Spine Talk w/ Dr. Usman Zahir

Episode Information

June 2, 2021

Spine Surgeon Dr. Usman Zahir talks about his childhood in Maryland, studying archaeology in college, the uses of endoscopic spine surgery, the importance of flexibility, and more.

Topics Include:

• His childhood in Baltimore, Maryland
• His fascination with archaeology in his youth
• Endoscopic spine surgery in-depth
• Laminectomy, explained
• How endoscopic surgery helps combat the opioid crisis
• The most common causes of spinal damage
• The benefits of chiropractic treatments
• Why being in shape is crucial to preventing spine injury
• How nerve damage is prevented during surgery
• Up-and-coming developments in spinal research
• Dr. Zahir’s recommendations for his patients
• Why Doctorpedia appeals to him
• What he does to stay healthy

Highlights

• “Even if you’re a physician, you can’t hide behind something. I mean, you’re really out there. And, you’re taking care of your fellow human beings. So I think [medicine] was just a wonderful way in my mind to live a kind of productive life where I was engaged with the community at large.”
• “If you’re going through a less invasive approach, oftentimes these patients don’t need [opioid] pain medicines. They may be fine with just Tylenol after the operation, instead of a Percocet.”
• “A lot of the people who come in with back problems are oftentimes bodybuilders or weightlifters, and they’re doing very heavy deadlifts or heavy squats with very heavy weights. And these are just exercises where if you’re lifting those kinds of weights, your posture needs to be perfect when you’re doing the routine.”
• “Part of what we do as a physician, as a surgeon, is educating these kinds of athletes about proper lifting techniques and just being aware that there are just certain routines that put them at a very high risk for developing serious back injuries.”
• “I think chiropractors definitely have a major role in helping people with back problems for sure. There’ve been many research studies that have looked at chiropractic treatments, physical therapy, even massage. It does offer benefits. It definitely does.”
• “A lot of my patients are people who are doing a lot of sedentary work. And especially with coronavirus, so many people work from home, and we’ll test them. We’ll check them in the office and [they have] extremely tight hamstrings. And that person’s actually complaining about back pain. I’ll put that same patient in physical therapy and they’ll get therapy to treat their hamstrings and stretching out all these other joints. And guess what, their back pain gets better.”
• “There’s a lot of research going on right now with stem cells, and looking at ways of treating spinal cord injuries by targeted treatments in that.”
• “I think what Doctorpedia can do is really provide a framework that is being provided by board certified physicians, and it creates a sense of trust. And I think having a kind of platform that is standardized, that is trusted, validated, and extremely transparent, I think it will be a very comfortable and safe place for patients to get their medical information from.”

Relevant Links

• Doctorpedia Spotlight Interview
• Dr. Zahir’s Website

Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

Daniel Lobell: (00:25)
Hello, and welcome to the Doctorpedia podcast. I’m your host Daniel Lobell and I’m honored to be joined on the line today by Dr. Usman Zahir here. Dr. Zahir, how are you today?

Dr. Usman Zahir: (00:37)
I’m doing great. Thank you. How are you doing?

Daniel Lobell: (00:40)
Not too bad. I can’t complain. So I’m excited to get into what you do, but I like to start at the beginning with the doctors and ask a little bit about your background. Where did you grow up?

Dr. Usman Zahir: (00:50)
Yeah, so I was born in New Jersey, but at the ripe old age of one, my parents moved to Maryland and primarily it was because my dad was looking for a place for some more open space. And so I pretty much grew up in Maryland. Went to school there, all my undergraduate, medical school, residency fellowship, everything in Maryland. And even from a career perspective, everything within Maryland and then the DC metropolitan region.

Daniel Lobell: (01:20)
My wife is from Baltimore. So I’m a no stranger to Maryland whenever we go back to see her family.

Dr. Usman Zahir: (01:28)
Yeah, I was in Baltimore for about 10 years, because I did my medical school and my residency and my fellowship there. So pretty much from 2002 to 2012, I was in Baltimore, so very familiar with it and, right in the inner harbor, not too far from the aquarium.

Daniel Lobell: (01:48)
Oh, the inner harbor, that’s where my wife always jokes about the bodies floating.

Dr. Usman Zahir: (01:52)
[Daniel chuckles] Yeah… Baltimore unfortunately does have a bit of a bad reputation when it comes to that, but there are clearly parts of it that are really nice. They’ve tried their best to revamp the city and, it was a good time. It was a good 10 years.

Daniel Lobell: (02:11)
That aquarium that you brought up is actually a very impressive aquarium. I love aquariums and that’s one of the best I’ve been to.

Dr. Usman Zahir: (02:18)
Yeah. No, it’s nice. It’s a big tourist attraction for the city, for sure. And there are a few other places, I mean, there’s some decent restaurants in Baltimore, and of course the sports stadiums, there’s a lot of athletic type activities.

Daniel Lobell: (02:34)
It’s a city with a lot of charm, for sure. I think, despite all of the issues, it’s a charming place.

Dr. Usman Zahir: (02:42)
Yeah. It’s had its challenges, which is the case of most large cities, but in Baltimore, sometimes some of these things are a little more magnified specifically with the crime and when you’re working at a large academic hospital, you need to see some of the effects of that. The kind of injuries that come into the hospital. And the hospital was definitely engaged in a lot of efforts to kind of address some of those things, but it’s definitely been a challenge.

Daniel Lobell: (03:16)
So your name is not a typical name that I’ve heard very much. Usman. Are your parents immigrants or where does that name come from?

Dr. Usman Zahir: (03:26)
Yeah, so my parents are from Pakistan. My father came to this country in the mid 1970s. He settled in New York in the New Jersey area. And that’s where he did his residency. So he was here for a few years and then he moved to Maryland. But yeah, Pakistani background.

Daniel Lobell: (03:46)
So your dad’s a doctor and your mom, was she also involved in medicine?

