What If Your Spine Surgery Wasn't Necessary? with Dr. Betsy Grunch (Ep 166)

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Dr. Betsy Grunch: [00:00:00] It's on the onus of the chiropractic profession to recognize that these patients and the challenges they face in traditional modern medicine and resorting to chiropractic treatment, wanting to help them, but also knowing their risks of manipulation, you know, that's where they can get themselves into trouble too, with really hurting people.

Dr. Linda Bluestein: Welcome back every bendy body to the Bendy Bodies podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility md. A Mayo Clinic trained expert in connective tissue disorders like the Aler Danlos syndromes, dedicated to helping you navigate joint hypermobility and live your best life. Today we'll be speaking with neurosurgeon, Dr.

Betsy Grunch. Oh my gosh, I just looked out my window and saw this incredible double rainbow. So now my A DHD is kind of kicking in, but we're [00:01:00] gonna have a great conversation. As you know, I've already spoken to a number of different neurosurgeons, and it's so important to have these conversations because neurosurgery is a very, very big decision, and you wanna make sure that you are making the best possible choices.

It is possible to have symptoms without really having findings on imaging to explain the symptoms. And likewise, you can have findings on imaging that possibly correlate with the symptoms, but not always. So it's really, really important to gather as much information as you possibly can so that you can make the most informed decisions.

Dr. Betsy Grunch is a board certified neurosurgeon at Long Streete Clinic in Gainesville, Georgia, specializing in minimally invasive spine surgery and neurotrauma care. Honored as a top doctor by Georgia Trend and Atlanta Magazine. She was named one of Atlanta Magazine's, women Making a Mark in 2023, known online as Lady Spine Doc.

Dr. Grunge shares her expertise with millions of followers, simplifying neurosurgery with content that educates, inspires, and connects with both medical professionals [00:02:00] and the public. As always, this information is for educational purposes only and is not a substitute for personalized medical advice.

Stick around until the very end. So don't miss any of our special hypermobility. Here we go.

Oh my gosh. I am so excited to finally be here with Dr. Grunch. We have had, uh, computer issues, software issues, uh, emergencies like this. I feel like this is a long time coming, so I'm so happy that we're finally sitting down to chat. Yes, absolutely. Oh, I'm so happy. So can you start out by telling us your journey into neurosurgery and how, briefly how you ended up here?

Dr. Betsy Grunch: Um, yeah, it's been a wild ride. So I, um, first off, I have to apologize for my raspy voice. I have a little bit of laryngitis, so I don't normally sell like this. Basically, you know, I think everybody that goes into medicine kind of has some type of draw or something that [00:03:00] led them to the field. For me personally, it was, um, um, I was, uh, teenagers in that time of my life where I was kind of trying to decide what I wanted to do when I wanted, when I grew up and my mom was involved in an accident when I was a freshman in high school and she suffered a spinal cord injury.

And so that kind of, kind of catapulted me into the healthcare field. Um, in terms of, you know, just kind of going through her rehab and recovery and trying to understand like why something like that can be so devastating. So, um, so her journey with her, um, surgeries and recovery really fascinated me about neuroscience, particularly about the spine and um, and, you know, eventually led me to where I'm at today.

Dr. Linda Bluestein: Yeah, you're right. I think so many of us have a personal story that really impacted our, our path. So it's always interesting to hear. And do you have any direct experience treating patients with [00:04:00] connective tissue disorders like EDS? And if so, what led you into that uh, space? 

Dr. Betsy Grunch: I mean, I think being a spine surgeon, naturally speaking, like people with connected tissue disorders have spine disorders, 

Dr. Linda Bluestein: right?

Dr. Betsy Grunch: So, um, so yeah, I mean I have a really broad experience. And then of course being, um, the fact that connective tissue disease. Autoimmune disease are kind of more prevalent in females. Um, and myself being a female healthcare provider, I think naturally, um, uh, I, I, I see a fair amount probably I would venture to say more than normal, um, of patients, uh, with these types of processes.

Dr. Linda Bluestein: And if you were to explain to another neurosurgeon who's not familiar with connective tissue diseases, not familiar with EDS and in particular hypermobile EDS, um, how would you explain that to them? 

Dr. Betsy Grunch: Oh man. So, I mean, you know, I think that anybody that doesn't understand or appreciate that this is, [00:05:00] um, and, and since he, that they need to be knowledgeable.

And I think it's, um, you know, the way I like to describe it is I think we as surgeons in particularly, we look at images and we make decisions based on static images. And the thing about hypermobility disease. Is, it's not a static problem. So like, you know, people, um, our, our bodies are meant to be in motion and, and we're forced in particularly in my field, of having MRIs and x-rays done in one moment in time.

Mm-hmm. And it's so, um, difficult to sometimes really conceptualize what may be going on outside of that image and what, you know, and, and trying to conceptualize how to interpret that, how to treat that and how to manage it. 

Dr. Linda Bluestein: Yeah. No, that makes sense. 'cause dynamic imaging would be preferable probably for anybody, but especially for people with connective tissue [00:06:00] disorders.

Dr. Betsy Grunch: Right. Yeah. I, I mean, like every patient that comes into my practice, whenever I first see them as a new patient, I get dynamic imaging, x-rays, flexion, extension, lumbar, cervical, whatever the case may be. Um, just so I can try to appreciate like, what does that patient look like? Inflection, what does that patient look like in extension or weight bearing?

MRIs and cts are, are done typically with non-weight bearing when the patient's flat in one position. Um, and dynamic imaging of dynamic MRIs and cts are very difficult to get. So, um, so a lot of times I like to kind of interpret what I'm seeing on x-ray and then translate to what that may look like when I look at their MRI.

What does that look like potentially as a weight-bearing image or as a collection image. And, um, it takes a little bit more thinking outside the box that I think what a lot of people are maybe accustomed to doing. And 

Dr. Linda Bluestein: in terms of subtypes of Ehlers Danlos [00:07:00] syndromes, are there certain ones that you think that you see more frequently than, than other subtypes?

Dr. Betsy Grunch: Oh, that's a great question. To be quite honest with you, most patients that come to me don't really have a type or subtype. Um, you know, I think I see a lot of underdiagnosed or misdiagnosed or does not diagnose patients. Um, so I'm not, you know, it's very rare that someone comes in and they know they're subtype.

Mm-hmm. It's usually me being like, I think you've got a connective tissue disorder. I think you have EDS. I need you to go get screened. 

Dr. Linda Bluestein: Sure. And what would be the things that you would see in the exam, in the history taking process that would make you say that to somebody? 

Dr. Betsy Grunch: A lot of times it's, it's people that have gone underdiagnosed or misdiagnosed for a long period of time and don't have the answers, but have real pain.

Um, and so, you know, it's looking at those patients with certain body habit or certain [00:08:00] body types, real, you know, skinny, long neck, very tall patient. Um, not that's just a, you know, a very stereotypical, um, appearance. But, um, you know, looking at patients and asking them those questions. Do you feel like you are.

