Why won't the Surgeon Operate on my Spine?

There are legitimate reasons why a Surgeon will not offer elective Spine Surgery on patients.

Bear in mind,  we are talking ELECTIVE SPINE SURGERY,  not emergency surgery.    As you know,  elective surgery may definitely be warranted,  as the patient has debilitating pain,  or loss of function that does not improve with non surgical care.  The Surgeon,  however,  must match the complaints,  to the findings on diagnostic testing, and also gauge the Patient expectation.  If there are inconsistencies among those factors,  the results may still be better than prior to surgery,  but the expectations will be such that the outcome will be considered a failure by the patient.   Unfortunately,  poor outcomes do happen.  A prudent Surgeon will do what he or she can to minimize these poor outcomes.  Sometimes,  that is by refusing surgery.

As a Surgeon,  my goal is to help patients with their surgical needs.  In emergent situations,  I am called to try to resolve a potentially limb or life threatening situation.  While patient expectations are also important,  in emergency situations,  the pressing needs to save the situation is primary.   In emergency situations, while the patient expectations and outcomes are important,  equally important are the community expectations on treating emergent situations.  Patients who refuse emergency operations are required to sign documents indicating refusal of emergent treatments Against Medical Advice.  

As far as ELECTIVE SPINE SURGERY goes,  surgeons have the right to refuse surgical treatment if there is no emergency situation.  As many patients think their situation as emergent (although medically,  it is not),  they question  the refusal,  and demand surgery.  Often times,  there are specific reasons surgery why will not be offered:

1. Physical examination findings do not match the identified problem on diagnostic testing.

2. Pain complaints do not seem consistent,  or out of proportion to the findings on testing.

3. The identified condition is too diffuse, and successful surgical outcome is difficult to predict.

4. The patient,  and family may be unrealistic about the effects of surgery.  As I like to say, ” if you are 60 years old,  the surgery will return you back to being 60 years old.  The surgery will not make you 20 again. ”

5. There is a need of a much more complex surgical procedure,  one that is not amenable for proper management in a private practice setting.  Sometimes, the surgery is too large in scope.  Certainly,  the technical aspect can be performed by any competently trained Surgeon.  The aftercare,  and monitoring necessary during and after surgery may not be available in all Hospital settings.  These surgeries may be better off in a Tertiary,  or Teaching Hospital Environment.

6. The technique desired by the patient is still experimental,  with no proven track record.  In the past,  I was involved in FDA trials of new technologies.  The study patients had tremendous guidance and followup.  The prime objective was always the safety of the patient.  If you want experimental treatment,  please get enrolled in one of the studies.  Use of experimental procedures,  otherwise,  has a fair amount of medical and financial risks.  I do not perform any experimental surgeries any more.  If you want this type of surgery,  please look up studies in ClinicalTrials.gov.  There are over 700 trials going on that is being monitored by the FDA.  In my opinion,  this is the safest way to participate in experimental spine surgical procedures.

In the end,  Surgeons decline to offer Elective Spine Surgery because they cannot predict a good outcome,  or the procedure desired is experimental.  Frankly,  it is my opinion that Surgeons who refuse elective surgery are probably trying to do what is best for their patient.  As you all know,  you can always find someone to do your surgery.  There is too much incentive to say Yes.  Please consider why a certain surgeon would say no.  Get other opinions.  Learn about the Surgeon. 

Your Office Visit: Meeting Expectations

Your Office Visit: Meeting Expectations

In a busy Orthopaedic Practice, there are common expectations shared by patients and their doctors alike.  When those expectations are met,  this leads to increased satisfaction in the office visit.

From a patient’s perspective, eye contact from the doctor is an important part of the visit. Nothing could be worse than sitting in an exam room where the physician stares at a computer screen while asking questions, never looking up to speak with them. The attention paid to the patient by looking into their eyes helps them know that they were heard and understood.  This also allows the doctor to get a better sense of what the patient is trying to communicate and demonstrates compassion.

Often, patients would like to have more time with the doctor to fully discuss the reason for their visit. They feel rushed to state their concerns, before the doctor checks his watch and quickly exits. A good practice for any patient is to bring a list of questions to ensure that all their concerns are addressed.  By being prepared, this guarantees an efficient use of time for both the patient and the doctor. In return, the physician appreciates when a patient is prepared for their visit.

It is easy to see how important communication is between the patient and the doctor. A misunderstanding could lead to dissatisfaction in the office visit. Often times patients are scared, they don’t understand the terms the doctor is using and they are not able to absorb everything that was told to them. It is a very good idea to take notes during your office visit and to ask pertinent questions at that time. Patients are most satisfied when they leave with a good understanding of their issue and feel that all their questions were answered.

Patients and physicians must take ownership to ensure a successful consultation. When the above steps are taken, expectations are not only met, but often exceeded.

Go Suck on a Tailpipe

Seriously, would you ever consider doing this? Probably not. Outside of the fact that you would cause serious and possibly life threatening burns to your mouth and face, car exhaust is unhealthy. Emissions from motor vehicles contain dangerous gasses such as carbon monoxide, carbon dioxide, sulfur and nitrogen oxide (which can react with other naturally occurring chemicals such as water vapor to form nitric and sulfuric acid), carbon soot, particulate matter, and various hydrocarbons. We know how dangerous carbon monoxide can be….hence most of us have carbon monoxide detectors in our houses, especially if you use natural gas or oil to heat your home in the winter. The other compounds contribute to the formation of smog, acid rain, and the ugly brown haze overlying much of the country. Don’t believe me? The next time you are flying and are coming in for a landing during a warm sunny day, look out the window. You can usually see a distinct delineation in air quality between the ground level air (which has a brownish tint) and the clearer air just above it. The amount of harmful gasses emitted from cars is obviously decreasing with each new model year and advancement in technology. The next time you look under your hood or look at your owner’s manual, take a second to notice how complicated your emissions system is.

Now, let’s compare this to a cigarette. Yup, you probably saw this coming. According to the US Department of Health and Human Services, cigarette smoke contains over 7,000 chemicals. Some of these include carbon monoxide, benzene, toluene, formaldehyde, and hydrogen cyanide. You may not be familiar with the chemicals themselves, but you are likely familiar with what they are used for….such as embalming fluid and chemical weapons. Now think about what separates you from those chemicals……a small piece of cotton acting as a filter. We previously discussed how complicated a car’s emissions system is, yet it still produces toxic chemicals. Yes, the filter does cut down on inhaled particulates compared to non-filtered cigarettes, and you are therefore exposed to less toxins overall (and NO, I am not advocating non-filtered cigarettes). Common sense will also tell you that if a car’s emissions problem could be solved with a piece of cotton in the tailpipe, you would not need such a complicated emission system.

So, one may then reasonably ask: “Which is cleaner: Car Exhaust or a Cigarette?” You likely already know the answer. Because if it was the cigarette, you would not be reading this post. Think about this. The exhaust coming from a tailpipe of a car has less carbon monoxide than a filtered cigarette. Just keep thinking about this….especially if you smoke.

"Moneyball" and US Healthcare

This past week,  I had the fortune to attend the Becker’s ASC Review Conference in Chicago.  What a fascinating meeting!  Thought Leaders of Ambulatory Surgery Healthcare,  Orthopaedics,  Neurosurgery and Spine Management gathered to dialogue about the changes in Healthcare.    All agree excellent, safe  Patient Care can never be compromised.   All also agree the Payers will demand more efficient and cost effective delivery.  While everyone was putting on an optimistic face,  most understood that there would be significant changes coming to Healthcare,  and those who cannot change will not survive.  As panelist Dr. Hae-Dong Jho, MD, PhD had put it,  “a tsunami is coming!”

There were great speakers,  with great insight,  and experiences.  Deion Sanders and Bill Walton gave excellent,  memorable, motivational speeches.  Dr. David Nash provided an excellent overview on Population Health,  and the coming changes.   In my opinion,  the best discussion was by Billy Beane,  Oakland A’s General Manager.  The Speech was titled “MoneyBall,  the art of winning an unfair Game.”  Many of the points were based on the now famous Book written about him.

Mr. Billy Beane gave an insightful summary of how he turned around a smaller market,  smaller revenue Oakland A’s Team,  and produces RESULTS similar to the high salary teams like the Red Sox,  Yankees,  and Dodgers.   In the end,  it came down to analytics.  Certain traditionally high valued metrics just did not result in wins. Certain low cost factors did.  Knowing and understanding that,  he was able to assemble an effective (wins), lower cost team for the Athletics.   With smaller resources (MONEY),  he developed the same or better results.  With LESS,  he did MORE.  That is the definition of VALUE.

He understood that a MLB team is a business.  Just like any business,  the Laws of Economics apply.

Naturally,  his story has become the metaphor for what is happening in Healthcare.

25 years ago,  Spine Surgeons,  Hospitals,  Pharmaceutical Companies,  etc.  were the star players on the Healthcare version of the NY Yankees.  There was tremendous money in the the two biggest sectors that funded “BIG HEALTHCARE“.  Government (taxpayer funded) programs grew without any real restraint.  Employers were generous with their healthcare spending for employees.    The United States was the Big Market Team,  and could afford these superstars.  In fact,  each year,  the Super Stars demanded a greater salary.  Smaller market teams such as Canada,  Europe,  Asia could not really afford the “Big Salaries” of these Star players,  so they could not compete to afford these players.

Now the US is transitioning to become a Smaller Market Team.  The laws of Economics dictate, that in order to survive,  the Costs of the Players  (Costs associated with Hospitals,  ASC’s, Physicians,  Pharmaceuticals,  Device companies, etc.)  must at least match the revenues  (taxes,  insurance premiums), or else the long term outcome is default.

Mr. Billy Beane will not like this statement.  The Medicare/Medicaid Czars,  and the Health Insurance CEO’s are similar to Mr. Beane.  Their job is to assemble and negotiate a team of Hospitals, Doctors,  Pharma,  etc. with Cost restraints,  while providing excellent care.  Billy, please do not be offended by being lumped in with that bunch.   Brad Pitt will never be playing one of those guys in a feel good movie!  Maybe Marty Feldman?

For us Surgeons,  Physicians,  ASC’s,  Hospitals, Pharma,  etc. some of us may be “Cut” from the Healthcare version of NY Yankees  as we are now considered too expensive for the new small market team.

We have three choices:

1. Do our analytics to find out what we can do to WIN (provide better population health,  with less cost).  Get on base (better non-surgical management?), stop trying to steal base (Lumbar fusions for DDD?), and win instead of just looking good  (provide efficient care,  versus only productivity?).

2. look for another team to that still values our Star Status (develop a niche that others value).

3.  Do nothing.  You can talk about it ( NATO,  No action,  Talk Only,  as coined by the wise sage Anthony Yeung, MD).  Accept that you will be out of a job. Change careers.

Now I know many can argue there is fault with this metaphor  (for instance,  Gov healthcare spending is still going up,  but the goals are still a smaller market strategy of less $ spent per enrollee),  but you get the gist.  The resources overall, are shrinking .  But there is an opportunity to those who deliver value.  Remember that value does not mean you have to accept less.  It does mean that you must design a system that delivers more for the same.  

I am optimistic,  as Excellence will always be valued.  PLAY BALL!

Does Optimism Help Spine Surgery Results?

People who undergo elective spine surgery usually fall into three general groups:

1. Hard charging optimists,  that do not have time for the pain,  and dysfunction of spine problems.  These folks are often in a rush to go directly to surgery.

2. Cautious realists,  that spend appropriate time to understand their problem  and stepwise  increase the intensity and risks associated with their treatments.  The decision for surgery was a logical, measured process.

3. Medical Pessimists,  who are always the “ones who get the complications”.   No treatment has ever been successful.  They are convinced surgery will not work,  but are willing to try,  as there does not seem to be any other options.

There is a fourth group,  but this population probably should not get surgery.  This is the group that insists on surgery when the Surgeons have advised against surgery.  We will discuss that group on a separate blog.

From the perspective of the Surgeon,  appropriate criterion for surgery requires:

1. A specific complaint that is not improving,  or even worsening.

2. The complaint causes or can potentially cause significant pain,  and loss of functions.

3. There is no improvement despite conventional non-surgical therapies.

4. Diagnostic testing such as MRI’s show a finding that corresponds to the complaint.

5. Physical examination findings are consistent with the MRI related complaint.

6. Patient has a realistic expectation about the goal of  the surgery.  As the joke goes,  if you did not play the piano before the surgery,  you will not be able to play the piano after the surgery.

For each of the three groups above,  I have comments on them.

In group one,  the hard charging Optimist,  often times,  my only concern is about the usual urgency of going directly to surgery.  Often times,  these folks have a “I control my destiny” attitude that is great,  but also can be associated with impatience.  These patients often do great after surgery,  but I usually am concerned that they will not wait for the more non-surgical options to work,  or return back to full activities too soon.  Still,  this group tends to do well with surgery,  as optimism has been associated with faster return to function.  The science is still not hard about this,  but I too believe realistic optimism is a benefit for any medical treatment.

In group three,  the Pessimist group,  the results of surgery will still be good as they meet the criterion for surgery as outlined above.  For this group,  the hardest thing is to not let the minor setbacks interfere with the recovery.   This group needs positive feedback and a supportive group of friends and relatives who can encourage activity and patience.  In my experience,  this group will take longer to recover,  but are usually the most grateful group as they eventually experience a positive outcome,  despite their pessimism.

In group two,  the Realist group,  I find myself spending the most time with them.  In the end,  this group is very careful to follow all instructions,  and recover as expected.  I find the conversations most stimulating as this group may ask questions that cannot always be answered specifically.  I personally fall into this group.  As a surgeon,  I am methodical, realistic,  and have expectations based on the science.