Dr. Usman Zahir: (03:51)
No. My father was a physician. My mom, she would stay at home. She was a homemaker. But my uncle and my dad both were physicians and they both were kind of together up in New Jersey and New York when they first immigrated to the US. But they decided to stay together. So they actually moved to Maryland together. My dad was here without any kind of family. And so when my uncle came, they kind of just stayed together. And that’s oftentimes the case with new immigrants, just trying to keep a kind of a core group for support. And it definitely was helpful. So I grew up pretty much with my cousins. It was a unique type of a setting, which many Americans may not be totally familiar with, but I grew up in the same house with my cousins for about 10 years.

Daniel Lobell: (04:44)
It sounds fun to me. Did you have a good time?

Dr. Usman Zahir: (04:47)
It was awesome. I mean, for me, it was a great time. Because I had my own brother and my own sister and I had three other cousins. So I mean, that whole house was just full of activities. I mean, it drove probably our parents crazy. I mean, it was pretty cute. It was so fun. It was a lot of fun.

Daniel Lobell: (05:09)
Maybe not as fun for them, but definitely for the kids.

Dr. Usman Zahir: (05:12)
Yeah. Yeah. It was a lot of fun.

Daniel Lobell: (05:17)
Was it when you were a kid that you decided you also wanted to go into medicine or did that come later in life?

Dr. Usman Zahir: (05:25)
So it’s actually a good question because in most South Asian families, there’s this sort of stereotype that if your father’s a physician or your mom’s a physician, they’re going to kind of force you to become a physician as well, or a lawyer or whatever it might be. But my parents had a very hands-on, hands-off approach. I mean, they clearly were all about academics, they wanted us to do well in school. But they really kept a very open mind. They were like, “When you go to college, make sure you explore everything, because you only live once and you don’t want to have regrets with going in a certain type of field. Because either your father is like this and if you don’t like it, you’re gonna be miserable.”

Daniel Lobell: (06:05)
Right.

Dr. Usman Zahir: (06:05)
So when I was in high school and going into college, I mean, I had a lot of interests. I had an interest in history, archeology, business, finance, art as well. And so when I was in college, I tried to expand into all those interests as much as I could. So if there was a topic that I was interested in, I was like, let me do a little internship in it. Let me see what the practical day-to-day work is in that particular thing and see if I like it. So I always had an interest in medicine. So I was a pre-med major, but I almost did a minor in history. I did an archeological project for about a year. The University of Maryland had a research project with a city that was based in Israel.

Dr. Usman Zahir: (06:54)
Caesarea. And it’s a historical city in the sense that it was developed during the Roman period under King Herod. So it was just a very interesting research project because you’ve got a city that had a lot of firsts from that region. It had its own artificial kind of harbor that was built about 2000 years ago. And it was just a very phenomenal project. So I was with that project for almost a year and a half during my undergrad period. So it was just a nice chance to kind of explore working with some historians and archeologists. So that was kind of fun, but I had an interest in business and —

Daniel Lobell: (07:36)
You could have been Indiana Jones!

Dr. Usman Zahir: (07:39)
Well, that was the whole problem. I mean, growing up as a kid and you’re watching Indiana Jones. I was fascinated by that and every kid has this sort of fantasy about like digging for treasure or finding a treasure chest or something like that. So I always had that sort of an interest. So I did that, did a lot of stuff at business as well when I was in college. I had an interest in the stock market. So I started day trading when I was in college. That was something that I did on the side. I’ve always been kind of a curious George. If there was anything that I didn’t understand, or I didn’t know about, I wanted to learn about it. So I was like a sponge, you know? And so those four years of college I think were very helpful in exploring all my interests. But at the end of the day, I did decide just to do medicine.

Daniel Lobell: (08:32)
So what was it about medicine that ultimately attracted you to it?

Dr. Usman Zahir: (08:37)
Well, there are a few things. Number one, it’s one of those fields where I felt it would help me from a personality perspective. I was a very shy kid growing up, but at the same time, I wanted to be engaged in the community at large. So this is like one where it was actually helpful for me to get out of my shell. Because even if you’re a physician, you can’t hide behind something. I mean, you’re really out there. And, you’re taking care of your fellow human beings. So I think that was just a wonderful way in my mind to live a kind of productive life where I was engaged with the community at large. So that was one main reason. And the second thing was, it’s a very fascinating type of profession in the sense that people trust you to take care of them, to help them through whatever process they might have.

Dr. Usman Zahir: (09:31)
And it’s also a very challenging field in the sense that even though we’re kind of slow to adapting to technology, there’s still lots of innovation that are occurring within medicine. And I think the opportunity to grow and learn throughout your entire medical career was very appealing to me. Medicine is one of those things where if you don’t continue to learn, you stagnate. So I think for someone like myself who was interested in learning new things, it really offers the opportunity to just continue to grow throughout your professional career. And I was always worried about monotony. I really had a concern that I’d be doing the same thing every day and I’d get bored.

Daniel Lobell: (10:19)
I can relate to that. I’ve dictated a lot of the decisions in my life. I can’t stand the idea of being trapped in a routine.

Dr. Usman Zahir: (10:29)
Right. And so that was a fear. That was a big fear that I had. Being in a kind of profession where you’re seeing different people every day with their own life story and their own challenges. The core concepts are always the same, but everyone’s story is like a unique situation. And so to adapt to that, to troubleshoot, to problem solve, it’s a very engaging way to work. So I found that very appealing.

Daniel Lobell: (11:00)
Yeah. I can totally understand where that came from and why. I think if I was halfway decent at science, I might have wound up in the same boat, but I think that’s a prerequisite. I did have a lot of fun researching you. And I think you’re the very first spinal surgeon that I’m going to be talking to. So I have a lot of questions.

Dr. Usman Zahir: (11:28)
Yeah, absolutely.

Daniel Lobell: (11:29)
So you’re a board certified orthopedic spinal surgeon, is that correct?

Dr. Usman Zahir: (11:34)
Correct.

Daniel Lobell: (11:35)
And you also specialize in something called endoscopic spine surgery. I read a little bit about it, but I’d rather, than stumble through my understanding, let you tell people what that is.

Dr. Usman Zahir: (11:48)
Yeah. So endoscopic spine surgery is — so first of all, I’m an orthopedic surgeon and I’ve specialized in spine surgery. Endoscopic spine surgery is a specific way to do spinal surgery using very small tools. So, one of the — I don’t want to say the bad reps that spine surgery gets is that our surgeries are oftentimes very painful. All right. Traditionally, we think of large scoliosis surgeries where we’re putting large rods and screws in the spine. There’s just a lot of hardware.

