Episode Transcript
Welcome to Not Another TV Lawyer. I'm Chris Shaqib. I'm Jessica Hall. And this is a podcast sponsored by the law firm Terrell Hogan that's been in Jacksonville for greater than 50 years. And we are very passionate about helping people and personalizing our service to help them get the service they deserve.
Uh, once again, I'm Chris Shaqib with the podcast Not Another TV Lawyer. With me is Jessica Hall, and we've got, uh, a guest on today, Dr. Arkham, uh, Rahman, who is, currently practicing with the Jacksonville, Sunshine Spine and Pain, um, And he is, uh, double board certified medical doctor, uh, board certified in, um, physical medicine and rehabilitation, as well as pain management, and, uh, Dr.
Rahman, we appreciate you being here. Thank you. Thank you for having, having me here, Chris. Thank you, Jessica. So the purpose of this season of our podcast is to talk about issues that folks who have been involved in car accidents would find relevant, things that would be helpful to people who've been through car accidents.
And you're a physician, a medical doctor who practices in physical medicine and rehabilitation, as well as pain management. Um, what, uh, are Car accidents a large part of your practice? It's a very small part of my practice. Uh, you know, just a small percentage. Um, but, um, you know, it's part and parcel of what we do in physical medicine and rehab because, uh, we do muscular, skeletal, spine and disc and joint pain and soft tissue pain.
So it's part and part of everything what we do. All right, uh, now I understand you do minimally invasive type procedures, can you explain what that means? So there are, um, procedures that are much more invasive, uh, where, uh, you're putting in, uh, you know, cutting people up. and, uh, doing, uh, surgical, uh, operations with knives and suturing and things like that.
Whereas, uh, there are simpler procedures like, uh, from simple trigger point injections to joint injections to epidural and facet injections to nerve burning with needles. But going a step above, I do platelet rich plasma injections where your body's, uh, own growth factors help. for the patient's heal naturally.
I use bone marrow concentrate. Uh, so instead of like operating a disc with a open operation, you can actually put a needle in there, very thin needle, 25 gauge, and you can use the platelet rich plasma combined with the bone marrow concentrate to actually help stabilize or rejuvenate the discs so that it heals by itself.
If uh, the patient is a candidate for something a little more than that, then instead of spinal fusion with rods and screws or uh, basic um, uh, Open discectomy, I can put a little thicker needle there and actually take part of the core of the disc out to help decompress it and then cauterize and seal the edges of the disc, everything done through a needle, or I can put cylinders, uh, into the joints on the back of the spine that help prevent the slip forward and backward.
And instead of a spinal fusion, you can help the patient with that. So what do you call those procedures that you just described that would be as an alternative full blown spinal fusion? So, uh, you can call it, uh, uh, spinal fusion. There are two causes for that. One is, uh, disc related pain. One is instability.
For disc related spinal fusion, you replace it with percutaneous discectomy. So it can be endoscopic with a camera or without a camera, just with an X ray machine. And for these fusion where you're putting rods and screws because of spinal instability, you're replacing with something like ion fusion.
Now those are small cylinders you put in there with thin needles or. slightly thicker needles, but, uh, the same procedure has one version that is with rods and screws. One is just with the basic cylinders where nothing is left in there except those to stabilize the joints.
What's the recovery period for that type, those types of procedures? So the percutaneous discectomy and ion fusions are done under sedation and usually we're done in half an hour. Uh, for a single level, um, 15 minutes to half an hour based on, uh, what we are doing.
Patient should be able to go home in about an hour, hour and a half from the outpatient surgery center. They use a back place for a little bit, but most of the time we send them home on two or three days worth of medications. either pain medications or simply Tylenol and Aleve. And in three to five days tops, the needle pain is gone.
And majority of the time, most of the patients report improvement, significant improvement in discogenic pain, which you cannot even imagine with a proper open surgery or with a fusion surgery. Well, that's quite, that's quite a contrast to a traditional fusion procedure. you know, we're talking about someone who has a problem with a disc or instability, where they put them under general anesthesia, there's a long surgery, typically in a hospital, they are inpatient, and, uh, the recovery period is, is, you know, not overnight.