A little bit more bendy than normal, like, do you have any issues where you've had Subluxation of your joint or something like that. So those are all things that I try to ask patients whenever I have a suspicion of something that, you know, may be going on. Mm-hmm. 

Dr. Linda Bluestein: Yeah. And that stereotypical body habitus is so tricky because in my practice, which is of course mostly people with EDS or HSD, mostly hypermobile EDS, I, I should say specifically, or HHSD, there's a lot of people that do fit that stereotype, but then I have lots of people that don't.

So, um, yeah, it, it makes it, it makes it tricky. And of course if they, if they really have the erect long fingers and toes and, you know, [00:09:00] uh, pectus abnormalities and things like that, you know, sometimes. We would suspect, well, maybe they have Marfan syndrome or some other hereditary disorder of connective tissue.

Um, do you find yourself, because I know you're more aware of these conditions than by far, you know, most neurosurgeons. Do you find yourself sometimes referring these people to geneticists or, um, if you're to refer 'em to somebody else, would it be PM and r? Would it be genetics? Who would it be most commonly?

Dr. Betsy Grunch: Typically I'll refer a couple patients per month for genetics. Um, that's usually my go-to. I've found that at least maybe just region specific to where I'm at. Um, if I refer them elsewhere, I just tend to not get a whole lot of anything. Mm-hmm. Um, so, you know, I hate to send patients further down the line to feel like they're drowning.

So I, I, you know, I, I wanna try to get them to where, but you know, geneticists is the backup for that. It can be a long time. [00:10:00] Um, they can wait sometimes. Six months, 12 months for an appointment. Um, so I try to reassure them, Hey, we're just trying to get you answers. It's not necessarily gonna maybe change what we do, but, um, I think you need to hold on to that appointment so we can maybe get some clarity to the situation.

Dr. Linda Bluestein: Yeah. And I know people who, you know, have to wait years, so that's really, really challenging. And I'm sure when you are operating on people, you know, you wanna know, are they more likely to have, you know, the tissue fragility? Are they, you know, more ligamentous laxity? I mean, do they, might they even have vascular fragility?

Um, and so that's obviously really, really important. So, um, what do you see in terms of those kinds of things? Do you, do you feel like now that you're so more aware of this, are you able to kind of, you know, predict, uh, pretty well or how, how do you think that works? 

Dr. Betsy Grunch: Yeah, I think, um, I mean, able to give a, a good guess if I think someone has some type of.

[00:11:00] Connective tissue disorder and then handle that situation, you know, is the, is confirming the diagnosis gonna change my treatment plan a lot of times, like knowing or not knowing, not necessarily like if I suspect they may have vascular problems, that's a whole different ball game and, you know, referral pattern I may take to kind of judge, um, uh, pre-op, you know, risks stratification and that kind of thing.

Um, but in terms of wound healing, I think that really the question is are they a surgical candidate or not? Do I think surgery is gonna help them or not? And there are ways that we can mitigate risks with wound healing and stuff like that. And the biggest thing, you know, with, with hypermobility disorder in surgery is we often resort to, to fusion.

And fusion has a, a high risk of non-immune and then people will connective tissue disorder 'cause they don't heal their skin, they're not heal to bone. So, uh, we just kind of have to do everything in our power use. Instrumentation products for [00:12:00] bony fusion and stuff like that, that may be a little bit more hyped up, uh, than we would traditionally use or take more, um, steps to help, uh, provide patients the best, you know, endang the best result.

Dr. Linda Bluestein: And so, I know it's hard 'cause you, it's not like you have all these patients that are coming in that are saying, I have EDS or I have, you know, I mean, I'm not surprised to hear you say that, but of course the way I was gonna ask a lot of these questions is like, well in your EDS patients, so we'll just assume that we're talking about the people who you suspect, um, that they might have EDS and I've, I'm curious if you notice any particular patterns of, of, uh, problems in people with suspected connective tissue disorders.

Like do they have, are you noticing a difference in their degenerative disc disease, spinal instability, other, other deformities, other things like that? 

Dr. Betsy Grunch: Um. In terms of spine, I mean, you know, we see a lot of ciliac dysfunction. Mm-hmm. Um, I see a lot of that in my practice, [00:13:00] just baseline, because I think being a, a female provider and SI disease being a female condition, um, uh, I, I over proportionately see that, um, I'm also like one of the few providers in our region that really offers SI joint fusion as a solution.

Mm-hmm. So I'll often get patients that come to me with connected tissue disease with either, you know, uh, diagnosed or undiagnosed SI joint dysfunction. Um, spondylolisthesis is a really common problem that we see in EDS, particularly at like L four and L five. Um, it's, it's, that's the most common level we see just at baseline.

But particularly, you know, in patients with connective tissue disorder that, uh, first level, uh, that segment right out of the pelvis, which takes the most motion, the most stresses. Uh, it tends to be affected and that's why those dynamic films that I mentioned, those collection extension x-rays and that type of stuff is so important, [00:14:00] uh, to get on those new patient evals so you don't miss something.

Um, I don't see a lot, I'll say, you know, on socials and stuff, we see a lot of, of, um, patients with hypermobility talk about like, uh, OCI dissociation and that kind of stuff, the instability, cervical, cervical instability. I see a lot of that in my practice for whatever reason. Um, hyper aware of it, but, um, I don't know.

I, yeah, I think that's less common, at least for me. Mm-hmm. 

Dr. Linda Bluestein: Well, I think there's a few people that are probably like. Published a lot on that particular topic. And so I think that there's, um, if it gets to that point, but of course there's a lot of people that have mild, uh, cranial cervical instability or cervical instability that they're managing, you know, non-surgically.

Um, and I, and I think that oftentimes if they do need surgery, they might be going to, you know, a couple of people in the, in the US that really specialize in that. And [00:15:00] so I was curious about the, so the, with the spondylolisthesis, just for people who don't know, that's when the vertebral bodies are slipping on each other with flexion and extension.

And I'm holding my hands up right now for, for, for the purposes of the people watching the video. Would you say that's a pretty accurate description or do you wanna add to add to that? 

Dr. Betsy Grunch: Yeah, no, that's how I describe it. It's like, you know, if you have one bone and another bone, they should be line up one on top of the other.

But in a ceis they translate differently. They, they don't hold together correctly. So it hurts. 

Dr. Linda Bluestein: Yeah. And, and I love that you do a lot with sacroiliac joint, uh, dysfunction as well. Or you're able to do a surgical fusion, which of course, same thing with fusing any part of the body. Like we don't take that lightly, right?

That's a very, very, um, significant type of surgery. But it's great that you're able to do that as well because I feel like the more tools that you have in your toolbox, the better it is for the patient rather than they have to make sure that they have the right condition coming in to see you in the first place.

Whereas it sounds like they [00:16:00] might come in thinking that their problem is spondylolisthesis, but then as you're assessing them, you might say, no, I actually really think it's SI joint dysfunction, um, in instead, am I correct about that? 

Dr. Betsy Grunch: Yeah. Um, we, we often see SI joint pain and L four five potential pathology overlap a lot in how they present.