Daniel Lobell: (12:21)
Is that also because there’s so many nerve endings in the spinal cord?

Dr. Usman Zahir: (12:25)
Well, that’s part of it. The other thing is there’s multiple levels. So our spine is made up of multiple joints. So for instance, we only have two hips.

Dr. Usman Zahir: (12:37)
We have two knees, but with our spine, we have multiple joints. In the lumbar spine, we have five more major bones. In the thoracic spine, we have 12. In the cervical spine, we have seven. So it’s almost like seven, 12, all of these individual joints, they’re all kind of independent, that are linked together. So someone has a problem in their spine that involves multiple levels, it’s going to be a larger type of operation because you’re dealing with more joints. And therefore it can be more painful. It can be more painful because you’re basically crossing several levels in the spine. And so you’ve got a spine, which is a structure that’s very mobile generally, and we sometimes have to do procedures where we have to stiffen it up.

Dr. Usman Zahir: (13:22)
So we’re kind of changing the normal parameters that our spine wants to operate on. And that can be a very painful process for many patients.

Daniel Lobell: (13:31)
And when you’re stiffening it up, is that because the movement is prohibiting it from healing properly? Is that what’s going on there?

Dr. Usman Zahir: (13:38)
Yeah. So the kind of traditional surgery patients have is a spinal fusion. And typically what happens in that is you have individual joints in the spine that have worn out and they’re no longer functioning. Some of them might be slipping out of place, which causes pain, because when those joints slip out of position, they’ll press on nerves. And so people will feel leg pain in the process. So basically in some of our surgeries we’re actually stiffening up the spine to prevent it from slipping any more. And in return by doing that, we’re helping them with their leg pain.

Dr. Usman Zahir: (14:14)
So it’s kind of like we’re doing something negative to the spine in the sense that we’re reducing its motion, but the consequence of that is we’re actually helping them with their pain in a way. But that process can be painful for the patient because it can be, it can be a fairly large operation. Now, going back to what you mentioned about endoscopic, endoscopics is oftentimes a non fusion approach, although there are some endoscopic fusions that one can do. It’s a non fusion approach to help patients who have back and leg pain. And instead of making a large incision, we’re putting a tiny camera in the spine to do the surgery, small little scope. So most people are familiar with arthroscopic surgery. Because they may have had a friend or a family member who had a knee problem.

Dr. Usman Zahir: (15:04)
And the doctor went in with a little camera and arthroscope, and they went and just kind of fixed the issue. Okay. Arthroscopes are in different surgeries, they’re in the shoulder. And even urologists have scopes that they use to treat bladder issues. General surgeons use scopes for issues with the belly. You may have heard of people going and getting their gallbladder taken out, and they’re just making small little stab incisions in the belly and they’ll go in and do it. So I think most people in the general public are familiar with scopes, small little tools to do surgery, but in spine surgery, it’s only been until recently that it’s been accepted as a way of doing spinal procedures.

Daniel Lobell: (15:48)
Why is that?

Dr. Usman Zahir: (15:49)
In Europe and Asia. Part of it was because of the technology aspect of it. Some of the tools were not fine enough to do the procedures, or the visualization, the cameras weren’t strong enough. And the spine is different from other joints in the sense that most of the time when you’re doing a scope type procedure, we’re either pumping air in the camera to create space or we’re pumping fluid in to see things. The spine is very delicate. If you’re pumping fluid in the spine, you worry about causing injuries with that. So pumping fluid in the knee joint is a lot different than pumping fluid in the spinal space. You could create some issues. So I think over the years, people have kind of fine tuned some of the instrumentation and the safety profile. And in Asia and Europe, they’ve been doing it for quite some time. And in the US, up until 2017, for instance, Medicare was not approving the procedure. And so now it’s actually approved by Medicare as a reimbursable procedure. And so the way things work in the US sometimes is like, until you get paid for it, people don’t do the procedure.

Daniel Lobell: (17:06)
Right.

Dr. Usman Zahir: (17:07)
The technology has been there for a while, though. It’s been there for a while though.

Daniel Lobell: (17:10)
But I read that you’re one of the few that does do it, I guess. Are the other spine surgeons too spineless to try to try and do this? How does it work? Why are you one of the only ones?

Dr. Usman Zahir: (17:23)
Yeah. So at least in the area that I’m in, in the Maryland Virginia region, like in Virginia, I was the first one to do an endoscopic laminectomy in 2017, using some of the new tools that were available.

Daniel Lobell: (17:36)
What is a laminectomy? Is that what we’re talking about?

Dr. Usman Zahir: (17:41)
Yeah. So a laminectomy is basically a procedure where you go in the spine and you’re moving bone spurs that have narrowed the spine and are basically pressing on nerves. So the way our spine works is that we have these tunnels through which nerves are passing through. And as long as those tunnels are open, our legs are fine because the nerves are not being compressed. But when we start developing arthritis or bone spurs, it narrows the spinal canal. And so when it narrows the spinal canal, it’s kind of like a traffic jam. It just blocks the nerves and they can’t send signals to our legs to make them function. So oftentimes people, they complain about sciatica. It’s a very common thing people complain about. “I’ve got a pinched nerve in my back, that’s going down my leg, it’s really hurting me.”

Dr. Usman Zahir: (18:34)
And that can come from a disc. We have these structures in our spine that act like shock absorbers which we call discs. You can have a disc that’s actually pressing on the nerve, or you can have a bone spur. So with a laminectomy, it’s typically with bone spurs. And we go in the back and we just remove those bone spurs. You can do it through an open procedure. You can make an open incision, you can put retractors and you can try to look into the spine and do it that way. Or, you can make a smaller incision and put like a device like this, an arthroscope, which is very small. It’s less than a centimeter. You just put the scope in and you do the surgery using that instead. But the difference is you’re not cutting through as much muscle. So that same patient who’s getting the same surgery will have less pain after surgery because you didn’t do as much collateral damage. You didn’t have to cut through all the muscles to do the same surgery. So the goal is the same, you’re doing the same exact operation, whether it’s an open procedure or endoscopic, but you’re doing less collateral damage. And so the patients typically have less pain.

