Introduction
The vast majority of spine pain, such as general back pain, neck pain, radiculopathy, and/or sciatica, doesn’t require surgery. Published evidence is consistent on this point: most patients with spinal conditions improve with non-operative management, and surgery produces better outcomes when it follows a genuine trial of conservative care rather than preceding it. [5] The clinical challenge isn’t whether to avoid surgery but rather identifying the precise source of the pain, building the right non-operative plan, and knowing when that plan has reached its limits and escalation is appropriate.
At New York Bone & Joint Specialists, spine care is built around that challenge. Every patient with a spinal complaint is seen promptly by one of our non-operative sports medicine physicians as first contact, with escalation to our interventional spine specialists when conservative treatment has not provided adequate relief or when symptoms warrant a more aggressive non-surgical approach. Physical therapy is integrated from the beginning. Electrodiagnostic testing, such as EMG and nerve conduction studies, is available in-house for the cases where imaging alone does not tell the full story.
New York Bone & Joint doesn’t perform spine surgery. When a patient’s evaluation establishes that surgical intervention is the right answer, we refer to trusted spine surgery specialists. That honesty is intentional. We aren’t a surgical spine practice that offers non-operative care as an afterthought. We are a non-operative spine and musculoskeletal practice with the diagnostic depth and interventional capability to exhaust every appropriate option before that conversation needs to happen.
How Spine Care Works at New York Bone & Joint: The Pathway
New York Bone & Joint’s spine care model is built around the principle that the right physician should see the patient at the right stage of their care, not a surgeon at the first appointment, and not a general practitioner managing a complex nerve compression indefinitely without specialist input.
| Stage | Who Sees You | What Happens | When to Escalate |
| First contact: new spine complaint | Non-operative sports medicine physician (Drs. Munyak, Bytici, Davis, Razani, Martin) | Clinical evaluation, history, physical exam, review of imaging. Initial treatment plan: activity modification, physical therapy referral, anti-inflammatory management, and/or imaging if not yet obtained. | If symptoms persist after 4–6 weeks of conservative treatment, or if neurological symptoms are present at first visit, escalate to spine specialist. |
| Spine specialist evaluation | Dr. Michael Mizhiritsky (PMR/EMG) or Dr. Nick Gupta (interventional spine) | Full spine and neurological examination. EMG/NCS ordered when nerve function assessment is needed. Imaging reviewed and interpreted in clinical context. Treatment plan refined. | If EMG confirms nerve compression at a specific level and conservative measures have failed, interventional procedures are indicated. |
| Interventional procedures | Dr. Nick Gupta (interventional spine) or Dr. Efime Popovitz (pain management) | Epidural steroid injections, medial branch blocks, radiofrequency ablation, sacroiliac joint injections, or other targeted interventions based on diagnosis. | If two appropriately targeted interventional procedures do not provide meaningful relief, surgical evaluation referral is appropriate. |
| Physical therapy, throughout | New York Bone & Joint in-house physical therapy department, led by Cecilia Manubay, PT | Physical therapy begins at first contact for most spine patients and continues through all stages. Protocol is coordinated with the treating physician at each stage. | Physical therapy continues concurrently with all non-operative stages. |
| Surgical referral (when indicated) | Trusted spine surgery specialists, referred by New York Bone & Joint | When the evaluation establishes that surgical correction is the right answer, New York Bone & Joint refers to spine surgeons with whom we have established working relationships. The clinical picture, EMG findings, and imaging are communicated directly. | New York Bone & Joint doesn’t perform spine surgery. |
EMG and Nerve Conduction Studies: What Imaging Can’t Tell You
An MRI of the lumbar or cervical spine is an anatomical study. It shows structure: disc height, herniation, osteophytes, foraminal narrowing, canal stenosis. What it cannot show is function, such as whether a nerve root that appears compressed on imaging is actually conducting abnormally or if a disc bulge that looks significant is actually the source of the patient’s symptoms. [2]
This distinction matters clinically in two important ways. First, studies consistently show that a significant proportion of asymptomatic adults have disc herniations, disc bulges, and other findings on MRI that would appear pathological if interpreted without clinical context. [2] A finding on MRI is not automatically the cause of the patient’s pain. Second, imaging may not capture early or subtle nerve injury that is already producing symptoms. A patient with classic dermatomal radiculopathy and a negative or equivocal MRI may have a compressive lesion that is not yet visible on standard imaging but is already detectable on EMG.