Um, and it's so difficult. I mean, I've been definitely operated on people that I was convinced. That it was their spondylolisthesis and they have persistent pain after fixing that and it's SI joint pain or vice versa. We think it's si, but it's really like a, a little annular ter L four five or something like that.

So it's, it can be a little challenging and, um, even in the best diagnosticians hands, um, it's not always a perfect science. Mm-hmm. 

Dr. Linda Bluestein: Yeah, definitely. And I know having been on the, on the patient side and the clinician side, it's also hard because a lot of times when you're [00:17:00] asking questions like I, I feel like sometimes I have a hard time answering.

Like, I, I don't, I don't know. I mean, it feels like this, but then you, you know, so when, when you're doing your history portion, the physical exam I feel like might be a little bit easier. But when you're take doing the history portion, well, what makes it worse? What makes it better? You know, aggravating and relieving factors I think are sometimes, you know, hard for people to, to really identify or sometimes describe.

Um, and, and what are other diagnostic challenges that you, that you face with this population, would you say? 

Dr. Betsy Grunch: Um, I think the biggest thing is just getting over, like, a lot of them, uh, have this, I don't know, fear of the healthcare system because they have been either gaslit or, um, not had the right diagnosis, uh, made or felt, feel like.

Their pain isn't worthy. So I think that's the biggest challenge, is just earning trust and, um, trying to offer real solutions to a very difficult problem. [00:18:00] 

Dr. Linda Bluestein: And we talked earlier about, you know, uh, the quality of the ligaments and the vasculature and the, the quality of the tissues. Um, how do you assess preoperatively somebody's risk of bleeding, whether or not they have hypermobility, if they might be at risk for wound healing problems, um, et cetera.

Dr. Betsy Grunch: I mean, it's, it's if you know, going in that, you know, the IBD has or something like that, like you're going to pay particular attention. But I really try to rely on, okay, have you had surgery before? What complications have you had? How did they deal with that? How did you heal? Did you have a wound infection?

Um, you know, those kinds of things I ask of. Of every patient. Um, but it's particularly important in those patients where, you know, we're trying to make sure that we are stratifying the risks. And sometimes, I mean, you know, in, in some patients with a lot of risk factors and they need, maybe need a scoliosis surgery or something [00:19:00] really big.

I mean, is it really worth the risk? Um mm-hmm. And those are difficult conversations to have because you doing a multi-level scoliosis correction, are they really going to heal the whole construct? And is it really worth thinking this? Because sometimes, even though we're surgeons and we have fixes, sometimes things don't always are, aren't worth fixing because you can put them in a worse situation if you, if you, and if you didn't do anything at all.

Mm-hmm. So those are challenges that we, um, that require a lot of insight and thought and, um, and, and communication with the patient. 

Dr. Linda Bluestein: I, 

Dr. Betsy Grunch: I love that 

Dr. Linda Bluestein: you just said that because I have said for. Um, that patient selection. When it comes to surgeons, patient selection is everything. And back when I was operat, you know, doing anesthesia back in, um, Wisconsin, we, we all knew people who worked in the operating room.

You knew which surgeons were, you know, [00:20:00] likely to. Operate on people have kind of like a lower threshold and which surgeons were very selective in who they operated on. And I, I actually, one time after I moved to Colorado, I, I've gone to a number of different people's practices and kind of hung out with them for a few hours just to get a sense of what people were doing.

And this one orthopedic surgeon, uh, I had this, there was this patient that was arguing with him and he was telling her that he did not think she was a good surgical candidate. And it was just so ironic because he spent more time with her than with anybody else. And everyone else got offered surgery and she was being, you know, turned down for surgery and she was really upset.

And, um, and I get it. 'cause of course if you get to that point right, you, you're thinking often that that is the, the answer. But I really respect surgeons who are thoughtful in their selection process and, you know, really thinking through, um, the risks and making sure that the person is a proper candidate.

Yeah, agreed. What about non-interventional therapies? Are there [00:21:00] ones in particular that you, uh, often will recommend? 

Dr. Betsy Grunch: I mean, I think it depends on the problem. Um, I think education is so important because, um, like you kind of touched on a little bit earlier, there are patients that have pain and discomfort that like maybe aren't either the best operative candidate or maybe just don't yet quite have operative pathology, but it's so easy to want, like have pain and wanna fix.

Mm-hmm. But it's not always like A needs B. Um, and talking about taking the time to talk about this conservative options, whether it be strengthening with PT or traction or, uh, you know, medical management injections, alternative treatments, um, or those conversations sometimes take longer than surgery. And, uh, or surgical discussions and, um, and patients maybe aren't, some [00:22:00] patients aren't as receptive to that 'cause they wanna fix.

And, um, it's just really trying to again, explain why you feel that way so they understand and to know that might be their best choice or best outcome. Mm-hmm. I 

Dr. Linda Bluestein: think that's one of the most challenging things is, you know, there's people walking around that, you know, you do imaging on them and they have all kinds of abnormalities, but maybe they don't have pain.

And then there's people who have lots of pain and they may or may not have, you know, corresponding Im imaging, you know, uh, abnormalities. But then it's also hard to know, like you just said about the pathology maybe isn't there quite yet, you wanna make sure as a surgeon, of course, that those changes that you're seeing are actually explaining the symptoms.

Right, exactly. Yeah. I just wanna make sure that people understand that because I feel like it's just such a, I think that's just such a key concept because you can have. A certain set of symptoms and you can have a certain set of findings, but that doesn't mean that one causes the other. Right, [00:23:00] right, right.

Yeah. And that's 

Dr. Betsy Grunch: the challenge for the surgeon, the physician, whoever's making the diagnosis, is we often like, try to diagnose the imaging and you can't do that. You really have to. And it takes a good position, a good listener and a good diagnostician to like be able to put the two together. And, and, and even the best, like I said earlier, the best ones still make mistakes, but Right.

Um, it, it's, it's even more challenging in this patient population. 

Dr. Linda Bluestein: Yeah, definitely. And speaking of this patient population, are there any of the standard surgical techniques that you use that, that you modify? So we talked already a little bit about fusion. Um, if you're doing any kind of, you know, other fixation, instrumentation, um, grafting, is there other there things that you might modify, um, in that regard?

Dr. Betsy Grunch: Um, yeah, so I'll try to, you know, there's different products, especially spine fusion like that we can use to augment patients that we think that are [00:24:00] at risk for non-union. So different, you know, uh, like we might use a certain type of bone graft or, um, over another, or we might use a bone stimulator, but in a traditional setting, insurance may not cover that because it's not, you know, doesn't meet the criteria.

So you have to kind of explain why I think this patient needs. This product because of this reason. Um, and really going to bat for them to make sure that they can get what they need to give them the best chance of avoiding a pseudoarthrosis or a non-union, which would potentially lead to more future surgery.

Dr. Linda Bluestein: Right. Right. Oh, and the insurance piece is, so, I, I dunno why I called it the insurance piece. It's not like it's a piece, but dealing with insurance companies is so frustrating. Um, yeah. Yeah. 

Dr. Betsy Grunch: But it's a part of reality of healthcare, at least mm-hmm. In the US right now. 