To me,  the ideal type of surgical patient would be the one who is informed,  realistic,  yet optimistic.  There is plenty of research suggesting that in certain medical conditions such as heart disease, joint replacement,  cancer treatments,  etc., optimism is beneficial to regulate the levels of pain,  and  associated with faster return to activities in these patients.

If you are a pessimist,  you cannot change your personality. Still,  having confidence that the medical procedure will be beneficial does have positive effects!

Exercise for Arthritis

Patients Must Exercise for Arthritis, Even If it Hurts

It is human nature to avoid doing things that aggravate pain. Patients with arthritis many times avoid doing exercise when back, hips, knees or ankles are hurting. Although this may seem to make sense, it may actually be causing your arthritis symptoms more harm than good.

Exercise with even moderate walking can actually ease arthritis pain and improve symptoms. A national survey conducted by the Federal Centers for Disease Control and Prevention showed that more than half of people with arthritis didn’t walk at all for exercise. Only 25 % of arthritis patients actually meet the recommendation for activity, walking at least 150 minutes per week.

Although walking is a good exercise for people with osteoarthritis, it isn’t the only one. Exercise programs aimed to help patients with arthritis should include increasing the range of motion of the affected joint, strengthening of muscles, building endurance and improving balance. Swimming and bicycling may be best tolerated with arthritis of the hips and knees. Even walking in the pool is great exercise, to increase the range of motion, but does not put as much stress on the joints. Try looking up the Walk with Ease program, developed by the Arthritis foundation, or a local aquatics therapy program.

The fatigue, pain and stiffness caused by many types of arthritis often present difficulties to beginning that exercise regimen, but these are all symptoms that can and will improve with a regular exercise routine. Start out slow. Take a five minute stroll, swim or exercise bike. Do it every day, and gradually increase the time spent exercising and gradually increase the intensity. If you have heart disease, speak with your doctor before beginning your exercise program. Before you know it, you will begin to reap the rewards of your regular exercise program.

Hockey Spine Injuries

I’m from Tampa.  GO BOLTS!

At the time of the writing,  the 2015 Stanley Cup finals matches two high scoring,  and hard hitting teams.  Analysis by various hockey experts debate the merits of puck possession,  shots on goal,  power play conversions,  etc.

One factor this is important to us Spine Surgeons is the statistics on checking or hitting.   While there are clear rules on legal checking,  there does appear to be more leeway given during the playoffs and the Finals. Legal checking is part of the game,  and frankly,  by the time you reach the end of the playoffs,  the surviving teams are the ones that prevent the other team from getting too many good shots on goals.  That means unbalancing the shooter with legal hits.  That means more aggressive play,  and harder checking.   The proverbial “let the players play” sentiment can put some of the players at risk.   The ref’s must keep the game from deteriorating,  as high sticking,  and checking from behind are most associated with serious injuries.

There is a real risk of concussion,  and catastrophic spine injury during the game.  While legal,  checking can cause players to crash,  head on,  into the boards.  The forces are effectively like hitting your head into a wall,  with potential for brain injury,  and spinal fracture or dislocation.  It can be like a diving neck injury.   With increased awareness,  and penalty for checking from behind,  most hockey injury registries have seen a decrease in spine injuries.

Still,  during the finals,  the emotions are high,  and the risk/reward great.  One bad encounter can cause a life altering situation for the players.   Play hard, but play safe.  The ref’s have an important role in making sure of the latter!

Why I Should Be Out Of a Job

By this point in time, it is no secret. Medicine cannot cure many diseases, especially once they become chronic. Medicine is very good at managing and controlling chronic diseases, but cures are perhaps a few decades away. There is potential on the horizon with gene and stem cell therapy, but these treatments are still evolving and are not perfected yet.

So, what is a person to do?

The best way to treat chronic disease is to prevent it. Does it sound too simple? Well it is fairly simple, but I did not say it was easy. In general, our medical system does a very poor job in helping to prevent disease, but rather does a much better job in trying to treat it. Despite this, prevention should not necessarily be the responsibility of the medical system. Most of the responsibility for prevention actually falls on you, the patient. The reason why so many doctors are still in business is because many people fail to take care of themselves, thus leading to chronic medical conditions which could have been mitigated or even possibly prevented.

Both the mind and body need to be taken care of. Too often, we come home from a boring day at work, prepare a quick and easy meal, and then spend the remainder of the evening watching television. This is not healthy on multiple levels. Habits like this can lead to depression, obesity, high blood pressure, diabetes, etc.

Proper diet and exercise will do wonders for preventing or managing blood pressure, cholesterol, diabetes, and arthritis. Yes, that is right. Even people with arthritis benefit from regular exercise. People who exercise regularly also have better immune systems, and therefore get ill less often. Intellectual stimulation has been shown to help prevent dementia, help with depression, weight management, help manage chronic pain, and to prolong independent living. Television is not intellectual stimulation. Neither is surfing the internet. Reading books/periodicals, playing board games, doing cross word puzzles, having a stimulating conversation, and learning new skills all stimulate the brain. Think of the brain as you would any other muscle in the body….use it or lose it.

Essentially, if patients took my advice and took care of themselves, I would be out of a job.

It is never too late to start, however. Each and every day is an opportunity to make a healthy change for yourself. BUT, you must keep things in perspective. If you have been overweight and/or in pain for 25 years, don’t expect miraculous results overnight or even over a few weeks. You have to be committed to a permanent lifestyle change, which may take a few months or even years to notice the benefit. It may sound like a long process, but it is worth it.

Stem cells for Back Pain

Lately,  I am seeing more and more advertisements on the use of Stem Cells for Back pain.   While the concept seems fantastic,  I am concerned that the public is not getting the full picture about the science.

In this Blog,  I will attempt to simplify what we currently know about the reason to consider stem cells.

Stem cells are cells that are located within the body,  that has not yet transformed to perform a certain function.  Most cells in your body have already changed,  or differentiated to do certain things.  To give an example,  muscle cells are specifically designed to elongate,  and contract.  This allows you to move the bones, and the attached ligaments and tendons in a specific coordinated manner.  Once changed into a muscle cell,  that cell will always be a muscle cell.

Stem cells are different.  These are cells that have not yet changed.  Scientist belief these cells will transform,  when placed into a certain environment to accommodate a certain need.  As in the example above,  if the stem cell is located near the bones,  and there was a need to develop muscles,  the cells will transform to become muscle cells.

A few years back,  there was ,  and remains significant ethical controversies about the use of Embryonic Stem Cells.  This blog will not debate the merits of those cells.  Most scientists are now trying to avoid the controversy by using adult stem cells,  and placing them into certain environments,  hoping the cells will transform to develop the proper cell line for the job.

In the past few years,  there has been much excitement,  using various adult stems cells from fat,  skin,  etc and placing them in diseased areas,  hoping for transformation,  and healing of certain conditions.  The areas of research includes work related to heart muscles,  spinal cord nerves, eye corneal tissue,  diabetes, etc.  The cells are “manipulated” to hopefully transform into the appropriate cell.

In the spine.  there is much work being done to see if certain cells can differentiate into cartilage producing cells,  and help reverse the disk degeneration process.

While all the science seems promising,  we are still aways from actually knowing if some of these techniques will actually work,  and help in the long run,  without causing unintended complications.

For the Spine patients,  we are still not certain what type of cells work best in the very low oxygen environment of a diseased disk.  Also,  we are still struggling with the need for any other environment modifications such as compression reduction,  nutrition supply,  vascular supply,  and stem cell survival in the processing,  and manipulation stages.

For patients who want to consider these treatments,  I encourage you to enroll as a study patient.  You may or may not receive the stem cell,  but you will be monitored very closely for any complications, and your experience will help in answering the many questions.  Before you sign up,  please understand it is very early in the science, and there may be unintended consequences we will not know about until many years after implantation.  Still,  if interested,  many academic centers throughout the country are currently enrolling study patients.

The technology looks promising,  but the results are still unknown,  and the costs currently,  are significant and not covered by any insurance entities.  Beware of the hype,  and learn the science before you jump in.

Pt Responsibility- Friday Blog

You Are Responsible For Your Own Recovery

Often patients fail to realize the dramatic choices they have regarding their health and injuries. We get to choose how we treat our bodies and have a choice as to how we can take charge of our own recovery. Through healthy food choices, minimal daily exercise, adequate sleep, decreasing stress we get to choose how well our bodies perform for us. It is important as patients that we choose to address these issues and make choices that in the long term, can make a difference in how we age well.

Many times a patient comes in for an injury and wants the problem gone immediately. The physician spends a great deal of time with the patient assessing the problem, viewing imaging results and making suggestions to the patient on how to treat the problem. It is concerning to me as a nurse how many patients come back for the follow up appointment and have not followed any of the advice the doctor has recommended. They didn’t try the anti-inflammatory, as “I am not a medicine person” or didn’t try the home exercises, because “I just didn’t get to it as I intended”.  The doctor may have suggested weight loss, as increased weight contributes to so many Orthopaedic issues. What do you say to someone who comes back for follow up and has not tried any of the conservative advice that was recommended? They are wondering what to do now, but yet they haven’t done the “home work” that is a necessary part of their recovery. Why aren’t more patients willing to give it all they’ve got to address better health?

I have also been on the patient side, having struggled with weight loss, as well as with dedicating time to myself for adequate sleep and exercise. But I sure know that when I do these things, how much better I feel. Over the past year I have been nursing an injured knee, which causes pain with doing activities that I normally enjoy, such as walking and running. I finally finished it off with a round of golf, twisting it and causing meniscal injury. After viewing my MRI, my physician recommended a cortisone injection to settle inflammation, rest and ice. After a period of healing, I will begin strengthening exercises to assist in the proper tracking of my patella and get on the stick to lose that last 20 lbs. As well as weight loss, I need to get back on track with my supplements, such as fish oil, OPC-3 (my powerful antioxidant) and my vitamin D, all to decrease inflammation. I realize that when I stick to the plan and follow my physician’s plan, I will be able to remain active and be able to do the activities that I enjoy for a very long time.

We must take responsibility for our own recovery and it is my wish that all patients would realize that they have the ability to do just that. Take control and attain your utmost potential with regard to your optimal health! At Shim Spine we are here to encourage you in your journey!

What is the Difference Between Prolotherapy and PRP Injections?

Prolotherapy and PRP Injections

By now, you probably have heard about the latest trend in the treatment of muscle, tendon, and joint disorders. So called ‘Regenerative Medicine’ is rapidly evolving and has the potential to revolutionize how we are able to treat chronic medical conditions. Two of the basic treatments are Prolotherapy and Platelet Rich Plasma Injections (PRP). While Prolotherapy has been around for decades, Platelet Rich Plasma has only recently been used to treat musculoskeletal conditions. Both are relatively non-invasive and easy to perform. The mechanism of action is about the same for both, as they use the body’s own system to help repair the underlying problem. The way they do this, however is slightly different.

The premise of Prolotherapy is to induce an inflammatory response via injection of a variety of substances. The theory is based on the idea that inflammation is your body’s way of signaling that there is a problem. This results in a complex process of chemical signaling and cell migration, which ultimately leads to the laying down of new tissue and repair of the area over the course of a few weeks. The injections are cheap and usually require only minimal preparation.

Platelet Rich Plasma Injections are a little different. One of the cell types that are signaled by the body to migrate to the area of inflammation following Prolotherapy treatment or an acute injury are the platelets. The platelets release an abundance of growth factors, which is thought to promote tissue healing and repair as noted above. Essentially, PRP bypasses the inflammatory phase of Prolotherapy by directly injecting the platelets to the injury site. The procedure, however, is a little more invasive and time consuming than Prolotherapy. PRP involves drawing your blood, placing it in a centrifuge, separating the platelets from the other blood products (red cells and white cells), adding in an ‘activator’, transferring the solution back into a syringe, and then finally injecting the platelet solution to the problem area. Obviously, this process is more time consuming and requires special equipment to produce the platelet rich solution. Because of this, it is more expensive than Prolotherapy.

Sometimes it may take more than one injection to achieve the desired outcome. In addition, neither of these treatments are ‘passive’ treatments. This means that both require you to do a specific rehabilitation program following the injection so that the tissue may properly heal. Failure to perform the recommended rehabilitation program, will likely result in less than optimal results. These exercises, however, are usually able to be performed on your own at home and do not require the added expense of physical therapy.

So, while these treatments may offer the potential to help heal chronic muscle, tendon, and ligament injuries, you have to realize that there is both a physical and financial investment required in order to do so.

Are Infections the reason for Disk Degeneration?

Dr. Ganko et al Published an intriguing article called “Can Baterial Infection by Low Virulent Organisms Be a Plausible Cause for Symptomatic Disk Degeneration?: A Systematic Review” in the May 15, 2015 issue of Spine.

To summarize the paper,  prior studies on the prevalence of infections in disk material were pooled together to do a so called meta-analysis.   9 papers,  with a pooled population of 602 patients were analysed.  Only one of the papers had patients given prophylactic antibiotics before sampling the disk material.

The data showed that approximately 36% of the samples had evidence of a low grade bacterial infection.  The most common organism was Propionibacterium acnes,  a bacteria found commonly on the skin.  It is a low virulence bacteria.  This low virulence and destruction potential may be why it may be found in the disks without evidence of a full blown disk infection  (discitis).

As most of the samples were obtained in patients not given pre-operative antibiotics,  it may be why we do not see this high prevalence in patients in the US,  as pre-op antibiotics is fairly common.

The question remains, what is the reason for this high prevalence of infection?  As the patients who underwent the surgery had disk pathology,  back pain,  and/or sciatica,  is there a relationship with a low grade bacterial infection and the presence of the disk pathology?  Does the low grade bacterial infection make the disk more susceptible to developing a symptomatic disk pathology?

