Virginia Spine Institute

VSI Blog



True Story:

I had constant neck pain and numbness in my fingers. I started dropping glasses of water without even having a sensation of dropping. Then I had my first neck surgery… not from Virginia Spine. Ten years later, the symptoms returned only more acute. Then I had my second neck surgery…from yet another neurosurgeon. After just a few more years, my neck pain returned; and my lower back and right hip were painful; making it difficult to sleep. At this point, I was very discouraged- believing that I would become more debilitated with pain over time. My daily life was being affected; I dreaded going to bed because the hip pain would be constant and therefore I couldn’t sleep well. Walking was bothersome; by late afternoon as the pain increased, I was done for the day.

My greatest fear was that my quality of life would be limited. I wouldn’t get to see the world in the way I wanted to.  As my symptoms grew worse, I feared I would not be able to travel.

I had my first appointment with Dr. Subach; he reviewed my case in great detail and gave me confidence that there were several alternatives available to me other than surgery. Although at some point surgery might be indicated. I next worked with the physical therapy department; we travel 80% of the time, so on-going visits were not very workable. However, they got me started by giving me stretches and exercises to do on my own. They even showed my husband what I needed to do so he could coach me.

Later, I was referred to the pain management department and met with Dr. Nguyen. Once again he assured me that he could help me manage the pain. That assurance has made all the difference to me. He gave me cortisone shots in my hips (SI joints), which allowed me to walk easier. He explained that I could continue to receive cortisone injections over time. This was a relief to me as I thought it was not an on-going therapy. However, that was not the total answer. My hips continued to be chronically painful.

The great news is: if some therapy isn’t working just right, the doctor suggests trying another approach or additional treatment… until the right thing worked for me. Dr. Nguyen then recommended a procedure called Radio Frequency Ablation (RFA). RFA is an image guided procedure to pin-point the nerve area and using a high frequency radio wave “deadens” the nerves’ ability to transmit pain signals to the brain. It made a major difference. I have had this procedure on both SI joints and on my upper spine. The results have lasted about 2 years.

My therapy is a combination of treatments: on-going cortisone injections; Radio Frequency Ablation on a periodic basis; oral pain medication; and topical pain patches. My husband and I continue to travel 80% of the time. Now, I am pain free enough and agile enough to do sometimes arduous travel. A year ago we climbed the Sydney Harbor Bridge. It took training and persistence, but I was exhilarated to achieve this goal.

Another travel goal was to travel to Antarctica and walk on the continent. Again, the travel was arduous with travel excursions in zodiacs. But, we did it! We visit Africa every year or every other year. The hiking is hard, but I can do it.

More than anything I want to see our world.

Before we leave for extended travel, I make an appointment to see Dr. Nguyen as soon as we get home. Sometimes, I get in pain and struggle a bit, but I am confident that Dr. Nguyen and the staff at Virginia Spine Institute will help me every step of the way.

My advice?
Be persistent.
Keep talking to the doctors and staff.
Keep a journal so you can describe what you experience.
Schedule regular follow-up visits.
Realize no one thing is a silver bullet; try whatever is next recommended.

It can change your life.




Back pain, especially when it is severe can be extremely disabling.  People are often scared when the pain becomes incapacitating, as well as frustrated with their inability to live their life and be active.  Surprisingly staying active might be the solution in some cases.

The best treatment to manage severe back pain, especially in an acute phase, is to stop performing whatever activity is aggravating the pain.  If bending and twisting makes the pain worse, then stop bending and twisting.  If one is in such severe pain that they cannot even move, then a short period of rest may be required.  The best thing to do though, is to keep moving as much as one can without severely aggravating the pain.  Most acute pain episodes come from restricted joints in the back, tears to the disc, or other soft tissue injuries.  The good news is that most of these will respond to activity modification and appropriate exercise.  The use of anti-inflammatory medicine, such as, Advil or Aleve is often helpful.  It is important to get back to moving,  quickly and in a safe fashion to increase strength- which when done appropriately can help stabilize muscles and ligaments that support the spine, often times decreasing pain. It is important to stay consistent with an exercise and stretching routine as often as time in your schedule permits.  If an individual does not know how to start an exercise program on their own; a qualified physical therapist can provide excellent guidance and treatment to expedite the recovery.

The natural history of back pain is that most episodes will resolve spontaneously within two to four weeks.  In fact, 90% of patients get better through the tincture of time.  The problem comes when these episodes keep recurring.  People that have significant underlying spinal issues or degenerative conditions will often have recurrent episodes.  That is where the bigger problem exists and more appropriate intervention under the guidance of a spinal specialist is most appropriate.

