What is Multilevel Spondylosis? Guide & Treatment

Multilevel spondylosis, a degenerative condition affecting the spine, involves changes in multiple vertebral levels, contrasting with single-level spinal disorders typically addressed by organizations like the North American Spine Society. These changes, often identified through diagnostic imaging techniques such as Magnetic Resonance Imaging (MRI), can lead to nerve compression and pain. Treatment options vary, emphasizing physical therapy techniques, but in advanced cases, surgical intervention, sometimes guided by specialists in orthopedic surgery, may be necessary. Understanding what is multilevel spondylosis is crucial for effective management and improved quality of life.

Spondylosis, a term often encountered with increasing frequency in discussions about spinal health, refers to the degenerative changes that occur within the spine over time. It is not a disease per se, but rather a description of the gradual wear and tear that affects the vertebrae, discs, and related structures.

This degeneration can manifest in various ways, including the formation of bone spurs (osteophytes), the drying out or herniation of intervertebral discs, and the stiffening of ligaments. While spondylosis is often associated with aging, it’s important to recognize that it can also be influenced by genetic predisposition, injury, and lifestyle factors.

Common Areas Affected

Spondylosis can occur in any region of the spine, but it is most prevalent in the cervical (neck) and lumbar (lower back) regions. Thoracic spondylosis, affecting the mid-back, is less common. Each location presents unique challenges due to the specific biomechanics and nerve pathways involved.

• Cervical Spondylosis: Can lead to neck pain, headaches, and neurological symptoms affecting the upper extremities.

• Lumbar Spondylosis: Is a common cause of lower back pain, sciatica, and difficulty with mobility.

• Thoracic Spondylosis: May result in mid-back pain and, in rare cases, nerve compression.

Impact on Quality of Life

The symptoms of spondylosis can range from mild discomfort to severe, debilitating pain. This, in turn, can significantly impact an individual’s quality of life.

Everyday activities such as walking, sitting, sleeping, and even simple movements can become challenging and painful. The chronic pain associated with spondylosis can also lead to mood disturbances, sleep disorders, and decreased overall well-being.

Furthermore, neurological complications resulting from nerve compression can further limit functionality, affecting work, recreation, and social interactions.

The Progressive Nature

It is crucial to understand that spondylosis is often a progressive condition. This means that the degenerative changes tend to worsen over time, although the rate of progression can vary greatly from person to person.

Early intervention and management are therefore essential to slow the progression of the condition, alleviate symptoms, and maintain functionality for as long as possible. While spondylosis cannot be cured, its impact can be effectively managed through a combination of lifestyle modifications, medical treatments, and rehabilitative therapies.

Anatomy Under Attack: Identifying the Spinal Structures Affected by Spondylosis

Spondylosis, a term often encountered with increasing frequency in discussions about spinal health, refers to the degenerative changes that occur within the spine over time. It is not a disease per se, but rather a description of the gradual wear and tear that affects the vertebrae, discs, and related structures. This degeneration can manifest in various ways, ultimately impacting the intricate network of components that make up the spinal column. Understanding which structures are targeted by spondylosis is crucial for grasping the condition’s effects on overall spinal health.

The Vertebral Column: The Spine’s Foundation

The vertebral column, or spine, serves as the primary structural support for the body, protecting the spinal cord and enabling movement. It comprises a series of individual bones called vertebrae, stacked one upon another.

Each vertebra consists of a vertebral body, which bears the majority of the weight, and a vertebral arch, which encloses and protects the spinal cord. In spondylosis, vertebrae can develop bone spurs (osteophytes) as the body attempts to stabilize the spine. This can lead to narrowing of the spinal canal (stenosis) or the intervertebral foramen, potentially compressing the spinal cord or nerve roots.

Intervertebral Discs: Cushions Under Pressure

Between each vertebra lies an intervertebral disc, acting as a shock absorber and allowing for flexibility. These discs are composed of a tough outer layer (annulus fibrosus) and a gel-like inner core (nucleus pulposus).

With age and the progression of spondylosis, intervertebral discs can degenerate, losing their water content and elasticity. This results in reduced disc height, decreased cushioning, and increased stress on the surrounding structures. Degenerated discs can also bulge or herniate, potentially impinging on nerve roots.