The authors appropriately question the validity of the results,  and suggest more studies to try to answer these questions.   Still,  papers like these point out that we still do not fully understand the nature of disk degeneration,  the causes of disk herniations,  and the cascade of events that may contribute to the development of these disk findings.

The paper  does present another potential factor for why people develop disk degeneration.

Cost of Visit Blog

Why Does My Office Visit Cost So Much?

There are many “Behind the Scenes” reasons why your office visit is often a little more than what you had expected to pay.

First of all, the staff takes your call and schedules the appointment. It is necessary to gather information for the visit, including a brief reason for visit, verification insurance and contact information. Prior to the visit, the staff member verifies insurance benefits, obtains prior authorizations, as well as gathers appropriate imaging reports.

During the visit the medical staff takes your brief history, obtains vital signs and verifies medications you are currently taking and checks to see if refills are needed. Each and every visit is recorded and updated, requiring all to be in order so that proper billing and reimbursement takes place.

 The physician then sees the patient and reviews the patient’s condition and/ or discusses changes since last visit. Detailed documentation is now required in the electronic health record, in order to qualify for reimbursement from your insurance. He must also document need for any testing, new medications, therapy prescriptions, work notes, etc. Also, the physician prescribes medications and sends out to pharmacy to fill electronically.  He also faxes the notes to the patient’s primary care physician for review, which is also now required. He marks the encounter with his diagnosis and recommendations for follow up and forms are given to check out staff.

Once back up front, the necessary testing or imaging are scheduled or faxed to appropriate providers. Authorizations are then obtained for procedures that were recommended by your physician. Follow up is required by staff to the insurance company until the appropriate authorization is obtained, which can be a very lengthy process. Then the patient is called to schedule their procedure.

 In the meantime, the billing department gathers the information from the chart and sends out appropriate billing charges to the insurance company. They must also send copies of notes along with the billing in order to obtain proper reimbursement. If claims are denied, adjustments are made, or insurance information from the patient must be verified and claims sent out again. Payments received are then posted into the patient’s accounts. The patient is then billed for any balance due on their bill.

 It typically has taken 45 min to 1 hr to process your visit from start to finish, or even longer to obtain authorizations and to collect outstanding patient fees. This doesn’t even take into account the rent of the facility, electricity, malpractice, medical supplies, computer and phone technology and janitorial services.

 At Shim Spine, we strive to make each visit high quality, accurate, holistic, efficient and in a pleasant environment. We want to take the time to ensure each patient has a high quality experience. I know that patients often say “my visit was only 15 minutes” and are surprised to find what was charged for the visit. This may be a clearer picture of the value of your dollars spent. 

Five Tips for Guns and Spine Pain

Depending on where you get the statistics,  up to 45% of men and 25% of women own guns in the United States.  It is a Second Amendment right,  and I am not here to debate the merits and nuances of the Amendment.  As a Spine Surgeon however,  I do want to discuss a common complaint from gun owners.  That is Spine Pain.

From my own personal experience, I know proper form,  and proper gun fit (especially with rifles, shotguns) have significant bearing on the forces experienced by your body.

Here are 5 suggestions I have regarding Guns and Spine Pain:

1. Fitness is important.  Work on your core stabilization.  Specifically,  work on building your stomach and back muscles.  Good coordination of these muscles are necessary to minimize force effects on the spine.

2. Stretch before shooting.  Please consider the neck exercises and back exercises on our site.  A brisk walk, with stretching before hand will limber the muscles,  and prepare them for the recoil forces.

3. For beginners,  please use smaller caliber guns,  rifles, and shotguns.  The intimidation of the whole process makes for a muscle tension experience.  Add a significant recoil force  (larger caliber shots),  and you will be prone to greater injury.

4. Get lessons.  Only an instructor can show you the proper stance, and position for your gun.  First of all,  you need to understand  basic safety gun safety.  Then, an instructor can  make sure you are in the proper position to effectively,  and efficiently fire the gun.  That efficiency will mean you are in the proper form to minimize the forces of the gun.  That effectiveness will ensure reproducibility of the targeting,  so you understand the need to maintain the efficient stance and form.

Without proper instruction,  you will likely experience excessive forces,  and reduce your chances of hitting the target.

5. Get your Rifle/Shotgun fitted for your body.  While many people can use the rifle/shotgun off the shelf,  taller or shorter shooters usually need some adjustments to the gunstock.  As stated above,  the proper form and stance is very important to minimize the forces of the gun,  and therefore protect the spine.  The length of the gunstock can force a suboptimal position.  Your instructor, along with a gun smith may be necessary to define the ideal configuration of your rifle/shotgun.

A final thought is about the concept of disc herniations caused by the gun.  Unfortunately,  we probably will never know if that gun shot was the cause of the disk bulges as most of us,  after the age of 40 already have disc findings in our spine  (even though we do not even feel it).  If you have pre-existing spine pain, probably the best advice is to get an evaluation of your spine prior to shooting larger caliber rounds.   If you are a beginner, take lessons so you have proper stance and form.

Back Pain and the US Marines

In a tribute to our US Military,  I thought I would look at some information regarding Back Pain and the military.  I found this fascinating article published in the July 2012 Military Medicine Journal titled “Occupational correlates of low back pain among U.S. Marines following combat deployment.”

To summary the paper,  medical records of Marines deployed to Iraq or Kuwait during Operation Iraqi Freedom were analysed for Low Back Pain (LBP).  Within one year post deployment,   approximately 4.1 % of the Marines were diagnosed to having LBP.  Via data analysis,  the subset of Marines involved in construction,  or law enforcement has a higher prevalence of LBP.     Interestingly Marines engaging the enemy within the Combat Infantry did not have higher incidence of LBP even though they were experiencing the rigors of combat.  In fact, the non-combat Marines had a higher prevalence of LBP.

The authors of the paper suggested more studies to try to identify the cause of these data findings.

While we can speculate the cause for this result,  most will take a common sense approach to this information.  That is,  Our Combat Soldiers are the Best,  and they condition themselves,  or motivate themselves to perform under all circumstances.  Our Combat Soldiers just do not have time for Back Pain.  On this Memorial Day, WE  SALUTE our Military Men and Women,  who Bravely serve in the defense of our Nation.

THANK YOU for your SERVICE!

Why Do I Have to Fill Out These Forms Again?

It is very common to hear from patients, “Why do I need to fill out this paperwork again?” We understand that it can be very time consuming and tedious, but updating new patient forms is a necessity.

First of all, having the most up to date insurance information is a must. Many times a patient has had an insurance change since their last visit. It is a good idea to bring a copy of your insurance card to each visit, as we may need a copy for our records. It is imperative we update insurance info to expedite proper billing of claims. It allows us to obtain correct prior authorizations for procedures and keeps your treatment running smoothly.

It is also very important that we receive updates on medical history and medications at each visit. You may have forgotten that your Primary changed a medication six months since you had your last visit with us. It is important to know about this, as there could be medication interactions between that new medication and something that our physician might prescribe. It’ also possible you may have had a surgery or procedure that would be important for us to know about.

Another really important reason to update paperwork is to make sure we have the correct contact information. I have had occasions where I go to return a patient’s call and looked up their number, only to find that their number had been changed. We must have proper address to ensure that correspondence gets delivered in a timely fashion, as well as for billing purposes. Correct pharmacy information is also a must, in order to ensure that prescriptions get called to the correct pharmacy. Please verify with staff if you know that you have had a change.

The next time you come to the office and are asked to update paperwork, please understand that this is not to torture you. Why not bring a smile and a pen? We strive to make your experience as pleasant and as efficient as possible.

Not all Cervical Spine Fusion Devices are the Same

From http://journals.lww.com/spinejournal/Fulltext/2015/05150/Does_a_Zero_Profile_Anchored_Cage_Offer_Additional.7.aspx

If you go by the standards used by most Insurance Companies,  once you are Board Certified,  or FDA approved,  you are the same as any other Board Certified Physician,  or FDA approved device.  It is the effort to make Surgeons,  and medical Devices into commodities.  In other words,   there is no reason to pay more for a specific surgeon,  or a specific medical device,  as the generic is just as good.

While that may be true of certain aspects of healthcare,  we still see real world examples of why one group may be better than another.

In the May 15, 2015 Spine Journal,  Dr. YS Lee and colleagues published a paper called  “Does a Zero-Profile Anchored Cage Offer Additional Stabilization as Anterior Cervical Plate?”   Please note that Dr. Lee et al had no financial conflicts to disclose,  and no funding was provided for this study.

To summarize the study,  Dr. Lee and colleagues reviewed the results of cervical neck fusions with three different types of constructs. 1.  Stand Alone anterior fusion Cages  (SC),  2. Anchored Fusion cages, which are Stand Alone Cages with built in anchor cages (AC),  and Fusion Cages with Plating ( CP).

In 2008,  the US FDA  approved the use of an Anchor Cage device.  The advantage was the lower profile of the device,  and the theoretical reduced rates of  dysphagia.  Dr. Lee and associates compared the results of these AC’s to the other options.

Please read the paper to get details of the results.  The conclusions are that the AC’s,  while FDA approved,  had higher rates of subsidence,  and lesser rates of fusion compared to the CP group.   The data suggests that in patients that have a greater instability situation,  the CP is still a better option.

While this is a retrospective study,  it does bring into question the value of doing comparison studies on outcomes.  Unfortunately,  these studies do cost resources and there is potential conflicts secondary to the origin of the resources.  Still,  in this study,  it brings into question the value of any technique in a particular situation.  Nuances of situation,  technique,  and indications most likely will still make a difference.  That is why there is still an “Art” to surgery,  and not just the science. 

Buyer Beware

Not all medical supplements are created equal. This is partially due to the fact that supplements are not regulated by the FDA in the same manner as prescription medications are. The reasons for this are complicated, but can be found here. You likely have seen the familiar disclaimer on television, vitamins, or supplements: “These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.” So, if you read between the lines, the statement basically means: ‘This product works because we say it does. The product also contains what is on the label because we say so. Trust us.’

Yea, not so much. You may or may not be familiar with the recent lawsuit brought by the Attorney General of New York against Target, Walmart, GNC, and Walgreens. The suit claims that these stores were selling herbal supplements that contained little to none of the actual supplements listed on the label, therefore resulting in fraud. This is nothing new, as it has been known for many years that not every supplement company has been forthright in labeling of their products.

So, which ones are legitimate? Some companies will submit their products to independent laboratories for testing. The laboratories will test the supplement to verify that what is on the label is actually in the product, including the dosage. As a result, the supplement bottle will usually have a seal somewhere on the label to verify that the product has been independently verified. Mind you, this does nothing to verify the efficacy of the product nor does it promise the supplement to work, but rather simply means that what you see is what you get. The most common testing/verification companies are: Consumer lab, Natural Products Association-Good Manufacturing Practice (GMP), NSP, and United States Pharmacopeia (USP). A good article explaining these companies can be found here.

So the moral of the story is: Do your homework, because you do not always get what you pay for.

Role of Vitamin D and a Healthy Spine

Association between low levels of Vitamin D and spinal surgery outcomes

The role of Vitamin D in maintaining a healthy spine has been underestimated and overlooked by many. In the last few years, the relationship between Vitamin D levels and various components of spine health have been reported on with increasing frequency within the literature. In short, Vitamin D acts as hormone and serves many functions. One of its main functions is to promote calcium regulation in the formation of new bone. Additionally, Vitamin D appears to have a protective effect on the immune and neurologic systems, reduces systemic inflammation and is involved in cellular growth.

In a previous blog, we have reported on the association of low levels of Vitamin D and the presence of back pain. Many patients elect to undergo spine surgery as a means of trying to alleviate their chronic back pain. A study presented this week at the American Association of Neurological Surgeons (AANS) annual meeting looked at the relationship between low levels of Vitamin D and outcomes from lumbar fusion. The study conducted at the University of Utah studied 133 adult patients who underwent a fusion for spondylosis (spinal osteoarthritis) during a 13 month period. Surgery included cervical, thoracic, and lumbar fusions. Vitamin D levels were measured in each patient prior to undergoing surgery. The researchers labeled a Vitamin D level (25 Hydroxy) of less than 30 ng/mL as “insufficient” and levels below 20 ng/mL as “deficient”. Most laboratories define a normal range of Vitamin D between 30 ng/mL and 80 ng/mL. Some practitioners recommend levels of at least 50 ng/mL.

In this study, the average patient had a Vitamin D level of 27.8 ng/mL. The study analysis revealed a nonunion (failure of the bones to unite) was associated with Vitamin D deficiency at a rate of 28%. For patients who were not Vitamin D deficient, the rate of nonunion was 12%. In regards to how long it took to achieve fusion, those with a vitamin D deficiency took an average of 11.8 months to fuse while those with a Vitamin D level that was within the normal range took only 8 months. The analysis did control for age, sex, type of fusion, length of fusion, and type of bone graft used. Vitamin D was shown to be an independent predictor of nonunion.

This is one of the first studies to investigate the relationship between Vitamin D levels and outcome in spinal surgery. A previously published study by Stoker et al (2013) looked at Vitamin D levels in 313 patients who underwent spine surgery. Fifty-seven (57%) percent of patients had insufficient levels of Vitamin D while 27% were Vitamin D deficient. While the analysis of that study did not look at the effect of low Vitamin D levels on outcome from surgery, the authors did express concern for the high percentage of patient with low levels of Vitamin D and the potential effect on outcome. Ravindra VM et al. Vitamin D deficiency may be associated with higher nonunion rates for spondylosis. Presented at: American Association of Neurological Surgeons Annual Meeting. May 2 – 6, 2015. Washington, D.C. Stoker GE at al. Preoperative vitamin D status of adults undergoing spinal fusion. Spine. 2013 Mar 15;38(6): 507-515.