Dr. Linda Bluestein: Yeah. Yeah. Absolutely. And it is frustrating because like you just [00:25:00] alluded to, there might be something that would cost less money, but look beyond the more preventative side as compared to waiting until you have the non-union and need another surgery, which is gonna be a lot more expensive.

But in general, insurance companies, it seems like they really struggle with that more preventative type concept. 

Dr. Betsy Grunch: Yeah, for real. They do. I mean, because prevention. They're, they're a business too. So like prevention, does that prevent them from having to deal with that cost in the future or are they actually paying now to prevent it for another insurance company in the future?

So they don't think, think that way. It's a different mindset and it's, um, it's a little frustrating. 

Dr. Linda Bluestein: Mm-hmm. Okay. I think we're gonna take a quick break and when we come back, we're gonna talk about prognosis and what we think the future might hold, um, in this space. We'll be right back.

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Okay, we're back with Dr. Grunch. And I'm curious, we've obviously kind of been talking about fusion and we talked about sacroiliac joint fusion and fusion for spondylolisthesis. Um, what are some other surgeries that [00:27:00] you think that you've performed in patients that might have connective tissue disorders, whether they have a formal diagnosis or not, what are some other things that you might be operating on people for?

What would be the condition and the indication for the surgery and what would be the actual surgery that you would be performing? 

Dr. Betsy Grunch: Yeah, I mean, you know, we'd test a little bit on s joint disease and spondylolisthesis in the spine, but, um, often, you know, scoliosis is something, um, that can affect people with connective tissue disease that, um, may be underdiagnosed or misdiagnosed.

Um, and those are even the more challenging cases because those are higher risk, especially in the non-union setting. Like if they don't go on to fusion, trying to fuse 10 levels of the spine and you're a low, uh, you're a high risk, then, uh, inevitably speaking, if one level doesn't fuse, that patient could not have a successful operation.

[00:28:00] So those are, those are the ones that really give me the most heartburn, to be honest. Are you, are you doing that very often? I do a fair amount of deformity work, yeah. In my practice I probably do one or two a month, um, which is, you know, is, is a pretty high, high amount for, for a, uh, for a spine surgeon.

Mm-hmm. Mm-hmm. 

Dr. Linda Bluestein: Yeah, those are big surgeries. So you're talking about scoliosis where, uh, you know, I know you can't say like, oh, there's this magic number for the curvature, but what, it might be some indications for scoliosis surgery. 

Dr. Betsy Grunch: Typically speaking, I mean, we look at like an angle of 30 degrees, um, as their cob angle is something that we would really consider, uh, being in the, uh, area of needing correction.

Mm-hmm. Um, I mean, but that being said, I mean, there's patients that have less than that that we offer surgery to. Um, but that's kind of the number that we tos that's tossed around in the literature. 

Dr. Linda Bluestein: Mm-hmm. Mm-hmm. [00:29:00] Okay. And I know back when I was in the operating room for Neurosurgeries, um, I i's been a long time since I've anesthetized someone for like a big Harrington rod surgery or something like that.

But how do you do a repair do for scoliosis? 'cause I know I've had some people talk about some, you know, much more minimally invasive type of surgeries, but I don't know, you know, what the current standard of care is. 

Dr. Betsy Grunch: Yeah. I mean we, um, we de definitely don't do herrington rods anymore, thank God. Uh, so, um.

I mean the be the biggest thing for deformity correction is trying to restore the most natural alignment to the spine. So we talk about coronal and sagittal balance. So that's like if the patient is standing up and you're looking at them straight on, like, are they curved to the side? That's the coronal balance.

And the sagittal balance is looking at them from the side. So does their head sit over their pelvis? Is it two part [00:30:00] four? Do we need to correct the, uh, lumbar lordosis or pelvic incidents? Draw numbers we calculate. So a lot of statistics, physics, the math that goes into correcting some of these, um, deformities because, um, we know that overcorrection or undercorrection could potentially lead to further problems down the road.

And if they're a young patient, we wanna try to get them as perfectly corrected as possible so they don't have hopefully future issues. Their spine in 10, 15, 20 years down the road. 

Dr. Linda Bluestein: And in terms of patients maybe that you're not referring, uh, or not recommending that they proceed with surgery, do you ever recommend something like Schroth uh, physical therapy?

Do you find that to be helpful or are there other modalities or bracing or anything like that that you are often recommending for scoliosis? 

Dr. Betsy Grunch: Yeah, I mean, um, I'll, I, I talk a lot about core strengthening and, um, pelvic floor strength in women or men for that matter, [00:31:00] um, but tend to see it a lot more in women's health.

But, um, yeah, I mean those things are very vital to helping with the symptoms of scoliosis or anything really. Um, just to get on, get your spine and, and better conditions, weight-bearing exercise, um, and those, those types of things are, are. Crucial because when we're hurt, we don't necessarily wanna do those things.

Mm-hmm. But it's like a, it's like a dangerous cycle that happens. We hurt, we don't exercise, we don't strengthen our body, then we get weaker, then we rely more of our joints, and then those joints aren't good, they're hypermobile. So then you just, you are just in this continuous detrimental cycle to yourself.

Dr. Linda Bluestein: Mm-hmm. Yeah. It's really, really challenging. For sure. For sure. And in terms of, uh, secret IAC joint fusion, coming back to that again for a second, I, I wanna just ask how often after you fuse one side do you end up having to fuse the other [00:32:00] side? 

Dr. Betsy Grunch: I mean, gosh, it really depends on the patient. It is a often is a unilateral condition, but, um, you know, in a, in a large majority of patients, it, it can be bilateral.

The interesting thing is I used to, in the patients that I knew had bilateral side joint pain, I would just fuse both sides. It's really hard in the recovery because at least for in my practice and in in my outcomes, I've seen better recovery if I'm letting them baby that side in their healing process.

So like partial weight bearing, really trying to minimize load on that, um, joint that you just fused. And you can't do that if you use both sides. So I saw a higher risk of non-union when I was doing both sides at the same time. So I switched to doing just one side, let's do the worst side first, let you heal six to 12 months later, we'll come back and do the other side.

Mm-hmm. But what I found was that, and, and in a large majority of [00:33:00] patients where I did the one side, the other side almost like compensated or balanced out and they didn't necessarily need that side dying. So it's fascinating. I mean, I won't say that's the case for every patient 'cause we will go back in and infuse.

The opposite side in many patients. But, um, it's, it's interesting to see how sometimes fusing one side can almost correct the other side or maintain it and balance or in alignment. Mm-hmm. 

Dr. Linda Bluestein: Well that's great if they, if there's some people that can avoid doing that second side. And I've often thought that when people, this was rare of course, but every once in a while you'd see somebody come in for bilateral total knee replacements and you're like, oh my gosh.

Yeah. No, please. Oh yeah, no, thank you. I mean, I get that, you know, you have one, one horribly painful recovery period, but that just sounds really, really awful to me. Yeah. Um, I'm curious to ask your take. On chiropractors, because of course it's a, it's a whole field, right? I mean, it's, you know, [00:34:00] a whole lot of people that have, you know, some standardized training and they, they practice so differently though.