Facet Joints: Guiding Movement and Stability

Facet joints are small, paired joints located at the back of each vertebra. They provide stability to the spine and guide its movement, allowing for bending, twisting, and extension.

Like other joints in the body, facet joints are susceptible to degeneration in spondylosis. The cartilage that lines these joints can wear away, leading to bone-on-bone contact, inflammation, and the development of osteoarthritis. This can result in pain, stiffness, and reduced range of motion.

The Spinal Cord: A Vital Nerve Pathway

The spinal cord is a critical nerve pathway that transmits signals between the brain and the rest of the body. It runs through the vertebral canal, which is formed by the vertebral arches.

In spondylosis, the spinal cord can be compressed by bone spurs, herniated discs, or thickened ligaments. This compression, known as myelopathy, can disrupt nerve function and lead to a range of symptoms, including weakness, numbness, tingling, and bowel or bladder dysfunction.

Nerve Roots: Branching Out from the Spinal Cord

Nerve roots are branches that extend from the spinal cord, exiting the vertebral column through the intervertebral foramen. These nerve roots transmit signals to and from specific areas of the body.

Spondylosis can cause compression of nerve roots, leading to radiculopathy. Radiculopathy is characterized by pain, numbness, tingling, or weakness that radiates along the path of the affected nerve.

Foramen: The Exits for Nerve Roots

The intervertebral foramen are openings located between adjacent vertebrae, providing a passageway for nerve roots to exit the spinal canal.

In spondylosis, these foramen can narrow due to bone spurs, disc degeneration, or facet joint arthritis. This narrowing, known as foraminal stenosis, can compress the nerve roots as they exit the spine, leading to radiculopathy.

Ligaments and Spinal Muscles: Supporting Structures

Ligaments and spinal muscles are supporting structures that play a crucial role in spinal stability and movement. Ligaments connect vertebrae to each other, providing support and limiting excessive motion. Spinal muscles provide the force necessary for movement and help to maintain posture.

In spondylosis, ligaments can thicken and lose their elasticity, contributing to spinal stiffness and reduced range of motion. Spinal muscles can become weak or strained as they attempt to compensate for the degenerative changes in the spine.

The Care Team: Medical Professionals Involved in Spondylosis Management

Spondylosis, while a common condition, often requires a multifaceted approach to treatment. Navigating the landscape of medical specialties can be daunting, but understanding the roles of various healthcare professionals is crucial for effective management. A collaborative team is essential to address the diverse needs of individuals living with spondylosis.

Orthopedic Surgeons: Surgical Intervention and Spinal Stabilization

Orthopedic surgeons are often the first point of contact for individuals experiencing significant pain or functional limitations due to spondylosis. These specialists focus on the diagnosis and surgical treatment of musculoskeletal conditions, including those affecting the spine.

When conservative treatments fail to provide adequate relief, orthopedic surgeons may recommend surgical intervention. Common procedures performed include:

• Spinal Fusion: This involves joining two or more vertebrae together to eliminate motion between them, providing stability and reducing pain.

• Laminectomy: This procedure removes a portion of the vertebral bone (the lamina) to create more space for the spinal cord and nerves, relieving compression.

• Foraminotomy: This surgery enlarges the intervertebral foramen, the opening through which nerve roots exit the spinal canal, alleviating nerve compression.

• Discectomy: This involves removing a damaged or herniated intervertebral disc that is pressing on a nerve root or the spinal cord.

Neurosurgeons: Addressing Complex Neural Compression

Neurosurgeons specialize in the surgical treatment of conditions affecting the brain, spinal cord, and peripheral nerves. In the context of spondylosis, neurosurgeons are typically consulted for complex cases involving significant spinal cord compression or neurological deficits.

Their expertise is crucial in procedures that directly impact the spinal cord and its delicate surrounding structures. Neurosurgeons often collaborate with orthopedic surgeons to provide comprehensive surgical solutions for severe cases of spondylosis.

Physiatrists: Non-Surgical Management and Rehabilitation

Physiatrists, also known as physical medicine and rehabilitation (PM&R) physicians, focus on restoring function and improving the quality of life for individuals with physical impairments or disabilities. Their approach to spondylosis management centers on non-surgical interventions and rehabilitation strategies.

Physiatrists play a critical role in pain management. They design individualized treatment plans that incorporate physical therapy, medications, and interventional procedures to alleviate pain and improve functional abilities.