Do Patients remember their Past Medical History?

As a Doctor,  I spend a significant amount of time obtaining detailed information  about the problem from patients.  That is known as obtaining a history.  From experience,  I know that most patients remember their current complaints and treatments.

The harder part is to have patients remember their prior treatments,  or prior episodes of the same.

Unfortunately,  patients tend to be poor historians.  There may be multiple reasons for that.

While most people do give their best effort in trying to remember past situations,  human nature is such that we often forget episodes,  when the memory will cause ourselves a disadvantage. From a survivalist perspective,  there may be some rationalization for that behavior.

(As we enter the political season,  how often do we hear people say  “I don’t recall..”)

Perhaps the most interesting research on the correctness of the self-reported history given by patients has been performed by Dr. Eugene Carragee,  Professor of Orthopaedic Surgery at Stanford University,  and  Editor in Chief of the Spine Journal.

In 2008,  he wrote an Article in Spine titled  “Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents.”  To summarize the paper,  retrospective review of patient histories after having a motor vehicle accident, had a poor percentage recalling prior histories of prior spine pain,  drug use,  alcohol abuse and psychologic problems than a matched group without an accident history.

In a followup paper in 2009 titled  “Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident?”  Don,  and Carragee reported on the auditing of prior histories of  335 patients randomly selected for review after being involved in a motor vehicle accident.   The self-reported prior history of prior spine pain,  alcohol abuse,  illicit drug use and psychologic issues did not correlate well with the prior medical records.

In my clinic practice,  I look at each patient individually,  and believe what they tell me.  Still,  I am amazed by how often people forget their prior complaints and treatments.  These research papers suggest that medical history forgetfulness is quite common.  That is why Doctors often use the prior medical records to formulate opinions about issues such as chronicity,  and causation.

For patients,  please try to obtain prior records before you guess about your prior histories.  It can sometimes be embarrassing to find out about your memory lapse!

Ever Wondered Whether to use Cold or Heat?

Patients often ask me whether it is best to use heat or cold for injuries and pain.

Immediately following and injury and for the first 2-3 days, applying cold is best. Cold application constricts blood vessels, which decreases swelling and blood accumulation at the injury site. It is the swelling and inflammation that causes the pain and slows down healing.

Applying and ice pack or gel pack 20 minutes on, then 20 minutes off, approximately three to four times per day goes a long way in keeping down discomfort and swelling. It is also important to allow the skin a chance to recover after application to prevent damage to the skin or frostbite.

A heating pad is best used for muscular aches and pains, beyond the initial 2-3 days. Heat will bring more blood flow to the area, which will then aid in healing. Heat is also great to apply prior to physical activity to loosen tense or sore areas. Remember to use intermittently as well and do not sleep with heating pad on, as this may cause burns to the skin.

It is good to know that something as simple as an ice pack or heating pad can assist with our discomfort

Would You Like Some Meat With That Burger?

Let’s face it, we have all had a fast food burger at some point. Either out of convenience or craving, it is a cheap meal on the go.

Or is it? Is using the term ‘meal’ being generous?

When you think about it, how is it possible to buy a full hamburger (bun, patty, cheese, and condiments) at a restaurant (which has significant expenses to cover) for less than $1? The answer is probably something you have known deep down inside, but were too afraid to ever acknowledge. In essence, you get what you pay for. Today I came across an article published in Annals of Diagnostic Pathology via an article on Yahoo! in which the authors sampled ‘meat’ from 8 fast food restaurants. They tested the ‘meat’ for water content and performed microscopic analysis for recognizable tissue types. The findings were not all that surprising, but disturbing nevertheless. The tested fast food hamburgers were actually made from very little meat (median, 12.1 %; range 2.1-14.8 %). Approximately half of their weight was made up of water. Besides having high fat and water content, other things found in some of the hamburgers included: ground bone, cartilage, and plant material. Luckily, no brain tissue was present (i.e. no risk of ‘Mad Cow Disease’). Sarcocystis parasites were discovered in 2 hamburgers. Let me highlight something…….ALL THE BURGERS CONTAINED LESS THAN 15% MUSCLE (MEAT), WITH THE LOWEST BEING 2.1%. Now, while eating cartilage, nerves, blood vessels, etc. may sound gross, in reality it is not uncommon. Think about how animals consume meat in the wild (and how humans probably did thousands of years ago). You don’t see a lion with a fork and knife eating a meal….no, they eat everything. The same with most of the animal kingdom. I am not saying it is very appetizing, but it is reality.

This does not just pertain to hamburgers. Chicken and fish nuggets don’t exist in nature. ‘Rib-wiches’ are a delicious, but entirely unnatural phenomenon. These items are cheap, but are highly processed and likely contain very little ‘meat’.

As noted above, you get what you pay for. So, the next time you wonder why the burger at a restaurant costs $15 compared to $1 at a fast food chain, you probably have your answer. Better yet, make the burger yourself at home, this way you know exactly what you are eating.

Obesity Means more Spine Surgery Complications

Obesity means more Spine Surgery Complications.  Surgeons cannot be politically correct about  Obesity.  The truth is Obesity makes surgery more difficult,  and less successful.

In the April 1, 2015 Edition of Spine,  Dr. Burks,  from the University of Virginia reviewed the data on Obesity and the associated rates of Incidental Durotomy during Lumbar Surgery.    It is well know that obesity has been associated with increased rates of complications such as wound infection,  blood loss,  and even mortality.  Likewise,  Obesity is associated with longer surgery times,  higher costs,  and greater risk of developing medical events such as heart attack,  breathing issues,  and blood clots.   To complete the analysis,  it means worse outcomes.

Dr. Burks and colleagues looked a the data regarding lumbar spine surgery,  and compared the obese  ( body mass index greater than 30),  the morbidly obese (BMI greater than 40),  and normal body weight patients.

The data analysis shows  non obese patients to have a significantly less rate of  these incidental durotomies.

As a spine surgeon,  I found this data interesting,  as previously,  it was thought these dural  openings are most associated with more complicated,  or revision type surgeries.  But this paper shows that even within groups of patients with revision,  or more complicated surgeries,  there is still a higher rate of dural openings when stratified by non-obese vs obese.

As a Spine Surgeon,  I know that obesity is definitely a factor in terms of planning the surgery,  counseling the patient,  and predicting an outcome.  As I have been in practice for more than 20 years,  I usually counsel obese patients to try to lose weight before any elective surgery.   In a fair number of instances,  the weight loss itself took care of the problem and surgery was cancelled.  To me,  sometimes,  the obesity,  and the associated medical conditions such as heart disease,  diabetes,  and diffuse arthritis makes the risk of surgery not worth any anticipated improvements.  In that situation,  I would advise against surgery.

While I cannot counsel obese patients on HOW to lose the weight,  I certainly can counsel obese patients when the risks overshadow the chances of a successful surgery.  It makes for a difficult conversation.  Unfortunately,  not everyone will accept my recommendations against surgery.  At the same time,  I am sure Obese patients can find Surgeons willing to take on the greater risks.  Just understand,  another Surgeon will not take away the risks associated with your obesity,  or your medical conditions.    In life or death matters,  the risk should be accepted.  In elective surgery,  the risk should be discussed, and quantified.      

The Inside Scoop Following a Steroid Injection

At Shim Spine, we will do our best to fully explain the procedure and make sure all questions are answered prior to the injection. However, we do understand it is a stressful time for the patients. I sometimes get phone calls from patients the following day, stating that the injection “didn’t work”. ”What should we do next?”

First of all, it is important to realize that steroid injections do not work immediately. Initially, you may feel immediate relief from the local medication that is used during the injection. As this wears off, you may even have an increase in pain following an injection. It is important to give 7-10 days for the effect of the steroid to reach its full benefit. The steroid works to decrease the inflammation and by doing so, decrease pain.

What can you do? You can apply ice to the painful area. If you are able to take your anti-inflammatory medication, please do so as prescribed by your physician. Occasionally, your doctor will prescribe stronger pain medication to get you over the initial acute phase.

Within two to three days following the injection, you should begin to feel slight improvement. Slowly begin your prescribed home exercise and stretches. A little time and a positive attitude is beneficial. The goal is to get you back to your normal function as soon as possible.

It is very important to schedule and present to the office for your follow up appointment. It is crucial for us to document the effectiveness of your injection, how much it did or did not help, what kind of symptoms you are still experiencing in order to continue to customize and treat your remaining symptoms. This will also document effectiveness of the injection for your insurance company, as some improvement is necessary to assure proper coverage of these services or possible future services.

An Alternative to Steroids?

Everyone has heard of the proverbial “cortisone” shot for various aches and pain. Hurt your knee? Get a cortisone shot. Shoulder pain? Back pain? Pretty much any pain? Get a cortisone shot.

That mantra has been around for years. Unfortunately, as time passes and we learn more about medicine, we are learning that not only are cortisone shots not a ‘cure all’, but they can actually cause harm. Too many steroids can lead to a number of unwanted side effects; such as: uncontrolled blood sugar (especially in diabetics), stomach ulcers, hormone problems, suppression of the immune system, osteoporosis, weight gain, tendon damage, and cataracts. This is not to say that you should not have a corticosteroid injection. They can and do work when used appropriately, but the old mantra of automatically getting 3 corticosteroid injections has fallen out of favor.

But what if the pain comes back after a few days or you don’t get the results that you want? What if you can’t have steroids? What if you don’t want steroids?

There ARE other options for injections. There are 2 other types of medications which I have recently started to use for various injections. One is Traumeel and the other is Zeel. These are homeopathic (i.e. natural) anti-inflammatory agents. While the exact mechanism of action is still not completely understood (don’t worry, this is actually pretty common even with prescription medications), these agents do not result in any of the potential adverse side effects that the steroids do. Because of this, they can be administered more often in effort to help your pain. Traumeel is typically used for muscle and tendon injuries, whereas Zeel is usually used for arthritic conditions. Traumeel is primarily made from plant based compounds, whereas Zeel contains both plant and animal based compounds. If you are vegan, vegetarian, or have concerns about the use of animal based products, please make sure you let me know prior to your injection.

For specific information regarding each of the medications, I recommend the following websites:

http://www.drugs.com/drp/traumeel-injection-solution.html

http://www.drugs.com/drp/zeel-solution.html

So far patient feedback has been positive with these medications, and I am happy to be able to offer a natural alternative for ‘cortisone’ shots.

Boxing and Spinal Injuries

While it is well known that boxers  can suffer brain injuries from repetitive contact,  spine injuries can also occur during the boxing match.

For boxers who develop neck pain after a match,  often times,  it is attributed to sprains and strains of the neck.  But if there is no rapid resolution of symptoms,  a screening x-ray can be helpful in identifying a potential instability condition such as Os Odontoideum.

Os Odontoideum is the term used to describe a non-union of the C1-C2 anterior bodies.   Normally,  during fetal development,  these bones naturally fuse togethe to form the axis of the spine.  The axis allow the head  to rotate around the neck,  without causing a dislocation,  While it is still not completely known how these Os Odontoideum develop,  theories include a congenital (you were born like that) basis,  or secondary to a fracture of the C1 and C2  areas during early childhood.

For people who have an Os Odontoideum,  they are susceptible to developing a castastrophic neurologic injury secondary to potential instability of the spine.  For Boxers,  the forces delivered to the head can cause a prior asymptomatic problem to become dramatically evident.  Not too long ago,  some debated whether  boxers should have screening of the neck.

For boxers with normal spine anatomy,  there are still concerns regarding the forces impacted on the skull,  and potential to cause injury to the ligaments and disks of the spine  (especially the neck).   While the use of gloves and head gear can dampen the forces experienced by the structures,   the forces generated can be significant enough to cause structural injury to the spine.

Most Ring Side Physicians are trained to look for neurologic changes of the boxers.  While often times,  the changes are secondary to brain concussion,  the Physicians must always consider a spinal cause of complaints.

This past Saturday,  we watched the “Fight of the Century”  between Floyd Mayweather and Manny Pacquiao.  While the boxers put on a great match,  the forces applied to the Boxer’s spines were significant.

How to Prepare For Your Office Visit

I am a Registered Nurse at Shimspine. I want to share ways to improve the patient experience. It is important to maximize the patient/ doctor interaction so patient’s concerns are addressed in a pleasant and relaxing environment. In the end, it is about getting your needs met, and your questions answered. These are some suggestions to help each patient be prepared for each visit, and get the maximum value from the Shimspine Doctor visit.

• Whenever possible, download patient forms from the office website and bring the completed form with you at the time of your visit. This keeps your appointment on time and allows you to provide the detailed information necessary for your office visit.
• Bring your insurance card to all appointments and a copy of your ID card, which will be scanned in for proper identification and to minimize fraudulent claims being filed on your plan.
• It is important to bring actual x-rays and MRIs images and applicable test results for review with your physician. The written report by the Radiologist is not enough!
• Bring a list of all current medications and allergies, as well as pharmacy contact information.
• Bring a list of questions to discuss with your physician regarding your problem. Use that time to get the most from your visit, making sure to get all of your questions answered. Takes notes if needed, so as to recall specific instructions when you get back home.
• Bring a family member or friend who will be able to remind you about your most important issues concerning your medical problem. The emotional support is always helpful.

At Shimspine, our goal is to provide a great patient experience. As our Patient, you can help achieve that goal by preparing for the visit, obtaining the necessary information and tests, and writing down your most important questions.
Please spend some time on our website. Dr. Shim has made a video on what to bring, how to prepare, and what to ask (https://www.shimspine.com/preparing-appointment/)
These are the suggested questions you should ask during the visit: https://www.shimspine.com/wp-content/uploads/2014/07/Surgery-Questions-Download.pdf

Why Did My Pain Come Back?