Daniel Lobell: (19:39)
It seems kind of basic in a way. The less cuts, the less pain. The less you’re cutting up, the less somebody is going to feel cut up. So ultimately the best surgery is the most minimal surgery, that gets the job done.

Dr. Usman Zahir: (19:56)
Yes. And what you just said is critical. That gets the job done. Because as spinal surgeons, we’re not trying to do cosmetic surgery where we’re trying to make just small incisions, because they look nicer.

Daniel Lobell: (20:07)
Nobody’s coming to you for a sexier spine? [Both chuckle]

Dr. Usman Zahir: (20:12)
But if you make a small incision and you weren’t able to take care of the patient’s pain, then you haven’t done them a service. So the key is that the less invasive surgery should be able to accomplish the same exact goals as the traditional open surgery. They should be equivalent as far as improving pain with the legs. But the benefit of course is that the recovery process is typically quicker with the less invasive approach. And especially with the whole opioid crisis in this country. And physicians are aware that oftentimes our surgeries are very painful and we’ll prescribe patients pain medications, and some patients may sometimes get dependent on those pain medicines because of the procedures they went through. So obviously if you’re going through a less invasive approach, oftentimes these patients don’t need those pain medicines. They may be fine with just Tylenol after the operation, instead of a Percocet.

Daniel Lobell: (21:07)
Who knew that the key to keeping people off drugs was tiny cameras? That tiny cameras could solve all the problems in the world.

Dr. Usman Zahir: (21:16)
Well, I don’t know if it will solve all the problems. I mean, there’s clearly lots of issues with the opioid epidemic and some of it has to do with just over prescribing and not monitoring things. But I personally think that we are turning the corner in some ways with that over the past year or two. And we’re seeing less and less patients on these sorts of drugs.

Daniel Lobell: (21:39)
Wow, and you say in the last year or two? That’s so recent, that’s incredible.

Dr. Usman Zahir: (21:42)
Yeah. But part of it’s because it’s the state. I mean, our state societies are really pushing hard on it. Some pharmaceutical companies as well, they’re restricting these medications. Before it was just very easily accessible. And doctors were very liberal with prescribing these sorts of medicines after procedures. Now we’re very specific. Someone’s had a surgery, we’re counting. We’re like, “All right, you probably will need this just two or three days, that’s it.” Before it was like “All right, this patient needs it for two weeks.” That was a very common type of practice. But things have changed. So some of it’s government led, some of it’s physician led, consumer protection led… you have all these forces that are trying to get a handle on this. So I think over the long run, things will continue to improve with that.

Daniel Lobell: (22:31)
What are some of the most common causes of spinal damage that land people in your office? And do you recommend chiropractic as a way to keep people and their spine healthy?

Dr. Usman Zahir: (22:45)
That’s a great question. I think the most common condition that I see in the office is a herniated disc. And it’s typically a younger person. Typically in their thirties or forties, and they may have lifted something improperly. They may have just bent at the waist instead of really squatting down on their legs if they lifted something heavy, and they did it in like a twisting motion. And some people will feel a pop in their back when it happens, but they’ll just come in the office with severe leg pain, like intractable leg pain. And that’s the most common condition that I see in the office. The second most common condition I would see is just arthritis in the spine. Those are typically people a little older, 50 plus 60, 70.

Dr. Usman Zahir: (23:38)
And these patients typically will just have a situation where the normal discs that we have in the spine are no longer as healthy. They’ve developed bone spurs, have developed a very stiff spine. And some of that could just be from poor body mechanics over many years. Poor, let’s say, lifting techniques. Some of it could be genetics. We see some patients where there’s an extensive family history of back problems or neck problems. So we see a little bit of that. But those are some of the most common problems. Patients who would just come in with back or neck pain, and that patients who come in with, let’s say a herniated disc where they’re actually suffering from leg pain. I mean, patients with herniated discs have typically more leg pain than back pain. In some very severe cases, they’ll have weakness. They’ll come in and their foot’s dragging. I mean, that’s like an emergency when that happens.

Daniel Lobell: (24:39)
I think that happened to my dad because my dad, years ago, broke his back carrying his friend and his wheelchair up the subway steps. And he’s always had issues with his leg since. He had several back surgeries and I think for a while his foot was dragging. So that that’s familiar to me.

Dr. Usman Zahir: (24:59)
Yeah. The foot drop, we’ll call it basically the foot drop. So yeah, those are some of the more common conditions. I do take care of a fair number of athletes. A lot of the people who come in with back problems are oftentimes bodybuilders or weightlifters, and they’re doing very heavy deadlifts or heavy squats with very heavy weights. And these are just exercises where if you’re lifting those kinds of weights, your posture needs to be perfect when you’re doing the routine. Like if you lose your technique posture, let’s say you’ve done a few reps and you’re getting a little tired and you’re getting a little sloppy in your alignment. I’ve taken care of so many weightlifters who injured themselves doing deadlifts. So part of what we do as a physician, as a surgeon, is kind of educating these kind of athletes about proper lifting techniques and just being aware that there are just certain routines that put them at a very high risk for developing serious back injuries, which oftentimes it ends up needing surgery.

Dr. Usman Zahir: (26:08)
So that’s a big part of the practice too.

Daniel Lobell: (26:13)
That’s why I always say, “Stay out of the gym!” [Both chuckle]

Dr. Usman Zahir: (26:18)
I wouldn’t say that I’m endorsing that, but there are clearly some exercises that I think people should probably do away with. And they could probably find some alternatives.

Daniel Lobell: (26:29)
Right.

Dr. Usman Zahir: (26:29)
But you asked about chiropractic treatments and I think chiropractors definitely have a major role in helping people with back problems for sure. There’ve been many research studies that have looked at chiropractic treatments, physical therapy, even massage, back massage. It does offer benefits. It definitely does. I think the key is to kind of figure out whether or not a treatment is working or it’s not working. And so part of what I do as a physician is helping my patients who are looking for non-operative options, to make sure that they’re seeking options that are perhaps good for them and their specific condition.

