Surgery

5 Ways to Minimize Failed Back Surgery and Continued Back Pain

cmaynard — Thu, 05 Nov 2009 08:35:52 -0800

November 5, 2009
by: Sylvia Marten

A back surgery may not achieve its desired results for various reasons that are out of the patient’s hands; with that said, there are some things that patients can do to minimize the chance of an unsuccessful surgery in which postoperative [url:145,type=|term|,content=|back pain|] is present.

Be Confident in Your Diagnosis

The number one reason that back surgeries are not effective is because of misdiagnosis of the probable cause of back pain, leading to operation on the wrong anatomical lesion. Prefacing this point, it’s important to know that [url:1583,type=|node|,content=|spine surgery|] is only indicated when there is an identifiable anatomical lesion causing spinal instability or nerve pinching.

With this stated, assess your spine surgeon’s confidence in his or her diagnosis of the source of your back pain. Ask them about the specific anatomic lesion that would be addressed by the surgery, the alternatives to surgery, and what would happen if the condition is left untreated, and also question the surgeon on why he or she is recommending the specific surgery.

If the surgeon is unsure about the diagnosis, if you are not confident in the answers provided or if you would just be more comfortable, consider getting a second opinion. Visiting a different spine surgeon can allow the patient to get another perspective on radiographic findings and see what that surgeon would suggest for the situation.

Remember that if you are going to have surgery, you owe it to yourself to know that you’re doing it for the right reason. Understand how to get an [url:673,type=|node|,content=|accurate back pain diagnosis|].
Trust Your Spine Surgeon

It goes without saying that your spine surgeon will play a major part in the success of your surgery. Regardless of whatever surgery is suggested, ask the surgeon about his or her experience performing the procedure. For example:
- How many of the recommended surgeries does this surgeon perform each year?
- How have other patients fared in the past following a similar surgery by this surgeon?
- Does the surgeon have any patients who have had the same surgery and would be willing to talk to you about their experiences?
- Who would be assisting with the surgery?
As you will be entrusting this person with your health during surgery, it’s important to be confident and comfortable with your spine surgeon. Consider these specific [url:1549,type=|node|,content=|questions to ask your spine surgeon|].

Know the Percentages

Patients should know that even with the best surgeon and indications, spine surgery is not 100% guaranteed to produce a successful result. In other words, a spine surgery can be performed for the right anatomical reason and done according to textbook, yet some pain may still exist following surgery.

To cover some of your bases in regards to this above point, know the success rates of the recommended surgery. For example:
- Certain surgeries like a discectomy or microdiscectomy for a lumbar herniated disc that is causing [url:887,type=|node|,content=|leg pain|], and a spine fusion for spinal instability from spondylolisthesis are more predictable operations.
- On the other hand, surgeries like a discectomy for a herniated lumbar disc causing [url:896,type=|node|,content=|lower back pain|] or a spinal fusion for multi-level lumbar degenerative disc disease are far less likely to be successful.
Knowing the success/failure rates of specific back surgeries can provide patients with a better feel for the surgery, yet patients should not put full stock in these success rates as applied to their situations. For example, just because a surgery is successful 90% to 95% of the time doesn’t mean that it will automatically be so for you.

Learn more about what you can expect from [url:1615,type=|node|,content=|spine surgery for lower back pain|].

Be Ready to Rehabilitate

Back surgery is more than just the surgery, with rehabilitation playing an important role in making the surgery as beneficial as it can be. Probably the second most common reason that back surgeries do not succeed is because of inadequate or improper rehabilitation following the procedure.

With this in mind:
- Understand what your rehabilitation program will entail following surgery (how many hours per day/times per week, etc.)
- Speak to a physical therapist to learn more about your rehabilitation program and to get a projected schedule of what will be expected of you
- Honestly ask yourself if you will be dedicated and self-motivated to rehabbing to the best of your abilities after surgery.
Learn more about the importance of [url:1239,type=|node|,content=|rehabilitation and exercise following spine surgery|].

Set Realistic Expectations and Avoid Stress as Best as Possible

Easier said than done when it comes to having surgery, this point hits on the overall theme of doing your homework prior to surgery.

Ideally, the more prepared you are for surgery, the more prepared you’ll be for it afterward. Extensive research has demonstrated how the patient’s overall experience and ultimate outcome from back surgery can be improved with psychological preparation.

From having confidence in your decision to have surgery to making accommodations in your work and daily life for rehabilitation prior to surgery to even having your [url:6591,type=|node|,content=|post-operation must-haves|] all in order before the operation, there are many ways in which you can minimize certain stressors and focus on what matters the most: achieving effective pain relief after surgery.

Learn [url:1453,type=|node|,content=|how to prepare psychologically for back surgery|].

More on this Topic:

[url:1969,type=|node|,content=|Specialists Who Treat Back Pain|]
[url:1583,type=|node|,content=|Lumbar Spine Surgery|]
[url:1472,type=|node|,content=|Lumbar Decompression Surgery|]
[url:1582,type=|node|,content=|Lumbar Spinal Fusion Surgery|]
[url:1545,type=|node|,content=|Scar Tissue and Pain after Back Surgery|]

Effectiveness of Sciatica Treatment, Herniated Disc Surgeries Compared in Recent Study

cmaynard — Wed, 15 Jul 2009 09:27:47 -0700

July 15, 2009
by: Sylvia Marten

View Sciatica Videos

Examining the effectiveness of conventional microdiscectomy and tubular disectomy surgeries for treatment of [url:996,type=|node|,content=|sciatica symptoms|] resulting from a [url:885,type=|node|,content=|herniated disc|], a recent study found and opined that the minimally invasive, tubular surgery did not result in better outcomes for patients despite such claims in the past.

[url:1584,type=|node|,content=|conventional microdiscectomy|]. The most commonly performed surgery for patients with sciatic leg pain from disc herniation, [url:5991,type=|node|,content=|microdiscectomy|] (also known as lumbar decompression surgery) entails the removal of a small portion of the bone over the nerve root and/or disc material under the nerve root to relieve neural impingement and provide more room to heal.
[url:6025,type=|node|,content=|tubular discectomy|]. Introduced in 1997, tubular discectomy involves a similar procedure to the one described above, with the exception that it is performed through a tubular device. This type of herniated disc surgery has been described as producing less tissue damage and resulting in a faster rate of recovery, the latter point serving as the basis of examination for the Sciatica Micro-Endoscopic Discectomy trial.

Performed by researchers in the Netherlands, this trial involved 328 patients (ages 18 to 70 years) who:

had persistent leg pain from lumbar herniated discs for more than 8 weeks
were hospitalized in 7 general hospitals in the Netherlands from January 2005 to October 2006
were randomized to either a tubular discectomy (approximately 167 patients) or conventional microdiscectomy (161 patients).

A blind follow up was conducted a year later, with functional ability, pain and a self-view of recovery assessed via a series of questionnaires and surveys.

Findings on Microdiscectomy and Tubular Discectomy

According to the study, conventional microdiscectomy produced more favorable results than tubular discectomy after one year for:

functionality. The mean score on the Roland-Morris Disability Questionnaire (RDQ), which has a 0-23 score range with higher scores indicative of worse functional status, was 3.4 for conventional microdiscectomy and 4.7 for tubular discectomy.
leg pain. On the visual analog scale, the 1-year mean difference was in favor of conventional microdiscectomy (with scores of 4.2 mm for leg pain and 3.5 mm for [url:145,type=|term|,content=|back pain|]).
self-reports of recovery. 120 of 151 patients (79%) who had conventional microdiscectomy reported good recovery a year later while 107 of 156 of patients (69%) who had tubular discectomy reported good recovery a year after the minimally-invasive procedure.

It should be known that this randomized control trial by no means knocks the validity of tubular disectomy as a minimally-invasive procedure for herniated discs; rather, it challenges certain claims like it increasing the rates of recovery.

Source: JAMA

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[url:1001,type=|node|,content=|Sciatic Nerve Anatomy and Sciatica Symptoms|]
[url:1016,type=|node|,content=|The Truth about Sciatica|]
[url:715,type=|node|,content=|Lumbar Herniated Disc|]
[url:884,type=|node|,content=|Treatment Options for a Lumbar Herniated Disc|]
[url:9574,type=|node|,content=|Surgery Options for a Herniated Disc|]
[url:18207,type=|node|,content=|Lower Back Pain after Surgery|]
[url:7996,type=|node|,content=|Sciatica Treatments|]

What Back Pain Patients Should Know about Stop-Smoking Drugs Chantix and Zyban

cmaynard — Tue, 07 Jul 2009 11:43:47 -0700

July 8, 2009
by: Sylvia Marten

The U.S. Food and Drug Administration (FDA) just announced that a black box warning will be carried on two popular, “stop-smoking” drugs – varenicline (Chantix) and buproprion (Zyban, Wellbutrin) – following a report detailing some very significant side effects with their use.

According to the FDA’s adverse event reporting system, use of these two drugs has been linked with serious changes in behavior, including:

depression
agitation
hostility
thoughts of suicide.

More specifically, the report linked:

98 suicides and 188 attempted suicides to use of varenicline
14 suicides and 17 attempted suicides to buproprion use.

While noting the importance of getting people to quit smoking, the FDA added that it simply wants closer monitoring of these two drugs.

Consequently, the FDA is going to ask the manufacturers of Chantix and Zyban – Pfizer and GlaxoSmithKline, respectively – to conduct clinical trials examining behavioral changes with usage of these drugs.

Smoking has long been linked to causing back pain and is often a reason why surgeons may not want to perform spinal surgery on certain patients.

Since smoking can slow down the recovery time after back surgery, many patients may have to quit smoking prior to surgery.

If you have recently quit smoking in wake of a scheduled back surgery, or have stopped smoking following back surgery, it’s important that you know the risks of stop-smoking drugs, as the above information about Chantix and Zyban demonstrates.

And if you have used any of these stop-smoking drugs and noticed changes in your behavior similar to the symptoms listed above, get in touch with your doctor as soon as possible.

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[url:738,type=|node|,content=|Does Smoking Cause Low Back Pain?|]

[url:6679,type=|node|,content=|Quitting Smoking: A Must for People with Back Pain|]

[url:6742,type=|node|,content=|Ways to Quit Smoking|]

[url:6741,type=|node|,content=|Why It Is So Hard to Quit Smoking?|]

[url:6724,type=|node|,content=|Quitting Smoking before a Spinal Fusion|]

Latest SPORT Data Supports Back Surgery for Degenerative Spondylolisthesis

cmaynard — Thu, 11 Jun 2009 12:36:10 -0700

June 11, 2009
by: Sylvia Marten

Spine-Health has blogged in the past about the Spine Patient Outcomes Research Trial (SPORT), including one study concluding that [url:6608,type=|node|,content=|back surgery was better for patients with degenerative spondylolisthesis|].

Well, SPORT just recently released the latest data on this study. Its verdict? The newest data supported this earlier conclusion, finding that back pain relief was more prevalent four years later for those patients who voluntarily had lumbar laminectomy surgery as opposed to those who voluntarily passed on this surgery.

Here’s a quick summary of these latest SPORT findings:

Identical Approach, Longer-Elapsed Time Frame, More Crossover, Similar Results.

To recap, there were two cohorts in this study: 304 patients in a randomized cohort (meaning that they were randomly chosen either to have or not have laminectomy surgery to treat their [url:6000,type=|node|,content=|spondylolisthesis|] and [url:152,type=|term|,content=|spinal stenosis|]) and 303 patients in an observational cohort (meaning that these patients voluntarily chose to have or not have this surgery).

It should be known that 66 percent of those patients who were randomly chosen to have surgery did so within four years and that 97 percent of those patients who chose surgery also had a laminectomy in that time period.

More telling were the latest findings that 54 percent of those people who were randomized not to have surgery ended up having surgery within four years and that 33 percent of those who voluntarily passed on surgery eventually had it. For more than a half and approximately a third of these specific patients, not having surgery apparently wasn’t as beneficial in terms of providing back pain relief.

