Physicians

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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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.

Is Your Pain Medication Prescribed Off-Label?

Mon, 01 Oct 2007 14:46:35 -0700

October 1, 2007
by: Sylvia Marten

Experts estimate that 21% of prescriptions for common drugs are written for off-label uses. According to a study on Off-Label Prescribing published in the Archives of Internal Medicine, three-fourths of those prescriptions were for off-label uses that lacked scientific support. What's going on?

First, let's talk about what we mean by on "label" drugs. In the U. S. , the FDA requires that drug makers submit, test and get approval from the FDA for specific uses of their product before the product can ever be marketed. To obtain approval, pharmaceutical manufacturers must submit extensive study data demonstrating safety and effectiveness, a process which usually takes several years and millions of dollars. When a product is approved by the FDA, a specific "label" for that product is approved too. The label must include the product's approved indications, dosage and method of administration, and use in specific populations.

So, what is "off-label"? After the FDA approves a drug for its specific use, physicians can prescribe the product for uses not covered by the approved label. This is "off-label" use. Off-label uses include:a drug prescribed to patients with conditions not listed on the approved label; departure from the approved drug dosage, method of administration, or patient population; and unapproved product combinations, such as using two different drugs to treat a single condition. This practice is perfectly legal but it lacks any kind of oversight.

"Off-label" drugs for back pain. Among the types of drugs commonly prescribed off-label, most common were heart drugs and anti-convulsants (indicated for seizures). For example, gabapentin, brand name Neurontin, had one of the highest proportions of off-label use among specific medications, namely for neuropathic pain (it is only indicated for use in controlling epileptic seizures and in pain from post-herpetic neuralgia). Neurontin also happens to be a quite commonly prescribed drug for people diagnosed with chronic back pain or chronic low back pain. This of course means the drug is being prescribed off-label in the back pain patient population.

Patients should always consider carefully all medications that are prescribed to them. It is fair for patients to ask their doctors whether a prescription is on or off-label, and this can be easily and more thoroughly researched on reliable health information websites that address medications, such as MedlinePlus, the FDA, or condition-specific sites. If off-label, it is important to know whether there is sufficient data to support its use or if the practitioner's decision is based on anecdotal evidence. The patient should weigh off-label recommendations against the alternatives with his/her practitioner, and ultimately decide if he/she is comfortable with an off-label drug for the specific health issue being addressed. It is important for patients to keep in mind that a drug prescribed off-label to them is a drug that has not been approved by the FDA for some element of their specific health situation.

Is "off-label" drug prescribing good or bad? There isn't a clear cut answer. Anecdotally, many of my colleagues and personal circle of friends have experienced off-label drug use with positive results. For example, our children have been prescribed albuterol for various severe pulmonary episodes (not asthma, for which it's indicated) with much success. The Spine-health.com message boards are full of stories of people taking medications off-label for back pain or [url:887,type=|node|,content=|leg pain|] as prescribed by their doctors, with many experiencing much needed pain relief not possible with approved drugs. So, off-label use can be positive in that it expands access to important health benefits that may not be possible with alternatives. On the flip side, concerns and warning bells should go off with respect to safety and the long-term impact of a drug use that has not been extensively studied.

The study authors cited several reasons as to why the high percentage of off-label prescribing is occurring, with some reasons being legitimate and others not. The practice itself raises issues that require addressing, including a better/faster process for getting legitimate additional uses for a drug indicated, but also for ensuring patient safety for patients dutifully following an off-label treatment protocol as prescribed by physicians they trust.

Posted by: Sylvia

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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

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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

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Get Your Back Pain Diagnosis from a Physiatrist

Wed, 11 Jul 2007 12:33:21 -0700

July 11, 2007
by: Stephanie

Whenever someone with bad back pain asks me where to get help, I say I would start with a diagnosis from a [url:1720,type=|node|, content=|physiatrist|] who specializes in back pain. Here is why:

Most physiatrists can provide you with the broadest array of treatments for [url:140,type=|term|,content=|back pain|]:

Spinal injections (for diagnostic and therapeutic purposes)
Prescription pain medications and anti-inflammatories
Heat and ice and other pain modalities
Physical therapy
Education on ergonomics, posture, etc.

I like the general orientation of the physiatry, which is to provide enough pain relief to enable patients to make progress with rehabilitation – the best long term solution. (I’m not saying that practitioners in other specialties don’t have this focus, many do, but my impression is that physiatrists are most likely to have this focus.)
Most physiatrists have a strong surgical referral network. So if you really do need surgery, they would be able to refer you to a surgeon who they know has done a good job for other patients.
Many are part of an integrated clinic or network of clinicians to provide coordinated care, e.g. chiropractors, [url:170,type=|term|,content=|pain management|] specialists, physical therapists, psychologists who specialize in pain, etc. For complex cases, this is often the best way to go.

Again, let me repeat, I realize that clinicians in many [url:1969,type=|node|,content=|specialties|] have many of the above qualities, and I am not saying that every physiatrist is good at treating back pain. I am highlighting this specialty’s training and approach to treating back pain because, in general, this seems to be a medical specialty that many consumers don’t know about, and I would like those seeking back pain relief to know about this option.

Posted by: Stephanie

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For Physicians: Paging Dr. Google

Tue, 03 Jul 2007 04:33:42 -0700

July 3, 2007
by: Sylvia Marten

As you may know, Google is the preferred search engine for finding online health information among both health professionals and consumers. At least in the U.S., Google has become the de facto search engine for most search activity.

But how accurate (and helpful) is the information contained in Google’s health search results? A recent study decided to put Google to the test.

Two British doctors took 26 complex patient case histories and tried to use Google to diagnose the causes (Source: Tang, H. British Medical Journal. 11/10/06. BMJ.com).Their findings? Google was right almost 60% of the time. The researchers concluded that “...in difficult diagnostic cases, it is often useful to ‘google’ for a diagnosis.”

But there is a catch: for each case, the doctors carefully selected the most appropriate search terms to start with and they used their expertise to select from among the results. To this, they state “patients doing a Google search may find the search less efficient and be less likely to reach the correct diagnosis.”

As a health professional, the implications include:

Google may be considered a useful tool for you and your medical staff, as long as medical expertise is applied upfront to the search terms and as a screen to help choose among the search results. The use of Google in conjunction with your other tools, e.g., PubMed, provides another source of potentially relevant, quick and current information and keeps you abreast of what your patients are experiencing online.

Patients can also reap benefits from using Google to research their condition, but will need guidance from you as to the appropriate search terms and how to select from among the search resultsTo help your patients with online research, you can:

Document the specific condition and treatment options that apply to each patient, so they know the right terms to use online. You can literally write out the terms and give the patient relevant handouts to take home. You’ll save your patients a ton of time and frustration by narrowing their search.

Guide patients to the highest quality online health sites so they can better sift through the search listings that result from any one health term search. The hallmarks of quality health sites? Among others, the site should:

Have qualified medical/health experts write balanced, fact-based articles
Blind peer-review all articles prior to publication
Clearly distinguish peer-reviewed health content from advertising and from content written by sponsors
Publish dates and sources on their medical content

Contrary to what some medical “experts” say, you cannot use a site’s domain name extension to determine the trustworthiness of its content. You can find high quality (and not-so-good quality) content on .com sites but also on .org, .edu and .gov sites. Judge instead based on the three quality criteria above.

Review and clarify what your patients find online. Patients, especially those with chronic conditions like back pain, should be applauded for trying to learn all they can about their condition. There’s a lot of bad info out there that can create confusion and even harm. Understand what they are reading and help them sort out the good from the bad.

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