Pain Management Specialists: Targeted Pain Relief

Pain management specialists are physicians who specialize in the diagnosis and treatment of chronic pain conditions. In the context of spondylosis, they utilize a variety of techniques to reduce pain and improve function.

These techniques include:

• Epidural Steroid Injections: These injections deliver corticosteroids into the epidural space, the area surrounding the spinal cord, to reduce inflammation and pain.

• Facet Joint Injections: These injections target the facet joints, small joints located in the back of the spine, to alleviate pain caused by arthritis or inflammation.

• Neuropathic Pain Medications: These medications, such as gabapentin and pregabalin, are used to manage nerve pain associated with spondylosis.

Physical Therapists: Restoring Function and Mobility

Physical therapists are essential members of the spondylosis care team. They design and implement exercise programs to improve strength, flexibility, and range of motion.

They also educate patients on proper body mechanics and posture to prevent further injury and manage pain. Physical therapy is often a cornerstone of both non-surgical and post-surgical rehabilitation for spondylosis.

Radiologists: Imaging and Diagnosis

Radiologists play a critical role in the diagnosis of spondylosis. They interpret imaging studies, such as X-rays, MRIs, and CT scans, to identify the underlying causes of pain and functional limitations.

Their expertise helps to determine the extent of spinal degeneration, nerve compression, and other abnormalities. This information is essential for guiding treatment decisions.

Neurologists: Addressing Neurological Symptoms

Neurologists specialize in the diagnosis and treatment of disorders affecting the nervous system. In the context of spondylosis, neurologists are consulted when patients experience neurological symptoms such as numbness, tingling, weakness, or changes in reflexes.

They can help to determine whether these symptoms are directly related to spondylosis or if other underlying conditions may be contributing.

In summary, effective spondylosis management requires a collaborative approach involving a team of medical professionals. Understanding the role of each specialist ensures that patients receive comprehensive and coordinated care.

Unveiling the Condition: Diagnostic Procedures for Spondylosis

Spondylosis, a condition characterized by spinal degeneration, demands accurate diagnosis to guide effective treatment strategies. This diagnostic journey typically involves a combination of clinical evaluation and advanced imaging techniques. This comprehensive approach ensures that the underlying causes and severity of spondylosis are fully understood, paving the way for personalized management plans.

The Foundation: Physical Examination

The diagnostic process invariably begins with a thorough physical examination. During this evaluation, a healthcare professional will meticulously assess the patient’s reported symptoms, including the location, intensity, and nature of the pain. They will also investigate any associated neurological symptoms, such as numbness, tingling, or weakness in the extremities.

Range of motion testing is a crucial component of the physical exam. It assesses the extent to which the patient can move their neck or back in various directions. Limitations in range of motion, accompanied by pain, often indicate the presence of spinal degeneration.

Furthermore, a neurological examination is performed to evaluate nerve function. This involves testing reflexes, muscle strength, and sensation to identify any signs of nerve compression or damage. The findings from the physical examination provide valuable clues that help guide subsequent diagnostic investigations.

The Power of Imaging: Visualizing Spinal Structures

Imaging techniques play a pivotal role in confirming the diagnosis of spondylosis and assessing the extent of spinal degeneration. Different modalities offer unique perspectives on the spinal structures, enabling healthcare professionals to identify the specific anatomical changes associated with the condition.

X-rays: An Initial Assessment

X-rays are often the first-line imaging study used to evaluate the spine. They provide a basic assessment of the bony structures, revealing abnormalities such as vertebral misalignment, fractures, or bone spurs (osteophytes).

X-rays are particularly useful for evaluating spinal alignment and stability. They can help identify conditions like scoliosis or spondylolisthesis, which may contribute to spondylosis. While X-rays do not visualize soft tissues, they offer valuable insights into the overall structural integrity of the spine.

MRI: Unveiling Soft Tissue Details

Magnetic Resonance Imaging (MRI) provides detailed images of the soft tissues within the spine, including the intervertebral discs, spinal cord, and nerve roots. This imaging modality is invaluable for detecting nerve compression, disc herniations, and other soft tissue abnormalities that may be associated with spondylosis.