Again, many people can get well in a properly focused non-operative program with the addition of prescription medicines, skilled physical therapists, potentially injections, and only a few will ultimately need to go on to surgical intervention.  While getting this managed by a competent spinal specialist, the patient can experience the best and most rapid restoration of their full and active lifestyle.

Unsure if physical activity is right for you? Be sure to address any questions or concerns with your medical provider.




Dr. Brian Subach joins guests Richard Deyo and reporter Dan Keating on the Diane Rehm Show {npr} to discuss Concerns about the Increase in Spinal Fusion Surgery

Program Foreword:

“More than ever before, Americans want to be as active as possible as they get older. No longer willing to be hampered by aches and pains, Americans are demanding more mobility as they age and appear more willing to consider surgery. But some medical experts are concerned about the dramatic increase in spinal fusion surgery for back pain. Over the last 20 years, the procedure has risen six-fold in this country, becoming more common than hip replacements. Join guest host Susan Page for a panel discussion about worries that financial incentives for doctors may be influencing medical decisions.”

Featured Guests:

Richard Deyo: professor, physician and researcher, Oregon Health and Science University. Author of the book: Hope or Hype: the Obsession with Medical Advances and the High Cost of False Promises”
Dan Keating: reporter, The Washington Post.
Brian Subach : spine surgeon and president, Virginia Spine Institute.

Click here to listen!




What it is:

Lateral epicondylitis or as it is more commonly known, “tennis elbow” is pain on the “outside” of the elbow (lateral epicondyle) felt with pressure or when a person resists wrist extension (squeezing or hand shaking, lifting, etc) .


How it happens:
Tennis elbow happens with an overuse of the muscles in your arm, forearm and wrist, which combined results in elbow pain. In addition to this pain, complaints of pain and weakness with grip strength are also common (ie: opening a jar). Repetitive wrist extension and gripping can cause overloading and overuse of the tendons associated with wrist extension. This can lead to degeneration or failed healing of the extensor tendons. These tendons attach to the outside of the elbow, where the pain is felt.



Who does this affect?

  • Lateral epicondylitis most commonly affects people between the ages of 30 and 60 (1-3% of the general population).
  • Lateral epicondylitis most commonly affects a person’s dominant hand.
  • It affects men and women equally regardless of socioeconomic class.

Although 40-50% of tennis players are diagnosed with tennis elbow, tennis players only account for about 5% of all people affected by lateral epicondylitis.  15% of people who work in industries that require repetitive hand use suffer from lateral epicondylitis.  This condition can vary from a mild irritation to debilitating, to the point where people cannot perform activities of daily living or work tasks.

Things to try on your own:

1. Resting and activity modification. Try to rest the injured arm or modify tasks. Proper ergonomics in the office or at home can help to minimize irritation to the extensor tendons.

2. Use ice or a cold pack for 15 minutes over the outside of the elbow after increased activity or at the end of the day.

3. Use an over-the-counter tennis elbow brace to help decrease the load placed on the extensor tendons during activities. {Virginia Therapy & Fitness Center has this product available for purchase}

4. Do basic wrist stretches to maintain wrist extensor muscle and tendon mobility.

If your symptoms do not resolve, you should treatment from a physical therapist. Your problem may stem from an irritated nerve in the neck. Your elbow pain may also be a compensation for a dysfunctional shoulder or wrist. A dysfunctional neck is often implicated when a person has pain in both elbows. Physical therapy can help by using modalities and manual therapy to decrease the inflammation to the tendon and improve healing, identifying and correcting dysfunctions of the upper quarter that could be the underlying cause of the elbow pain, and providing guided exercise to improve the flexibility and strength of the wrist extensors and prevent recurrence of the problem.


John Fainsan, PT, MSPT, MTC, CSCS
Physical Therapist


Do you have a question for one of our physical therapists? Post it in the comments below!



Tom was recently in our office and presented Dr. Schuler with a metal artwork piece that says “You’ve Got My Back” and has the We’ve Got Your Back Race For Spinal Health logo. Tom shared that he is feeling great and most importantly PAIN FREE. He was inspired to create this artwork after he himself had set the goal to run the 5k and complete it after a successful surgery! He’s not a runner so this was the ultimate goal for him; he wanted to do it because he could. We are so proud of his accomplishments and honored to have him as one of our Spinal Champions!


Tom inscribed the back with “ Dr. Schuler and VSI staff. Thank you for all you’ve done for me”.



True Story:

In the winter of 2004 I was skiing off trail on a very steep terrain when I hit ice, which sent me tumbling backwards down the mountain and eventually hitting a small tree.  I was airlifted off the mountain and treated for injuries to my chest and a concussion. When I returned home from my ski trip, I resumed all my usual activities- biking, walking, swimming, kayaking, and taking care of the house and my family. Gradually, though, my back began feeling very painful, and I was unable to continue certain exercises. I went to a doctor who told me my symptoms were primarily due to arthritis. I had some improvement in my pain after trying anti-inflammatory medication, injections, and physical therapy; eventually I was able to return to my active lifestyle.

