Thank you for your insights on all of these conditions, your approach, patient care, everything you do. So, what's the best way for patients to find you?

Um easiest thing is to uh jenkinsneurospine.com, my website. Um we do have obviously we have a presence on a number of the the patient uh Facebook groups, whether it be the Ehlers-Danlos Syndrome group, the just for hypermobility patients, the Berd- one of them several of the Berlotis uh Facebook support groups. Um we do have an Instagram channel. It's at jenkinsneurospine. Um I have X. If you want to follow me there, I'm also on LinkedIn. Um but uh and LinkedIn is under my full name Arthur L Arthur _L_Jenkins_III.

Um but that's much more for the professionals. Um it's where we talk about everything from what the insurance companies are doing to our patients to congratulating each other on you know, latest academic or publications or things like that. Um Or just come to the office. We have one office in Manhattan and one office in White Plains.

Thank you.

My pleasure. Thank you very much.

Thank you for joining us on another episode of Care Beyond the Pain. The pain journey is rarely a straight line.

To learn more about how to navigate it, you may visit our website manhattanpainmedicine.com or read our book Pain Answered found on Amazon. Until next time.