Adding more intrigue to this study were the responses of those patients who voluntarily had surgery for their back pain. This group of patients reported improvements of 15.3 points for bodily pain and 18.9 points for physical function, and decreases of 14.3 points on the Oswestry Disability Index, signifying that gains experienced two years after back surgery were still maintained four years later.

At the end of the day, these latest findings confirm how laminectomy surgery may have wonderful results for people dealing with spondylolisthesis. Still, one must not rush to assume that surgery is always better than not having surgery when addressing spondylolisthesis associated with spinal stenosis. It should be noted that non-surgical treatments may adequately alleviate back pain for others, as very well may have been the case for the 70 percent of the observational patients who initially passed on and still did not have surgery four years later.

As each patient’s case is unique in itself, it ultimately comes down to the patient and his or her doctor examining their options and making a decision that they are most comfortable with and feel is the best course of action at the time.

Source: The Journal of Bone and Joint Surgery

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FDA Approves Third Cervical Artificial Disc: the Bryan Cervical Disc from Medtronic

mlepore — Wed, 03 Jun 2009 08:00:17 -0700

June 4, 2009
by: Spine-health Staff Writer

After long trials of deliberation, Medtronic’s Bryan Cervical Disc became FDA-approved on May 12, 2009. The Bryan Cervical Disc, designed to alleviate [url:149,type=|term|,content=|neck pain|] and related disability caused by degenerative disc disease, had received a favorable FDA recommendation back in July of 2007.

Although approved, conditions have been put in place for the approval of the Bryan for the next ten years. Medtronic will be conducting a post-market study, which will include tracking of patients' neck disability index scores, radiographic information, neurological status and a number of other outcomes in addition to data on adverse events and explanted devices.

What is unique about the Bryan is it is designed to better mimic natural disc shock absorption. It is made of titanium and polyurethane, which is softer than the nuclei of competitive discs, such as the Prestige’s metal on metal design. The polyurethane in the Bryan raised questions on wear debris during the FDA panel, but was determined to not be an issue for short-term use. Long-term use is an area of concern though, and will be under surveillance.

The Bryan (Medtronic), Prestige (Medtronic) and ProDisc-C (Synthes) are the only cervical [url:164,type=|term|,content=|artificial disc replacement|] options for the U.S., although there are expected to be more approvals and launches soon. At this point, Medtronic has not commented on the Bryan’s approval, or on projected launch dates when it will be commercially available.

Posted by: Spine-health Staff Writer

Additional Artificial Disc Replacement sources:

[url:1379,type=|node|]
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[url:1388,type=|node|]
FDA approves Medtronic’s Bryan Cervical Disc

Spinal Fusion Surgery Worth the Cost for Stenosis Patients?

mlepore — Wed, 25 Mar 2009 11:56:57 -0700

March 25, 2007
by: Spine-health Staff Writer

View Spine Fusion
Surgery Video

Back pain affects more than 80% of people in the U.S. at a cost of more than $100 billion a year. While many conditions can be treated conservatively (non-surgically), sometimes surgery is the only way to provide considerable relief. The question becomes whether or not the high cost of [url:165,type=|term|, content=|spine surgery|] is worth it.

Rush was one of 13 sites across the country that followed patients in this Spine Patient Outcomes Research Trial (SPORT). This study is significant, as it is the first to systematically track health care expenditures along with health outcomes. With more than 650,000 spinal surgical procedures being formed annually in the U.S. at costs exceeding $20 billion, the value of this investment is an important consideration.

The study consisted of 3,900 patients with one of two conditions: spinal stenosis treated with laminectomy, and spinal stenosis with associated slipped vertebrae, treated with spine fusion surgery. The patients were divided into groups of non-surgical vs. surgical treatments; of the surgical patients, 320 underwent laminectomy and 344 had spinal fusion.

Researchers used the Quality Adjusted Life Year (QALY) scale to perform a cost/benefit analysis over a two-year post-surgery period. Laminectomy was calculated to cost $77,000 per QALY gained, while spinal fusion surgery was estimated to be $115,000 per QALY gained. In the United States, $100,000 is the maximum at which procedures are considered cost effective.

While the initial analysis indicates that laminectomy offers better value than spine fusion surgery, a definitive assessment of long-term cost effectiveness is still in the works. Cost effectiveness is an important consideration in providing patients with quality care, but the bottom line is that for many patients suffering from back pain, relief is worth any cost.

The study is published in the December 16 issue of the Annals of Internal Medicine.

By: Spine-health staff writer

Sources:

Surgical Treatment of Spinal Stenosis with and without Degenerative Spondylolisthesis: Cost-Effectiveness after 2 Years
http://www.annals.org/cgi/content/abstract/149/12/845

Additional Reading:

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Some Medical Devices Escaping Close FDA Review

Ben Parr — Wed, 18 Mar 2009 11:41:07 -0700

March 18, 2009
by: Spine-health Staff Writer

Recently, congressional investigators have reported that several medical devices, ranging from certain hip joints to a type of defibrillator, have received FDA approval without close scientific review. The Government Accountability Office reported that the agency approved 228 medical devices without full review from 2003-2007. Some of these lesser-reviewed products have been recalled due to malfunctions and other problems; one device was an external defibrillator to assist heart attack victims.

The GAO report was released as the FDA’s Center for Devices and Radiological Health was the subject of allegations claiming that scientists were pressured to approve medical devices against their professional judgment. Nine FDA scientists recently wrote the Obama transition team complaining that a “corrupted” review process was putting public health at great risk. These matters will surely raise the level of congressional scrutiny over the FDA’s medical devices branch.

In 1976, Congress set up a three-tiered classification system for medical devices. Low-risk devices, like bandages and reading glasses, could gain approval simply by notifying the FDA before going to market. High-risk devices—mostly devices implanted in the body, like pacemakers and heart valves—required tighter scrutiny, and manufacturers were required to provide evidence of the product’s safety and effectiveness.

The problems began when exceptions were made for improvements to devices already on the market. Manufacturers simply had to convince the FDA that the devices were “substantially equivalent” to their precursors. In 1990, Congress ordered the FDA to stop this practice, but it continues to go on, even today.

The FDA has acknowledged the problem, but has not committed to how or when they are going to resolve it. Current suggestions include either carrying out full reviews of all products, or reclassifying some devices as lower risk, if appropriate. The GAO report found at least two-dozen distinct types of devices that have escaped close scrutiny, including metal hip joints, external defibrillators, and electrodes for pacemakers, potentially putting patients around the world at risk.

Patients considering back or neck surgery should ask their surgeon about the spinal devices he/she plans to use and understand important factors such as FDA labeling, time on market, number of patients implanted, etc. Patients should feel completely comfortable about the choice of devices for their [url:1583,type=|node|,content=|spine surgery|] and have a right to know what will be used and why.

By: Spine-health staff writer

Sources:

High risk medical devices escaped close review, ABC News/Associated Press

GAO Report

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Surgery for Lumbar Spinal Stenosis Provides More Pain Relief than Nonsurgical Treatment

Stephanie — Tue, 01 Apr 2008 07:45:33 -0700

April 1, 2007
by: Sylvia Marten

Surgery is more effective than nonsurgical treatment in providing pain relief for patients with [url:708,type=|node|,content=|lumbar spinal stenosis|], new study results find.

At all update points, both the study participants who had surgery and who had non-surgical treatments showed improvement: however, the participants who had a [url:6023,type=|node|,content=|laminectomy|] showed greater improvement in their pain levels and ability to function, while those who had non-surgical [url:1053,type=|node|,content=|stenosis treatments|] showed only a moderate improvement. The improvements were maintained at 2 years of followup.

These above results stem from the Spine Patient Outcomes Research Trial (SPORT), a large 7-year trial undertaken at 13 prominent spine centers and sponsored by the National Institutes of Health. The study included 654 patients with lumbar spinal stenosis (without associated degenerative spondylolisthesis).

Study participants who had the [url:18464,type=|node|,content=|spinal stenosis surgery|] had standard posterior decompressive [url:6023,type=|node|,content=|laminectomy|], and those who had non-surgical care had one or a combination of at least active physical therapy (such as stretching, exercise), education for home exercise and ergonomics, and possibly nonsteroidal anti-inflammatory drugs.

Source: New England Journal of Medicine. 2008;358:794-810.

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First Cervical Disc Replacement Surgery with ProDisc-C

spine-health — Fri, 25 Jan 2008 07:01:34 -0800

January 25, 2008
by: Sylvia Marten

The very first ProDisc-C surgery was performed last week since the FDA approved the device in December 2007.

Michael E. Janssen, DO, a Denver surgeon and a Spine-health.com Member, became the first physician in the United States to perform two cervical disc arthroplasties using the ProDisc-C Total Disc Replacement System. The ProDisc is designed to treat patients suffering from cervical disc degeneration and disc herniation, which occurs when natural shock absorbers in the [url:1113,type=|term|,content=|cervical spine|] become worn and start to degenerate, often resulting in pain, discomfort, and impaired cervical mobility creating neck and upper arm pain.

One of the patients was an active 35 year old male with cervical disc degeneration that developed as a result of a traumatic hockey injury, causing pain, stiffness, and numbness in his left-hand. The second patient was a 53 year old female accountant who had been suffering with neck and upper extremity pain from a disc herniation compressing her spinal cord.

Both surgeries were performed on January 16, 2008, and both patients pre-operative symptoms were gone the following day. The patients were discharged from the surgery center on January 17, 2008 with minimal pain.

The full story is available here.

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How I Decided to Have Back Surgery

spine-health — Fri, 21 Dec 2007 13:44:19 -0800

December 21, 2007
by: Dawn

This is my story about having [url:165,type=|term|,content=|back surgery|] that went very well. I think the key for me is that the surgery was done for the right reasons, I had researched my surgeon by talking to other patient’s of his who had the same spinal fusion done, and I had read up on the Internet on some good sites, including www.spine-health.com, to help with my decision to have surgery and help with my expectations.

2 1/2 years ago I was diagnosed with Spondylolisthesis Grade 2. After many years of pain in my legs now I finally knew why. I tried just about everything to avoid the surgery. I used a natural anti-inflammatory (Wobenzyme) to keep the inflammation down, I used a rolling pin and rolled my legs everyday to help lessen my [url:887,type=|node|,content=|leg pain|] through-out the day. I also tried numerous therapies. I read some of the bad stories on message boards on the internet and didn't want anything to do with the surgery. I really felt that the message boards were discouraging, there wasn’t anything positive regarding the surgery, and everything I read was so disheartening.

I was out to dinner one night and ran into a woman who also had [url:6000,type=|node|,content=|spondylolisthesis|]. She had surgery to correct the spondylolisthesis 5 years earlier and has had no complications. She had the same surgeon that I had.

In September of 2007 I finally decided to go ahead with the surgery. At this point my leg pain was so bad I could not sleep through the night; I would wake up in pain and toss 5 or 6 times per night. I could not stand for more than a minute, sometimes two. I would have to sit down, and sometimes it didn't matter where I was – my leg pain was nearly unbearable. I could not stand in a grocery line or at the movies.

The anxiety of spinal fusion surgery was another obstacle. With surgery, the “What if’s” are horrible.

What if I end up in a wheel chair?
What if the surgeon slips?
What if they fix the wrong thing?
And then there is the ultimate" what if I die"? I don't want my children left without a Mother.

Like I said "What if's are terrible!" I even talked to yet another patient (with the same surgeon) who had the same surgery for spondylolisthesis a few months earlier. She gave me the extra strength I needed to go ahead with it.

Admission into the hospital on Oct 1, 2007 at 5:30am, now the stressful “sit and wait game” started 5:30AM; the next 2 hours were the longest 2 hours of my life. Finally they took me into the operating room it was about 7:30am. I asked how many people get up, change their minds and leave. And I felt myself float off.