Dr. Usman Zahir: (27:11)
Obviously if someone has an unstable spine or has significant osteoporosis, which means weak bone, I might be a little cautious telling them to get chiropractic treatments if they have those types of risk factors. And most chiropractors will probably educate those patients as well, but that might be a risky situation. But patients who have sciatica, pinched nerves, back pain, I have a lot of patients that I sent to chiropractors for helping them get through that process, or physical therapy. Physical therapy definitely does work. A good number of our patients will not need surgery by trying those treatments.

Daniel Lobell: (27:51)
I have a friend who’s a chiropractor, and I always joke with him that he only has one diagnosis: subluxation. I’m like, “Everything is subluxation with you.” So this is sublux sublux. I’m like, “Is there any other diagnosis that chiropractors have besides subluxation?’ And he always laughs. But what is subluxation, and do you deal with it as well?

Dr. Usman Zahir: (28:17)
Yeah, so subluxation is one of those terms which might mean something different to a different professional. As spinal surgeons, when we think about subluxations or, we sometimes use the term instability or something unstable. It means that when we are testing the spine or looking at the spine in different positions, we’re seeing the spine shift out of place. So for instance, if I take the spine and ask the patient to flex forward and I take an x-ray of them in that position, and then I have them extend backwards and I take an x-ray in that position as well, for me, instability or subluxation, you’re going to see a shift in the spine between those two positions. Now, in some cases, it can be normal. It can be what we call physiologic, which is like, yeah, there’s a little shift, but it’s not concerning.

Dr. Usman Zahir: (29:18)
Maybe the person’s just very flexible. I mean, we have some patients who are very flexible and then they have what we call very lax joints. They’re very flexible. And so we get x-rays and you see, “Oh yeah, there’s a lot of motion going on there,” but that’s normal for that person. They just tend to be very flexible and they’re going to have more shifts than the average person. But if we have a situation where we look at someone’s spine and everything is stable, nothing is shifting, but one level is really shifting out of place in certain positions, that can be a potential source for pain for that specific individual. And if that person has leg pain with that subluxation, then we have an answer right there. And sometimes we’ll get other tests.

Dr. Usman Zahir: (30:07)
Let’s say, if we get an x-ray and we see that shift, I might get an MRI as well. Because what you might find is, you might find that on the x-ray, there’s a shift, but when you get the MRI, you find out that there’s a disc herniation at the same level that there’s that shift. So it’s like, what came first, the chicken or the egg. So in this case, we assume that perhaps since the spine was shifting a bit at that level, it may have caused a disc herniation. So now you have two problems at one level. And then now, a patient who came in very confused about what the source for their pain is, we’ve been able to narrow it down to one particular level. And then that allows for more targeted treatments. Because if you don’t really know where the source of the pain is, it’s really hard to target your treatments in that area.

Daniel Lobell: (30:52)
Right.

Dr. Usman Zahir: (30:53)
So with every visit, we kind of narrow it down from a very broad type of diagnosis. We’re able to kind of narrow it down to like one specific level. Like your problem in your spine is at this particular level. And then if chiropractic treatments, if physical therapy hasn’t worked for that patient, we might send them for an injection. Maybe like a cortisone shot. But not just any cortisone shot. We’re going to put a cortisone shot right at that specific level with that problem. And that patient is going to do better.

Daniel Lobell: (31:27)
Because it’s extremely targeted.

Dr. Usman Zahir: (31:27)
Yeah. It’s very targeted compared to someone who comes in the office and they’re like, “Yeah, my back hurts.” And you’re just touching the back and putting a needle in and giving him a shot. That’s not going to be as effective as an injection that has been checked by x-ray by the MRI, exactly which level the problem is coming from. Those patients can do much better with this injection than just giving them a run of the mill shot in the office.

Daniel Lobell: (31:54)
So when you brought up the flexibility that some people have in some spines versus others, it made me think about contortionists. Is somebody who’s able to be extremely flexible with their body in a better position with spinal health or does it work the opposite way?

Dr. Usman Zahir: (32:15)
That’s a great question. I would generally say that people who are more flexible are less likely gonna have injuries. Because their capacity to deal with stresses is greater. So I have a lot of patients who are like yoga instructors, and they may be coming for other things because I do some orthopedics on the side and there’s some times I’m treating them for things that are not related to their spine. But you look at their flexibility and it’s amazing. Their hamstrings are really stretched out. Everything is really good. And what we’ve found in the spine, patients who aren’t that flexible are probably going to be more at risk for having problems. And the most common thing that I see are patients with very tight hamstrings.

Dr. Usman Zahir: (33:00)
So the hamstrings are these muscles in the back of our thighs, that are attached to our pelvis towards our knee. And there has been a correlation. If someone’s got very tight hamstrings, they’re often times dealing with back pain. And that’s a risk for people who are doing a lot of sitting. A lot of my patients are administrators, secretaries, people who are doing a lot of sedentary work. And especially with coronavirus, so many people working from homes at their desks and everything, and we’ll test them. We’ll check them in the office and extremely tight hamstrings. And that person’s actually complaining about back pain. I’ll put that same patient in physical therapy and they’ll get therapy to treat their hamstrings and stretching out all these other joints. And guess what, their back pain gets better.

Dr. Usman Zahir: (33:45)
It’s kinda like, just literally stretching out the hamstrings and doing some exercises in other areas actually helps the spine. And it’s all because everything is linked. It’s like a tug of war. You’ve got your spine going in one direction, you’ve got your hamstrings pulling down on the other direction. It just creates these abnormal stresses. And so to answer your question about flexibility, I would generally say someone who’s more flexible is going to tend to have less back issues than someone who isn’t. But you know, there is an extreme to that. And I’ll talk about another extreme. For instance, gymnasts. We know people who are in gymnastics are extremely flexible. And in their case, sometimes what we find is their extreme flexibility can sometimes cause problems. So we’re going to get a little technical here, but some of them are at risk for developing these stress fractures in their back because they’re so flexible.

Dr. Usman Zahir: (34:44)
They’re putting their spine in such an extreme position in some cases. Repetitively extending their back. You can have someone as healthy as a gymnast, very flexible, but they come in with a stress fracture in their back. And a good number of my patients are teenagers, young adults who may have done a lot of gymnastic type work. And they come in with back problems from maybe doing certain maneuvers that put their spine at risk for developing these sorts of fractures.