MRI is particularly sensitive for identifying changes in the intervertebral discs, such as dehydration or degeneration, which are hallmarks of spondylosis. It also allows for visualization of the spinal cord and nerve roots, enabling the detection of any impingement or compression. This information is crucial for determining the appropriate course of treatment.

CT Scans: A Focus on Bone

Computed Tomography (CT) scans offer detailed images of the bony structures of the spine. While MRI excels at visualizing soft tissues, CT scans provide superior resolution for evaluating bony abnormalities, such as facet joint arthritis and spinal stenosis.

CT scans are particularly useful for assessing the severity of facet joint degeneration, a common feature of spondylosis. The images can reveal the presence of bone spurs, narrowing of the joint space, and other signs of arthritis. CT scans can also help visualize the extent of spinal stenosis, which is the narrowing of the spinal canal that can compress the spinal cord or nerve roots.

Assessing Nerve Function: Electrophysiological Studies

In some cases, nerve function tests, such as Electromyography (EMG) and Nerve Conduction Studies (NCS), may be necessary to assess the impact of spondylosis on nerve function. These tests help determine if nerve compression or damage is present, and to what extent it is affecting nerve conduction.

EMG measures the electrical activity of muscles, while NCS measures the speed at which electrical signals travel along nerves. These tests can help differentiate between nerve damage caused by spondylosis and other neurological conditions.

The findings from EMG and NCS can provide valuable information for guiding treatment decisions, particularly in cases where nerve compression is suspected. These tests can help determine the severity of nerve involvement and identify the specific nerves that are affected.

Road to Recovery: Treatment Modalities for Spondylosis

[Unveiling the Condition: Diagnostic Procedures for Spondylosis

Spondylosis, a condition characterized by spinal degeneration, demands accurate diagnosis to guide effective treatment strategies. This diagnostic journey typically involves a combination of clinical evaluation and advanced imaging techniques. This comprehensive approach ensures that the… ]

Once a diagnosis of spondylosis is confirmed, the path to recovery involves a multifaceted approach, combining both non-surgical and surgical interventions. The primary goals of treatment are to alleviate pain, improve function, and prevent further neurological decline. This section will explore the diverse treatment modalities available, shedding light on their respective roles in managing this complex condition.

Non-Surgical Treatment Options

For many individuals with spondylosis, non-surgical approaches offer significant relief and improved quality of life. These conservative treatments focus on managing symptoms and enhancing the body’s natural healing processes.

Physical Therapy: Restoring Function and Mobility

Physical therapy plays a pivotal role in the non-surgical management of spondylosis. A tailored exercise program, designed by a qualified physical therapist, can improve strength, flexibility, and range of motion. Specific exercises may target core muscles to stabilize the spine, reduce pain, and enhance overall function.

Furthermore, physical therapists employ various techniques, such as manual therapy and modalities like heat or cold therapy, to alleviate pain and muscle spasms. Patient education on proper posture, body mechanics, and ergonomic principles is also crucial to prevent further injury and promote long-term spinal health.

Medications: Managing Pain and Inflammation

Pharmacological interventions are frequently employed to manage the pain and inflammation associated with spondylosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to reduce inflammation and alleviate mild to moderate pain.

For more severe pain, analgesics such as opioids may be considered, although their use is typically reserved for short-term management due to the risk of dependence and other side effects. Muscle relaxants can help alleviate muscle spasms, while corticosteroids, administered orally or via injection, can provide potent anti-inflammatory effects.

Spinal Injections: Targeted Pain Relief

Spinal injections represent a more targeted approach to pain management in spondylosis. Epidural steroid injections involve injecting corticosteroids into the epidural space, the area surrounding the spinal cord and nerve roots. This can reduce inflammation and alleviate pain radiating from compressed nerves.

Facet joint injections target the facet joints, small joints located between the vertebrae. Injecting corticosteroids into these joints can reduce pain and inflammation, particularly in cases of facet joint arthritis contributing to spondylosis symptoms.

Surgical Treatment Options

When non-surgical treatments fail to provide adequate relief or neurological symptoms worsen, surgical intervention may be considered. Surgical procedures for spondylosis aim to decompress nerves, stabilize the spine, and reduce pain.

Laminectomy: Decompressing the Spinal Cord

Laminectomy involves removing a portion of the lamina, the bony arch of the vertebra, to create more space for the spinal cord and nerve roots. This procedure can alleviate pressure on these structures, reducing pain, numbness, and weakness.