I was out of surgery at 9:30AM and awake at 11:00AM. By 1:00 I was drinking broth and visiting. At 1:30 I took my first walk down the hall and stood at the end of the hall. As I stood there tears filled my eyes, I turned and looked at Tom (who’s arm I held) and remarked “I'm standing and I have no pain”! I was standing there in the middle of the isle, I let go of him and stood there for a few minutes. This was the first time I stood in one place for more than a minute, possibly 2, without being in horrible pain, and sitting down. While walking or standing I was always looking for a place to sit because I knew it would not be long before I was forced into sitting down. And I was still standing! It was like a taste of freedom, being trapped in a body that can't do the things you would like to do is horrible. I HAD NO PAIN! I STILL HAVE NO PAIN!

I checked out of the hospital the following morning, once home I began walking a 1/2 mile the first day, 1 mile the second day. I'm walking 1-3 miles per day. I have no pain in my legs!! I sleep without pain!! I have truly gotten a part of my life back that I thought was gone. I hiked a mountain in Utah last week; I'm looking forward to so much now. Thanks to my surgeon.

I am not writing this to encourage surgery. It’s just that when I was thinking about spinal fusion for my spondylolisthesis I read so much negative stuff on the Internet, I wanted to write to let people know about a positive experience.

Sincerely,

Dawn

New Back Surgery Technologies

Wed, 28 Nov 2007 02:15:46 -0800

November 28, 2007
by: Sylvia Marten

Technological developments in spine are occurring at an ever increasing rate, but what does this mean for patients? To date, most new technologies have involved reducing the postoperative pain and speeding recovery, and lately, technologies to preserve motion in the spine (as opposed to a fusion).

Often, new technology represents more of a marketing tool for physicians than a true advancement in patient outcomes.

None of these technologies, however, change what we as surgeons can treat. Indications for spine surgery for pain are still limited to decompressing a nerve root or stabilizing a painful motion segment. Spinal conditions that include an anatomical defect that causes nerve root pinching or a painful motion segment may be amenable to surgical correction. Patients that have back pain that cannot be attributed to either of these problems still do not have a surgical option.

Surgical success is mostly determined by first having an accurate preoperative diagnosis, not by what technology is used to do the surgery. Even the best technology will not be useful if what is operated on is not what was causing your pain.

Spine surgery is like any other field of medicine in that it is really more of an art than a science. Practicing spine surgery involves trying to improve ones techniques for accurately diagnosing patients’ problems, and then improving ones surgical technique. To some extent, all this focus on new technology can be a distraction. Often, new technology represents more of a marketing tool for physicians than a true advancement in patient outcomes.

This is not to say new technologies are not helping. Patients in particular need to temper their enthusiasm and be realistic about what can and cannot be accomplished. Truly useful technologies often take years to be verified. There are multiple technologies that were once thought to be the next best thing for back pain but are no longer used. Technologies such as chemonucleosis, percutaneous discectomies, laparascopic lumbar fusions, and to some extent, intradiscal electrothermocoagulation (IDET). At one time or another all of these technologies had seemed to hold the promise of a significant advancement in treating low back pain but have now been largely or completely abandoned.

Just as in the rest of life, with [url:165,type=|term|,content=|back surgery|] there are no simple answers, and relying on new technologies alone to improve outcomes is probably not going to be all that reliable. The judicial use of newer technologies combined with rigorous scientific study holds the promise of eventually improving overall patient outcomes. In my opinion, an accurate preoperative diagnosis trumps any of the new spine technologies, and always will.

Cervical Artificial Discs: Valuable New Technology or Fashion?

Wed, 12 Sep 2007 16:55:19 -0700

September 12, 2007
by: Sylvia Marten

Spine surgery, like many other areas of medicine that are experiencing rapid technological growth, is often subject to fashion trends. At this period in time, the fashion is tilted towards motion preservation technology – both in the lumbar spine (low back) and [url:1113,type=|term|,content=|cervical spine|] (neck). The first artificial disc was approved for the lumbar spine in November of 2004 (Charite, Depuy Spine Inc.) to much fanfare, but for a variety of reasons it has largely not lived up to its expected dominance in the spine industry.

In this author’s opinion, cervical artificial disc replacement should enjoy better overall acceptance and success than lumbar artificial disc replacement by insurance companies, physicians and patients for several reasons:

Preserving motion in the neck will work, because motion is not causing the pain

By its very nature, treating a cervical disc herniation with a motion preservation device (cervical artificial disc) is very different than treating chronic low back pain with a motion device. This is because motion is not the cause of pain for neck surgery, so using artificial disc replacement to preserve the motion (instead of fusion, which limits motion) is practical.

Neck surgery is done to relieve pressure on the nerve root. After removing the cervical disc something needs to replace the disc space or it will collapse (kyphosis). Traditionally, what has been left in the disc space is a bone graft to create a fusion and prevent disc space collapse. However, the motion in the disc space is usually not in and of itself a pain generator, and therefore preserving the motion in this space with a cervical artificial disc is reasonable.

Chronic low back pain because of a painful disc is entirely different from neck surgery. With low back pain, the disc itself may be the pain generator, or something else with the motion at the disc space may be generating the pain. Spine fusions for chronic low back pain work by limiting the motion at the painful level; but preserving the motion in this area by using a lumbar artificial disc may preserve the source of the pain.

Neck surgery to relieve arm pain is a more reliable procedure

When neck surgery is done to relieve arm pain (or [url:165,type=|term|,content=|back surgery|] is done to relieve leg pain, or [url:998,type=|node|,content=|sciatica|]) due to a pinched nerve the surgery is very reliable. However, neck surgery for either chronic neck pain (vs. arm pain), or low back surgery for chronic back pain (vs. [url:887,type=|node|,content=|leg pain|]) is not nearly as reliable. Artificial disc replacement surgery in the [url:149,type=|term|,content=|neck|] is indicated for arm pain, whereas the artificial disc replacement in the lumbar spine is not for leg pain (herniated discs). Lumbar artificial disc replacement is designed to treat chronic low back pain due to a painful disc (degenerative disc disease). Lumbar disc herniations resulting in leg pain, if they are treated surgically, are treated with a microdiscectomy, not a fusion or artificial disc.

Indications for cervical artificial disc surgery are more clear-cut

Besides being a more reliable surgery than lumbar artificial disc replacement, cervical artificial disc replacement will also have the advantage in that a new disease entity will not need to be considered. In lumbar artificial disc replacement the disease entity it was intended to treat - lumbar artificial disc disease - is not clearly defined and there is still quite a bit of controversy concerning proper surgical indications for degenerative disc disease, whereas cervical disc herniation resulting in arm pain ([url:1038,type=|term|,content=|radiculopathy|]) is very well defined and the indications are not at all controversial. For this reason, insurance companies will not be as reluctant to cover any added expense for a new procedure.

When the Food and Drug Administration approved the first lumbar artificial disc many felt that insurance companies would automatically cover the procedure. This did not happen and many have still not approved it as an alternative to fusion surgery. This was unprecedented in medicine as approval usually meant coverage. With the new realities of cost containment in medicine, new technologies with not only have to be proven safe and efficacious, they will also have to be cost conscious.

Incredibly Effective Ways to Check Out Your Surgeon

Wed, 29 Aug 2007 19:38:44 -0700

August 29, 2007
by: Stephanie

When it comes to selecting a surgeon, I'll take skill over personality anytime. But the $64,000 question is, how do you assess a surgeon's skill? When you buy a new TV or vacuum cleaner, you can rely on Consumer Reports and talk to friends who have the same model. But there's no "Consumer Reports" for doctors, and it's infinitely harder to find someone you know and trust who has had the same surgery for the same condition.

To help you navigate the murky waters of getting the real scoop on your surgeon, here are several little known and highly effective ways to find out about your surgeon's skills and expertise:

Talk to the nurses
The nurses see the surgeon's results – they see the successes and they see the mistakes -- and they know the difference. If you need surgery ask to speak with the operating room (OR) nurses who cover that surgeon, and speak with the anesthesia personal as well. Be specific in asking them "If you needed this surgery, who would you have do it?" Do this very early in the process at the hospital you will be going to. Of course the nurses usually won't come right out and say "That surgeon's a dirtbag." But you can usually pick up on their overall opinion of the surgeon through your discussion anyway (e.g. by what they don't say, but what they omit, with their facial expressions). For example, if the nurse says, "I sent my Dad to him" that's about the highest praise there is. Conversely, if the nurse says "He's such a nice guy" but declines to comment on his surgical skills, that is a big red flag. Just be careful how you interpret what they say. For example, when ERNurse (on our Pain Forums) asked the OR nurses about her surgeon one made a face and said, "He's so *** picky in the OR," she ignored the nurse's negativity and instead interpreted it to mean that the surgeon was precise, picky about sterile fields, and wanted everything to be right – all good things.

Most people are not too comfortable "cold calling" on nurses to ask them questions in the hospital, and many times hospital policies discourage people from walking around and asking random questions. If this is the case, you can first ask to speak with the Nursing Director, tell her what you're doing and why, and use the Director's authority to gain access to the rest of the nurses you need to speak with.

Nurses you'll want to speak with include:

Operating room nurses (and anesthesia personnel), who see how the surgeon performs in the operating room
Nurses who work on the floor where surgeon's patients usually go after surgery (they see the recovery experience of that surgeon's patients vs. other surgeons patients)
If you're still not sure, you can ask to speak with the Risk manager of the hospital, who is usually a supervisory nurse. Again, she will give you just basics but the tone in which she talks with you might allow you to pick up on subtleties.

Get specific references
Ask for references from three patients, but don't ask the surgeon for these. Ask the physician who referred you to the surgeon (this will typically be your primary care physician). That way you're more likely to get a balanced view. Then, provided those patients give the surgeon good marks, ask your surgeon for two more references, and this time ask for references only from patients who have had your specific surgery for the same diagnosis.

For those of you who are wondering, yes, you can ask your doctor for references from other patients. A good surgeon will be happy to give you references and does this sort of thing all the time. A good surgeon will have plenty of patients who are happy to serve as references. And a good surgeon knows that if you're confident about your decision to have surgery and your choice of surgeon, then you'll do better after the surgery.

Ask around
You really can't do too much of this. If you have any friends who work in the healthcare field, see if they can find out about your surgeon. The healthcare universe is actually quite small when it comes to surgeons, and often it just takes a couple phone calls for someone who works in health care to find out about the reputation of a surgeon.

Know the answers to some questions
When you ask your surgeon questions, make sure you have an opinion about the correct answer to some of the questions so that, even though you don't have an MD or DO, at least you will be able to gauge the credibility of some of their answers. To do this, look up everything you can about your surgery -- there are a many free information sources on the Internet (just be sure you can trust the source). Use the knowledge you gain as a basis for an interview with your surgeon. For example, if your surgeon is recommending an ALIF for lumbar degenerative disc disease, look up the principal risks of this surgery on Spine-health.com and then ask the surgeon what they are. If he fails to mention one or several of the main risks, this is a red flag.

the very least, confirm that he or she is board certified or board eligible in his or her specialty, and see if he or she has any issues with the state medical board or other reported issues. Also read as much advice as you can on how to select a surgeon, such as [url:6634,type=|node|].

All of the above takes time, but when you consider the gravity of the situation and all the risks involved with having surgery (including, when it comes to having [url:165,type=|term|,content=|back surgery|], the risk of having continued or even increased pain after the surgery), then it is definitely worth the time and effort.

Special thanks to the collective insights and experiences of Spine-health's active and vibrant Pain Forums for contributing most of the above points.

Good luck!

Posted by: Stephanie

More reading:

[url:6643,type=|node|]
[url:6592,type=|node|]

Lumbar Artificial Disc Replacement Not Covered In People Over 60

Mon, 27 Aug 2007 12:00:42 -0700

August 27, 2007
by: Sylvia Marten

Medicare has decided it will not pay for lumbar artificial disc replacements in people over 60 years of age. The reasoning for the CMS' (The Centers for Medicare and Medicaid Services) decision is the lack of data on using such devices in the 60+ population, according to Scott Boden, MD, a Spine-health.com Medical Advisor.

This August 2007 decision affects the Prodisc-L (made by Synthes), approved by the FDA in August 2006. The first lumbar artificial disc approved by the FDA in 2004, the Charite disc (made by DePuy Spine, a Johnson & Johnson company), was already covered by a similar decision made by CMS in May 2006.

