How do we determine when surgery is necessary and I’m gonna let you take this Dr. let’s be honest. > So when surgery isn’t it when patients come to the clinic essentially they will oftentimes have tried conservative management school of tried injections they’ll tried lifestyle modifications and they still have bad pain. So really barring anything catastrophic that would that require surgery which we’ll talk about in a second your decision to have surgery is essentially up to you so you can either have the pain or the gold surgery is to take away the pain and oftentimes the deformity. Things that necessitate surgery are things like instability so if your spine is moving back and forth on each other so two vertebral bodies that you’ll have right here okay if they’re moving back and forth these can actually damage your nerve roots essentially, because if we look and we’re gonna look at the bio digital graphic in a minute but essentially the movements of the bones themselves can squish the nerves okay. Things like tumors for example may oftentimes require surgery or radiation or some sort of intervention or fractures that can lead to instability in the long run. So barring any of those things or nerve compression that causes difficulties with movement or paralysis decisions may have surgery it’s up to the patients. > And talk to you obviously have conversations with your patients on when it’s time. Right? > Yeah. When it’s time most of the patients they already have they know and for the most part the patient already is making the decision alongside with also we already are telling the patient okay you try a B and C so basically you try physical therapy some medications and despite the injection to aid or aid didn’t help or they didn’t help you long term or you’re having recurrence of symptoms despite doing an exercise program so it’s time just to take action and most likely start getting a surgical conversation, and for the most part motivation they take it well because they already know that they have tried all the steps prior.