In the spring of 2011 I participated in a 62-mile hike in D.C., and around the 22nd mile I had excruciating pain in my back.  I had to stop the hike. I resumed conservative treatments of medications, physical therapy, and rest; nothing seemed to relieve my discomfort. At this point, I began considering surgical options. I sought opinions from three surgeons before meeting Dr. Subach from the Virginia Spine Institute. He provided me with the most thorough consultation based on x-rays, surveys, and examinations. His advice was to offer me the best surgical option that would return me to the active life I’d always been able to enjoy.

Based on my x-rays & MRI, Dr. Subach diagnosed me with  spondylolisthesis at both L3/L4 and L4/L5 levels with an obvious scoliosis posture leaning toward my left.  The MRI scan showed severe spinal stenosis at the areas of spondylolisthesis, as well as compression of the exiting nerve roots. Based upon this diagnosis, Dr. Subach advocated for a three-disc fusion, where the previous surgeons had been recommending a 5-level fusion.

Approaching the date of my surgery, I was pretty apprehensive about the lengthy procedure, but I took Dr. Subach’s advice and continued to exercise as much as was possible until the operation. In 2012, I underwent a TLIF ( transforaminal lumbar interbody fusion) at L2/L3, L3/L4, and L4/L5.

During my recovery in the hospital, I wasn’t in any particularly bad pain. I was able to get up and do laps around the hospital floor almost immediately.  Once I was back home, I was able to go out for walks in the neighborhood and then go back to my gym at just two weeks after surgery.  I gained back my lost two inches, skied this winter, went kayaking on Puget Sound, enjoying numerous walks, and back doing boot camps, stretch classes, etc.

While I still think surgery or any invasive procedure should be a last resort, it should be an option to consider for anyone in enormous pain or whose activities have been sorely reduced due to pain.  And don’t wait too long to consult with an expert.

It is one year out from surgery, and I have absolutely no pain and don’t even take an occasional Advil.  We just moved from the east coast to the west coast, packing up our house of 30 years.  For four months I was lifting boxes (carefully) and reaching into the far recesses of the house; all with no ill effects.  This surgery was nothing short of miraculous.


Check out Susan’s full story in the Spinal Research Foundations most recent Journal by clicking here.



Tis the season to be indulging in festive treats and decadent drinks. Don’t let the extra calories lurking around every garland decorated corner make you a statistic. What statistic are we referring to? The extra consumed calories tend to add up to an extra pound or two for most Americans during this time of year. We’re not saying not to partake in a decorated sugar cookie or a glass of Egg Nog, instead we’re offering some tips on how to combat those pesky pounds withe some inventive ways to burn calories!

Top 10 Sneaky Ways to Burn Calories This Holiday:

  1. Writing Holiday Greetings: Finally a reason to send a note of well wishes to all of your friends and family! For every 60 minutes of writing, you will burn 72 calories! 

  2. Caroling Through the Snow: Belt out your favorite holiday tunes to your heart’s content, for every 20 minutes you will burn 45 calories. 

  3. Grab Your Skates: Ice skating round and round the rink wil burn 239calories for every 30 minutes spent on the ice. 

  4. Cross Country Skiing: The aerobic activity at a moderate pace will burn 307 calories for every 30 minutes spent traversing the snowy terrain. 

  5. Downhill Skiing: Going downhill your thing? A moderate pace wi;; burn 181 calories for 30miutes of parallel turns and hockey stops. 

  6. Recreational Sledding: Grab the kiddos and burn 239 calories for 30 minutes of fun! 

  7. Household Chore, Ironing: Need to make your Ugly Holiday Sweater spiffy for a party? Make sure you spend 15 minutes getting the wrinkles out and burn 31 calories in the process! 

  8. Park Further Away: Most likely if you’re out doing last minute gift shopping, or any shopping at all, the choice parking spots will be next to impossible t o find. Have the last laugh and park in the furthest spot, and on your way back grab that holiday flavored latte you were craving, you deserve it! 

  9. Take the Stairs: Skip the elevators and take the stairs instead, you can burn anywhere from 10-15c calories (depending on the number of flights)! 

  10. Chopping Wood: Looking to roast some chestnuts by an open fire? You’ll need some fire wood, so get out there and chop (please use proper form and caution) and you can burn 206calories in 30 minutes of this outdoorsy activity.


So now we’ve armed you with some fun and creative ways to burn a few extra calories. Keeping up with your exercise routine will also have you ahead of the holiday gain. Here’s a great smartphone app if you want to track calories you burn.