Both the Prodisc and Charite disc FDA IDE clinical studies tested patients between the ages of 18 and 60. Based on the age limitations in these studies and in Medtronic’s Maverick lumbar disc study, CMS says it “is convinced that the indications for LADR will exclude the over age 60 population, and that these age limitations are not specific to one manufacturer’s disc implant.”

What about people under age 60 with pain and disability from lumbar degenerative disc disease, the prevalent and severe condition the artificial disc was designed to treat? It’s still left up to individual insurance companies to decide. The CMS acknowledged “some evidence does exist for patients age 60 and under” to benefit from artificial disk technology. However, it believes the ProDisc clinical trial design created more uncertainty in benefits and thus would not come forth with a statement supporting artificial disc replacement in the under age 60 population.

For those of you interested, the exact wording of the decision is below.

The original CMS decision about Lumbar Artificial Disc Replacement was made on May 16, 2006, and was specific to the Charite Disc, the only lumbar artificial disk available at the time:

“LADR with the Charite^TM lumbar artificial disc is not reasonable and necessary for the Medicare population over 60 years of age; therefore, LADR with the Charite^TM lumbar artificial disc is non-covered for Medicare beneficiaries over 60 years of age. For Medicare beneficiaries 60 years of age and younger, there is no national coverage determination, leaving such determinations to continue to be made by the local contractors. Medicare coverage under the investigational device exemption (IDE) for other lumbar artificial discs in eligible clinical trials is not impacted.”

On August 14, 2007, the CMS issued the following in its decision memo:

“The Centers for Medicare and Medicaid Services (CMS) has determined that LADR is not reasonable and necessary for the Medicare population over sixty years of age. Therefore, Section 150.10 of the Medicare National Coverage Determination (NCD) Manual is amended to reflect the change from non-coverage for LADR with a specific implant to non-coverage for the LADR procedure for the Medicare population over sixty years of age. For Medicare beneficiaries sixty years of age and under, there is no national coverage determination, leaving such determinations to be made on a local basis.”

Further reading:

CMS decision memo for Lumbar Artificial Disc Replacement
[url:1734,type=|node|]

Posted by: Sylvia

How and When to Get a Second Opinion Before Surgery

spine-health — Wed, 15 Aug 2007 16:39:46 -0700

August 15, 2007
by: Peter

It is often said that no one should have spine surgery unless they receive a second opinion from another surgeon. On the surface, this would sound like good old common sense, as two opinions are better than one. However, there is a trap in this line of thinking. When a patient sees a physician for a second opinion, this next opinion has a tendency to always sound smarter than the first opinion. This is a well-recognized phenomenon, but in reality the second opinion may not be the best one.

When should you get another opinion?

Certainly if you are not comfortable with the first physician, then seeing another surgeon for an opinion is a good idea.
If a surgeon cannot answer questions about the rationale for a proposed procedure or is vague on the surgical plan, another opinion is a good idea.
If you suspect that the initial referrals was made on the basis of economic interests rather than who is best suited for your surgery, go for another opinion. (Referring physicians favor local surgeons who will do the surgery in a local facility, especially if they are in a multispeciality clinic. This is not saying that these physicians are not capable but that there is a possibility that the first referral one receives may not be the best.)
Another time it is good to get a second opinion is if the initial [url:165,type=|term|,content=|back surgery|] did not work and another surgery is being proposed. This is especially true if it involves fusing further segments of the spine. Often, if the initial fusion surgery does not work, further surgery will not be helpful. Only in very specific circumstances (i.e. pseudoathrosis) is further surgery likely to be beneficial.
There are times when a surgeon will ask a patient to get a confirmatory opinion prior to proceeding with surgery. In these cases it is best to let the treating surgeon pick the second opinion as they are best able to determine whose opinion they would value.

Otherwise, picking a surgeon for a second opinion is often difficult. As previously stated, the goal is to get an opinion from a respected, experienced and ethical surgeon. While it is not perfect, word of mouth is probably still the best measure as to who could be helpful in the second opinion process. This is, however, still a relatively arbitrary process.

The best thing for a patient seeking another opinion is to keep an open mind. You need to be as judgmental about the second opinion as for the first, and need to grill the second physician even further than the first. Beware of surgeons toting unrealistic expectations or who are overly dependent on “cutting edge” technologies. Focus on their experience with your specific type of back surgery and what the surgeon's past outcomes with that surgery are. What are the alternatives to a proposed procedure, and what is the expected natural history of the patients condition if they do not have the procedure? What are the risks and possible complications of the procedure, and if it doesn’t work, what would be the subsequent plan? Read all [url:6634,type=|node|,content=|38 Questions to Ask Your Surgeon Before Having Surgery|].

Remember, the worst thing to do is assume the second opinion is automatically going to be better than the first. Keeping an open mind will prevent you from falling into this trap. And if you’re still not sure, ...get a third opinion.

Posted by: Peter Ullrich, MD

6 Things to Know About Cervical Artificial Discs

Mon, 06 Aug 2007 15:00:35 -0700

August 6, 2007
by: Sylvia Marten

In mid-July, the FDA gave final approval for Medtronic to make the first ever cervical artificial disc commercially available in the U.S.: the Prestige Cervical Disc.

The Prestige Cervical Disc is an artificial disc used to replace a problematic disc in patients with single-level (meaning only one spinal disc is affected) [url:685,type=|node|,content=|cervical degenerative disc disease|]. Disc degeneration is a normal part of aging, but painful degeneration is caused by a fall, a twisting injury or repetitive wear-and-tear to the [url:1113,type=|term|,content=|cervical spine|]. Symptoms of cervical degenerative disc disease include low-grade pain from a stiff or inflexible neck and numbness, tingling, or weakness in the neck, arms, or shoulders as a result of nerves in the cervical area becoming irritated or pinched. [url:1566,type=|node|,content=|Cervical fusion surgery|] is the current gold standard treatment for cervical degenerative disc disease.

So, what do you need to know? A few things:

In general, surgery for neck pain is much less reliable than surgery to relieve arm pain from cervical degenerative disc disease. Thus, if the only or predominant symptom is neck pain, surgery should be recommended only as a last resort or even avoided altogether.
Not all patients who are candidates for cervical fusion surgery are candidates for [url:1380,type=|node|,content=|cervical artificial disc replacement|].
Although the Prestige is already in use in Europe, the U.S. clinical study was conducted on 541 people. As a condition of FDA approval, Medtronic must conduct a seven-year study of the device’s long-term safety and effectiveness. One of the big questions with artificial discs, both lumbar and cervical, is just how long the device will last.
The Prestige Cervical Disc was found by the FDA to be as safe and effective as cervical fusion, not more so. The theoretical advantages of discs over fusion include quicker post-op recovery and more flexibility in the neck, but the FDA panel said the results weren’t strong enough to support a superiority claim.
Cost for artificial disc surgery with the Prestige is expected to be about the same as for a cervical fusion – in the $30,000-$35,000 range. Fusion surgery generally enjoys good insurance coverage, while artificial disc replacement coverage, so far only lumbar, has been inconsistent.
The day after the FDA approved the Prestige, Medtronic’s Bryan cervical disc received a recommendation for approval by the FDA (potentially available Winter ‘07). The Bryan is said to more closely resemble a natural spinal disk than the Prestige and could emerge for use in multiple disk replacements at some point in the future. There are also several [url:1388,type=|node|,content=|other cervical discs being studied|] which may be approved in the next several years.

Artificial discs are a new and potentially exciting alternative for people with pain and disability from cervical degenerative disc disease. However, patients should proceed with caution, especially this early in the game, and be armed with as much information as possible before making a decision about surgery for arm pain and/or [url:149,type=|term|,content=|neck|] pain.

Posted by: Sylvia

56 Things to Do While Recovering from Surgery

Wed, 01 Aug 2007 21:43:11 -0700

August 1, 2007
by: Stephanie

About to undergo surgery? With a little planning, you can make the most of your recovery period. Here is a list of ideas– compiled largely from ideas and contributions from the Spine-health.com Message Board to help get you started. This list was written specifically for people having [url:165,type=|term|,content=|back surgery|], but most of the ideas are applicable to recovery from most types of surgery.

Pure entertainment

Download music (legally) from the Internet; fill up your ipod from itunes

Randomly explore the internet; see what the rest of the world is searching for using Google Trends

Play games that can be played by yourself. There's an amazing variety of games now available – here's a great list. Develops thinking skills, pattern recognition, etc.

Read (or listen to) the classics: To Kill a Mocking Bird, A Catcher in the Rye, The Grapes of Wrath, The Old Man and the Sea , The Great Gatsby, The Call of the Wild, War and Peace. These books are almost always available from your library, and often on sale at the large book stores.

Listen to books on CD. Sometimes it's easier to listen to a book than to read, very relaxing.

Have your kids read to you

Play classic board games with your kids – Monopoly, Scrabble…

Rent a season of a TV series that you had always wanted to see. Entourage is hilarious. Or rent an old series, like Cheers or The Dick Van Dyke Show.

Download books from, e.g. from www.netlibrary.com

Do crossword puzzles or Sudoko puzzles or print up some kakuro, which are number versions of crossword puzzles

Play the guitar (or learn to), or ask someone to play an instrument or sing for you.

Watch old movies. This is great if you are feeling fuzzy from the pain medications – the classic old movies are slow-moving, so it's easy to follow the plot

On a budget? Rent movies from the library instead of from the video store – it's usually a fraction of the price and you can keep the movie for a week.

Enjoy Xbox or Nintendo, Gameboy, Sony PSP, or any handheld electronic games

Some like the handheld game of Simon – it's not too difficult, so good if the pain medications are affecting your concentration

Read the entire Harry Potter series (no these books are not just for kids, the stories and characters are riveting!)

If you prefer, read the original magical book series, The Narnia Chronicles by C.S. Lewis

For the women - give yourself a manicure, a facial, look through magazines to find a new hair style you'd like to try

Read the entire New York Times – that will take at least a half a day!

Emotional care

Go sit out on your deck or porch for awhile each day and get some fresh air

Get free therapy online and make friends with other people who are in similar situations on the Spine-health.com Discussion Forum: "...finding this site and spending time here was a great help during recuperation - both in regard to having something to do but also for learning and understanding about our surgeries and recovery, and also being able to help and assist others here - that's why I am still active here 7 months after surgery."

Start a Carepage – an online diary that allows you to chronicle your recovery and automatically notifies your network of friends and family each time you update it.

E-mail a loved one who is having difficulty empathizing with your condition and invite him or her to view the Message Board so they can see what you and others in your condition have to go through

Talk with others real time who are laid up in similar situations in an online Chat Room

Read and comment on blogs that deal with recovery from surgery; or start your own blog!

Connect with an old friend who you've lost touch with. Try sending him or her a card or letter via old fashioned mail.

Learn to meditate and practice practice practice. Meditation is great for reducing stress and producing an overall feeling of calm and well being, all of which contributes to healing.

Productive time

Scrapbooking and putting all those old pictures in an album. Use … to create online photo albums of all your digital prints

Plan ahead for your next vacation - research and plan it online.

Become on expert on a specific subject – rent documentaries, read books, and use Google Scholar to do free online research on a certain subject. Ancient Greece? Bird watching? History of golf? Research and learn all about whatever interests you.

Sort out pile of mail, bills, catalogues etc., that has been piling up on kitchen counter since before your surgery.

Put your financials online with Quickbooks or a similar financial management program.

Make some gifts the old fashioned way – knit or crochet a baby blanket for someone who's expecting a baby soon, needlepoint something to decorate the baby's nursery, or make advance holiday gifts.