Foraminotomy: Enlarging Nerve Root Passages

Foraminotomy aims to widen the intervertebral foramen, the opening through which nerve roots exit the spinal canal. By removing bone or tissue obstructing the foramen, this procedure can relieve nerve root compression and alleviate radicular pain.

Spinal Fusion: Stabilizing the Spine

Spinal fusion involves joining two or more vertebrae together to create a solid, immobile segment. This procedure can stabilize the spine, reduce pain associated with instability, and prevent further degeneration. Fusion may be considered in cases of severe spondylosis, spinal instability, or significant pain that is unresponsive to other treatments.

Discectomy: Removing Damaged Disc Material

Discectomy involves removing a portion or the entirety of a damaged intervertebral disc that is compressing a nerve root or the spinal cord. This procedure is often performed in conjunction with a laminectomy or foraminotomy to provide further decompression.

Factors Influencing Treatment Choice

The choice of treatment for spondylosis is highly individualized and depends on several factors, including the severity of symptoms, the location and extent of spinal degeneration, the patient’s overall health, and their response to previous treatments. Non-surgical options are typically exhausted before considering surgery.

Younger patients with more localized disease may be candidates for more aggressive surgical interventions, while older patients with multiple comorbidities may benefit from a more conservative approach. A thorough evaluation by a multidisciplinary team of healthcare professionals is essential to determine the most appropriate treatment strategy for each individual.

Understanding the Connections: Related Conditions Associated with Spondylosis

Spondylosis, a condition characterized by spinal degeneration, often presents alongside other related spinal ailments. Understanding these interconnected conditions is crucial for accurate diagnosis, comprehensive management, and improved patient outcomes. These conditions can contribute to or exacerbate the effects of spondylosis, creating complex clinical scenarios.

Degenerative Disc Disease (DDD) and Spondylosis: A Symbiotic Relationship

Degenerative Disc Disease (DDD) is intrinsically linked to spondylosis. It’s not actually a "disease" but a descriptive term for the gradual deterioration of the intervertebral discs. These discs, acting as cushions between the vertebrae, lose hydration and elasticity over time.

This degeneration results in reduced disc height and increased stress on adjacent spinal structures. The progression of DDD frequently precipitates spondylosis, as the body attempts to stabilize the spine in response to disc degeneration. This often leads to the formation of bone spurs and facet joint arthritis, hallmarks of spondylosis.

Spinal Stenosis: A Common Consequence of Spinal Degeneration

Spinal Stenosis, the narrowing of the spinal canal, is a frequent consequence of spondylosis. The degenerative changes associated with spondylosis, such as bone spur formation and thickening of ligaments, directly contribute to the narrowing of the spinal canal.

This narrowing can compress the spinal cord or nerve roots, leading to a variety of neurological symptoms. The severity of spinal stenosis varies, ranging from mild discomfort to significant pain and functional limitations. Surgical intervention may be necessary in severe cases.

Radiculopathy: Nerve Compression and Radiating Pain

Radiculopathy refers to nerve compression or irritation as it exits the spinal column. Spondylosis-related changes, such as herniated discs or bone spurs, can directly compress nerve roots.

This compression leads to radiating pain, numbness, tingling, and weakness in the extremities. Cervical radiculopathy, affecting the neck and arms, and lumbar radiculopathy, affecting the lower back and legs (sciatica), are common manifestations. Accurate diagnosis and targeted treatment are essential for managing radiculopathy.

Myelopathy: Spinal Cord Compression and Neurological Deficits

Myelopathy is a serious condition resulting from spinal cord compression. In the context of spondylosis, myelopathy typically arises from severe spinal stenosis or direct compression from bone spurs.

The consequences of myelopathy can be profound, including gait disturbances, loss of fine motor skills, bowel and bladder dysfunction, and even paralysis. Prompt diagnosis and intervention, often surgical, are crucial to prevent irreversible neurological damage.

Bone Spurs (Osteophytes): The Body’s Attempt at Stabilization

Bone Spurs, also known as osteophytes, are bony projections that develop along the edges of bones. In the context of spondylosis, bone spurs form as the body’s attempt to stabilize the spine in response to degeneration.