This is a very frequent question. Quite often following an injection procedure, your pain may significantly improve or even completely disappear for a certain period of time. Unfortunately, the pain may come back, especially if it is chronic or there is significant underlying degenerative disease.

Yes, the pain did go way and come back. Most of the time for chronic conditions we are unable to actually fix the underlying problem. So therefore, the treatments are performed in effort to help control the pain and allow you to increase your activity to improve your quality of life. Sometimes an injection procedure may give you a few months’ worth of relief from symptoms. Sometimes just a few hours. Obviously, the injection that worked for a few months is a better long term treatment option than the one that lasted for only a few hours. Despite this, however, sometime injection procedures are performed for diagnostic purposes. The relief from these types of procedures is typically only a few hours, but the purpose of the procedure is to help your physician determine the source of your pain and figure out which treatment options will be best for you in the long term. So it is imperative to tell your physician on follow if you felt any relief, even for a few hours, following the procedure. Failure to do so may wind up actually hurting you in the long run by disqualifying you from a procedure or other treatment which may have the potential to provide you with longer lasting relief.

All treatments have a time limited benefit to them, not just injections. Massage therapy, Acupuncture, Chiropractic care, and medications rarely completely cure symptoms after one treatment. Medications are metabolized, hence they need to be taken at specific intervals. Likewise, the benefits from Massage therapy, Acupuncture, and Chiropractic care are typically short lived and treatments need to be repeated every few days or weeks. Most injections are the same way. Every treatment has an expected lifespan, and nothing will last forever; especially if your pain is chronic.

So, it is important for you to maintain the proper perspective when having a procedure, trying a new medication, or new treatment plan. Did it offer any benefit at all? How much? How long did the benefit last? Accurate answers to these questions will help your physician develop the best treatment plan possible.

Disc Degeneration Causes Abnormal Motion

As Physicians,  and especially as Spine Specialists,  we know that disc degeneration is a normal aging process.  We also know that back pain prevalence does correlate to age,  but at the later stages of life,  there is usually less back pain.  While some of the causes of pain,  is not purely physical,  we are getting more information on how the degenerative process may cause specific pain patterns.

In the March 1, 2015 issue of SPINE,  there was a interesting article by Lao, et al,  about the Effects of Disk Degeneration on Segmental Mobility.

In this study, 162 volunteers,  with the average age of 45.5 years  had Kinetic,  or dynamic MRI’s of their lumbar spine.  Each of these consecutive volunteers were known to have back pain,  but without history of spinal surgery.  Their spines were imaged,  and the degree of disk degeneration was catagorized.  Translational  (forward and backward motion) and angular motions were measured.

This study confirmed that during the early stages of disc degeneration,  there was more movement of the spine levels.  As the disc degenerated to the later stages,  there was less mobility.

Based upon this information,  the take away message is consistent with what we have traditionally told patients.  Most patients with chronic back pain are most effected earlier on in the pain cycle.  As patients age,  there seems to be less pain.  We attributed the lessening of the pain  secondary to psychological accommodations,  activity restrictions, and reduced activity levels from normal aging.    This recent study also confirms that the science demonstrates a stabilization of the spinal segment motions as the disc degeneration process progresses.

Once again,  the human body has demonstrated the ability to accommodate and ameliorate the natural degenerative process.

Candy for Breakfast?

Depending on how old you are (or feel), that may actually sound pretty good. Generally, however, it is a bad idea. Minimal nutrition. No vitamins. No Fiber or Protein. Too much sugar. I bet a bowl of yogurt and granola sounds healthier, doesn’t it? Well, depending on the product, your breakfast may have as much (or more) sugar than a piece of candy. Of course, no one will argue that yogurt is more nutritious than a candy bar, however it is important to be aware of what you eating….especially if you are diabetic or trying to limit your sugar intake. This does not just apply to granola and yogurt. Breakfast cereals, breakfast bars, and prepared meals may have way more calories and additives than you may think.

You may have noticed that fast food and chain restaurants have started posted Calorie and nutritional information on the menu. This was required by the FDA at the end of 2014 in effort to help consumers realize how many calories they are actually consuming. You may be surprised that the ‘healthy salad’ you ordered has almost 1,000 Calories, which is about half of the recommended daily Calorie intake for the entire day. Likewise, I recently looked at the label of a protein supplement bar while at a local pharmacy chain. I was astounded that it contained 50% of the RDA of saturated fat and almost 400 Calories. Even more surprising, 3 pieces of chicken sausage has the same amount of protein with far less saturated fat and 150 less Calories!!!!! Balance Bars, Cliff Bars, Power Bars, etc. also have a substantial amount of Calories, fat, protein, and sugars. When used appropriately to supplement a vigorous workout or meal that is fine. BUT, these are not appropriate snacks just because you are hungry.

So, the take home message is to read the labels of what you are eating and be more aware of what you are actually consuming. You will likely be surprised at the number of Calories, fat, protein, and sugars in what you are eating.

Robot Assisted Spine Surgery: A developing technology

The technology that allows spine surgeons to perform often complex procedures has grown rapidly in the last two decades. Some of these technologies including minimally invasive endoscopic and laser spine surgery has been joined by robotic assisted spine surgery in the last few years. These technologies have been developed with the potential to offer patient better outcomes and safer operations. To date, many of these technologies has not been proven to be any more effective than traditional approaches. Some surgeons will go as far as to say that these offer more in terms of marketing hype than actual clinical benefit.

Robotic assisted surgery continues to evolve. Robotic surgery has been used in the areas of prostate and gynecologic surgery since the early 2000s. Potential benefits for use of robotic assisted surgery include a shorter hospital stay, less blood loss, few complications, a faster recovery, and less scarring. To date, over 1.5 million surgical cases have been performed worldwide using the da Vinci robot, across several different surgical specialties. The da Vinci robot was used for the first time to perform a successful lumbar fusion in 2012.

Robotic surgery utilizes a magnified 3D vision system and instruments that offer enhanced visualization, precision, and greater control than human hands. The primary use of robotic assisted spine surgery has been for pedicle screw placement so far. To some, the use of robot assisted surgery is about expanding the limits of capabilities to develop newer techniques while other surgeons embrace this type of technology to improve upon outcomes and clinical results for procedures already being done.

A systematic review of all published literature from 2006 to 2013 looking at pedicle screw placement comparisons between robot-assisted versus conventional fluoroscopy placed, found mixed results and insufficient evidence to recommend one technique over the other.

A prospective, randomized control trial published in 2012 (Ringel et al), comparing robot assisted pedicle screw placement to conventional fluoroscopic guided placement showed more accurate screw placement in the conventional group, 93% to 85%. A matched cohort comparison study from 2014 (Schalto B et al) showed more accuracy by robot placement (83.6%) compared to conventional fluoroscopy (79.6%).

Advocates for the use of robotic spine surgery contend that if this system can truly reduce the rates of revision surgery due to errant screw placements, there will be significant cost savings that justify the high cost of this technology.

The lack of good quality data makes it difficult to draw any firm conclusions about this new technology at the present time.

In summary, robotic assisted spine surgery is in its infancy and offers hope for improving surgical outcomes. The full capabilities of this technology are yet to be determined along with defining what specific conditions can be treated and who the ideal candidate is. More data is needed to evaluate whether the push for robotic assisted spine surgery is more about marketing hype or is a true sustainable technology that will produce better clinical results than conventional methods in spinal surgery.

Which Spine Surgeon? Which Doctor? Witch Doctor?

For many medical conditions,  the patient does have a choice.   While the pain,  or discomfort can be severe at times,  unless the problem is limb or life threatening,  you can explore your options,  before deciding on the best direction for you.

Insurance companies,  and the government deal with large populations concerns,  when considering their plan of action.

As an individual,  you have unique concerns,  only felt by you.  It does not matter that these feelings are experienced by anyone else.  Only YOU can feel what you feel in your own body.

Most insurances, and plans use prescribed pathways or steps to authorize your care.  It is almost cookbook.  As long as you are responding to the accepted treatments,  there is an expectation of improvement.  General medical Doctors,  and physician extender providers such as Physician Assistants and Nurse Practitioners often will monitor your progress,  and often times, that is a perfectly good way to obtain your healthcare.

But what if you are no longer responding to the cookbook treatments?

What if your unique set of complaints do not completely fit into the cookbook patterns?

That is the unfortunate part of practicing “Cookbook medicine”.  Patients are unique.  Patients also need to know that they are being treated as an individual.

In terms of Spine Surgery,  we know that there are often several different questions that should be explored and discussed with the individual patient.

1.  What are the goals of the surgery?

2.  What is a realistic expectation after surgery?

3.  What are the known risks?

4.  What are the potential future concerns regarding the surgical treatment?

5.  How will the recovery time effect my family,  my job,  my finances?

These factors should be discussed with the patient by the Surgeon.

In terms of choosing your Spine Surgeon,  you must consider these questions:

1.  Does the Surgeon have experience with the condition?

2.  Has the Surgeon (or surgical team) thoroughly explained the procedure?

3.  Does the Surgeon have a good reputation amongst the medical community,  and the operating room staff?

4.  Do I Like the Surgeon?

It turns out liking the Surgeon,  or your Doctor is a very important aspect of satisfaction,  and positive outcome.  If you like your Surgeon,  it is likely your Surgeon likes you.  It means you will have a better, more confident attitude about your surgery.  It will also likely mean you will be more likely to follow instructions,  and do the necessary exercises and therapy to improve your outcome.

If you have a choice,  please consider  which Surgeon,  and which Doctor.   Please avoid the Witch Doctor.

Why does my knee hurt when it rains?

Does it seem like you are able to predict the weather better than any meteorologist? Does your joint pain seem to worsen when it rains?

Well, you are not alone. And, it is not just an old wives’ tale……your joints may actually hurt more when the weather changes. There is scientific validity to this phenomenon. The reason involves some pretty simple physics. There is pressure inside and outside of your joints. Normally when the outside pressure changes, a healthy joint is able to adjust the pressure inside the joint relatively easily. Unfortunately, when your joint becomes arthritic, it is harder for the pressure to equalize. Similar to trying to clear your ears when flying if you are congested……not a fun thing to do. Stormy weather is usually accompanied by a low pressure weather system. As the outside (ambient) pressure starts to decrease when the weather system approaches, your arthritic joints are not as easily able to equalize to the new ambient pressure. As a result, there is a relatively higher pressure inside the joint compared to outside of the joint. This results in increased tension on the tissues, hence increased pain. You may have also noticed similar episodes during altitude changes when flying or when SCUBA diving.

While treatment of arthritic conditions can be complicated, the easiest way to help prevent this from happening is to maintain a healthy weight and engage in a regular exercise program. While you can not reverse arthritic changes that have already occurred, it is possible to decrease the stress on the joint and slow down the progression of the arthritis. This will result in an overall better quality of life with less pain.

Hoffmann Sign and Myelopathy

As Spine Specialists,  we often rely on the so called Hoffmann Sign to identify people who have cervical myelopathy.  The video above demonstrates a positive finding.  Various studies have opined that a positive Hoffmann Sign highly correlates to the presence of cervical myelopathy.

It is accepted knowledge that a positive Hoffmann response can also indicate the presence of Central Nervous System (Brain) abnormalities,  as well as the presence of MS,  or ALS.  People who have significant anxiety,  or Hyperthyroidism can also present with this sign.  The sign by itself,  can also be just a unusual finding in a normal person.  However,  traditionally,  the presence of the finding is of some concern.

In the April 1, 2015 Spine paper titled Hoffman Sign, by Grijalva etc al,  there is an excellent investigation on the significance of the finding.  The authors conclude “the sign has too low a positive value to be relied upon as a stand-alone physical examination finding” for predicting the presence of cervical spinal cord compression or brain pathology.

As a practicing Spine Surgeon,  I still rely on the sign,  as when it is positive,  and I have concerns about cervical myelopathy, the presence accelerated the likelihood of ordering diagnostic testing.

If the sign is not present,  I am less likely to order testing,  unless there are other manifestations of cervical myelopathy.

How Much Exercise Do I REALLY Need?

Many exercise fads have come and gone, each claiming to be the best way to get in shape, lose weight, and live longer. Some are extremely intense, and some are so minimal that they sound too good to be true.

The current government recommendations for exercise in an adult are:

• 2 ½ hours of moderate intensity aerobic activity combined with 2 or more days of general muscle strengthening exercises WEEKLY —-OR—-
• 1 hour and 15 minutes of vigorous intensity aerobic activity weekly combined with 2 or more days of general muscle strengthening exercises WEEKLY

So what defines moderate vs. vigorous activity?

• Some examples of moderate activity are: walking fast, water aerobics, riding a bike on a flat surface, and pushing a lawn mower.
• Some examples of vigorous activity are: Jogging or running, swimming, riding a bike fast or on hills, and playing basketball.
• A good rule of thumb is:
  • During moderate activity, you should be able to talk with minimal to moderate effort, but not sing
  • During vigorous activity, you should not be able to say more than a few words without stopping to take a breath

This exercise does not have to be performed in 1 session…it can be broken up into smaller segments. If you choose to do this, make sure that you do the exercise in segments of at least 10-20 minutes.

Those recommendations do not sound like a lot, but the reality is that not everyone has the time to exercise on a regular basis. Between family and work life, household chores, and other commitments sometimes there are just not enough hours in the day to get everything done.