Learn the almost-lost art of lace making

Learn to write left handed (or right handed, if you're a lefty) to exercise a new part of your brain

Inventory all the stuff you want to get rid of around the house and garage, and sell it on E-Bay

Get started on that novel you've always wanted to write

Make a Honey-do (or handyman) list for all those odd jobs that need to get done around the house

Help build the online encyclopedia Wikipedia by editing or starting any topic where you have expertise

Learn origami and create beautiful origami gift boxes or figures

Learn calligraphy and make your handwritten notes gorgeous! This is especially valuable if you have horrible handwriting like mine…

Create list of recipes that are easy to prepare that you can make once you're up and around but still recovering. Here's a list of spine-friendly recipes

Feeling better by doing good

Every day write a short thank you (or love note) to the person who is caring for you and put it in the same place for them to find each day.

Write thank you notes to everyone in the hospital who was helpful to you
Pray in your own way.

E-mail thank you notes to all the websites you found especially helpful (hint, hint!) … makes all the hard work worth it J

Read online verses from the bible about healing and related topics

Anytime you reach out to help someone else in need, you will feel better. Less lonely. Less depressed. Volunteer with an organization that allows you to call and talk to people who are lonely (such as people in nursing homes or people confined to their house).

If you don't yet have a cause that you're passionate about, research one online (start here) and make a plan to start donating your time and energy to something you care about once you can get around

Be an excellent host or hostess – send out invitations to your friends and family, schedule visits, greet your visitors enthusiastically even when you're in pain, and encourage them to talk about themselves and their lives. It will go a long way to help take your mind off your situation, and will make it a pleasant visit all around.

Getting mobile again

If you can't walk much yet, have someone drive you to Wal-Mart or Target and ride one of the rascal scooters.

Just walk walk walk. Try to gradually work up to 10,000 steps a day

Wear a pedometer to encourage you to walk whenever possible

[url:1195,type=|node|,content=|Get comfortable shoes|] for walking that are easy to get on and off. Crocs are a favorite – they're lightweight, slip on so you don't have to bend over to get them on or off, and have some traction to help avoid slipping.

[url:1199,type=|node|,content=|Walk on a treadmill|] and set a progressive goal (e.g. go for 2 minutes longer each day) that is OK'd by your doctor. Chart your progress each day so you have a visual confirmation of how far you've come!

[url:1284,type=|node|,content=|Sign up for a water therapy|] - it's very gentle on your back, as the water supports you while you exercise and prevents any jarring motion.

Of course, check with your doctor first before doing any of the above.Many of these ideas do require a laptop and Internet access. If you don't have a laptop, you can buy an inexpensive one (starting at $600) or try to borrow one from a friend or family member. Wireless internet access is a good idea so you can access the Internet from your bed, a recliner, or wherever you're most comfortable.Any more ideas? Please add your comments!

Posted by: Stephanie

Laser Disc Decompression for Spinal Stenosis: Does it Work?

Mon, 30 Jul 2007 15:46:34 -0700

July 30, 2007
by: Peter

[url:5998,type=|node|,content=||]
[url:5998,type=|node|,content=||] [url:5998,type=|node|,content=|See the Spinal Stenosis
Interactive Video|]

As a practicing spine surgeon, I am often asked by patients if their [url:1580,type=|node|,content=|disc decompression surgery|] can be done with a laser. There is a perception by the general population that lasers are a modern, almost futuristic, up and coming technology. The reality is that lasers have been around for a long time and are almost completely useless when it comes to spine surgery.

[url:17599,type=|node|,content=|A laser|] is a focused beam of light that can be used for cutting soft tissue. In eye surgery, they are definitely useful and have changed corrective eye procedures drastically. In the spine, electrocautery is much more practical for cutting soft tissue. Lasers can cut disc tissue, but it is far easier and more reliable to mechanically grab the disc fragment and remove it from compressing the nerve. Also, since discs lie right next to the nerve root, one risks the chance of damaging the nerve root with the laser. Lasers cannot cut bone so they cannot be used to decompress patients with [url:152,type=|term|,content=|spinal stenosis|].

It seems to me that the most practical use for lasers in spine surgery is for marketing. Like most businesses, spine surgery is very competitive, and having an edge in marketing can make a practice standout. I knew a spine surgeon who would tell his patients he could use a laser to do their surgery. He would cut the skin with a scalpel, then bring in a laser to cut the subcutaneous fat, then go back to electrocautery. However, since the laser was so slow, he would only use it for about thirty seconds before he went back to electrocautery. The laser performed no useful function during the surgery, but helped him for marketing purposes.

Spine-health.com has thousands of pages of information, all of which have been peer reviewed by a medical advisory board of prominent spine physicians. However, there is not one article on laser surgery as it is not an accepted spine procedure. At the major spine meetings and in the major spine journals there is a paucity of (if any) peer reviewed articles documenting any use of lasers in spine surgery.

So, if mainstream spine surgery is not interested in lasers, and lasers are primarily only useful as a good marketing tool, why do patients remain so interested in lasers? Perception plays a central role, and many patients perceive lasers to be a useful technology. Lasers are often perceived as an effective surgical approach for spine surgery because of two reasons: placebo response, and the tendency to always think the second opinion sounds more knowledgeable.

Placebo response: Patients with pain want to get better, and if they undergo an invasive procedure, they will try to get better if at all possible. The placebo response in patients with chronic pain can be as high as 70%, even if the procedure was a complete sham and did not address their spine pathology. However, in patients with true pathology the response doesn’t last very long. I recently operated on an elderly woman who had a degenerative spondylolisthesis and severe lumbar spinal stenosis. She had initially seen a local surgeon who had recommended a posterior decompression, instrumentation and fusion (which is what she needed for correction of her condition). She went to a center that claimed a laser surgery would suffice. After the laser surgery, she felt better for a couple of weeks, but then realized her pain was about the same. This is the placebo response. When I saw her and offered her the surgery she should have had in the first place, the reason the laser surgery had failed became apparent. I could see that none of the bone around the nerve roots had been removed, as would be expected since a laser surgery would have limited exposure and limited ability to deal with the anatomic problem causing the pain.

We did perform the surgery that was needed and she has subsequently done very well, as would be expected since this is a reliable surgery. The previous laser surgery had been touted as a minimally invasive surgery, which is its main benefit, but the drawback is that it does not address the pathology of lumbar spinal stenosis – the laser surgery does not remove the bone that is pressing against the nerve root and causing the pain. Unfortunately, since her laser surgery was not covered by insurance, the patient was out the cash.

Second opinion. The other factor that allows lasers to be marketed for spine surgery is that almost any second opinion for surgery has a tendency to sound smarter than the first opinion. The above patient had seen another surgeon prior to going to having laser surgery, and the first surgeon had recommended the appropriate surgery for her condition (decompression, instrumentation and fusion). The surgeon who wanted to use the laser, however, probably sounded smarter since he gave the second opinion. I have frequently heard that nobody should have a spine surgery unless they get a second opinion. The danger is that the next opinion a patient obtains may or may not be any smarter that the first opinion, and it may be based more on marketing than on any sound medical science. This is not to say that patients shouldn’t get second opinions – I am very much in favor of the patient having as much information as possible prior to deciding on surgery. Just be aware of the natural tendency for the second opinion to sound better.

Posted by: Peter Ullrich, MD

Think Carefully About your Surgeon's Recommendations

Mon, 16 Jul 2007 17:26:57 -0700

July 16, 2007
by: Peter

[url:1582,type=|node|,content=|Spinal fusion surgery|] for low back pain has gotten quite a bad reputation for delivering poor results. Because it is a painful, dangerous, and costly surgery, spine fusion should only be offered for the most severe symptoms and clearly defined pathology, but sadly this is not always the case.

Recently, I saw as a second opinion a young man who had been offered a three level fusion by another surgeon - a prominent academic surgeon at a medical school in a different area. This 19 year-old male was very debilitated with low back pain and bilateral [url:887,type=|node|,content=|leg pain|] that was made worse with activity. The young man was taking large doses of oral narcotics to control his pain and had already maximized his non-surgical treatments, including three epidural injections.

The only abnormalities that his MRI scan revealed were [url:1051,type=|node|,content=|congenital stenosis|] of his lumbar spine, made somewhat worse at L4-L5 by a slightly bulging disc. The surgeon recommended and booked this young man for a three level decompression, instrumentation and fusion and told him that "additional levels of the spine may need to be fused once they see what is going on during surgery".

This is truly an unbelievable opinion. The chance that a three level fusion would relieve the patient's pain is only about 50%, AND there is a 50% chance that the surgery would actually make his pain worse. Even if the surgery did provide pain relief, it would only be temporary until the next level of the spine wore out and started causing pain. The spine is meant to move and fusing three levels, especially in a 19 year old, completely alters the biomechanics of the spine. In the spine surgery world, the term "fusion disease" is used to describe the ongoing or worsening pain that follows a multilevel fusion.

This young man's scan and x-rays did not show any pathology that would warrant a fusion. The number one determining factor whether or not a fusion surgery will deliver the desired reduction in pain is a proper preoperative diagnosis that clearly identifies the [url:1470,type=|node|,content=|cause of the patient's pain|]. I can't stress this enough. Fusion surgery does work very well for discrete pathology. One (or maybe two) level severe [url:815,type=|node|,content=|degenerative disc disease|], [url:6000,type=|node|,content=|spondylolisthesis|], tumor, fracture or infection all can be successfully treated with a fusion that removes the motion at a painful motion segment. But this young man did not have any of these problems, so a fusion would be unlikely to help him. At the most, a one or two level [url:1581,type=|node|,content=|decompression surgery|] to treat the [url:1051,type=|node|,content=|spinal stenosis|] could have been considered to treat the pain.

There is no way to justify a reckless use of fusion surgery such as the recommendation that this man received, and it typifies what is wrong with fusion surgery today. At best, that surgeon does not understand what pathology is and is not amenable to a fusion procedure. At worst, he is motivated purely by a profit motive and does not care about the damage and pain he is inflicting on patients. Having a three-level fusion at age 19 would have severely damaged this patient's life forever.

It just takes a few unskilled and/or irresponsible surgeons to ruin a lot of people's lives. Patients should take all precautions to get educated about their options and understand exactly why the surgeon is doing the surgery, the risks and benefits, and their other options, before deciding on fusion surgery.

Posted by: Peter Ullrich, Jr., MD

6 Sites for Checking Out Your Hospital

Sun, 15 Jul 2007 14:20:59 -0700

July 15, 2007
by: Sylvia Marten

Are you scheduled for [url:165,type=|term|,content=|back surgery|] or considering it? In addition to a thorough check of your surgeon, you should probably check out your hospital too. While the surgeon is arguably the key factor in the procedure itself, the hospital staff, environment, and guidelines can impact things like choice of medication and use of antibiotics – choices that can cause variances among different hospitals, such as post-op infection rates for back surgery patients.

The notion of “hospital quality” would have been nearly impossible for consumers to ascertain even a few short years ago. But now, as part of the push to improve health care quality and lower costs, hospital information is becoming public.

Thanks to Theo Francis at the Wall Street Journal for compiling a list of hospital comparison resources available to the public.

Two major categories of data cover:

Best practices - which tracks how often hospitals follow recommended guidelines for particular procedures. Online resources include:

Procedure outcomes - which tracks how patients that have particular procedures actually fare. This data often covers mortality rates, readmissions and complications. Online resources such as:

This hard data should be considered along side the qualitative data provided by talking to others:a hospital’s reputation for back surgery (and ideally, for the particular type of surgical procedure e.g., fusion surgery, artificial disc replacement) in the community, the experiences other patients have had at that hospital, what a hospital’s employees say, and what a prospective patient learns and feels by calling up the hospital’s quality department or talking with the medical staff.

What other resources have you found helpful in assessing hospital quality?

Posted by: Sylvia

More reading:

[url:1556,type=|node|]

38 Questions to Ask Your Surgeon Before Having Back Surgery

Thu, 28 Jun 2007 18:02:14 -0700

June 28, 2007
by: Stephanie

Surgery Videos

This subject comes up a lot in our forums - "I'm considering surgery, what questions should I ask my surgeon?" From articles on Spine-health.com and contributions from our discussion forum members, we've compiled a list that you can print up and take with you to your consultation. Good luck!