Jessica probably knows more about that. than most people would. Yeah, I am scheduled for a uh, laminectomy in a couple of months, but I've already had a ACDF surgery, anterior cervical disfusion surgery, on C6 and C7. And I had that procedure last year, and I still find deficits when I'm doing things that I thought would improve.
So, I think, uh, I think if people are considering surgery, they really need to look at all possible options, such as alternative methods that you described? Of course, uh, there are different candidates for different surgeries. So, with the advantage of the, um, percutaneous discectomy as opposed to a lumbar fusion for discogenic pain, is that there is, the disc still maintains the movement, There is nothing stopping it from moving so the adjacent segment degeneration doesn't happen.
However, if the disc, such as a cervical disc, uh, in the neck has dried out and collapsed enough, then the holes on the side, they have narrowed down significantly. Because of that, they are pinching the nerves that are coming out and supplying the arms. So, unless If there is, there is symptom of pain going into the arms, usually most of the pain will be from the facet joints and you can do a diagnostic block and if it is useful.
In that case, uh, for example, legal insurance covers, uh, us to do platelet rich plasma and the A2M peptide plasma concentrate injection there. Your body can heal itself amazingly. What kind of, uh, I didn't mean to interrupt you, but what kind of workup do you do when a new patient comes to your office and they say, Hey, I've been in a car accident.
Yeah. Yeah. What can they expect if they come to your office? Well, it all depends from patient to patient. X rays are invaluable. With my time with Hemshaw Orthopedics when I worked three and a half years in Massachusetts, X rays are the most important starting point, and looking at them with your eyes is the critical thing.
Because there is so much that the X rays tell you, and then beyond that, based on the patient to patient, Ideally, MRI or CT scan, if MRI cannot be done and based on what we're looking for. So, MRI scan is good, but the critical thing is to be able to see things with your own eyes, not rely on radiologists, because just like you cannot have a neurosurgeon operate on your brain without looking at the films himself, same thing here because there's so many.
Subtle things in the spine, you really have to look at it and figure out what you're dealing with combined with the patient's history and exam findings to have a full picture of this is what the patient has. These are the structures that are causing the pain. Pain usually never travels alone. If something is bad enough to affect the disc, it would have been bad enough.
Starting with the lower back to impact the facet joints, possibly some ligaments, and definitely, in most cases, some variation of sacroiliac joint. So you have three pain generators in there. In the neck, it is commonly the, the discs, commonly discogenic pain travels with the facet joint pain, but if there is a significant whiplash injury with flexion extension, it can rupture the ligaments on the back called interspinous ligaments.
ligaments which are really easy to diagnose with local palpation and a simple anesthetic block that improves the pain and you know they're involved. And then between standard injections to regenerative, rejuvenative injections with the platelet rich plasma, most of them can heal. Okay. So, we've covered a lot of top, uh, a lot of, uh, words that some people may not understand.
Um, so let's start with the disk. What's a disk? A disk is a liquid jelly cartilage core, to put it in simple words, uh, sealed by a core In the lower back, 100 plus layers of ligament that seal the jelly inside. That's a cushion between square blocks of vertebra, so we can bend forward, backward, and to the sides.
Sometimes we develop weakness of the ligaments, etc., that make the segment slide forward and backward, which is not natural. But the disc, the texture of the jelly or the cartilage core is like the cartilage of the ear, and those small globules of, like, cartilage are stuck together by here, like, of fibrin.
fibers. So that is the disc, which is the gel cushion core. In the neck, the gel is smaller and the seal around it is incomplete. But, uh, that is in general the structure and the disc, if the ligaments on the back with accident, bending forward, falling, this, that, moving, lifting, uh, the ligaments stretch out and slowly start to leak.
Half the people start to get some pain. from the either biomechanical pressure from the bulging disc onto the nerves, you know how the disc pinches the nerve, or people might have chemical inflammatory pain because of, let's put it in simple words, acid and chemicals leaking out from the disc. The contents of the disc can be inflammatory.
So either biomechanical pushing or chemical irritation, we start to get pain. But the curious thing is, Half the people with a bulging herniated disc usually have pain from it and the other half don't and relating to the car accident, Chris, what happens is a person may have a completely totally unchanged MRI that was done the day before the accident to a week after the accident, yet the person's disc may be painful now.