| What EMG and Nerve Conduction Studies Tell Us that MRI Can’tIs the nerve actually injured? EMG measures the electrical activity of muscle fibers innervated by a specific nerve root. If that nerve root is compressed to the point of causing nerve injury, the EMG shows characteristic changes in the muscle that are physiological, not anatomical. A bulging disc may or may not be compressing a nerve root to the degree that causes nerve injury. The EMG tells us whether it is. [8]Which level is symptomatic? A patient may have disc pathology at multiple levels on MRI. The EMG, by testing the muscles innervated by specific nerve roots, identifies which level is producing the neurological symptoms. This guides the targeting of interventional procedures and, when surgery is being planned, confirms the operative level. [7] [8]How severe is the nerve injury? EMG findings can distinguish between mild axonal loss, moderate compression, and severe injury patterns. This severity assessment helps set realistic expectations for recovery and guides the urgency of escalation.Pre-operative confirmation for spine surgeons: Some of the most respected spine surgeons in New York City refer patients to Dr. Mizhiritsky for pre-operative EMG evaluation before proceeding with spinal surgery. The EMG findings confirm the symptomatic level, clarify the clinical picture, and in some cases change the surgical plan. The physiological confirmation that the nerve is actually injured at the level being operated on is a standard that the most rigorous surgical programs hold themselves to.“The most valuable thing an EMG can do is confirm that the anatomy and the physiology agree. When they do, when the disc herniation at L4-L5 corresponds to EMG changes in the muscles innervated by the L4 and L5 nerve roots, the clinical picture is complete and the treatment plan is clear. When they don’t, such as when the MRI shows a bulge but the EMG is normal, or when the EMG shows nerve injury at a level that looks relatively normal on imaging, that discordance is some of the most important diagnostic information we can have. It tells us we may be looking in the wrong place, or that there is more going on than the imaging revealed.” — Dr. Michael Y. Mizhiritsky |
Spine Conditions We Treat
New York Bone & Joint’s spine team evaluates and manages the full range of cervical, thoracic, and lumbar spinal conditions through non-operative means. The following are the most commonly seen conditions.
| Condition | Spinal Region | Primary Symptoms | First-Line Non-Surgical Approach |
| Cervical Radiculopathy (Pinched Nerve) | Cervical (neck) | Arm pain, numbness, or weakness in a dermatomal distribution. Neck pain with radiation. Positive Spurling’s test. | Physical therapy (cervical stabilization, traction), cervical epidural steroid injection if physical therapy is insufficient [4] [10] |
| Lumbar Radiculopathy (Sciatica) | Lumbar (low back) | Leg pain, numbness, or weakness radiating below the knee in a dermatomal pattern. Positive straight leg raise. | Physical therapy, lumbar epidural steroid injection (interlaminar or transforaminal) [3] [4] |
| Herniated Disc | Cervical or lumbar | Acute or chronic radicular symptoms from disc material compressing a nerve root. | Physical therapy, NSAIDs, epidural steroid injection at symptomatic level. Most resorb over 6–12 weeks. [1] |
| Spinal Stenosis (Lumbar) | Lumbar | Neurogenic claudication: bilateral leg pain and weakness with walking, relieved by sitting or forward flexion. | Physical therapy, lumbar epidural steroid injection, activity modification [3] [4] |
| Degenerative Disc Disease | Cervical or lumbar | Axial neck or back pain, stiffness, exacerbated by loading. May have radicular component. | Physical therapy, pain management, activity modification. Injection when axial pain is refractory. [6] |
| Facet Joint Arthropathy | Cervical or lumbar | Axial neck or low back pain, worse with extension. No radiculopathy. Positive response to facet loading. | Medial branch blocks (diagnostic) → radiofrequency ablation if confirmed facet-mediated [9] |