Questions before you decide to have the surgery

What type of surgery are you recommending? Why?
What is the source of the pain that is being addressed? How do you know this? (Exploratory back surgery is not done).
Please explain the procedure - at a very high level/with some detail/in great detail. The amount of information depends on your personal preference – some want to know everything, some not so much! To actually see the surgery (animated – no gore) – view our [url:204,type=|term|,content=|Spine surgery animated videos|].
What are my non-surgical options?
What is the natural course of my condition if it is not surgically addressed?
What would you recommend if this were your friend/wife/sister/daughter etc…?
How long will the surgery take?
What are side effects, potential risks and complications?
Please explain the risks and how they relate to me personally. For example, chances of having a non fusion if you are overweight, a smoker, risks if have a grade 3 spondy, etc.
What if you get in there and see something different than you expected?
Do I need to donate my own blood? If yes, why? For most types of [url:165,type=|term|,content=|back surgery|], blood does not need to be donated ahead of time.
Do you perform the whole procedure? Will any students/other surgeons be doing any parts of the operation? If yes, who are they and what are their qualifications? Some surgeons only do a small part of the operation, others do the whole thing. If another surgeon is required, e.g. a vascular surgeon, their role is important and it would be good to know their qualifications..
Who else will assist you in the operation? What is their background and qualifications?
What are the long-term consequences of the proposed procedure? E.g. will the operation ever need to be re-done? If it is a fusion, will it lead to degeneration at other levels of the spine?)

Questions about the surgeon

How many times have you done this procedure? In general, when it comes to surgery "practice makes perfect", so more is better. (However, if the doctor is recommending something that is not often done, such as multi-level fusions, more would not necessarily be better.)
Are you board eligible or board certified? You can usually look on the wall and see a certificate.
Are you fellowship trained in spine surgery? This is more important if the surgery is a fusion, artificial disc replacement, or other more extensive procedure.
If I want to get a second opinion, who would you recommend? (Someone not in the same practice)
Statistically the success rate for this type of surgery is _%. What is your personal success rate, and how many of this type of surgery have you done?
Can I talk to other patients who have had a similar procedure?

Any defensiveness on the part of the surgeon when you ask these types of questions may be a red flag. A surgeon with good results and appropriate qualifications will not be threatened by these types of questions and will respect your attention to these matters.

Questions about what to expect after the surgery

What kind of pain should I expect after the surgery and for how long?
How long is the hospital stay?
May a family member spend the night with me in the hospital?
How do you manage the pain in the hospital?
Which pain medications will I be sent home with? What are possible side effects of these prescriptions? E.g. Constipation, drowsiness, etc.
Will you know before the surgery if I will need a backbrace afterwards? If so, will I be fitted for one before the surgery?
Who can I call if I have questions after the surgery? What is the process for communication?
How often will I see you after my surgery?
What symptoms would warrant a call to your office?
What symptoms would warrant immediate medical attention?
What limitations will I have after surgery and for how long?
How long will I be out of work? School? Whatever...
What kind of help will I need when I return home?
When can I drive again?
When can I resume normal (light) household chores?
What expectations do you have for my recovery?
When is it safe for my spouse and I to have sexual relations again?
How soon after the surgery can I start physical therapy?

Good luck with your decision and your recovery!

Posted by: Stephanie

More resources:

[url:1457,type=|node|,content=|Practical Advice for Recovering from Back Surgery|]
[url:1536,type=|node|,content=|Preventing Constipation after Back Surgery|]
[url:1547,type=|node|,content=|How to Select a Spine Surgeon|]
[url:6592,type=|node|,content=|How to help your surgeon help you|]
[url:6591,type=|node|,content=|Back Surgery Postop Recovery Tips|]
[url:6593,type=|node|,content=|Top 10 Reasons to Run from your Surgeon|]

Sometimes Surgery is Quickest Path to Sciatica Pain Relief

spine-health — Fri, 22 Jun 2007 17:09:10 -0700

June 22, 2007
by: Stephanie

The study, published in the May 31 New England Journal of Medicine, compared surgical treatment of back and leg pain (sciatica) caused by disc herniation.

Dante Implicito, MD, an orthopedic surgeon in Paramus, NJ, pointed out that non-surgical treatment or a wait-and-see approach isn't always right for the patient in term of quality of life. Some people are in so much pain, they can't function or may risk losing their jobs, so they opt for surgery ([url:1584,type=|node|,content=|microdiscectomy|]) sooner. "(This study) shows that there can be tremendous improvement if patients are selected well for surgery," he said.

HealthDay reports: "The study...included 283 people who had severe sciatica -- leg pain caused by a compressed nerve in the spine (a [url:885,type=|node|,content=|herniated disc|]) -- for at least six to 12 weeks prior to the start of the study. Half of the group was selected to undergo early surgery -- an average of 2.2 weeks into the study; while the other half was chosen to receive conservative treatment with the option of surgery at a later date. Thirty-nine percent of the conservative treatment group eventually decided to have surgery, and the average time from the start of the study to the surgery was 18.7 weeks."

The findings:

Those who had a microdiscectomy sooner reported faster pain relief than the non-surgical treatment group.
Recovery for both the groups was same (95%) at the end of one year; however, the patients undergoing an early surgery experienced faster relief from sciatica.

Dr. Implicito emphasized that the most important thing someone with back pain can do is see a specialist with as much specific training in back problems as possible. "Back pain comes in a lot of different 'flavors', you need to be evaluated and diagnosed by a very well-trained person so you know what's relevant to your condition."

Posted by: Stephanie

Primary sources:

SOURCES: Weinstein, J.N. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2257-2270. Peul, W.C. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2245-2256. Deyo, R.A. The New England Journal of Medicine, May 31, 2007; vol 356: pp 2239-2243.

Additional reading:

[url:151,type=|term|]
[url:884,type=|node|]

Spinal Fusion Vs. Universal Healthcare

spine-health — Fri, 08 Jun 2007 18:07:54 -0700

June 8, 2007
by: Stephanie

Jonah Lehrer takes an interesting look at the issue of the expense of [url:1757,type=|node|,content=|spinal fusion|] - usually about $50,000 for a surgery - and the mixed reports over whether or not it has any real therapeutic benefit.

The point is illustrated in real time on our back surgery message board discussions - for some people the surgery was a godsend, for others a failure, and still for others it made their pain worse. So what's the right answer? I think it's messy, and that's the difficulty with coming up with fair and equitable universal healthcare coverage.

With spinal fusion, when it's done by a surgeon with expertise and finesse for a patient with the right indications, spinal fusion can provide almost immediate relief for excruciating and disabling pain. But the devil is in the detail - how to evaluate each surgeon's diagnostic and surgical skills? That's the real question.

Posted by: Stephanie

Additional resources:

[url:1462,type=|node|,content=|Deciding on surgery for degenerative disc disease|]
[url:1540,type=|node|,content=|Choosing the best spine surgeon|]

CMS Proposes Denial of Coverage for Artificial Disc Replacement

spine-health — Fri, 08 Jun 2007 17:38:30 -0700

June 8, 2007
by: Stephanie

The Centers for Medicare and Medicaid Services has proposed that [url:1435,type=|node|,content=|lumbar artificial disc replacement|] “is not reasonable and necessary for the Medicare population over sixty years of age.”

The proposal is largely based on the known risk factors in the event that the surgery would need to be revised and the lack of data for individuals over age 60. The CMS had previously issued a non-coverage decision for just the [url:1438,type=|node|,content=|Charite artificial disc|], but since then the Prodisc has been approved and a number of other discs are in various stages of development and clinical trials. This proposal would expand the coverage to include all lumbar artificial discs. The proposal leaves coverage decisions for individuals under age 60 up to local Medicare agencies.

While few people over age 60 actually are indicated for artificial disc replacement, CMS coverage decisions do have influence over insurance company decisions about coverage for the artificial discs.

This is a proposed determination at this point not a final decision. Before issuing a final determination CMS is requesting comments from the public.

Posted by: Stephanie

Back Surgery Best for Patients with Degenerative Spondylolisthesis

Wed, 06 Jun 2007 17:53:41 -0700

June 6, 2007
by: Sylvia Marten

Surgery Videos

The recently released results of the second SPORT study showed that patients who selected surgery to treat their [url:709,type=|node|,content=|lumbar degenerative spondylolisthesis|] had better outcomes when compared with those who selected nonsurgical treatment. The study included two groups of patients:

Randomized group – 304 patients
In the randomized group, 304 patients were randomly selected to receive either standard posterior decompressive [url:6023,type=|node|,content=|laminectomy|] (with or without a [url:1582,type=|node|,content=|spinal fusion|]) or nonsurgical care. Nonsurgical treatments included [url:171,type=|term|,content=|physical therapy|], epidural steroid injections, NSAIDS, and opioids. There was significant crossover from patients in the surgical and nonsurgical groups, with 64% of the surgical group having surgery and 49% of patients assigned to nonsurgical care also having surgery.

Because of the large percentage of patients who crossed over to from non-surgical treatment to surgical and vice-versa, the results of the study are really only meaningful by evaluating how the patients were actually treated, (vs. by their randomized groups).

Observational group – 303 patients
This group was allowed to choose whether to have surgery or receive nonsurgical treatment. 97% of patients who selected surgery went through with the operation, and 25% of the nonsurgical group ultimately chose surgical treatment.

The surgery for [url:6000,type=|node|,content=|spondylolisthesis|] included a decompressive laminectomy with or without an accompanying spinal fusion.

The large cross-over of patients and the favorable outcomes show what doctors and patients already know: those with pain fare best when their care was left to the individual discretion of patient and surgeon.

Primary source:

Surgery vs. Non-surgical Treatment for Lumbar Degenerative Spondylolisthesis

Surgery best for degenerative spondylolisthesis

Wed, 06 Jun 2007 13:59:36 -0700

June 6, 2007
by: Sylvia Marten

The recently released results of the second SPORT study showed that patients who selected surgery to treat their lumbar degenerative spondylolisthesis had better outcomes when compared with those who selected nonsurgical treatment. The study included two groups of patients:

Randomized group – 304 patients

In the randomized group, 304 patients were randomly selected to receive either standard posterior decompressive laminectomy (with or without a spinal fusion) or nonsurgical care. Nonsurgical treatments included physical therapy, epidural steroid injections, NSAIDS, and opioids. There was significant crossover from patients in the surgical and nonsurgical groups, with 64% of the surgical group having surgery and 49% of patients assigned to nonsurgical care also having surgery.

Observational group – 303 patients

This group was allowed to choose whether to have surgery or receive nonsurgical treatment. 97% of patients who selected surgery went through with the operation, and 25% of the nonsurgical group ultimately chose surgical treatment.

The study showed that patients in both groups who chose surgery to treat their lumbar degenerative spondylolisthesis and spinal stenosis fared significantly better in terms of pain relief and function at 3 months, 1 year, and 2 years than those who received non-surgical treatment. The surgery for spondylolisthesis included a decompressive laminectomy with or without an accompanying spinal fusion. The large cross-over of patients and the favorable outcomes show what doctors and patients already know: those with pain fare best when their care was left to the individual discretion of patient and surgeon. Primary source: Surgery vs. Non-surgical Treatment for Lumbar Degenerative Spondylolisthesis

Are Cadaver Bone Grafts Safe?

Tue, 05 Jun 2007 18:50:23 -0700

June 5, 2007
by: Peter

Not too long ago there were numerous articles concerning the illegal harvesting of non-donated cadaveric [url:1577,type=|node|,content=|bone graft|]. Normally, patients need to be screened before being harvested and conditions such as infection or bone tumors need to excluded from the donor pool. There is a relative shortage of donor bodies, and this has led to a black market of bone harvesters. Basically, once a family gives a loved one over to a cremation or burial service, they do not know if anyone is harvesting and selling tissue from the deceased. X-rays have even shown bodies that have had their long bones harvested and then replaced with PVC piping prior to burial.