I mean, there's the, you know, uh, people that do the newa type of chiropractic and, you know, specialize in like the, um, you know, upper part of the cervical spine and, uh, doing all kinds of very, very specialized treatment there. But, you know, it's also hard because there are still chiropractors that do some more aggressive type treatments.

So I would love to know your opinion about, uh, chiropractic therapy in particular for people with a possible connective tissue disorder. 

Dr. Betsy Grunch: Yeah, I mean, chiropractic medicine is one of, is, um, it's easy to kind of ball it up into one, but it's, I mean, it can be very useful and, and, um, patients, um, but it can also be harmful.

So it, it's. There's not a lot of, unfortunately, it's not a very evidence-based field. Um, and, you know, we [00:35:00] need that to make clinical decisions and, and in, in patients with connected tissue disorders that are kind of set up for that, like, I'm going every avenue possible to try to help my pain. I hurt pain, but the healthcare field is telling me I shouldn't hurt.

So I need to go here to try to get, get help. But going to chiropractic field, if they have, you know, vascular pathology or more pro to dissection, going and getting the high velocity neck manipulation could be, I mean, it could kill them. I've seen it before. So it's so challenging. It's on the onus of the chiropractic profession to recognize that these patients and the challenges they face in traditional modern medicine and resorting to chiropractic the treatment, wanting to help them, but also knowing their risks.

Of manipulation, you know, that's where they can get themselves into trouble too, with really hurting people because, um, they, you know, are, are more vulnerable to, um, [00:36:00] either spine or vascular injury with any type of, of, of high velocity, you know, manipulation or whatever the case may be. 

Dr. Linda Bluestein: And in terms of, uh, I don't know how often you see this patients that have loss of the cervical lordosis, so, you know, loss of the natural, uh, spine curve in the cervical spine.

Um, I know there are some chiropractors who like specialize in restoration of that curve. I don't have enough data myself to know if they are often successful. Do you happen to have any opinion about that? 

Dr. Betsy Grunch: I mean, I'm not seeing any good data to suggest that anything that you can do from a chiropractic standpoint can really fix reliably.

Deformities. Mm-hmm. So, I mean, we see it a lot on social media and, and things that go viral and stuff like that. But like, the reality is there's just not a lot of evidence to back that, that proclamation. Mm-hmm. And you just have to [00:37:00] tread that very, very lightly if you're, if you're patient, I mean, you deserve to know like what your risks and benefits are and what is the data behind that.

And, um, how are you gonna help me? And is this worth my time? Is this worth my money? And is it, and, and those are, and, and time is money, really. So you need to, to be able to, to know what, what, you know, you may expect from any type of treatment. 

Dr. Linda Bluestein: Absolutely. And if it, if they can take something that maybe is slightly out of position and improve the position, but it doesn't stay, it doesn't hold, then, you know, are you, are you any better off than you were before?

Yeah, exactly. Exactly. Okay. So getting back to surgery, um, you, we talked quite a bit about fusions and how important that is to have, uh, you know, to actually be able to form that union between, uh, between the bones. Do you ever use cadaver bone or, you know, other things like that? [00:38:00] 

Dr. Betsy Grunch: Yeah, all the time. I mean, cadaveric, DBM or whatever the case may be, allograft treatment is the mainstay of, of grafting for spine.

Mm-hmm. Um, there's other things we use like autograph. So patients own a bone, um, that has their own stem cells in it that, um, can lead to higher success. Um, there's other products like eye factor or infuse that have a higher concentration of hormones in the, that product that can augment or like, kind of put gasoline on the fire of a fusion.

Um, that wouldn't be natural in. Cadaver bone or, or their own bone. Um, and those products are more costly, um, and sometimes aren't necessarily covered. Um, so yeah, it's, there's a lot of the, and they, some of them have risk. So nbu for example, carries a black box warning of increasing your risk of cancer. So yeah, it's to, you have to be careful.[00:39:00] 

Dr. Linda Bluestein: Yeah. Yeah. Wow. And these are tough decisions for patients to make. I feel like, you know, we now have patients have so much access to information, you know, they can go online and they can look at. A large number of papers. 'cause of course a lot of things are open access now that they weren't when, back when I was in school.

And um, you know, it's more information can sometimes be, it's a great thing in a lot of ways, but also can be really overwhelming and then you feel a lot of responsibility as the patient. Um, so I'm curious to ask also, are there anything, are there any tips that you give people preoperatively to help with the fusion process in terms of like, nutrition or other things that they can do to maybe improve their outcomes in that, 

Dr. Betsy Grunch: in that regard?

Um, yeah, nutrition is important. You know, making sure that you're eating as good of a diet as you can. It's like protein heavy things are gonna give you good healing properties in the healing cascade. Um, you know, activity modifications are important, [00:40:00] like listening to your, what your doctor says to do and not do brace or not brace or whatever the case may be.

It's very important. Um, and then, you know, things like nicotine cessation, incredibly important to talk about in patients no matter what their disease process is because that can lead up to a 50% failure rate. And those are things that we don't even talk about operating on a patient when they're at the right body weight.

Um, you know, I think those are conversations that are difficult to have. Diabetics making sure that their glycemic control is good screening for osteoporosis, is their bone quality good? Those are all things that, at least in my mind, not my mental checklist on every patient I operate on, you know, that I go through in my mind and make sure I'm asking those questions.

Mm-hmm. 

Dr. Linda Bluestein: Yeah, that's really important 'cause you're, you're wanting to set them up for success, which, which is great. I do remember back when I was working in Wisconsin, there was one of the neurosurgeons that would [00:41:00] do, I can't remember if it was a urine test or a, a serum test, but they would do check for nicotine.

Yeah. Usually a blood test. Okay. And cancel the case. Yeah. If it came back positive, they would cancel the case the day of, you know, so, 

Dr. Betsy Grunch: yeah. I mean, I'll do it pre-op. I don't like to cancel cases day of surgery because it's just so much stress on the system that's prepared. Um, but you know, I, I, I ask everyone, I screen everyone, if they're positive, we cancel it ahead time.

Mm-hmm. If they're negative and you had a suspicion, sometimes you have to check a day of surgery. But, um, that's, that would be unfortunate. Mm-hmm. 

Dr. Linda Bluestein: And tell me a little bit more about, about the body weight, uh, picture. 'cause I feel like I'm very aware of that when it comes to total joint replacements and the risk of wound infection and DBTs and things like that, or deep venous thrombosis, blood clots in the legs.

Um, tell me more about what your process is. 

Dr. Betsy Grunch: There's some similar data in the spine that [00:42:00] higher the BMI, the more likely for wound infections. Non-union, which is crucial. Um, the recovery and their, uh, pain and their experience. Um, so in our approach, so in spine, it's not like a joint replacement. You do it the same way every time.

In spine, you can come anterior, you come lateral, you could come oblique you com posterior, like different ways of getting to a particular level. There's different implants that we use depending on the approach. So like an anterior approach, you're gonna get the biggest implant in there, which for someone that's overweight, um, maybe best because you want more surface area or fusion.