| Sacroiliac Joint Dysfunction | Sacral / pelvic | Low back and buttock pain, may radiate to posterior thigh. Often misattributed to lumbar pathology. | Physical therapy, SI joint injection (diagnostic and therapeutic). [3] |
| Spondylolisthesis | Lumbar (usually L4-L5 or L5-S1) | Low back pain, possible radiculopathy if nerve root is compressed. Worse with extension. | Physical therapy, activity modification, epidural or nerve root block for radicular component. Surgical referral if neurological compromise progresses. |
| Scoliosis (Adult) | Thoracic or lumbar | Back pain, asymmetry, progressive deformity. Pain often from degenerative changes rather than curve itself. | Physical therapy, pain management. Surgical referral for progressive neurological compromise or severe curve progression. |
| Ankylosing Spondylitis | Lumbar, sacroiliac | Inflammatory back pain improving with movement, morning stiffness >1 hour, young adult onset. | Rheumatology co-management, physical therapy, NSAIDs. Interventional for refractory SI joint pain. |
| Cervical Spondylosis / Myelopathy | Cervical | Neck pain, arm symptoms, and (if spinal cord is compressed) hand clumsiness, gait changes, hyperreflexia. | Physical therapy for mild spondylosis. Urgent surgical referral for cervical myelopathy: cord compression is a surgical emergency. |
| Muscle Strain & Acute Back Pain | Cervical or lumbar | Acute pain, often with identifiable mechanism. No radiculopathy. | Activity modification, short-term NSAIDs, physical therapy within 1–2 weeks. Most resolve within 4–6 weeks. [1] |
| When surgical referral is appropriate: New York Bone & Joint refers for surgical spine evaluation when: (1) conservative and interventional treatment has been appropriately administered and has not provided adequate relief; (2) there is progressive neurological deficit, such as worsening weakness, bowel or bladder involvement, or signs of cervical myelopathy; or (3) the initial presentation is severe enough that non-surgical management is clearly not the appropriate starting point. The referral is made with full clinical context, including EMG findings, imaging, and a summary of all treatments tried and their outcomes. |
Physical Therapy: The Foundation of Non-Operative Spine Care
Physical therapy is not what we recommend when everything else has failed. It is the first and most consistently evidence-supported intervention for the vast majority of spinal conditions. [6] For acute low back pain, cervical strain, disc herniations that haven’t produced significant neurological deficits, and degenerative spine conditions, structured physical therapy is the primary treatment, not the consolation prize after injections haven’t worked.
At New York Bone & Joint, physical therpay is integrated into the spine care pathway from first contact. Our in-house physical therapists work in the same center as the spine physicians and communicate directly about each patient’s progress. The physical therapy protocol for a spine patient is built from the clinical picture, including the EMG findings when they are available, not from a generic ‘back pain’ template.
“One nuance I want patients to understand about physical therapy and spine care: the goal of physical therapy for a spine condition isn’t simply to strengthen your back muscles. It’s to restore the neuromuscular control patterns that spinal pain disrupts, to decompress neural structures through specific movement and positioning, and to reduce the central sensitization that chronic spine pain produces over time. A good spine physical therapy program is specific, progressive, and informed by the clinical picture. That is what New York Bone & Joint’s physical therapy team provides.” — Dr. Michael Y. Mizhiritsky
When Should You See a Spine Specialist?
Most back pain resolves with rest and time. But some presentations warrant prompt evaluation. Seek a spine evaluation without delay if you experience:
- Pain radiating below the knee: Dermatomal leg pain suggests nerve root compression and should be evaluated to assess severity and determine if imaging and nerve testing are appropriate.
- Numbness, tingling, or weakness in the arms, hands, legs, or feet: Neurological symptoms indicate nerve involvement that requires clinical and potentially electrodiagnostic evaluation.