While intended to provide support, these bone spurs can inadvertently compress nerve roots or the spinal cord. Their presence is a key indicator of spondylosis, and they often contribute significantly to the associated pain and neurological symptoms.

Managing Spondylosis: Key Concepts for Improved Well-being

Spondylosis, a condition characterized by spinal degeneration, often presents alongside other related spinal ailments. Understanding these interconnected conditions is crucial for accurate diagnosis, comprehensive management, and improved patient outcomes. Beyond treating individual symptoms, a holistic approach that considers several key concepts is paramount for long-term well-being.

This involves proactively addressing inflammation, implementing effective pain management strategies, acknowledging the complexities of multi-level disease, and tailoring treatment to the specific location of the spondylosis within the spine.

The Critical Role of Inflammation Management

Inflammation is a central player in the pathology of spondylosis, exacerbating pain and contributing to further degeneration. Controlling inflammation is not merely about symptom relief; it’s about slowing the progression of the disease itself.

Therefore, a comprehensive management plan must prioritize anti-inflammatory strategies.

These often include lifestyle modifications such as adopting an anti-inflammatory diet rich in omega-3 fatty acids, fruits, and vegetables, while limiting processed foods, sugars, and saturated fats.

Medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may be prescribed, but their long-term use should be carefully monitored due to potential side effects.

In some cases, corticosteroid injections may be considered to provide localized, targeted anti-inflammatory relief.

The Importance of Proactive Pain Management

Chronic pain is a debilitating hallmark of spondylosis that significantly impacts a patient’s quality of life. Effective pain management extends beyond simply masking the pain; it seeks to restore function, improve mobility, and enhance psychological well-being.

Multi-Modal Pain Relief

A multi-modal approach is often the most successful, combining pharmacological interventions with non-pharmacological therapies.

This may include physical therapy to strengthen supporting muscles and improve range of motion, as well as alternative therapies such as acupuncture or massage.

Psychological Support

It’s important to acknowledge the psychological component of chronic pain, as depression, anxiety, and stress can amplify pain perception. Cognitive-behavioral therapy (CBT) and mindfulness techniques can be invaluable tools for coping with chronic pain and improving overall mental health.

Addressing the Complexities of Multi-Level Disease

Spondylosis frequently affects multiple levels of the spine simultaneously, creating a complex clinical picture.

Diagnostic Challenges

Managing multi-level disease presents significant diagnostic and therapeutic challenges. Identifying the primary source of pain and neurological symptoms can be difficult when multiple spinal segments are involved.

Advanced imaging techniques, such as MRI and CT scans, are essential for accurately assessing the extent of degeneration at each level.

Treatment Strategies

Treatment strategies must be tailored to address the specific pathology at each affected level, considering the severity of degeneration, the presence of nerve compression, and the patient’s overall functional status.

Location-Specific Considerations: Cervical, Lumbar, and Thoracic Spondylosis

The clinical presentation and management strategies for spondylosis vary depending on the location of the affected spinal segment.

Cervical Spondylosis (Neck)

Cervical spondylosis can cause neck pain, stiffness, headaches, and radicular symptoms that radiate into the shoulders, arms, and hands.

In severe cases, spinal cord compression (cervical myelopathy) can lead to gait disturbances, balance problems, and bowel or bladder dysfunction.

Lumbar Spondylosis (Lower Back)

Lumbar spondylosis commonly presents with lower back pain, stiffness, and radicular symptoms that radiate into the buttocks, legs, and feet (sciatica).

Spinal stenosis, a narrowing of the spinal canal, is a frequent complication of lumbar spondylosis, causing neurogenic claudication (leg pain with walking).

Thoracic Spondylosis (Mid-Back)

Thoracic spondylosis is less common than cervical or lumbar spondylosis.

It can manifest as mid-back pain, stiffness, and, less frequently, radicular symptoms that follow the rib cage.

Because of the location in the mid-back, thoracic spondylosis can also cause referred pain patterns that are often misdiagnosed.

Dealing with multilevel spondylosis can feel overwhelming, but remember, you’re not alone, and there are definitely ways to manage the discomfort and get back to doing the things you enjoy. Hopefully, this guide has given you a clearer understanding of what multilevel spondylosis is and the treatment options available so you can have a productive conversation with your doctor about the best path forward for you.