Um, but you know, also them being overweight is very challenging to get there safely, you got a deeper area, more tissue to go through. And again, those are, uh, really important issues that you need to be transparent about. And I think these [00:43:00] conversations are a little easier now in modern medicine, at least in the past.

Two years where I can say, Hey, you know, I'm very concerned about, I think you need surgery, but I'm very concerned about your rest, so why don't, let's talk about Ozempic or Manjaro or something like that. Those are easier conversations than they were a few years ago when you're like, I know you hurt, but we need to work out, you know?

Yeah. Like it's, yeah. Yeah. 

Dr. Linda Bluestein: Right. So, and, and that's a great transition 'cause I just wrote down GLP ones. Um, because I remember you had a post I think a while back about, uh, GLP one or glucagon-like peptide, um, receptor agonists medications, which you just mentioned a couple tirzepatide, um, uh, semaglutide.

There's quite a few available now. Yes. Um, and you were posting something about those medications and intracranial pressure, I believe. Is this ringing a bell or could you comment on that? Yep. 

Dr. Betsy Grunch: Yeah. So GLP ones actually. Change the way our [00:44:00] body brain produces CSF, which is fascinating. Mm-hmm. So those, those medications can reduce the amount of CSF that you produce.

So we knew that patients that are on GLP ones and they have PSED tumor cerebri increased the cranial pressure. They got better, but it wasn't because they were losing weight, the effect was quicker than the weight loss. Mm-hmm. And so the scientists, you know, uh, figured out that it was actually altering or reducing the way spinal fluid is produced, which is amazing.

I mean, that's, that's, you know, breakthrough that can really help people, um, tremendously that are suffering. And maybe patients that aren't necessarily, that have this problem, that aren't overweight. Maybe qualify to get them approved for these medications that could help them. Mm-hmm. 

Dr. Linda Bluestein: Yeah. And, and I've had a lot of patients say that they got started on GLP one and it really helped stabilize their mast cells.

And I know in the literature there's, there's a [00:45:00] case report and there was another study that came out fairly recently. It's not like there's a ton in the literature about this yet, but anecdotally I'm hearing from, from quite a few patients, a lot of patients are of totally normal body weight or even maybe their BMI is a little on the lower side, but they're being prescribed these medications for mast cell activation.

And I'm hearing some positive things from a lot of people, generally much more positive than negative. I think I have only one patient who just really couldn't tolerate even a, a low dose. But, um, it's. It's really fascinating. And they also started though at like one 10th the usual dose. Like it's really, really low.

Um, often from a compounding pharmacy and kind of titrated up. Um, so, so that's also really interesting in this population especially. And a lot of people have been prescribed acetazolamide for a similar Yeah, similar problem. So, so how would you compare and contrast those two 

Dr. Betsy Grunch: options? Eze, Olamide is, is riddled with side effects.

So, um, it's [00:46:00] very difficult to find someone that can really tolerate that very well. Um, and it's the, the mechanism of action is, is different than the GLP one. So, um, I think it's just, um, it's, I mean obviously it's a little easier to come by and they both have good data to help, but I think you're gonna have more side effects than the patients that take Acetazolamide than, um, than the GLP ones.

And, and the, and the benefits just keep. Rolling out with those medicines. It's, it's really interesting. I mean, I know they get a lot of, some negativity, but, you know, the cardiovascular benefits, the, you know, all these other things that are coming out about, um, how it, it can help is, is very interesting to see the future and how, um, these medications hopefully can make us healthier humans.

And when 

Dr. Linda Bluestein: should a patient with EDS or a, you know, possible connective tissue disorder, when do you think that [00:47:00] the right time is to seek of an evaluation from a neurosurgeon? 

Dr. Betsy Grunch: Um, I mean, at the, that, I mean, you could seek an evaluation anytime you want, but you need to be able to make reasonable decisions because there are surgeons that, like you said earlier, like there risk stratification isn't good.

Their patient selection is not good. And just because someone says you need surgery, do you really need surgery? Mm-hmm. So I think it's always good to get ideas and thoughts, but if you're making a decision on something that could alter your body forever, you really need to take that into deep thought, ask, get multiple opinions.

You know? Um, I, I, I, it's just, uh, I've seen a lot of patients make the wrong decisions about surgery and then end up suffering. And then [00:48:00] there's nothing that we could do once it's been done. Right. Just hard. 

Dr. Linda Bluestein: Yeah. No, really hard. And what about Tarof cysts? Is that something that you operate on or have, have you seen very often?

What are your thoughts about that? 

Dr. Betsy Grunch: Yeah, I mean, we see them a lot just incidentally speaking. Um, you know, tarof cyst are something that, um. Is found on MRI reports a lot. Um, and there are patients that are symptomatic from it and there are patients that are not symptomatic from it. There are patients that, um, you know, you get on the internet and you'll find so much stuff about it.

Um, and it's challenging. Um, and I don't know if I have a grand solution here. I have operated on them. Yes. Um, it's, you know, you could see peroneal cysts or TAL cyst on a nerve root that's compressive and causing problems. But for every one of those, I think you'll find 10 times more that are just incidentally [00:49:00] found and not really, um, causing issues.

And it's challenging, again, going back to what we said is people want a solution and maybe that just isn't really causing the problem. Um, I know there are some specialists that really focus on this in their practice and I've had patients that have gone to. Texas and had that surgery done and done well, but I've also seen patients that have gone ahead, it done and end up developing arachnoiditis or something 20 times worse.

Mm-hmm. Um, and so it's, it's, it's definitely, you know, definitely a very delicate topic. 

Dr. Linda Bluestein: Yeah. Yeah. And I'm glad you mentioned Arachnoiditis 'cause I definitely wanna circle back to that. But, but I do wanna ask, um, 'cause I, I, I've had surgery actually for Tarlo cyst, um, and I had, um, uh, a block beforehand to a selective nerve root block to determine if that tarlo cyst was likely the causative factor in my symptoms.

Is that the approach that you would normally take to [00:50:00] help determine if that tarlo cyst or perineural cyst is symptomatic or not? 

Dr. Betsy Grunch: Yeah, we can use, uh, diagnostic injections, but usually, so Tarof cys, they're down the sacrum. Mm-hmm. So it's gonna be challenging to. Do a nerve block, you know, S two, S3, those kinds of things.

So, um, the ones that are easier or like, you know, if they're on a motor neuron or causing radicular pain or something like that, um, those are a little bit easier to diagnosis are the ones that I've had the most success with, with, um, either pre-op injections or just going in there and, um, fenestrating the cyst to see if the patient gets better.

Dr. Linda Bluestein: Then let's talk a little bit about Kada Aquinas syndrome, because I feel like, you know, I, I have this very, very complex patient population and every once in a while I'll get a, a message in the portal. You know, I suddenly lost the ability to hold my urine and it's not, you know, just a little bit of stress incontinence.

It's like, no, my urine is just like coming out and, [00:51:00] or stool incontinence, which, you know, ordinarily, and what I was taught was, you know, this is a neurosurgical emergency. Yeah. Um, but a lot of these patients have had so many problems and I feel like even if they go in emergently. To the ER or something that they may or may not get a, you know, prompt evaluation.