- Pain that worsens despite rest or over-the-counter treatment: Persistent symptoms after more than 2–3 weeks suggest a structural problem that will not resolve with observation alone.
- Morning stiffness lasting more than one hour: This may suggest an inflammatory arthritis such as ankylosing spondylitis requiring rheumatologic evaluation in addition to spine care.
- Pain following a fall, injury, or significant trauma: Requires imaging to rule out fracture before any treatment begins.
- Hand clumsiness, difficulty with fine motor tasks, or changes in gait: These are signs of possible cervical myelopathy (spinal cord compression) requiring urgent evaluation.
Seek emergency evaluation immediately for back pain accompanied by loss of bowel or bladder control, saddle anesthesia (numbness in the perineal region), or bilateral leg weakness. These are signs of cauda equina syndrome, which is a surgical emergency.
Why Choose New York Bone & Joint for Spine Care?
| New York Bone & Joint Advantage | What It Means for You |
| Same-day to same-week access | Non-operative sports medicine physicians available same day or next day. Spine specialist consultations same week. Walk-in orthopedic urgent care at 1198 Third Avenue. No appointment, no ER. |
| EMG in-house, trusted by NYC’s top spine surgeons | Dr. Mizhiritsky’s electrodiagnostic evaluations are trusted by some of New York City’s most respected spine surgeons for pre-operative confirmation. The same diagnostic precision is available to every New York Bone & Joint spine patient. |
| Non-operative first by design | New York Bone & Joint doesn’t perform spine surgery. Our clinical incentive is to provide the most precise non-operative care, not to fill an OR schedule. When surgery is genuinely the right answer, we say so and refer appropriately. |
| Sports medicine team as first contact | Every New York Bone & Joint sports medicine physician evaluates and manages spine conditions. You are seen promptly by a qualified physicianm not placed on a waitlist for a specialist who will see you in six weeks. |
| Interventional procedures when indicated | When conservative management reaches its limit, Dr. Gupta and Dr. Efime Popovitz provide the full range of interventional spine procedures (such as epidurals, medial branch blocks, RFA, SI joint injections, and PNS) in the same practice. |
| Physical therapy integrated with spine care | In-house physical therapy informed by your clinical picture and EMG findings. Your physical therapist and spine physician communicate directly. No referral chain. |
| Co-founded by a spine specialist | Dr. Mizhiritsky did not join New York Bone & Joint as a hired physician. He co-founded it. His clinical philosophy based on precision diagnosis, conservative-first, evidence-based escalation is built into the practice’s DNA. |
References
- [1] American Academy of Orthopaedic Surgeons. Low Back Pain. OrthoInfo. orthoinfo.aaos.org/en/diseases–conditions/low-back-pain
- [2] Jarvik JG et al. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2003. pubmed.ncbi.nlm.nih.gov/12353946
- [3] Chou R et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine. 2009. pubmed.ncbi.nlm.nih.gov/19363457
- [4] Cohen SP et al. Epidural steroid injections: a comprehensive evidence-based review. Reg Anesth Pain Med. 2013. pubmed.ncbi.nlm.nih.gov/23598728
- [5] Deyo RA et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009. pubmed.ncbi.nlm.nih.gov/19124635
- [6] Hayden JA et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database. 2005. pubmed.ncbi.nlm.nih.gov/16034851
- [7] AANEM. Clinical guidelines for electrodiagnostic evaluation. American Association of Neuromuscular & Electrodiagnostic Medicine. aanem.org
- [8] Thoomes EJ et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018. pubmed.ncbi.nlm.nih.gov/28838857
- [9] Facchini G et al. A comprehensive review of pulsed radiofrequency in the treatment of pain associated with different spinal conditions. Br J Radiol. 2017. pmc.ncbi.nlm.nih.gov/articles/PMC5605093
- [10] Abdi S et al. Epidural steroids in the management of chronic spinal pain. Pain Physician. 2007. pubmed.ncbi.nlm.nih.gov/17256030