The biggest scandal to date involved Biomedical Testing Services (BTS) which had harvested hundreds, perhaps thousands, of cadaver bones that had not met FDA tissue donor eligibility requirements. Although the FDA felt the risk of transmission was low, they encouraged companies that had purchased bone tissue from BTS to offer patients implanted with the tissue free communicable disease testing. Specifically, patients were offered tests for hepatitis, syphilis and HIV (the virus that causes AIDS). The tissue from BTS had been processed in the normal manner, but the FDA still felt there might be some (although little) risk of subsequent disease transmission.

Stealing tissue is a gruesome business, but for the patients that had been implanted with stolen bone, this was an especially unwelcome turn of events, to say the least. To my knowledge there have not been any proven infections because of the stolen bone, and the overall risk to receiving an infection from cadaver bones has always been and remains very low. There are, however, good synthetic alternatives for bone graft, and recent advancements in spinal fusion technology have largely obviated the need for using cadaveric bone for [url:1792,type=|node|,content=|spinal fusion|].

Bone graft often provides two components to a fusion, the first being structural support, and the second is as a scaffolding and signal for the body to start the fusion process. Structural support can be provided by other materials such as PEEK (a type of plastic), carbon fiber, or titanium. All of these compounds are inert and the body really does not care if they are implanted. They are not a biological graft such as allograft (cadaver bone) but in some ways this is good. The first reaction to a structural allograft implanted in the [url:948,type=|node|,content=|intervertebral disc|] space is that the host bone goes through osteolysis, or resorption of bone around the graft. So the fusion construct initially gets weaker before it gets stronger. Inert materials do not cause this reaction. The other problem with a biological allograft used for structural support is that the host body has to very slowly cut new bone channels into the graft (Haversian canals) and then lay down new bone (enchondral ossification). This is an extremely slow process, and it takes many years for most implanted allograft structures to be fully incorporated by the host bone.

Stealing tissue is a gruesome business, but for the patients that had been implanted with stolen bone, this was an especially unwelcome turn of events, to say the least.

As far as the scaffolding and signal to fuse process goes, allograft bone is very poor at actually creating bone. It lacks the cells and proteins to initiate the fusion process. The gold standard for spinal fusion material is still cancellous bone harvested from the patient’s own iliac crest, but harvesting a patient’s own bone can be painful and has a fairly high incidence of postoperative complications. Fortunately, there are now numerous synthetic bone graft substitutes and extenders that can be used instead of a patient’s own bone. The most popular one at this point is bone morphogenic protein, or BMP, (Infuse-Medtronic) which is a protein produced by recombinant DNA technology that carries a strong signal for the body to grow bone. Since its release in 2003, it has been used to successfully grow bone in fusion surgery in thousands of patients.I have had extensive experience using bone marrow aspirated with a needle from the patient’s iliac crest and combining it with a very porous B-tricalcium phosphate (Vitoss- Orthovita) . This combination has been very reliable in growing bone in the intervertebral disc space, and has the advantage of not only being much less expensive than BMP, but also does not carry the theoretical risk of inserting a recombinant protein into a patient. BMP has been inserted into thousands of patients and the risk of inserting pharmacological doses of one protein does not seem to be great. However, just as with allograft bone, we do not know the true safety of these compounds and may not for years.

Bottom line, although allograft has traditionally been felt to be safe for human use, where there is a viable [url:1738,type=|node|,content=|synthetic alternative|], grafting of material from one human to another should be avoided. In some situations of spine surgery, such as long anterior strut grafts, allograft bone still may be preferable, but for short anterior interbody constructs, there are numerous synthetic alternatives.

By: Dr. Ullrich

More reading:

[url:173,type=|term|]
[url:1577,type=|node|]

Top Ten Reasons You Should Run from Your Surgeon

Tue, 08 May 2007 18:36:12 -0700

May 8, 2007
by: Peter

Read this before selecting a surgeon to operate on your back.

If the surgeon says "Everyone does well with this surgery". There is no surgery that does not have risk and always has a good outcome.
If hip surgery is their main focus and spine surgery comprises only a small part of their surgeries - it takes a lot of practice to get good at operating on the spine.
If they cannot clearly articulate what they think is the anatomic problem that is causing your pain and how they propose to correct it.
If they state "I always do the neck first and then do the back". This sounds ridiculous but it happens. It is highly unlikely that a patient would have anatomic lesions in both the neck and back.
If they propose doing a multilevel fusion in the lumbar spine for [url:815,type=|node|,content=|degenerative disc disease|]. The spine is meant to move and although fusing one or possibly two levels for a badly degenerated disc is reasonable, fusing multiple levels rarely is necessary or advisable.
If the surgeon does not offer a patient any [url:806,type=|node|,content=|non-surgical treatment options|] they may be operating under the old [url:6587,type=|node|,content=|"I have a hammer so everything I treat is a nail"|] adage.
If they get perturbed by the [url:1505,type=|node|,content=|patient asking questions|]. A well qualified informed physician does not mind a patient asking questions. A marginal physician is more likely to be put out by an inquisitive patient.
If the surgeon states that he has never done this particular type of surgery but would like to try it.
If the first surgery does not work and the surgeon proposes doing it all over again. The most common reason [url:1470,type=|node|,content=|a surgery does not work|] is that the patient did not need the surgery in the first place.
If the given reason for proceeding with surgery is that the surgeon needs a new boat.

Posted by: Peter Ullrich, Jr., MD

Additional resources:

[url:1462,type=|node|]
[url:1792,type=|node|]
[url:1547,type=|node|]
American board of spine surgery

How to Help your Surgeon Help You

Tue, 01 May 2007 19:12:52 -0700

May 1, 2007
by: Sylvia Marten

Anyone who has experienced [url:137,type=|term|,content=|chronic low back pain|] knows how frustrating it can be to find a doctor to help. From a surgeon's perspective, I often see patients who have seen multiple other doctors and physical therapists and have not had relief of their pain. (After all, if non-surgical treatment was working they wouldn't be coming to me to get a surgical opinion in the first place.)

If you've had your back pain for a long time, you already know that finding the cause of the pain and an effective treatment is quite complicated. Treating chronic low back pain is almost like detective work, and the better the communication is between the patient and the physician, the better the expected outcome. Apart from basic courtesies such as arriving to your appointment on time with all your paperwork ready, there are several important things that you can do to assist in your own care.

Treating chronic low back pain is almost like detective work, and the better the communication is between the patient and the physician, the better the expected outcome.

Document the treatments you've already tried
Knowing ahead of time what you have tried and whether it worked (even if it worked for only a short time) is helpful. The more information you can give pertaining to your prior care, the less time will need to be spent [url:1872,type=|node|,content=|re-exploring these treatments|]. Being specific about the treatments is also very important.

Just saying you have tried physical therapy is meaningless. What the physician will want to know is what was tried in [url:1183,type=|node|,content=|physical therapy|] and for how long. Are you still continuing with an excercise program? Did the therapy just consist of ultrasound and hotpacks with no active excercise? Were you instructed in core stabilization exercises?

Similarly, if you have tried [url:1915,type=|node|,content=|pain medications|], the physician will want to know the specifics on which medications have been tried, at what dosage and for how long. Did they help with the pain or help increase daily functioning? The same is true for any injection. What kind of injection was it? Did it help and if so how much and for how long.

Having all of this written out prior to the appointment will help the physician be able to quickly understand and assess your situation, and it'll make sure you don't forget anything.

Bring any prior imaging studies
Besides the history and physical exam, the next most important piece of information to a surgeon is the [url:729,type=|node|,content=|imaging studies|]. The actual imaging studies are what will be needed. Reports on imaging studies (vs. the image itself) are pretty much meaningless as there is no standardized terminology for reporting on imaging study findings. Old studies can also be useful to see if there are any progressive changes.

Ask the physician in person for any paperwork
At the end of an interview, you should not be afraid to request any needs you have such as medication refills or return-to-work paperwork. It is far easier to close out all these practical problems of chronic low back pain while you have face to face time with a physician rather than ask their staff for these items on their way out of the office or calling back later.

Keep the peace
Lastly, while dealing with chronic low back pain is frustrating, and we all know that dealing with the healthcare system can also be frustrating, it never helps to get angry with your surgeon on the first visit. This may sound obvious, but it happens. Some patients lose perspective and take their anger and frustration out on the surgeon, which will not help the patient and may cause the surgeon to ask them to leave.

Remember, especially if this is the first time you are meeting with a surgeon, he or she is not to blame for your pain and may actually be able to provide your best chance for some pain relief.

Have clear expectations of what a spine surgeon can do for you
When you consult with a spine surgeon, what he or she will be mainly looking for is an anatomic lesion (problem) that is both the probable cause of your pain and is amenable to surgery. Basically, [url:1563,type=|node|,content=|spine surgery|] can only decompress a nerve or stabilize a painful motion segment, and these two conditions comprise a surprisingly small percentage of all the causes of chronic low back pain.

In about 80-90% of cases no anatomic lesion can be found as a cause of the patient's pain. This does not mean the patient has no reason for the pain he or she is experiencing; it just means that an anatomic cause of pain is not identifiable and this is not uncommon with back pain. Understandably, this disappoints many patients, as they may feel their pain has not been validated and surgery cannot provide a clear course of action for pain relief.

After the initial consultation, a spine surgeon should be able to tell a patient whether he or she may be a surgical candidate. Most patients conditions will fall into one of three categories.

They may definitely have a surgical lesion
They may have a lesion that is potentially surgical but requires further work up
They may have no identifiable anatomic lesion as a cause of their pain.

The patient is the only one who has the pain, and the only one who knows how it is impacting his or her life. The surgeon should be able to articulate what can technically be done and what kind of postoperative course and outcome a patient can reasonably expect. Armed with the knowledge from the surgeon a patient should be able to make an informed decision. The patient information on this site can help a patient with their decision making process.For those patients who have an anatomic lesion that potentially may be treatable by a surgical procedure, they will want to know the same above information before further workup. If they do not have enough pain to undergo surgery, further workup is not warranted. For instance, if the proposed surgery is a fusion for degenerative disc disease, and a discogram is necessary as a preoperative study to confirm if surgery would help, a patient may choose not to undergo the discogram if they do not wish to consider fusion surgery.

If a surgeon cannot articulate what a patient has and what type of treatment will be potentially advantageous, the patient may want seek yet another opinion. After all, deciding on surgery can be very difficult and if the surgeon cannot help in this process, it is doubtful he or she will be effective in helping one deal with postoperative rehabilitation or treating potential postoperative complications.

Additional resources:

[url:1547,type=|node|,content=|How to select a spine surgeon|]
How to find a good spine surgeon

Back Surgery Post Op Recovery Tips

Fri, 27 Apr 2007 12:40:50 -0700

April 27, 2007
by: Stephanie

The entire surgical process – from deciding to have surgery through recovery – can be a thoroughly stressful time. To help reduce your stress levels as much as possible, here’s a checklist of what you’ll need while recovering from surgery, both in the hospital and while recuperating at home.

Crocs. You will want to wear slip on shoes for several weeks (and maybe more) following the surgery so you don’t have to bend over to tie your shoes. Any slip on shoes will work. Crocs are a favorite – they are easy to get on, have some grip on the sole, and can be worn indoors and out. They are useful in the hospital, as you will be encouraged to get up and walk around as much as tolerated soon after the surgery.
Ice packs. Ice is a valuable pain reliever. Applying an ice pack to the numb the painful area will go a long way to easing pain and discomfort. [url:1664,type=|node|,content=|An ice massage|] can be very soothing. If your doctor or nurse doesn’t bring it up, you should ask about how to use ice or cold packs for pain control – it really helps! The hospital will probably have ice packs, but you may want to bring some just in case.
Sports bottle. You’ll be encouraged to drink a lot of liquids while in the hospital, and if you don’t want to have to sit up for each sip, bring a sports bottle with a squirt top so that you can drink while lying down or reclining without spilling all over yourself.
Laxatives and/or stool softeners. Chances are your doctor won’t bring up this subject, but it will be an important issue to you following the surgery. [url:1536,type=|node|,content=|Post operative constipation|] is a common occurrence and it can be a major source of pain and discomfort. Prune juice, apple cider, and/or over-the-counter laxatives and stool softeners will all help prevent postoperative constipation. Your hospital will likely provide these, but you may want to bring them just to play it safe.
Practice the log roll. You’re going to need to learn how to get into and out of bed safely, and a log roll technique will do the trick. It’s best to ask about this before the surgery so you can practice a bit and get the hang of it without any pressure or fear of pain. Many say that getting in and out of bed after fusion surgery is one of the most intimidating and difficult aspects of the recovery process.
Trash bags. Putting a trash bag on the bed will reduce the friction so you slide more easily onto the bed. Also, you’ll want a trash bag to put on the car seat for the ride home.