And if they do an imaging study and they see, oh, you have a tarlo cyst, but nothing else, um, that they often are, you know, kind of sent home without really any kind of an action plan. Um, I've had several patients who had tarlo cyst and also had, you know, saddle anesthesia and incontinence and things that we normally would, you know, associate with kata equina syndrome.

C Can you comment on that a little bit? And I guess I didn't really describe, other than what I just said about what Kata, Aquina, uh, syndrome is. 

Dr. Betsy Grunch: Yeah. Kata Equis syndrome is where you have compression of any of the nerve roots going, um, in the low back down to the sacral area. That can cause a constellation of symptoms like numbness in the groin, [00:52:00] perineum, um, urinary and bowel incontinence.

So those sacral nerves get, uh, imp pinched from compression. That's the neurosurgical emergency because those nerves. Are so delicate, they even compression for a very brief period of time can lead to permanent issues with sexual function, with the ability to go to the bathroom on your own, which as we know is life changing.

So, um, those diagnosed and the, and the patients can have incontinence for a multitude of other reasons. So it's a slippery slope of like, is this, did you have pain really bad? And so you urinated on yourself. Um, so I mean, easiest thing to do is if you have that, is to get evaluated because, you know, those symptoms in the combination with the compressive pathology is a neurosurgical emergency.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Betsy Grunch: In the absence of, of, of imaging, it's not, [00:53:00] um, an emergency. It, it could be representative of something that's, you know, totally different in another cause, but it's so. You don't wanna ever brush something off that could potentially be, you know, make the wrong choice, wait a day and this is how it's gonna be.

Right. Um, and those are the ones that, um, you know, call my office, say those symptoms, we, we know they gotta go to the er, whether or not it's real or not real, we gotta see. Mm-hmm. Mm-hmm. 

Dr. Linda Bluestein: Right. Because if you can relieve the compression, then you can potentially reverse those symptoms. But if you don't relieve the compression quickly enough, then like you said there, the changes are gonna be permanent.

So, yeah. Yeah. Are there neurosurgical emergencies that you want people to be 

Dr. Betsy Grunch: aware of? I mean, the biggest thing is just dissection and stroke. Um, I mean, I think of brain health out in spinal together, so, [00:54:00] um, you know, making sure that you don't. Subject yourself to a risk of getting something like that, like going to chiropractor.

But to be honest, you can get a dissection from doing anything. You can get a dissection from throwing your head over and brushing your hair upside down. So, um, you know, any types of neurological changes, uh, that are different for you, you know, your own body and the best, you're your own advocate. And if you know something is different or wrong, you gotta get it checked out.

And, um, it can be hard because sometimes you maybe don't feel like you're being listened to. Um, and you just have to be the best advocate for yourself that you could be. 

Dr. Linda Bluestein: Yeah. A lot of people I, yeah, have had so much gaslighting that they are afraid to go to the er. They're scared, which I scared. Yeah, I get it.

I get it. I totally get it. Yeah. Um, let's come back to Arachnoiditis before we're ready to wrap up. Um, can you, we, we just, you just touched [00:55:00] on that briefly as a comp, potential complication from spine surgery. Can you define that for us and what, what do you want patients to know about erect neuritis? 

Dr. Betsy Grunch: So, arachnoiditis is where, you know, your nerves typically float around and your, um, lumbar area, like little spaghetti, noodles and water and arachnoiditis is where they don't float anymore.

They can stick or scar either to each other or to the dura. And our body is meant to be, our, our body is in motion. So anytime we walk, kick, move our legs around, the nerves slide up and down and glide. Um, but if they no longer, if they're stuck or scarred, um, it can cause. Problems. It can cause pain, it can cause weakness, it can cause numbness, it can cause Coda Aquinas symptoms.

And um, it's, it's a little, uh, interesting in how patients can develop arachnoiditis. I mean, usually it's not just [00:56:00] spontaneous. Usually it's from something, it causes inflammation around the area. It could be infection, it could be bleeding in that area. It could be from a regular injection that you get, um, you know, epidural or a myelogram, maybe a test where, where in medicine where we inject something into the spinal fluid space, but your body has a bad reaction to it and swells up and then you get arachnoiditis.

So, um, I think it's just, you know, knowing the risk of that know, knowing that that's a, a, a known entity that again, can be misdiagnosed. Um, is, is. Knowledge is power, so mm-hmm. Um, knowing what those, you know, things could be. And, and the worst thing about arachnoid eyes is it's progressive and there's no cure and there's not a lot of treatment for it.

And it, and it sucks. So that's the, the hardest part for me making that diagnosis is knowing, okay, now we know this, now what, what else can we do? There's [00:57:00] neuromodulation spinal cord stimulation that can be an adjunct, um, and meds and other things like that, but it's still very difficult. 

Dr. Linda Bluestein: Yeah, these patients are really, really suffering.

And I, I've ended up with quite a few patients because when Dr. Forret Te, who has done so much research in this space, when he, uh, closed his practice, he, I was on his shortlist of people that he was recommending people to. So I, I have a number of erect his patients in my practice, and I just take a, you know, general anti-inflammatory type approach.

And, uh, you know, I, I follow his, uh, bulletins and things like that. And with, with a lot of the things that he recommends might, might be some hormonal therapies and things like that. It's like, well, it's worth a try because, you know, like you said, it's not like we have a lot of great double-blind randomized controlled trials that tell us that, you know, A, B, C is, we don't have a, we don't have a drug for that.

Um, at least not yet. So, um, yeah, no, that's a, a tough, tough, uh, condition [00:58:00] to have for sure. How, how often do you see tethered cord syndrome, um, and or CSF leaks? 

Dr. Betsy Grunch: Um, cord we don't see a lot of, in adult medicine, it's just not very common. Um, it's usually in the spina bifida patients, it gets cycled around in the pediatric world, even as adults.

They tend to still stay down there, but we will see it from time to time. Mm-hmm. Um, it's just usually if it remains asymptomatic throughout adolescents and that growth spurt, it's less likely to be a problem in adulthood. Um, and the other, what is the other thing you asked me about? Uh, CSF leaks? Oh, CSF leak, again, fairly rare, but, um, it's, uh, very difficult to diagnose and you have to be kind of astute to be able to, to have that even in your thought process or differential to, um, know if you think that patient may be suffering from that.

But, um, it's important to either, like, you [00:59:00] know, if we're talking about it through the nose or somewhere where it's actually visible, that's hard to. Not diagnose it, but those spontaneous CSF leaks from a nerve root cyst or sleep or something, those are so hard to do. Mm-hmm. Uh, to diagnose. And, um, I think those are the, the, the most challenging ones.

Dr. Linda Bluestein: Mm-hmm. And then you get to the point where you have to decide, do I have a myelogram or not Now doing something that may put me at risk of erect neuritis. Um, which some of my erect neuritis patients definitely had myelograms, which again, doesn't prove cause and effect for sure. Um, and speaking of cause and effect, really quick last question before we move on to the hypermobility hack.