Daniel Lobell: (35:18)
So, be flexible, but don’t be too flexible, in other words.

Dr. Usman Zahir: (35:24)
Yeah, I mean, I think the idea is that —

Daniel Lobell: (35:25)
Keep it in moderation.

Dr. Usman Zahir: (35:28)
Keep it in moderation, that’s a very reasonable way of thinking about it and just tells us that the human body has its limitations. There’s definitely a stress point, where at some positions, if you keep doing that position repetitively again and again, and again and again, and if it’s extreme, it’s going to potentially break, in that specific position. It’s just a matter of the fact, just like any moving part of, let’s say a car or any kind of mechanical type structure, there’s a failure limit for everything. So we see that with the spine as well.

Daniel Lobell: (36:03)
So I brought up earlier all the nerve endings that are in the spine. When you’re doing a spinal surgery, how do you monitor the nerves?

Dr. Usman Zahir: (36:11)
Great question. There are a few ways of doing it. Number one, we’re obviously looking at the nerves the whole time. So part of being a surgeon is being of course competent that you’re not going to injure the nerves, because we’re looking at it the whole time. But we also have some safety mechanisms in place for certain surgeries. So like when I do neck surgeries for instance, or when I do certain spine surgeries in the lower back, and I’m putting hardware in there, I’m putting screws and rods in. We use certain companies that monitor the nerves during surgery. It’s called neuromonitoring. And basically what you do is you put like electric probes on the legs and the arms, and there’s some technicians who are actually checking the nerves during the entire operation. So if I was doing something, let’s say that might irritate a nerve, let’s say I’m putting a screw in and it kind of just irritates the nerve during the process, I get live feedback from that neuromonitoring team. And they’ll say, “Hey, Dr. Z, we just noticed some activity with this specific nerve. Can you just check what you’re doing?” And that live feedback allows me to change exactly what I’m doing at that very moment.

Daniel Lobell: (37:21)
So there’s a nerve guy that comes in. It’s a job. Wow.

Dr. Usman Zahir: (37:25)
Yeah. It’s literally a job. Yeah. And they’re very specialized in doing that. I mean, they’re really experts with checking the nerves and they have their own little station in the OR and they’re typically working with the neurologist remotely. So there’s actually a neurologist who’s a MD neurologist. He’s not in the OR but he’s linked with that team. And they’re checking the nerves during the procedure. So that just offers another safety net because obviously the patient is asleep. If I’m doing something that’s irritating a nerve, the patients won’t tell me that I’m doing that. So the the neuro team is basically giving me feedback that normally an awake patient would give me, if I was irritating one of the nerves. So it’s very helpful.

Daniel Lobell: (38:13)
I wonder how did people even get into that kind of job? Where they become nerve monitors. Are they like very nervous people, or they’re people that just get on people’s nerves and somebody suggests it to them, like, “Look, you got a lot of nerve kid, I think you could…”

Dr. Usman Zahir: (38:30)
Yeah. I mean, they’re very detail oriented. If you look at their screens, it looks like a bunch of graphs with a bunch of like — literally they’re putting electrical cables on patients to check their nerves. And it just tells you how fascinating the nervous system is, that if you saw a patient that is linked up to some of these devices, and it’s like, “Wow, this is straight up from a movie or something,” like some sort of like crazy mad scientist experiment that you’re doing, but literally you can test nerves using cables. These are like electric cables, they’re little needles, you basically put it in the skin next to where the nerves are and we’re able to to sense. We can sense. And they can actually stimulate the nerves during surgery too. So if I’m doing a neck operation on someone and we want to test and make sure the nerves are okay, that the nerves from the brain are able to travel down into the legs, that team is able to stimulate the nerves from the head up high and see how it transducts down into the entire body.

Daniel Lobell: (39:41)
So when Christopher Reeve fell off the horse, wasn’t that the issue, that his nerves weren’t communicating from the brain to the spine. I remember something like that.

Dr. Usman Zahir: (39:53)
Yeah. When he fell, he broke his neck and it created a spinal cord injury in his neck. And so everything below where that injury was was affected. In his case, it was high up enough that it affected both his arms and his legs. He had some function, I think, in his arm. I can’t remember exactly which level he had that was affected. But yeah, that’s exactly the type of thing that potentially could happen during an operation. I mean, you could have a situation where something happens and then the nerves are damaged, but these sorts of tools that we have help monitor the nerves, to minimize some of those risks.

Daniel Lobell: (40:32)
Have they made any breakthroughs with regard to treating situations like the one that Christopher Reeve was in? Like if somebody were to have that happen nowadays, would they be in a much better position than he was in when it happened to him?

Dr. Usman Zahir: (40:47)
It’s interesting. There’s a lot of research going on right now with stem cells, and looking at ways of treating spinal cord injuries by targeted treatments in that. A lot of this is still very experimental, but there’s a lot of research going on in that area. And there is a thought that at some point we will be able to put certain stem cells into spinal cord, targeted for certain specific regions to help prepare that. And there’s some anecdotal evidence that it does work. I mean, there are people who are doing experiments right now. And I think as far as something that’s widely available for the general public, I don’t think we’re there yet, but on an experimental level, yeah, we are seeing some anecdotal reports for yes.

Daniel Lobell: (41:41)
So anecdotal reports is just like an anecdote at a party where a doctor says it.

Dr. Usman Zahir: (41:47)
No, not so much that. [Daniel laughs] It’s more like, they’re still trying to figure out exactly what’s the technique necessary to get a predictable response. Like you might have a situation where someone has a spinal cord injury and someone did the stem cell procedure and they saw some improvement, but then in another patient it didn’t work. So then the question is, why did it work in this person and not that person? So they’re still trying to fine tune the whole technique, the ways of doing the procedure, it’s still going through a type of a process.

Daniel Lobell: (42:20)
So it’s almost like Christmas lights, those string lights where like one bulb goes out and then all the bulbs go out from that bulb on. It seems like the spine kind of operates similarly.