Additional things you may want to bring to the hospital:

Lip balm or chapstick and hand moisturizer – the air in most hospitals is uncomfortably dry
Foot cream – if they put the special booties on your feet to help prevent a blood clot, you’ll want someone to put some moisturizer on your feet to prevent soreness
Comfortable robe – you’ll be encouraged to be up and walking around as soon as possible after the surgery, and those hospital gowns don’t afford much coverage in the back
Pajamas – if you bring PJ’s, make sure they button up the front so you won’t have to reach over your head to pull the top on.
Toiletries – in case you’re allowed to shower, and definitely toothpaste and toothbrush. You can even brush your teeth in bed – just spit into a bedpan.
Hairbands – if you have long hair and don’t want it to get all angle up, bring something to pull your hair back. Maybe a cap if you don’t want your visitors to see your unwashed hair.
Ear plugs - if you’re a light sleeper, use ear plugs to get some rest – hospitals are busy, noisy places. A walkman or IPod will also drown out the noise
Scratcher – bring some type of long stick for getting those hard to reach itches. A long-handled wooden spoon will work just fine, but you can also get a cute long-handled scratcher.

Recuperating at home:

In addition to everything from the above list (except maybe the ear plugs), you will need a few things to help with your recovery at home, such as:

Mini-fridge. Especially after a spine fusion, you probably won’t want to be running up and down the stairs during your recovery. A mini-fridge in your room allows you to stock up on water, juice and other essentials for the day. A cheaper alternative is a cooler that can be filled with ice packs or ice to keep your juice and snacks cool.
Wireless. This is a luxury worth mentioning. A wireless Internet connection will allow you to have your laptop in bed with you to keep in touch. For many, it’s helpful to be able to log onto supportive and informative discussion forums while recovering.
Grabber. After lumbar spine fusion, it is likely that you will be told not to bend over or reach up for anything for awhile. A simple grabber can an help you pick up stuff off the floor and reach for things from an upper shelf. They can usually be found at stores like Walgreens or Walmart (in the pharmacy area) for around $10.
Trash bags. Putting a trash bag on the bed (and recliner, and car seat…) will grease the skids, so to speak, and allow you to slide in and out with less friction.
Heating pads. Starting about two days after surgery, the doctor may allow you to use [url:1662,type=|node|,content=|heating pads|] to alleviate local pain and discomfort.
A squeeze bottle. After a fusion surgery it’s tough to twist or reach, even just to clean up after a BM. You can use a squeeze bottle filled with warm water (many women who have given birth vaginally will have done this). Moist wipes also work well, and if necessary you can use a pair of tongs (also available at most pharmacies) to hold onto the wipes so you don’t have to reach.
Extra pillows. [url:1329,type=|node|,content=|A few well placed pillows add support|]. Try placing one under your knees while lying on your back or in a reclining position (this takes stress off the low back), and use firm pillows to prop you up to a reclining position while in bed. If you’re a side sleeper, you’ll want a pillow to tuck between your knees to keep your low back at rest.
Shower mat. So you won’t slip in the shower.
Shower brush with long handle. To clean without bending, twisting or reaching. You can get liquid soap (and liquid moisturizer, like Dove) to pour on the brush.
Recliner or extra cushion. In the weeks following surgery, sitting can be painful or uncomfortable. It is best to avoid sitting for long periods. A recliner can help ease pressure on the low back, and sitting on something cushioned, such as an inflatable donut pillow or hemorrhoid pillow, can make sitting more tolerable.

Other things you may need (and/or may want to discuss with your doctor):

Shower seat and handicap rails in the shower. Not everyone needs these, but it is something you may want to discuss with your doctor.
Toilet riser. This will help immensely with going to the bathroom, especially if you’re a female and drinking all the liquids you’re supposed to! The ones with hand rails to lean on are most helpful.
Cane or walker. You may feel more comfortable walking with some added stability, and if so discuss getting a cane or walker with your doctor.

Devices such as a shower chair, toilet seat riser and walker or cane are usually covered by insurance, so check with your doctor and have it sent home with you from the hospital if its possible. These types of equipment are also available to rent or buy from most medical supply stores, and are often available second hand (and inexpensively) at Salvation Army or other resale stores.

Prepare your home:

When recovering from back surgery, it is best to [url:1458,type=|node|,content=|change a few things|] around in your house to ease your way back in to daily life.

Put stuff where you can reach it. It helps to put the stuff you use daily (toothbrush, plates and cups, pajamas, etc.) on shelves that are around waist level high so that you don’t have to reach up or down at all.
Have meals ready. Make meals ahead of time and freeze, or buy healthy microwaveable meals and snacks, so you don’t have to do any food prep. Frequent small meals throughout the day are best to help deter constipation.
Avoid the dishes. Use paper plates, silverware, and cups so you’ll have less cleanup to do. You won’t want to be bending over the sink to wash the dishes or to stack the dishwasher right after a fusion.
T-shirts. If your doctor will prescribe a postoperative brace, make sure you have plenty of clean, well-fitted cotton t-shirts or tank tops to wear under your brace. Ideally, you can wear the brace before the surgery in order to get used to it.
Raise your bed. You may want to raise your bed up a bit to make it easier to get into and out of. You can place sturdy storage bins under the bed frame to act as blocks.
Subcontract the laundry. You won’t be able to do laundry – or any chores that require bending or reaching - for awhile. My suggestion is to put someone else squarely in charge of the laundry, even if that means you have to pay extra to send it out to a dry cleaner who will wash and fold it for you.
Don’t trip! Remove anything you might trip on, such as throw rugs. Try to make sure someone else is responsible for picking up shoes and other items you could trip on while you’re getting used to walking around.

These are just guidelines and suggestions - your experience will be somewhat different depending on your clinical situation, your surgeon, your hospital, and the type of fusion you’re going to have. For example, from what I’ve seen, many people undergoing lumbar fusion surgery from the front (e.g. an [url:1575,type=|node|,content=|ALIF|]) versus from the back, have much less pain and many are able to go home from the hospital the same day as the surgery. Be sure to ask your doctor about what to expect so you can prepare accordingly. And remember, nurses are often more knowledgeable than the surgeon when it comes to knowing what will help with your recovery.

For those of you preparing for surgery, best wishes for a successful surgery and speedy (and uneventful) recovery!

Posted by: Stephanie

Additional reading:

Back Surgery Discussion Forum
Healthboards Discussion Forum
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[url:173,type=|term|]

Lumbar Herniated Disc: Is Surgery Better?

Sat, 31 Mar 2007 12:04:33 -0700

March 31, 2007
by: Sylvia Marten

Surgery Videos

A very large study, the Spine Patient Outcomes Research Trial (SPORT) has recently concluded and found that both surgical and non-surgical treatments tend to help patients with pain from a [url:715,type=|node|,content=|lumbar herniated disc.|] Due to problems with the study design, however, it is difficult to say much more than that. Unfortunately, because the trial did not demonstrate that surgery is superior to non-surgical treatments for a lumbar herniated disc, there is new concern among spine physicians that insurance companies may now cite this study as "evidence" that surgery is not necessary.

[url:1581,type=|node|,content=|Lumbar laminectomy|] or [url:1584,type=|node|,content=|microsurgical discectomy|] for lumbar disc herniations is the most common spine operation performed in the United States. Although this operation has a long history of safety and reliability, there are large variations in the frequency of the procedure in the U.S. There have been several studies in the past that have compared non-surgical treatment of [url:5990,type=|node|,content=|lumbar herniated discs|] with surgical treatment, but none have been on the scale of the recently released Spine Patient Outcomes Research Trial (SPORT). Published in the Journal of the American Medical Association in November, 2006, this study was coordinated by Dr. James Weinstein of the University of Vermont. It began in 2000, and included 13 different sites. 500 patients who agreed to participate in the study were randomized into either surgical vs. none surgical treatment arms.

The purpose of the study was to determine if there was either equivalence or superiority between the two types of treatment (surgery vs no surgery). The data were collected at multiple time intervals for 2 years and the two treatment arms were compared. Overall, both patient treatment groups had substantially improved by two years, and while there was a general tendency for the surgical group to do better, the differences between the two groups were not statistically significant.

Although the two groups fared roughly the same, the authors could not conclude that surgical and non-surgical outcomes were equivalent, because:

45% of the patients randomized to the no-surgery group switched to having surgery, and
40% who were randomize to the surgery group declined the surgery.

With this amount of crossover, it was difficult to draw any solid conclusion as to whether or not the two treatment options were equivalent or if one is superior.

The main problem with non-adherence to randomization and the crossover between groups is that there was a general tendency for patients with severe symptoms to choose surgery even though they had been randomized to the no-surgery group.

Patients who had been randomized to surgery and subsequently declined to proceed with surgery tended to have less severe symptoms. The authors also very wisely followed the patients who declined to be randomized during the two year follow up. These patients chose to have surgery at a better than 5:2 ratio. Basically, if a patient has severe symptoms and cannot manage their pain through non-surgical treatment options they will choose to proceed with surgery.

Both treatment options did eventually lead to satisfactory results in the majority of patients, so it can be concluded that a patient with [url:887,type=|node|,content=|leg pain|] due to a [url:885,type=|node|,content=|disc herniation|] can expect a favorable outcome. This study also was consistent with past studies in that surgery leads to a quicker resolution of symptoms. Lastly, both treatment options are relatively safe. The surgery group had no complications in 95% of the cases, and not having surgery did not lead to any episodes of serious neurological damage (e.g. cauda equina syndrome).

What patients can conclude from this study is that if they have pain from a disc herniation, trying [url:154,type=|term|,content=|non-surgical treatment|] is a reasonable option. If they can control their pain with non-surgical treatment options (medicines, injections, therapy, manipulation, etc...) continuing with this type of treatment is reasonable. If not, [url:165,type=|term|,content=|surgery|] is a reasonable option and can be expected to lead to quick and reliable resolution of the patient's symptoms.

For physicians, this study is useful in that it confirms that not all patients with leg pain ([url:1038,type=|term|,content=|radiculopathy|]) from a lumbar disc herniation need surgery. It also confirms that surgery is safe and reliable for those patients who fail conservative treatment.

The real danger of a randomized controlled study of this magnitude that did not show superior results with the more expensive surgical treatment option, is the federal and private health care systems of this country may use this information to deny patients surgical treatment. Payors of all kinds are trying to ration care they will pay for based on "evidenced based" guidelines from the literature. What is not provided, however, by the literature is that not all diseases have the same severity. There was little stratification in this study as to severity of symptoms, and what little stratification there was showed a general tendency for patients with more severe symptoms to choose surgery, even when randomized to the no-surgery group.

In an effort to save money, payors would like to deny patients' requests for invasive interventions. They will claim the treatment is medically "unnecessary". Of course, they have not seen or examined the patient, and are simply following an algorithm. In our practice, we are already seeing insurance companies denying surgery for patients with severe leg pain due to a disc herniation unless they first have three epidural injections. We have observed that patients with a lot of tethering of their nerve root (a positive straight leg raise) actually have increased pain after trying to inject around the nerve root. I have also noted over the years that patients with a very shallow canal are less likely to benefit from non-surgical treatment. Patients who have already had their pain for several months can expect little benefit from an epidural injection. At any rate, there are always extenuating circumstances, and this should not be a decision made by the insurance company, but a decision made by the patient after consulting a spine expert. It would be a travesty if this very Herculean effort at a large research study such as the SPORT study was used to deny patients care that is beneficial in certain circumstances.