So are you saying that in some of your adult patients you might actually see a tethered cord but you don't? Uh, it's not, but it's not symptomatic. You see asymptomatic tethered cord 

Dr. Betsy Grunch: sometimes. I mean, I guess you could see them asymptomatic and someone has a low lying conus or something like that. Um, that's pretty rare I would say.

Patients that [01:00:00] have like symptoms of tethered cord are usually pretty rare in adulthood because if they do have symptoms or, or, or tethering of their cord, they're usually gonna present during that growth spurt. Uh, but I have had a, a few patients that I think were symptomatic or maybe they, they had it, um, they weren't symptomatic, but then they got degenerative changes or something going on in their spine that tipped them over the edge.

Mm. Um, and so those are, um, those are some things that we see that's pretty uncommon, but you see 'em, um, if you, you hear. You see horses, you also see zebras. You just gotta recognize them. 

Dr. Linda Bluestein: Yeah. Yeah, definitely. And unfortunately, that's something that zebras tend to get more of. If you have a connective tissue disorder, then your, your risk of tethered cord definitely goes, goes up like with a lot of these, a lot of these things.

So. Okay, great. Well this is such great information and we always like to end with a hypermobility hack. Do you have a hack for us? 

Dr. Betsy Grunch: Um, [01:01:00] yes. So like, I think it's easy in the hypermobility patients to want to stretch, but I always talk about doing like strengthening before you stretch. So instead of like going forward to stretch in the morning first thing, um, and then go work out, you wanna like kind of activate your core, activate those muscles before you stretch.

Um, so you don't overdo it, you don't like pull something. So I always like to, I mean my go-to. Uh, core strengthening exercise for everybody is the glute bridge because for most people, no matter how, um, strong they are, how physically exertional are they can do the glute bridge. Um, and uh, just doing that, that's where you lay on your back, kind of lifts your pelvis up and hold because that engages as gluteal muscles, which we often don't do, and they're so important for your core strength.

So doing that, holding it three to five seconds and Lori down repeating that five to [01:02:00] 10 times also kind of auto aligns your SI joint and it fires as muscles that may help you as to doing it before you get out bed in the morning. Um, is, is important in activating your core and your, um, lower abs. So yeah.

So you recommend 

Dr. Linda Bluestein: doing that before you get outta bed? 

Dr. Betsy Grunch: Yeah. Or yeah, before you get out bed or Definitely before you do any type of, like, stretch so you can kind of, your body can. Your brain can engage and know the length of your muscles so you don't over, uh, stretch yourself and, and put yourself at at risk.

There's all already loosey goosey, uh, joints. You're gonna make them even more loose if you're not protecting them when you move. 

Dr. Linda Bluestein: Mm-hmm. Yeah. And I know some people love to do self manipulation and, uh, I, I, I should have asked your thoughts on that, but real quick, can you share your thoughts on self manipulation?

Dr. Betsy Grunch: Um, I [01:03:00] mean, you know, I think it's a easy way, like we're just, it's a almost like a habitual thing for some people, like popping your knuckles or popping your neck or whatever the case may be. Um, and to just realize like, am I doing that because it's like routine for me? Is that really doing anything to benefit me or is it just like, kind of this nervous habit that I have?

Mm-hmm. And, um, and try not to. To, to, to do those things that may put you again, at risk for, for hurting yourself. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Betsy Grunch: Mm-hmm. 

Dr. Linda Bluestein: Yeah. No, I, I, I view it the same way, especially because Yeah, you're, like you said, some people, it's a habitual thing, so you're doing it over and over and over again and, um, it feels good at the time, but it doesn't mean that it's actually beneficial for you.

Right. So, okay. Um, thank you so much for joining me today. And before you go, can you tell me if you have any special projects that you're up to, uh, research that you're doing, anything like that? And also where can people learn more about 

Dr. Betsy Grunch: you? I'm on almost all social platforms on [01:04:00] Lady Spine Dock is my handle.

Um, you can find me on most things. And, um, yeah, that's, that's basically it. I mean, my kind of like, my, uh, thing now is I just launched like a, a, a boutique lady spine doc.com where I sell, um, medical inspirational merch. And that's been kind of a new passion of mine. Um, and done some designs for EDS and raising awareness and raising funding for, um, conditions so you can kind of, you know, wear what inspires you and where your, um, condition, but also use that to kind of help support a good cause.

Does that go to a nonprofit 

Dr. Linda Bluestein: organization or, 

Dr. Betsy Grunch: yeah. Yeah. So, um, for the EDS design that I did, we had like a Bindi batty design, which was fun. Um, I actually worked with one of my patient's daughters who is. Uh, EDS patient and, um, just got accepted into Harvard. Oh, wow. And, uh, there's, yeah, she's a, a public health.

She's very smart, very, um, [01:05:00] uh, amazing person who also Desi has these designs. So, anyway, um, she, uh, selected a, it's a research institution, uh, for EDS. I'm blanking on the name right now because I, I wasn't expecting this question. Sure. But, uh, sure. Sorry, but yeah, yeah. No, no, you're good. Um, but I always try to, you know, uh, at least make something substantial, um, impact, uh, on, on, on the things that we do so we can, um, make, make a.

Dr. Linda Bluestein: Yeah. No, that's, that's amazing. I, I have a, a boutique, it's called the Bendy Bodies Boutique and sa, same thing where a, a large percentage of the proceeds go to the nonprofit EDS guardians. So it's, it's great when we can, when we can do things like that, so, yeah. Exactly. Yeah. Yeah. Well, thank you so much for joining me today.

It was so great to finally get to meet you. I know, I don't know how long we've been planning this for, but I feel like it's probably six months. Yeah. Yeah. I, I was gonna 

Dr. Betsy Grunch: say, I look back was like Christmas of [01:06:00] last year. Yeah. 

Dr. Linda Bluestein: I think. Yeah. So, so I think it's probably closer to a year than six months even.

So it's, it's, it's been a while. I'm fi I'm glad we finally got to sit down and, and chat and we almost 

Dr. Betsy Grunch: weren't even able to do it today because of the connection. 

Dr. Linda Bluestein: I know, I know. It's crazy. Literally, literally. And I've done this podcast, well, I initially did do it on Zoom, but then today we had to do it on Zoom instead of Riverside, which has not happened in the past year.

Plus that has not happened once, and it happened today. It's like. Just crazy. But anyway, thank you so much for taking the time to chat with me and, uh, share so much great information. 

Dr. Betsy Grunch: No problem. Have a good one.

Dr. Linda Bluestein: Well, I can't believe that I finally got to sit down with neurosurgeon, Dr. Betsy Grunch. We have really been trying to do this for a very long time, and I really think that this was such a great conversation and neurosurgical problems are so common and people. With connective tissue disorders like EDS, so it's great to hear [01:07:00] another neurosurgeon's perspective.

Thank you so much for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. I have lots of other resources that I want you to check out, including my newsletter, the Bendy Bulletin. You can check that out on substack@hypermobilitymd.substack.com. You can help us spread the word about joint and hypermobility and related disorders by leaving a review and sharing the podcast.

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