The truth is that any exercise is better than nothing. A recent article published in Medicine and Science in Sports and Exercise demonstrated that after 3 hours of sitting, be it in a car, at work, or on the couch, there was decreased blood flow in the superficial femoral artery. This was mitigated by standing and walking for just 5 minutes. So, while the above recommendations are for a minimum amount of exercise per week, don’t be discouraged if you can not obtain them. Perhaps make it your goal to eventually reach or exceed them, but realize that some REGULAR exercise is better than nothing at all, even if it is just 10 minutes per day during your lunch break.

Surgery for Recurrent Disk Herniations

Unfortunately,  even after successful lumbar discectomy surgery,  there is between a 5% and 15% chance of a recurrent disk herniation at the same location.  The reason is secondary to the nature,  and size of the lumbar disk.  Most disk herniations are pieces of annulus,  endplate ,  and or nucleus elements of the disk.  The fragments,  however,  are only a very small piece compared to the whole disk.   No matter how much disk is removed during the original discectomy surgery,  there is always more disk material available to herniate.

In addition to the amount of disk material still present,  the hole where the disk material herniated is still present.  Even though there is some scar tissue and repair of the hole,  it will never be as strong as the original annulus.  Just so it is clear,  once a disk herniates,  it will always have the 5%-15% chance of re-herniation,  with or without surgery.

If you have a recurrent disk herniation after prior discectomy surgery,  most Physicians will still try to treat the disk herniation non-surgically.

If you can no longer tolerate the pain,  there are different surgical options on how to handle your disk herniation.

1. Provided this is only the first recurrence,  many Surgeons will consider doing just a repeat discectomy.  The results for the proper patient is similar to the original surgery.  Some studies have suggested that central recurrent disk herniations at L4-5 should also be fused at the same time,  as the L4-5 level is most associated with discogenic back pain,  and development of instability.

2. After multiple recurrent disk herniations at the same level,  the standard answer is to consider repeat discectomy with fusion.  Successful fusion will prevent further recurrent disk herniations at the disk level, as most of the disk is removed,  and there will no longer be motion at that disk level.   Fusions,  however,  have associated complications,  including fusion failure,  hardware failure, and potential for accelerated degeneration of the disk levels above/below the level ( Adjacent Segment Disease).  The surgeon must consider the possibilities before pursuing the fusion, depending on factors such as age,  activity level,  medical condition,  etc.

3. A minority of Surgeons will recommend repeat discectomy and Total Disk Replacement.  The rationale is to remove the disk,  thus improving the leg pain,  as well as replacing the disk to prevent the Adjacent Segment Disease.  While the principles seem logical,  it usually requires both an incision on the back,  to remove the disk,  as well as an abdominal incision to replace the disk.  The anterior abdominal incision has multiple associated risks,  and the long term efficacy of Lumbar Total Disk replacement is still being challenged.

4. The latest concept is to perform the repeat discectomy,  but to protect the disk level bay placing posterior interspinous,  or posterior intralaminar stabilization devices.  This technology is relatively new,  but several of these devices have obtained FDA approval after rigorous testing.  The devices usually provide stability without causing fusion.  This technique has its advantage in that it can be easily converted to a fusion  if necessary into the future,  and can be performed on a minimal access,  outpatient basis.  At this time,  it is unfortunately a technique that will not always be authorized by certain insurance entities.

If you have a recurrent lumbar disc herniation after prior successful discectomy surgery,  the chances are good that you will have a successful repeat surgical procedure.  But know that there are different surgical options.  Please discuss them with your Surgeon.

‘Roid Rage

Some of the most commonly used medications in medicine are one form or another of steroids. There are generally two classes of steroids: Anabolic steroids and Corticosteroids. Anabolic steroids are the kind used to build muscle and are the ones abused by some athletes. The most common kind of steroids used in medicine are corticosteroids, and will be the type discussed here. Steroids can work wonders for many conditions and are likewise ‘miracle’ cures for many patients.

There are various different kinds of corticosteroids that are used. Some are used for anti-inflammatory and pain relieving purposes, while others are used to help regulate things like electrolyte and fluid balance. For anti-inflammatory purposes, steroids are typically given orally, intravenously, or by injection. Steroids can also work on certain neurotransmitters to decrease pain. That ‘cortisone’ shot your neighbor had for their shoulder was a form of steroid. Numerous diseases such as asthma, allergies, multiple sclerosis, Rheumatoid disorders, certain vascular disorders, and sports injuries all respond well to steroids.

So, if they are so good, why can’t we use them for everything?

Nothing in medicine comes without a cost. Too much of a good thing can be bad. Your body does make steroids naturally, as they are actually the building block for the hormones that help regulate your body’s basic functions. Because your body makes steroids naturally, things can go wrong when too much is given from outside. Your body works very hard to keep things in balance. If there is too much steroid floating around in the blood stream your adrenal glands will decrease the amount made or even stop making them. This is why patients are typically tapered down off of steroids….the taper allows the body to adjust to the changing dose and make more if its own. In addition, prolonged steroid use can lead to suppression of your immune system, weight gain, diabetes, osteoporosis/fractures, stomach ulcers, muscle weakness, and changes to your complexion, personality, and sexual function. All of these are potentially serious and some of these changes are irreversible.

There is also the on-going debate as to whether or not inflammation is actually a bad thing following an injury. Inflammation after injury is your body’s way of repairing itself. Inflammation initiates a complex cascade of events, which ultimately leads to healing of the area. Some theorize that inhibiting this inflammatory response through the use of corticosteroids will impair the body’s ability to heal, thus potentially resulting in instability and continued weakness. This may increase the potential for future injury and/or chronic pain.

This is not to say that steroids are horrible. In certain conditions, the benefits of using steroids outweigh the associated risks. But not every condition justifies using steroids regularly. Despite what you may think, or how much pain you are in, your physician may not agree with another ‘cortisone shot’ to help with your pain. That is why it is so important to have a long term outlook when managing your symptoms or condition. A short term fix now may result in much greater consequences later on.

Accident Related Neck and Back Pain

Having accident Related Neck and Back Pain?  Frustrated you cannot get an appointment to see your Family Doctor for the problem?  Why don’t you go see the Spine Specialist?

Before we criticize our Family Physician for not giving you an appointment.  Please understand the Family Physician’s predicament.  Your regular Health Insurance carrier required your Doctor to disclose any treatments related to injuries such as slip and falls, and  auto accidents.  The health insurer will then reject payment for these services until it is determined that the liability insurance is exhausted.  Sometimes,  the health insurance will reject all the Family Doctors bills until it is sorted out.  If you just think this through,  I think most will understand the reluctance of Family Doc’s and Internal Medicine Doc’s to evaluate their injured patients.

Orthopedic Surgeons, and Spine Specialists are used to dealing with injury situations.  Orthopedic Surgeons are the doctors called in to do the emergency surgeries related to catastrophic accident related injuries.  Typically,  the Orthopedic Surgeon staff are used to dealing with the complex interactions between health insurance and liability insurance.  Because these interactions are understood,  Orthopedic Surgeons can concentrate on the Injury Complaints.

If you have an accident related injury to the neck , back,  shoulder, knee,  etc.,  please get an evaluation.  If an office is set up to deal with the background issues related to insurance,  appointments will be easier to make,  and evaluations and care can be delivered  on a timely, and less stressful manner.

We Welcome Patients with Accident Related Injuries.  Call the office to see if we may be of help.

I Hate Doctors' Visits

I’ll admit that going to a doctor’s office is not fun…..often you sit in the waiting room for a long time, only see the physician for a few minutes, and have multiple pages of paperwork to complete. Unfortunately, the system is broken, very complicated, and unlikely to change under the current insurance model. So, here is my advice to you so that you can make the most out of your appointment with the least amount of difficulty:

1. BE EARLY FOR YOUR APPOINTEMNT: The reality is that both you (as a patient) and your physician have an ever increasing amount of required documentation to complete on each and every visit. So, showing up ‘on time’ will not allow you to complete the necessary paper work and will jeopardize the amount of time you can spend with the physician. Some practices allow you to compete the paperwork on-line prior to coming to the office, which can simplify things for you.
2. COME PREPARED: If you have multiple questions, please write them down beforehand. It is also beneficial to bring in a pen and paper to write down the answers, so you don’t forget any information. Bring in a list of medications and dosages if you do not know them off the top of your head. Your physician will likely not be able to prescribe you any medications without first knowing what you are currently taking. In addition, bring in copies of any relevant notes from other clinicians, lab work, or radiology studies. Please do not expect the office staff to be able to obtain these results for you once you arrive at the office, because they likely will not be able to so in a timely enough fashion to benefit your appointment.
3. DRESS APPROPRIATELY: If you are coming to the office to have your knee examined, a tight fitting pair of jeans is perhaps not the best choice of clothing. There may also be children in the waiting room, either waiting to be seen or here with their parents. Dressing provocatively will likely draw unwanted attention to yourself. Along those lines, you may be asked to undress and put on a gown once you are in an exam room. If you are timid about being seen in certain underwear (such as a thong or lace), it is not recommended you wear these on the day of your appointment.
4. BE RESPECTFUL: This applies both to your physician and other patients. a. Please understand that your physician has a plethora of things to do in a very short period of time during your office visit. Because of this, please understand if your physician limits the number of medical complaints, body parts examined, or questions answered. It is not that your physician does not care, but rather there is only so much which can be accomplished per visit. If you have multiple issues, or think that you will require more time than a standard visit allows, either prioritize your issues to focus on the top one or two, or call ahead and see if your appointment can be changed to allow for more time. b. In regards to other patients, please do not talk on the phone in the waiting room. It is rude and distracting. Show up early. If you are late for your appointment, it can potentially throw off the schedule for the rest of the day therefore making every other patient wait longer because of you. It is because of this that sometimes you will be asked to reschedule your appointment if you arrive late. It is not fair to the other patients who show up on time. If you know that you will be late, such as being stuck in traffic or having a flat tire, please have the courtesy to call the office and see what arrangements can be made. Likewise, understand that your physician has other patients to see as well.

In line with the above paragraph, be prepared for the visit and understand that all of your issues may not be covered in one visit. It is unfair to the remaining patients if you consistently use more than your allotted time. Some of the above suggestions may seem obvious, but are often overlooked. Simple things can help make your office visit more productive, efficient, and enjoyable.

The risks of waiting too long for Cervical Disk Surgery

While it is prudent to wait at least 6 weeks for elective cervical disk surgery,  waiting more than 6 months can lesser your chances of a more acceptable outcome.

Unless you have a severe loss of muscle control,  or inability to control your bowel and bladder control,  most patients should wait at least 6 weeks before considering neck discectomy operations.

Of the patients who have symptomatic disk herniations to the neck,  they often progress to one of three scenarios:

1.   Within six weeks,  the pain improves,  and any minor weakness starts to go away.  The initial few weeks are very painful.  With proper guidance,  and judicious use of medications,  injections,  and therapy,  greater than 90% of patients do get better without the need for long term management.  The key is having confidence in their Physician,  and accepting that the pain will likely improve,  even though it can be quite severe in the future.

2.  The pain does improve,  but only slightly.  There is some associated weakness,  and any sudden movement,  or change of direction causes a significant flare up of pain.  Most of these patients fail to improve despite medications,  therapy,  and steroid medications or injections.  If the pain pattern follows a certain distribution,  and the tests show a corresponding disk that can explain the pain pattern,  there  is a high likelihood of improvement.  Most patients choose to pursue surgery after 6-8 weeks of non surgical care.

3. The pain improves enough that the patient can perform most activities,  but it is a struggle.  There is a concern of dependency on narcotic medications,  or muscle relaxers.  Any change in physical demand causes increased pain.  The pain prevents proper sleep,  exercise,  and intimacy.  Despite the pain,  however,  the patient would like to avoid surgery,  and is now more than 6 months from the initial onset of the pain.

In the first two scenario’s,  the proper path is relatively easy.  In Scenario #1,  no surgery.  The patient is likely to fully recover.  While there is still a 5-10% change of a recurrent disk episode,  each future episode can be treated the same as long as the pain improves.

In Scenario #2,  the pain is significant enough that the choice of surgery is a reasonable next step.  In the properly selected patient,  there is greater than 90% chance of a significant improvement of pain and function after surgery.

The third scenario is difficult.  Traditionally,  surgeons have thought that this population of patient is at risk of poorer outcomes,  by waiting too long.  Another recent study,  published in the Spine Journal again supports that conclusion.

The bottomline is  the decision for surgery is still the perogative of the patient.  The patient,  however,  must understand that there are potential risks to delaying  surgery after 6 months.   If you are at a loss to what to do,  please get opinions by Surgeons that will take the time to discuss the pro’s and con’s of surgery in your individual situation.

Do Doctors Actually Help Patients?

A very interesting question…and this does not apply only to doctors. It applies to chiropractors, acupuncturists, physical therapists, nurse practitioners, physician assistants, etc. You see, as physicians and medical professionals, we are very good at taking care of acute and emergent medical issues. For example, no one will argue against the benefit of removing an inflamed appendix before it ruptures preventing a potentially life threatening infection. Or the benefit of using orthopaedic surgery to repair a severe fracture. On the other hand, the field of medicine as a whole really does not have much to offer when it comes to ‘fixing’ chronic conditions. Sure we have lots and lots of treatment options, but very few, if any, actually fix the problem. Most simply help control or manage the condition. Think about heart disease, stroke, and chronic pain conditions.

For the purposes of this blog entry, I will focus on chronic pain conditions. As noted above, we have lots of options to try in effort to help your pain, but there is seldom a true ‘cure’. And, there may not be anything bad about that. Sometimes the treatment is worse than the disease. My goal as a physician is not ‘cure’ your chronic pain. My goal is to decrease your pain to the point where it does not interfere with your normal activities, while minimizing the potential side effects from treatment. All medications and injections will have side effects on the body. Most of the time, these side effects are undetectable or tolerable. Other times, the side effects from treatment can be more debilitating than your underlying problem. In addition, there are always risks associated with any treatment, no matter how benign the treatment may be.