Share with us your favorite winter activity to burn off  extra calories


* calories burned are estimated based on an adult weighing 150 pounds.



‘Tis the season for all things festive. We want to keep you in that jolly mood by helping you to avoid unnecessary back pain this winter season. Whether you are lugging a heavy pine tree up your stairs or shoveling your driveway, there are several winter activities that may cause you to suffer from back pain caused by muscle fatigue, lower back pain, or even vertebral disc damage.

Five tips to keep your back healthy  & safe this winter:

1. Shoveling Your Driveway:

If you’re going to shovel your driveway here are some important tips to avoid injuries, find out what they are by clicking here.

2. Getting Around Town:

Whether traveling in the car or by foot, it’s important to take your time in getting to where you are going.

  • Allow extra time; a little bit of extra time, could end up saving you from dealing with a painful back injury
  • Don’t run to catch the bus, sidewalks could be covered in black ice and lead to a fall
  • Be sure to use handrails when taking the stairs
  • If traveling by car and you get stuck, be sure there are at least three people pushing, to avoid potential back strain.

3. Sport Proper Footwear:

Make sure you wear stable shoes, with a reliable tread. You can also purchase products that snap on to your existing footwear to provide better traction in wintery conditions. If you are unstable on your feet, perhaps think about investing in a walking stick to allow for more stability and to avoid falls.

4. Be Careful with Your Load:

Be sure to keep your balance by not carrying too many items. You can equalize the load by distributing the weight evenly on both sides of your body. If your items seem too heavy to safely manage, ask for assistance or make more than one trip. For some tips on proper lifting, click here.

5. Remember to Exercise:

We all wish we could hibernate all winter and the it is more than tempting to slack off on going to the gym. Be sure to keep up with your physical activities because having strong muscles and a strong core will give you an advantage in prevention. In addition, it’s important to remain physically fit all year through to stay healthy and happy. Want more tips on how to stay fit this winter? Click here.


Any tips we missed that you would like to learn more about? Comment below and we will pass your query on to one of our experts!



The weather has cooled down and the transition from fall to winter is officially upon us. Everywhere you look outside you see people out training for running events. 10 milers, 5Ks, Turkey Trots, and marathons are becoming more and more popular . One of the most common injuries to a runner is “runner’s knee” or patellofemoral pain syndrome. Knee injuries occur about 40 percent of the time from running. Patellofemoral pain syndrome (PFPS) typically causes localized knee pain that occurs after extended periods of sitting, during or after long runs, descending stairs and hills, and squatting. The development of patellofemoral pain syndrome can be attributed to a variety of biomechanical issues. Putting an extra load on the knee is typically due to poor mechanics. Those at a higher risk for developing patellofemoral pain syndrome may include individuals that have weak quadriceps or gluteals , overpronate during running, inadequate stretching.

You can run through the pain but it may exacerbate your symptoms. It is suggested to take extra rest days between long runs or decreasing running mileage. Uphill running may help alleviate the onset of PFPS and require activation of gluteal muscles. In addition, strengthening your gluteal muscles help control your hip and knee movement and prevent excessive wear on the knee. If the pain does not subside, a physical therapist can provide interventions to help improve body mechanics during running, utilize athetic taping, and provide rehabilitation to reduce your pain. Physical therapy can help improve running technique to help prevent a relapse. Shortening your stride length and contacting the ground with a slight knee bend can decrease the load on the knee.

To help prevent the onset of PFPS, it is suggested individuals stay in shape and overall good general conditioning level. Additionally, it is important to have a consistent stretching routine. It is best to do a 5 minute warm up followed by a stretching routine. When training for races, increase your training gradually while avoiding a sudden increase in intensity level of exercise.

Jessica Stepien, PT, DPT
Physical Therapist

Do you have a question for one of our physical therapists? Post it in the comments below!




Francis recently came in for a follow-up appointment about four months post spinal fusion surgery. When his back pain got in the way of daily activities and hobbies that he enjoyed, he came to the Virginia Spine Institute. His main objective when overcoming his back pain was to get back out onto his boat and be able to handle his trolling motor free of pain. Several injections and a surgery later, Francis strolls into VSI with a grin that lit up the room! He shared with us that just the week prior, he was on the Occoquan River, it was 6:00 am, the sun was rising, the leaves on the trees were breathtakingly gorgeous and to top it off it was a cloudless day. He was at the bow of his boat and flipped the motor and at that moment he was grateful for Dr. Schuler and the entire VSI team, for making that moment happen. { PS: he caught many fish that day!}

Congratulations, Francis! The entire VSI team is proud of your accomplishments and inspired by your success story.