Dr. Usman Zahir: (42:32)
It does. And in a way, everything is linked. It’s like a cable going from our brain. And as it goes down, it has these branches. It’s like a major highway. And you have these sort of branches where the nerves are leaving the spine at certain levels, like exit ramps off a major highway. So the main interstate highway is like our spinal cord. And then we have all these little exit ramps on this highway, which are individual nerves that are leaving the highway, going into our arms, into our fingers, into our legs, into our toes or feet. And so if you have a traffic jam with the major highway, everything downstream is going to get affected. But you can also have a situation where instead of having a traffic jam on the main highway, which would be the spinal cord, you actually have it on an exit ramp, which is like an individual nerve. And that’s going to be a very limited injury. If we just have it on a specific small exit ramp, for a specific nerve, it’s great. It’s very limited. Whereas something on the highway is going to be a lot more catastrophic.

Daniel Lobell: (43:39)
That’s a good way for me to visualize it. Unless that exit ramp leads to another major interstate in which case you’re in trouble. But if it’s just like some little neighborhood, maybe it’s not as big of a deal. [Daniel laughs] What is disc replacement surgery? I read that you do that as well.

Dr. Usman Zahir: (43:58)
Yeah. I do a fair amount of disc replacement surgery, specifically in the neck. And the idea is that if you have a disc that has worn out, and it’s no longer functioning, the traditional way of treating that problem when it causes a pinched nerve is to do what’s called a cervical fusion. So the doctor typically will go in from the front of the neck, they’ll put a plate, they’ll put some screws, they’ll put a bone piece of bone graft where the disc was and they’ll fuse it. Nowadays, we have some alternatives that. So instead of fusing the disc, you can replace it. So it’s like an artificial disc. It has a metal side and quite often a plastic kind of core and allows for flexibility. So especially in a young person who might be nervous about getting a fusion surgery where they’re like, “I don’t want to lose my range of motion. I have so many years ahead of me, as far as my life and my activity level. I want to maintain what my range of motion is.” A disc replacement allows the patient to still get that successful surgery that removes pressure on the nerve without having to fuse it. So that’s basically what a disc replacement is.

Daniel Lobell: (45:16)
Interesting. Yeah. That seems like a safer bet if you’re in that situation, especially if you’re young, as you mentioned.

Dr. Usman Zahir: (45:26)
Right. Yeah. It’s definitely an option. And there’s some cases where you can sometimes do two levels, you can do multiple levels. It’s not just one. But the thing with disc replacement is, it’s an artificial disc. So there’s always a chance that over time it could wear out as well, and someone may need a different procedure later on. But for someone who’s young or even someone middle-aged or whatever, who’s kind of looking to preserve their range of motion, it’s a very reasonable option to consider, for the neck.

Daniel Lobell: (46:00)
Right. What do you wish your patients knew, coming into you?

Dr. Usman Zahir: (46:06)
That’s a good question. I think from my perspective, when I have patients who come in, I do get a lot of very frequently asked questions. There are many patients coming in, everybody wants to have an MRI. Every patient that comes into the office, there’s a good number of them. They just feel like they need to have an MRI. And they feel like if their doctor’s not ordering them an MRI, they’re not typically getting adequate care. Like maybe the doctor doesn’t care about their situation. And I think what I wish, maybe from my perspective, I just really want our patients to know that we have their best interests at heart and we can assess them and we can make the diagnosis oftentimes without ordering a lot of unnecessary tests.

Dr. Usman Zahir: (46:57)
I think we have a situation where it’s like we have this idea that the more tests we get, we’re getting better care and it’s not necessary. You just need to get a good history. And maybe we’ll examine someone and give them a good plan afterwards. So I think sometimes that’s something that I see that I wish some patients knew, they just realize that we’re going to provide you a good plan here, but it may not require you getting a lot of unnecessary tests initially, at least. Right. So that’s one thing that I would say I wish patients kind of knew. Another thing I would wish patients knew that quite often, when they come in with injuries like a neck sprain or a back sprain, many of these will get better on their own too.

Dr. Usman Zahir: (47:45)
So that’s another thing. Sometimes it just requires a little bit of patience. It’s pretty amazing, like anyone with a neck or back injury, I would say the vast majority of people within four to six weeks, it’ll get better even on its own. Even if they didn’t come and see the spine doc or whatever, it’ll oftentimes just get better on its own. We live in a society sometimes where people want immediate results. They kind of just spring their back this morning and they’re like, “I want the pain to go away completely.” They just want it to go away completely. And that’s fine. Maybe that person’s in a situation where they just need to get release immediately. And we can clearly provide ways of getting them some relief. But in some cases also have to have reasonable expectations that our body has its own healing process.

Dr. Usman Zahir: (48:32)
There’s a healing timeframe and it just requires a little bit of patience. And with some treatments we can definitely get over it. So on that end as well, just being patient and letting the body do its healing. There’s some people who have an injury and they want to get back to doing exactly what they did the day before that injury happened. And sometimes we have to restrain them. “So you injured your back. Yes, I know you’re a CrossFit trainer. I know you’re doing club stuff, but we have to figure out a way to get this under control first, before you can go back to doing that.” So having reasonable expectations, I think is a very important thing as well.

Daniel Lobell: (49:13)
“Slow down, buddy, take it easy. Sit on the couch for once.” The doctor diagnosing you to do less. “Don’t exercise! What? Alright.” [Daniel chuckles] But it makes sense. You’ve got to let the body heal. What’s your view on the online health space and do you encourage or discourage patients to look online for information?

Dr. Usman Zahir: (49:36)
I definitely encourage them. I think patients these days are a lot more informed than even what I saw five years ago. They’re coming in with a lot of questions. It can sometimes be a little challenging, because if you search a few things on the internet, it seems like we all have that same condition. Someone may have back pain, they’ll go on the internet and search up back pain and suddenly they’ll come to the office and think they have cancer. Because they saw an article that said back pain can be associated with cancer. So there’s a balance, but that sort of information that I think our job as physicians is to help patients to put everything in perspective. Yeah, cancer can clearly be a source for back pain, but it’s not the most common cause.