There are some emerging treatments which show promise, such as platelet rich plasma and stem cell injections, however the protocols for these treatments are still evolving and may not be appropriate for everyone. In certain cases, however, these treatments have been shown to be beneficial. In addition, certain conditions are amenable to improvement without any medical intervention. Smoking cessation, weight loss, dietary changes, and regular exercise can work wonders for chronic conditions such as low back and joint pain, high blood pressure, and diabetes. These treatments, however, require effort from you as the patient and are considered ‘active’ rather than ‘passive’ treatments. In addition, these are generally things that you can do without direct medical supervision.

Despite how it may appear, the purpose of this blog entry is not to discount any of the treatments we do. On the contrary, many patients note tremendous benefit with various treatments. But rather, the real purpose of this blog post is to help you as a patient set realistic expectations in terms of outcomes. If you decide that your pain is tolerable and not interfering with your normal activities, then treatment may not be needed. Likewise, if your symptoms are bothersome enough to interfere with your daily activity, then it is worthwhile to explore what treatment options are available. If this is the case, however, it is also necessary to understand what the long term goals are.

Low Back Pain After Lumbar Discectomy

Unfortunately,  up to 25% of patients who had lumbar discectomy surgery may have recurrent back pain after surgery.  A recent study out of Vanderbilt University performed a meta analysis of available studies on discectomy patients,  as well as prospectively following patients that had surgery at Vanderbilt.  The results of both the meta analysis and the prospective study revealed very similar data.

Only 6% of patients had repeat discectomy surgery at the same level of the original discectomy surgery.  Within two years of the discectomy surgery,  15% to 25% of patients did report episodes of back pain.   

Based on this information,  patients should be aware of the possibilities after surgery.  For the most part,  the statistics are in favor of a good outcome.  Still,  that means 1 in 20 lumbar discectomy patients will have an additional discectomy surgery at that level.  Also,  almost a quarter of the patients will have episodes of back pain after the operation.

Fortunately,  there are other non surgical treatments available for patients who do have the recurrent disk condition or the recurrent lower back pain.

For patients contemplating lumbar discectomy surgery,  please discuss the plans just in case  you are one of those patients who have these recurrent complaints.

Is your ‘Doctor’ a physician?

This a valid question, which often is not as obvious as you may think. Traditionally, most people associate ‘Doctors’ with either being a Physician (MD/DO), Optometrist (OD), Chiropractor (DC), or an academic expert in a specific field (i.e. PhD). But, did you know there are many other fields which have expanded to offer doctorate level degrees? For example, you can now get a doctorate in business administration. Although unlikely, it is theoretically possible to answer a phone call from ‘doctor’ so and so thinking that they are calling about your medical condition, whereas it may actually be the financial office calling to discuss payment. In addition, psychologists, pharmacists, physical therapists, physician assistants, nurses, and nurse practitioners also have the ability to obtain doctorates in their fields. This is not to discredit the hard work it takes to earn a doctorate level degree. On the contrary, they have every right to call themselves a ‘Doctor’, as the term technically only reflects the highest degree earned, not a specific profession.

The grey area occurs, however, when this distinction is not made inherently clear to patients, be it deliberate or not. In the United States, there are currently only two doctorate level degrees which allow practitioners to call themselves ‘Physicians’. These are the Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) degrees. If your clinician has one of those degrees, then you are being treated by a physician who has gone to medical school.

I am not saying that you cannot be treated by another clinician, or that non-physicians provide inferior care. This is a personal decision that you should make. When making this decision, however, make sure you know the credentials of the person who is treating you, rather than just calling them ‘Doctor’ and assuming they are a physician.

Does Cold Temperatures increase Back Pain?

Cold Temperatures are associated with more back pain.   While most of us believe that,  there is some scientific data that suggests the statement is true.  The Northeast has experienced a record cold winter,  and I am sure many are tired of the effects of Old Man Winter.  Unfortunately,  the cold is associated with increased musculoskeletal complaints,  and it may be more than the increase physical activities associated with dealing with the winter snow.

A 2013 Article from Sweden retrospectively looked at about 100k worker profiles from the 1970’s.  It stratified the population interms of manual construction workers,  versus foreman and office workers.  It also stratified the location of the workers in terms of province locations from the north, to the warmer south.  The study concluded that “Outdoor work in a cold environment may increase the risk of low back and neck pain.”

A February 2014 Study from Finland made a fascinating correlation of warmer weather inhabitants have a higher temperature threshold before reporting a  musculoskeletal pain complaint.  In other words,  people who lived in warmer temperatures were more likely to complain of pain with a smaller degree of temperature change than the more hardy colder temperature dwellers.    This seems to follow the stereotype of the more stoic,  robust cold weather inhabitants.  Still,  the data did show that overall colder temperatures were associated with more musculoskeletal complaints,  including spine pain.

Frankly,  this data should be a great talking point to Southern Locations during these Winter months.  “Come to the warmth,  and relieve your back pains”.  There is scientific data to support that statement!

Does nicotine make pain better?

Surprisingly, the answer can be yes. Your body actually has receptors that respond to nicotine throughout the central and peripheral nervous system. This, however, is a good thing and a bad thing. It is good because stimulation of these receptors (through a complex process) ultimately results in the release of various neurotransmitters that reduce pain. It is a bad thing because the introduction of nicotine (which is not a naturally occurring substance in the body) can alter the normal functioning of this process.

Here is a simplified version of how it works:

1. Stimulation of receptors in specific parts of the brain will result in the release of a neurotransmitter called dopamine. Dopamine is linked to the body’s natural reward and pain relief system.
2. Nicotine results in the release of endorphins, which is your body’s version of opioids.
3. Nicotine causes an increase in adrenal function (epinephrine, norepinephrine), which results in increased arousal and a decrease in pain perception.
4. Nicotine also results in the release of other neurotransmitters associated with mood and the reward system, such as serotonin.

Hence the reason why nicotine is so physically and psychologically addictive.

So, if nicotine stimulates a natural pain relief pathway, why do smokers still have pain? Why is smoking actually associated with worse pain?

Just like anything in life, too much of a good thing can be bad. Similar to street drugs and prescription pain medications, when the body is exposed to nicotine on a constant basis, it becomes dependent on the chemical and tolerance develops. This results in dysfunction of the pathway, to the point where it may no longer result in any benefit, no matter how much is used. Over stimulation of the system can also result in a paradoxical hypersensitivity to pain, just like what occurs with the prolonged use of opioid medications.

The truth is smokers are more likely to have chronic pain than non-smokers. Is this because those with chronic pain are more likely to start/increase their smoking in effort to control their symptoms? Possibly. However, studies have shown that smoking directly contributes to heart disease, peripheral vascular disease, decreased oxygen in the blood/tissues, nerve damage, accelerated degeneration of the discs in the spine, impaired and delayed wound healing, prolonged recovery from injury and surgery, osteoporosis, osteoarthritis, and fractures (amongst other issues). These conditions all can result in chronic pain. Decreasing the body’s ability to repair itself following an injury will also worsen any underlying pain. In addition, as noted above, excessive use of nicotine alters the body’s natural reward and pain relief system, thereby interfering with its attempts to control the pain.

So, then, what about other forms of nicotine? The same thing applies. Any introduction of nicotine (such as through e-cigarettes, topical patches, chew, gum, etc.) can alter the normal functioning of this process, not just smoking.

The take home message: If you decide to use nicotine, realize this a choice you make which will alter part of the body’s natural pain relief and reward system. By doing so, you may be setting yourself up for problems later on which may directly lead to you suffering from chronic pain. Bad choices sometime have bad consequences.

Minor Trauma Does not Cause Serious Low Back Problems

People come to the Doctor’s office because they have concerns that they caused a major low back problem with a minor traumatic event.  Luckily,  the research shows that Minor Trauma does not lead to a permanent change to the spine.

The study was performed at Stanford University by Carragee et al.   There were 200 volunteers.  The average age was 39 years.  27% were smokers.  76% had disk degeneration findings on MRI.  13% had moderate to servere spinal stenosis.  All had no know prior history of back pain.

Major Injuries were defined as back pain episodes associated with high-energy trauma that resulted in visceral injury (bowels,  bladder, etc), long bone fractures,  or pelvic or spine fracture or dislocation.

Minor Injuries,  or Minor Trauma was injuries that report a pain scale of >2/10, lasting more than 48 hours, but not meeting the criterion for a Major injury, outlined above.   Minor Trauma examples included lifting injuries,  falls,  sports injuries,  and road traffic accidents that did not meet the Major Injury catagory.

The study identified people who were at risk for degenerative lumbar disk disease,  but had no history of low back pain episodes.    All study volunteers were then examined with x-rays, MRI’s and physical examinations.  All volunteers were followed every six months to see if these people who were at risk for have lumbar disk disease would have a significant change in there spine with minor trauma.   After the traumatic episode,  the spines were again examined,  and MRI’ed.

By definition,  a serious back pain episode was defined as having a pain scale >6/10 lasting at least a week with disability from the usual occupation.

The results showed minor trauma was NOT associated with a significant adverse Low back pain event.  For each 6 months in the study,  the volunteers demonstrated a 2.1% risk of developing a serious low back pain episode without any trauma.  After a minor trauma,  2.4% developed a serious low back pain episode.

Followup MRI’s evaluating new serious low back pain rarely demonstrated any significant structural changes in the MRI.

The study concluded that Minor Trauma does not appear to increase the risk of serious low back pain episodes or disability.  Over all good news!  Even with an episode of increased back pain,  minor trauma does not cause a significant structural change to a spine.  

Perimeter Shopping

In an earlier post, I alluded to the idea of ‘Perimeter Shopping’ for food. Let me explain to you what I mean by it:

In general, when you go to a supermarket for your groceries, how is it laid out? Where are the fruits, vegetables, dairy, and fresh meat? Where do the organic and ‘natural’ foods tend to be? Where are the frozen dinners, snacks, and other processed foods?

Easy……The healthier foods tend to be on the perimeter of the store, whereas the processed foods are located more in the aisles.

This is not to say that everything on the perimeter is good and everything in the middle is bad. After all, the hot dogs are usually not too far away from the lean chicken and the doughnuts are next to the multigrain bread in the bakery. Likewise, items like olive oil and whole grain cereals are found in the aisles. Just like frozen vegetables are found in the same aisle as frozen pizza.

Therefore, this advice is just a rule of thumb, and not an absolute rule in regards to shopping. The important thing is to be smart when shopping. Buying frozen broccoli and roasting or steaming it at home is much healthier than buying the box of frozen broccoli and cheese, even though both dishes contain broccoli. Likewise, getting sliced bologna at the deli is likely not healthier than getting pre-packaged turkey breast. Just because the deli has freshly made fried chicken (and it is on the perimeter) does not make it any healthier than the frozen chicken nuggets.

When in doubt, look at the label and compare the calories and ingredients. If you can’t pronounce an ingredient, chances are you do not want to eat it.

This is a good place to start, but is not the only thing you need to do to lose weight and be healthy. More diet and nutrition tips will be presented in future blogs, so please keep reading.

Insomnia and Back Pain

Do you struggle with getting a good night’s sleep? A recently published study from the University of Haifa in Israel concluded that those who do not sleep well are nearly one and a half times more likely to suffer from back pain. Historically, approximately 80% of the population will suffer from back pain at some point in their life. In a large majority of cases, there is no specific identifiable cause.

It is estimated that at least half of those who suffer with back pain complain of difficulty sleeping, or insomnia. In this case, insomnia is defied by difficulty falling asleep, maintaining sleep, wakening during the night or waking up earlier than normal for more than one month.

The study conducted by researchers, Dr. Maayan Agmon and Dr. Galit Armon was based over an 8 year time period and included over 2100 examinations. The patients in this study were all healthy, employed adults. Each of the patients came in for a routine physical health exam on three occasions during the study period. Back pain was diagnosed by examination, had to be present for at least 3 months, and was confirmed by interviews. The study controlled for confounding variables including socioeconomic status and lifestyle. Overall, those who suffered from back pain had nearly a 150% greater likelihood of having disrupted sleep. The association was even greater for women. While the results showed that insomnia was a predictor for the development of back pain, back pain was not found to be a predictor for insomnia in this study. There are additional studies in the medical literature showing the opposite association, that sleep is commonly disrupted due to chronic low back pain.

The reasons for this? Past research has shown that the quality of sleep may decline with age. There also can be a psychological component involved. Stress and worrying about insomnia may disrupt the sleep cycle even further. There appears to be a connection between pain, inflammation, and the immune system. A 2006 study of sleep deprivation showed an increase in inflammatory mediators that are involved in autoimmune diseases (Irwin M et al Archives of Internal Medicine 2006). Increased muscle tension may lead to back pain and without quality sleep to help the body “reset” itself, the body is unable to perform normal restorative functions. There are likely other biological and physiological reasons for this adverse association that remain unknown.

Why Diets Don’t Work

Another new year will likely bring in another promise to lose weight matched with a new set of fad diets. Odds are you WILL lose weight with any of these diets….but, the chances of keeping the weight off is much less. Why is this? It is pretty simple actually. A lot of fad diets are not sustainable. Really, you mean I can’t live on lemon juice and a multivitamin forever? Exactly.

I am prepared to give you the absolute secret to weight loss without any gimmicks, commitments, or money down!!! Sound too good to be true, well it’s not.

The secret is: burning more calories than you take in. That’s it. Simple.

Yea, right. If it was that simple, dieting would not be a billion dollar industry with so many pitfalls.