We don't fully understand how it happens, but it is something that happens, uh, and, uh, you know, then suddenly you have to treat it. Right. I, I can't say. How many times I've kind of had that experience where the patient will be sent for an MRI, the patient is having pain, and the MRI is kind of inconclusive, but the symptoms are not inconclusive.
They, they're pretty clear. And that seems to be something that just happens. It's, you know, Folks are always hoping that, you know, that it's exact when they get an MRI and it will show everything. Is that really what happens in practice? Uh, right. The expectations are that MRI is going to show me what I have, but, you know, clinically The structures that are causing the pain are already talking to us.
You listen to the patient, you know, this is not absolute. There is a flow, things flow into each other. But a disc will typically cause much more pain in the lower back with sitting and driving. Discogenic pain is usually more in the core central area or veered off to the side. We're not talking about sciatica, which is disc and or nerve pinch.
from the arthritis or disc combined. So disc will usually cause more pain sitting and driving. That's a very simple giveaway for that. If a disc is unstable, it'll cause pain with standing, walking, sleeping, etc., whatever. But sitting and driving half an hour plus is a disc that's asking for help. Okay. So another term you used was facet joints.
And I, I know a lot of people talk about discs, but I, I know that when I first started handling auto accidents many years ago, uh, facet joints was something I hadn't heard before. Can you explain what that is? These are joints on the back of the spine. They which form from a lower projection from two vertebral bodies where the bones that are coming towards each other they prevent you from bending back too much or looking up or side bending too much.
So based on where you are in the spine. So facet joints can be injured easily in car accidents and actually In, uh, multiple car accidents, uh, we have seen on people that passed away that there might be micro fractures in the facet joints, particularly facet or facets, uh, in the upper cervical spine, et cetera.
So these joints usually cause pain across the neck. mid back, lower back area, and the curious thing is whenever we have, and that pain typically in the lower back increases with bending backward and backward to the sides, in the neck it increases with looking up or bending the neck to the side. But the fun thing that happens in spine is that as people develop these, uh, facet joint pain or disc pain, we tighten up the muscles on the back of the spine.
to stabilize, uh, to prevent us possibly from moving so much so we won't injure ourselves. When these muscles on the back of the spine become tight, there are nerves that are supplying just the back two, three inches or four inches of the backside of the spine. skin, et cetera, and the dorsal ramus, they can be pinched and then we get numbness, tingling or burning all over the spine, whether it's in the neck, mid back, lower back, which comes from muscle spasm with the dorsal ramus irritation, so.
Okay, so the, would that also include sometimes radiating, uh, I know we have numbness and radiating pains. That is very true. Facet joint pain can be just across the spine or it has been documented that many patients get radiating pain down the leg or legs or into the arms with facet joints. particularly the upper cervical facets are very important.
These are, uh, implicated in causing headaches. So if we get headaches right at the base of the head in the occipital area, and so the one, two, three, four facet joints are known to cause, uh, headaches also, which can be very tricky and difficult to treat. Facet joints. Joints. Diagnosing a problem with, you know, some kind of trauma to the facet joint from a car accident.
Uh, is that something that will always be visible in an x ray? No. Uh, a young person, we will, x rays should generally be negative unless there is some significant, uh, trauma to the spine and it's unstable or a fracture or something else. It is usually a clinical diagnosis, uh, where you examine the patient, which patient has pain across the back or are mixed pain from multiple structures and then you simply put anesthetic x ray guided injections where you put anesthetic with or without some steroid into the joints or onto the nerve that supplies the facet joints and we will have the patient get up and say, Oh my God, I feel so much better.
Right. So because I've had clients who the diagnosis of a facet injury, came after x rays seemed to be negative, after even MRI was negative, but they have the clinical findings that, you know, that suggest something and then they do exactly what you described and it's, it's identified as a facet injury.
One thing I should add, and based on my life experience, what I see is, you know, facet joint injury may not be there. On the x rays in the young or old people, as we get older, we'll have arthritis in the facets naturally. But um, as we get older, usually, in my experience, the pain becomes more biomechanical because the discs tend to be less of pain generators as we start to get into our, uh, 50s or especially higher up into our 60s and 70s.
The younger we are, the, it doesn't mean that they're not going to have facet joint pain, but the disc becomes. a bigger and bigger part of the paint picture. Okay. Is that because as we get older, the discs start losing their volume. They start desiccating, they're getting, what, drying out and shortening because there's less fluid in there, or?