Dr. Usman Zahir: (50:19)
So that sort of understanding or perspective is sometimes not available on the internet because the internet is just a lot of data. A lot of it’s unfiltered and unsynthesized data that’s just all out there. And so for a lay person that may not have the kind of medical background when they’re looking at that information, everything looks like a crisis. It’s the same thing when you look at the side effect profile for a medication. Let’s say someone was written for a prescription and you go in and look at all the possible side effects for that medication. Those are all possible side effects. It doesn’t mean for that individual you’re going to have that. It’s good to kind of be aware of it, but it can be kind of information overload. You know, it’s like, “Oh my God, this medicine that I was prescribed can cause this condition,” it’s probably like a 0.001% chance of having it, but for them to get concerned by it.

Dr. Usman Zahir: (51:16)
So, I think our job as physicians, I do encourage patients to read as much as they can about it. And I tell them to bring all their questions to the office. And what we do during that visit is to help answer whatever questions they might have. And if they have these sorts of perspectives, based on what they’ve seen on the internet, I will help guide them through whether or not this is likely going to be an issue in their case or not. But I do feel being informed is still better than not being informed. And so I generally still do encourage them to read and do as much research as they can, but I make myself available. I’m like, “Look, if you have any questions, feel free to contact our office. We’re happy to help.” If you have any further questions about the situation.

Daniel Lobell: (52:04)
Sounds like a good approach to me. We’re here talking on behalf of Doctorpedia. So what do you think with regards to Doctorpedia, how do you feel that they could best assist the online health space?

Dr. Usman Zahir: (52:19)
That’s a good question. Right now, our healthcare system’s become extremely complex. There are many stakeholders, many players that are involved in it, large health systems, you have pharmaceutical companies, you have large medical organizations, et cetera. But despite all these kinds of stakeholders, at the end of the day, physicians, we are really at the forefront. We are directly taking care of the patients and we are really the point at which a lot of medical care is provided. And we have a bit of an expertise in a wide variety of specialties, wide variety of medical specialties, specifically targeted to certain regions. And so we are experts in those specific areas. So I think for patients who are looking to get information that’s well validated, that is free of bias.

Dr. Usman Zahir: (53:18)
The surgeons and physicians, we should be really the sources for a lot of that sort of information. And I think what Doctorpedia could really do is provide a kind of a well-validated site where patients can trust that this information is being provided by physicians who don’t have a conflict of interest. And if they do, it should be well laid out. If they have any kind of conflicts or whatever, it should be well disclosed. And I think transparency is extremely important in today’s online space, where when we read information, we don’t know exactly who or what entities behind that piece of information. And I think what Doctorpedia can do is really provide a framework that is being provided by board certified physicians, and it creates a sense of trust. And I think that’s something that I think it’s a kind of a space where there’s a lot of room to have a kind of niche in that specific area on the online space. So I think it will be a very helpful source. And right now a lot of patients are getting their information through Instagram, through videos, through a wide variety of media type sources. It’s almost like information overload in some ways as well. And I think having a kind of platform that is standardized, that is trusted, validated, and extremely transparent, I think it will be a very comfortable and safe place for patients to get their medical information from.

Daniel Lobell: (54:50)
Makes sense. And I believe that that’s basically the goal of Doctorpedia and what they’re working towards. So hopefully that’s how it will pan out. I like to ask this question to all the doctors as we wrap up the interview, and that is: what do you personally do to stay healthy?

Dr. Usman Zahir: (55:11)
As far as what I would personally do to stay healthy, I really watch what I eat. Regardless of what are our best efforts are, we don’t have a lot of control over what’s in the food chain. I, myself, I have a few food allergies. I’m allergic to wheat, I’m allergic to dairy products, et cetera. So that has forced me to really watch the type of foods that I eat. So from a diet perspective, I do eat quite a bit of organic food. I kind of look at where food is sourced from, whether it’s farm raised or if it’s something wild. I’m always doing that type of research on my own. So that’s one thing that I would do. Second thing, as far as from a sports perspective, I’m still involved in intramural tech sports, so playing basketball, biking, especially on the weekends, I try to incorporate that into my normal, type of routine. So it’s hard to do a lot at one time for myself. I do a little bit every day. So in the end I’m hoping that this will be a more sustainable way of doing things.

Dr. Usman Zahir: (56:24)
Because I’ve definitely had a period of my life where I would go one or two or three weeks intense on certain exercise type routines and everything. And then it was overwhelming and I stopped doing it. And so I figured like I’m just going to keep very reasonable goals and I’m just going to spend like 20, 30 minutes a day doing something, whether it’s biking or going to the gym. And then when you keep the kind of goals and you keep it consistent like that, then you’re more likely to continue it over the long-term.

Daniel Lobell: (56:56)
So true. Yeah. I think it comes back to the same thing that you and I don’t want to get caught in a routine as well, because as soon as you start getting hooked into one thing, it’s like, “Ah, I gotta change it up immediately.” And and pacing ourselves, I think. I say ourselves like you and I, you know how guys like you and I are! I think we have some stuff in common and I think like keeping some kind of pace moderation to things is much better than going extreme into anything because you’re burnt out on it, and then you wind up back to square one in no time.

Dr. Usman Zahir: (57:33)
Totally agree. Totally agree.

Daniel Lobell: (57:35)
Do you have anything planned for the Doctorpedia site on the platform?

Dr. Usman Zahir: (57:41)
Yeah, there are a lot of ideas running around creating certain channels for certain certain topics and just working on ways of delivering information that’s easily accessible and easy to understand, because it’s going to be a fine line between having just a lot of data, data, data, information, which can be overwhelming. Instead of having something more practical, easy to understand and something that patients can take from it and really apply to themselves.

Daniel Lobell: (58:17)
Right.

Dr. Usman Zahir: (58:17)
So specifically on the spine side, I definitely have an interest in providing some services in that regard.

Daniel Lobell: (58:26)
Very cool. Well, I’ll be looking forward to seeing that stuff up on Doctorpedia. Dr. Zahir, it’s been a real pleasure getting to learn from you, getting to talk to you and I very much enjoyed it. Thank you.

Dr. Usman Zahir: (58:39)
Well, thank you very much for having me. It was very enjoyable.

Daniel Lobell: (58:44)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.