So there, there'll be a lot of factors, Chris, but, uh, what happens as we get older is, number one, we develop arthritis of the facet joints. So, uh, they're more prone to injury because like a knee arthritis, you know, we may develop arthritis for 30 years and now 30 years and one day suddenly it starts to hurt.
Same thing. The facets are, Developing arthritis as you get older and the arthritis, which is rough, is easy to irritate with a car accident trauma. So maybe that's one of the reasons. And, uh, the other reason for the disc is that as we start to develop arthritis somewhere, et cetera, things become, uh, Less mobile, we become tighter and tighter, the discs, like you said, are more degenerative in older age, so, um, and they're drying out, maybe their chemical composition also changes somewhat, so with a stiffening spine, maybe the trauma to the disc is also less, the remainder of the disc, and facets are more, um, easy to irritate, so maybe that's why.
So, switching gears, uh, talking about more big picture, um, How do patients typically come to you? Are they coming to you at immediately after the, uh, an accident or if they're, if it, if they've been in an accident or do they come to you as referrals from other physicians? What's the normal way that, patients come to you?
Uh, majority of the time, patients will, uh, just come to me from their primary care doctor who knows me and has been sending me some patients for, um, interventional, uh, pain care. So, uh, if they have an accident case, they'll say, Dr. Aman, um, you know, they'll send their follow up to us. Other than that, many times, they'll Uh, my own patients, existing patients, if they get involved or someone else they know gets involved, they'll say, you know, why don't you call Dr.
Rahman and go and see them. And, um, sometimes, you know, some other, uh, chiropractic physicians or other people that know me, they will refer me patients. And in, uh, some cases it might, uh, come, um, from, um, Uh, a law office if they think that, uh, I've done a great job in helping people. So it can be multiple ways I may get a referral.
All right. So some of the ways you, you get patients are referrals from other physicians who are sending them to you as kind of a specialist or not kind of a specialist, a specialist. And then, uh, other ways, other times that can be the patients come to directly for their initial care. Correct. All right.
And what, what are the things you're looking for, say, for a patient who comes to you and you're the first physician he or she has seen? What, what are you, what are you looking for in someone when they say, I've been in a car accident and I'm, I'm in pain? What's the normal process? So, um, when I see the patient, depends how soon they've seen me, immediately after the car accidents, uh, if they're needing something, I'll say simply take Tylenol.
Why? Because Tylenol is an analgesic. It'll help some with pain, but according to one school of thought, if you let the body have some inflammatory reaction, in that case, that promotes the healing. Just like with the platelet rich plasma, the, red blood cell poor or leukocyte poor, if I put it that way.
Leukocyte poor platelet rich plasma doesn't cause inflammatory reaction, but we are beginning to see that the more inflammatory, what we call a little bit bloody or leukocyte rich PRP, seems to help more. So we let them have an inflammatory reaction for a week or two, and then we say, okay, now going on to anti inflammatories.
Ibuprofen, Aleve or the other ones are good. During this time, as long as there's no red flag that the patient has suffered a major major trauma, uh, we will get x rays and, uh, if one area is significantly hurt, we will get an MRI in that case. If there is any indication of brain injury, getting an early MRI is important to be able to, with special protocol, it'll be important to have it to compare in future, but, um, Start them on rehab.
So, some kind of anti inflammatories, starting on rehab, doing a basic workup and seeing what is not improving, or if there is a red flag somewhere, do an MRI there, and see how it is. If there is one area of their body that is, shoulder is particularly bad, in that case you try to do a short acting steroid injection.
It's like throwing a bucket of water on the fire. Why mess up the system with a four month steroid when you can throw a bucket of water, bucket of water on the fire and maybe the fire goes out. So if that simple injection helps them participate in therapy better and with a quality of life or be able to sleep better so they can heal better.
You do something like that and let. The team work on them with rehabilitation, etc. If there is a problem, something is not getting better, then you go on and start to do the next level treatment, uh, whatever is needed. Okay. In your practice, do you only take, uh, health insurance, or do you also take Uh, personal injury protection through the auto carrier or what, uh, what kind of insurance does your practice accept?
I'm on pretty much all the major insurance panels, Medicare, Blue Cross, United, Aetna, Humana, et cetera, Cigna, I'm in network tri care, Cigna, I'm in network provider for all of them. And we also accept, uh, the, uh, car accident insurance patients. All right. So it sounds like you. take just any type of, almost any type of insurance that would be available.
Correct. Okay. Now you talked about PRP, platelet rich plasma, and I've heard a lot about that over the past, I don't know, five, five or six years. Um, it seems to be something that they're using in a lot of different things. I've heard of it used for, and don't, Jessica don't say that this has any relation to me, but for people with hair loss, have talked about it.
Um, I've heard it used there. I've heard it for people with issues with their knees or their ankles and or just a lot of different places for people who may not know what it is. Could you just briefly explain what what it is? So we're blessed with Incredible, God has blessed us with incredible healing powers of healing within our own body.
While it is not like liver that can regenerate so much of itself, but our blood plasma has growth factors that help us heal. So the platelets are the ones that cause the blood to clot. And they have healing properties. the signaling agents that bring on, bring in the repair cells, fibroblasts, your own stem cells, to put it in simple terms, to come and repair the local area.
So, except for smokers where PRP is usually, not a good idea because they don't heal very well, um, we can take a person's blood, a certain amount, uh, 30, 60 cc's, whatever it may be, spin it up to get the, uh, platelet concentrate portion of the yellow plasmas with a centrifuge.
If we spin the blood for a certain protocol, the red blood cells settle down. We have the plasma left over the bottom of the plasma has the platelet concentrate. If we take that and we can inject, for example, the the ligaments or the joints, uh, shoulder, hip, knee or the spinal facet joints. Even the discs, you know, Dr.
one of our pioneers of our field, Dr. Gregory Lutz in Hospital for Special Surgery in New York, around 2001 to injected, uh, multiple patients discs with platelet rich plasma. And he saw there I think about remarkable two thirds or more improvement in pain and majority of the patients saw significant improvement in pain with rare exception without surgery.
So we can do it now in spine, joints, soft tissue, hair loss, uh, sexual wellness, uh, Uh, aesthetics, uh, face, facial rejuvenation, we originally started to do it for tendo atlas tear, we know Kobe Bryant did that, uh, skin grafting, it helps it graft because these are your own growth factors.
So many applications, even with NAION, the semiglutide related vision loss, there is some study going on that PRP might be able to help with regaining the vision back. Goodness. It, and what's amazing is you're basically, uh, trying to heal yourself with yourself, with your own blood, or the components of your own blood, uh, which to me is the thing that always surprises me because, you know, and you've got pharmaceuticals that are Things that typically have side effects, and then there's surgery which can have complications.
But being treated with your own blood, uh, are there any complications typically associated with PRP? Ah, none that I know of. And, um, the fun thing is that there was just a study out in the UK recently where for lumbar epidural injections, People have done platelet rich plasma, plate, uh, lysate, and epidural injections.
But in the UK they saw that, uh, by doing, uh, PRP epidurals, the effects were even better than steroids, uh, for the duration of the study. So they were very impressive. Yeah. And it, you know, How long has PRP been available? I think must have been around minimum 40 years or more because when I started to work at Hampshire Orthopaedics in 1999, it was already an established thing where some of the advanced practitioners were healing their tendoacle stairs and, uh, et cetera with platelet rich plasma injections.
Wow. if someone listening to this wanted to get in touch with you and become your patient, what would be the best way for them to contact you? very simple. Either call the office at, uh, (904) 651-8206 or simply go to sunshine spine.com and send us a message or, uh, try to book an appointment.
Okay. Well, Dr. Rahman, I really appreciate you being a guest on our podcast, Not Another TV Lawyer.
It's my pleasure. Thank you so much for having me,
Thanks again for listening to Not Another TV Lawyer. We hope that you will tune in to the next episode. Not Another TV Lawyer is sponsored by my law firm, Terrell Hogan Law. Terrell Hogan represents people in a lot of different areas of injury type law, as well as business claims throughout the state of Florida.
We represent people in auto accidents, trip and falls, people who have been exposed to asbestos and developed conditions related to that. Victims of medical negligence, victims of defective products, including medical devices and pharmaceuticals. Please feel free to look us up at www. terrelhogan. com. We look forward to hearing and being with you soon.