Okay, so here is what you have to know and do. As I said above, any diet that results in you burning more calories than you consume will result in weight loss….no matter how unique it may be. But, can you keep the weight off? Is the diet healthy to stay on for the long run? The reality is that lifestyle changes need to be made as part of the diet plan. Only by changing your lifestyle can you keep the weight off.

I don’t expect you to make these changes overnight. As a matter of fact, I do not want you to. The more dramatic the change you make to your lifestyle, the less likely you are to stay with it. Think about smokers trying to quit: Very few can successfully go ‘cold turkey’. Most wind up relapsing. Generally, the more successful patients are the ones who gradually phase out smoking over time. The same with weight loss. A combination of diet and exercise are ideal to make the weight stay off. Just like you would not go and run a marathon tomorrow without training, you should not make abrupt and major changes to your diet overnight. I recommend a gradual tapering down of prepared, processed, and sugary foods. Notice how I said taper down, not taper off. Sure it would be great to eliminate these foods completely, however that is likely unrealistic. So, yes, you can still enjoy a piece of birthday cake or French fries on occasion, but realize that these foods are relatively high in calories and low in nutritional value and need to be balanced out by other means. The key is everything in moderation and nothing in excess.

There are other things to discuss, such as ‘perimeter shopping’, changes to snaking habits, and types of exercise that I will address in future blogs. But for now, the purpose of this post was simply to explain the basic concepts of weight management and open to the door to future discussions.

Spine Surgery Effective for Senior Population

There is a healthy fear of spine surgery,  especially in the senior citizen population.  At the same time,  so many are in such pain,  there is a willingness to have spine surgery.  Luckily,  there is evidence that Spine Surgery is safe for the over 80 year old population.

In the February 4, 2015 edition of the Journal of Bone and Joint Surgery (http://jbjs.org/content/97/3/177),  Dr. Rihn et al presented “Efffectiveness of Surgery for Lumbar Stenosis and Degenerative Spondylolithesis in the Octogenarian Population”.

To summarize the findings,  the Spine Patient Outcomes Research Trial data was analysed comparing the results of spinal stenosis and spondylolithesis surgery patients younger than 80 years of age,  to those 80 years and older.

58 patients greater than 80 years olds had surgery.  749 patients younger than 80 years had surgery.    When comparing the results,  both groups had significant benefit from surgery.  Most importantly,  the older group did not have any greater a risk for complications.  

Highlights of the data show the older population to have higher rates of high blood pressure,  heart problems,  and bone problems.  The older population,  however,  were thinner,  smoked less, and had less depression.

Analysis of the surgeries performed,  indicated the older population had more simple laminectomies (“removal of bone spurs”),  and less bone fusions.

To be fair to the study,  the results were similar,  but the types of surgeries performed,  and the type of patients that had surgery was different.

For the over 80 years old crowd,  it is still good news.  If you have severe stenosis,  and do not improve with non-surgical care,  surgery may still be an option.  Ultimately,  you and your surgeon must match the surgical option to your complaints,  test results,  and your current medical conditions.  Prudent surgeons will still weigh the risks versus the potential benefits.  By this data,  at least it does not show any significant increased risk for properly selected individuals.

Why does my doctor spend so much time on the computer?

Chances are you have noticed a disturbing trend in your physician’s offices over the past few years: Your physician seems to be paying more attention to their computer than you. You are not alone. This has been a rising form of tension amongst both patients and physicians. Odds are that your physician is just as unhappy about it as you are.

Let me explain how this came to be. It is actually pretty simple: the government says we have to. The Centers for Medicare Services (CMS) has come forth with a set of required guidelines that physician’s offices have to follow in regards to computerized medical records, or else we will be financially penalized in an escalating fashion over the next few years. The intentions were good. In theory, computerized medical records are supposed to make medical information more legible, easier to share, decrease medical errors, and improve overall patient care. CMS actually initially incentivized physicians for using electronic medical records in the beginning. Unfortunately, things are not as simple as they should be. CMS has established evolving regulations for providers to meet in order to satisfy different stages of their ‘meaningful use’ criteria. Some of the criteria make sense and are easy to comply with, such as sending a certain number of prescriptions electronically. Others have become costly, complicated, and burdensome. As a matter of fact, in 2015 over 200,000 physicians will potentially face financial penalties because they did not meet the meaningful use criteria in 2014. This has led to a tipping point in physician frustration, with some experts suggesting that practices may actually start to give up on being compliant with ‘meaningful use’ due to the administrative burden and frustration with the process. The issue is very complicated, and would require way more than 1 paragraph in 1 blog post to explain.

Safe it to say, however, physicians in general are not happy with the increasing requirements that meaningful use has thrust upon them. In my opinion, which happens to be in agreement with other physicians, many of these requirements do little to actually improve your care as a patient, and result in nothing more than increased administrative burden on the physician and/or office staff.

So, the next time your physicians brings a lap top with them into the exam room or sits behind a desk and starts typing on a computer during your visit, please understand that we are not doing this because we want to. I personally feel bad for having less eye contact with patients and not giving as much direct attention during an encounter as I probably should, however there is currently no feasible way for me to complete my electronic charting requirements in a reasonable amount of time without doing so. As I said above, if given the choice your physician would likely take a sledge hammer to their electronic medical records and go back to the way things used to be. Unfortunately this is not likely to happen anytime soon, so please bear with us as we try to navigate this process together.

Thank you for your understanding.

What is Minimally Invasive Spine Surgery?

Here in Tampa,  we are in a media war over Spine Surgery Services.  It has become a very competitive business,  with many Centers or Institutes deploying expensive marketing teams touting expertise in Minimally Invasive Spine Surgery.  It does sound great.  But what does Minimally Invasive Spine Surgery mean?

About 30 years ago,  spine surgery was associated with larger incisions,  long recoveries,  and unpredictable results.  With better diagnostic tests (CT scans,  MRI’s,  etc) spinal surgery has become more predictable for certain problems.  At this time,  most spine surgeons will agree that the most straight forward problems,  such as single level disk herniations,  focused spinal stenosis,  and single level spinal instability has predictable surgery success rates.

The use of magnification,  and x-ray localization,  and smaller incisions has become mainstream. I will submit the smaller incision is what most patients consider as being Minimally Invasive Spine Surgery.   Because of that definition,  I will submit most spine surgeons today are using some forms of minimally invasive spine surgery.

On the other hand, Spine Surgeons have some more specific criterion to define Minimally Invasive Spine Surgery (MIS).  Some surgeons define MIS as using blunt dissection and muscle sparing techniques to minimize post operative scaring.  Some surgeons define MIS fusion as approaches that spare the multifidus muscles.

In the end,  no matter what you call it,  there is a hope that the MIS technique will have some identifiable advantages.  Unfortunately,  that has not been as easy to prove.   Most scientific studies have shown that if the goals of surgery has been achieved,  no matter the specific technique,  the results are good.  Some MIS studies have show some short term benefits such as faster recovery.   Others, however,  have shown increased complication rates,  and increased rates of revision surgery.

Because of the competitive nature of the Spine Surgery business,  I am afraid the term Minimally Invasive Spine Surgery has become more of a marketing term than a medical one.  While many Surgeons are determined to prove the specific techniques beneficial,  it is still too early to say all the techniques are true advantages.

Surgeons that are focused on achieving the goals will likely achieve good outcomes.  From the patient perspective,   they should find that Surgeon that has that focus.   Forget the marketing.  Let the scientific community debate the merits of the techniques.  Patients should look for the surgeon with predictable results,  and experience to determine the likelihood of surgical success.

Pain in the Neck…From Using a Smartphone

In 2012, it was estimated that there were over 91 million smartphone users in the U.S., of which 89% reported using their phone throughout the day to text, read emails, browse the internet, play games, download apps, play music and engage in social media sites. These numbers continue to increase daily.

While the benefit of technology continues to expand our ability to communicate and network, it also has created another medical problem. The name “text neck” was coined by a chiropractor over 7 years ago from trying to explain the source of neck pain and headaches in a teenager. Since that time, this problem has become more widely recognized within the population.

Think about how you find most using their smartphones. Their head is bent downward (flexed) and shoulders rounded as they are focused on reading and typing. This can persist for hours. This places excessive stress on the muscles that support the head and neck. A recent study published by Dr. Kenneth Hansraj, a spine surgeon in New York, has shown that that flexing the head forward to focus on portable electronic devices such as a cell phone can place an extra 60 lbs. of pressure on your neck (Surgical Technology International 2014 Nov 25: 277-279). As the average human head weighs 10 – 12 lbs., pressure in the spine doubles for every inch the neck is flexed forward.

A prior study of 859 subjects, conducted in Sweden came to this same conclusion. The more time subjects spent texting, the greater the likelihood of developing neck and shoulder pain (Gold JE, Driban JE, Thomas N, et al Applied Ergonomics 2012 March 43(2):408-412)

It is true that the younger generation spends the most time on smartphones, but complaints of neck pain has also been widely reported in those 50 and over. Since degeneration is already common in the mid and older crowds, the added insult of sitting with the neck flexed for extended periods does not help matters. This becomes an overuse, repetitive problem that may linger or remain permanently aggravated. The human neck was not designed to be flexed forward for long periods of time!

Many experts have chimed in on reducing the risk of developing neck pain from smartphone use. Dr. Dean Fishman who originally developed the “text neck” diagnosis has even developed a smartphone app toe remind users to avoid flexing their head forward for long durations. The main recommendations are to take frequent breaks from using electronic devices, focus on holding the phone or device up so that the neck stays in a neutral alignment, exercise regularly to strengthen the neck and upper back muscles, and always be cognizant of posture.

Sex and Pain Meds

By this point, I am sure you have heard the numerous warnings about how the long term use of certain pain medications can affect your body. Opioid medications, commonly called ‘narcotic’ pain medications, have been under the microscope over the past few years. This is for good reason. The explosion in the use of opioid pain medications has enabled us to learn a lot more about these medications than was originally thought. Initially, these medications were designed to be used only for short term purposes (such as following surgery) or for terminally ill cancer patients. For various reasons, the use of prescription opioids has grown over the past few decades and a lot of patients are now using these medications on a daily basis.

The potential side effects of long term opioid use are numerous. Some are well known, such as dependence, addiction, constipation, and sedation. But we now know that these medications can affect your body in other ways. Chronic opioid use has been shown to permanently affect learning and the formation of new memories. They have also been shown to actually worsen the perception of pain (there will be more on this in a future blog).

So what does this have to do with sex? After all, that’s the only reason why I am reading this anyways.

Ok, gotcha. So in addition to the above mentioned side effects it has also been found that the chronic use of opioid medications leads to alterations in numerous hormones in the body, some of which are the sex hormones. While an in depth explanation and discussion of the endocrine system is beyond the scope of this blog, I will explain the basics. When opioid medications bind to the parts of the brain called the hypothalamus and pituitary, they prevent the release of sex hormones; namely testosterone, estradiol, leutinizing hormone, and follicle-stimulating hormone. In women, this can cause menstrual irregularities. In men, this can cause erectile dysfunction, loss of muscle mass, and decreased sperm count. In both sexes, the decreased hormones can result in decreased libido, fatigue, generalized weakness, osteoporosis, depression, anxiety, and anemia (amongst other things).

This is not to say that you absolutely have to stop taking your pain medications, as it is not easy to have sex when you are in a lot of pain. But, it does hopefully open your eyes to the potential side effects of these medications and make you think about talking with your doctor about possibly trying to taper down these medications to as low a dose as possible.

Spine Surgery Information on the Internet

How do you know the Spine Surgery information on the internet is true?  Unfortunately,  it can be difficult to know.  The internet is a wonderful result of much scientific effort.  Prior to its existence,  information was controlled by governments, publishing entities and media conglomerates.  By virtue of the costs,    very few could disseminate information rapidly to the masses.  Now,  with the internet,  via social media,  blogs and websites,  information can be generated instantaneously.  This rapid exchange can be a great source of  information,  or disinformation.  Because of the competitive nature of the world,  the internet can and does generate demand,  mold opinion,  and creates action.   Because of private agenda’s,  the information is often slanted in a certain way.

Medical information is no different.   There is a so called Medical Industrial complex designed to promote more utilization of its products.  No modern business is without a website,  and a social media team promoting it’s products.   Of course,  there is the concern that certain information on the internet is biased,  or not accurate.

In the January 15, 2015 issue of Spine,  Dr. Elhassan et al  reviewed the information on Discectomy-Related Information on the Internet.

53 website were identified, and analysed.   Almost half the sites were commerical sites.  7 were governmental,  6 by individual physicians,  and only three were produced by academia.

Dr. Elhassan concluded the overall quality was poor,  with only 20-30% of websites considered of good quality.

Unfortunately,  sometimes there is blurring between providing unbiased information,  and marketing.

To the internet surfer,   I  would recommend using the information as general guidelines.  For specific situations,  only a qualified Doctor can give you recommendations that is individualized.   In the end,  the internet is a great tool,  but is never a substitute for personalized,  individual care.

But, that’s not what Dr. Oz said….

There is no denying that media influences the way we think. Most of what we do is influenced by advertising; from the type of clothes we buy to the food we eat. Medical care is not immune to this. Think about how many commercials you see daily for one prescription drug or another. It may surprise you that there are only 2 countries in the WORLD which allow pharmaceutical companies to directly market to consumers. These are the United States and New Zealand. This is a very controversial topic, with the pharmaceutical industry stating that it informs consumers about healthcare options, while opponents claim that it leads to higher healthcare costs and potentially unnecessary treatment. This is an ongoing debate, which has even been discussed in Congress. The issue has yet to be settled.

Most direct to consumer advertising is obvious. You pick up a magazine or watch a commercial and there is the advertisement for the product. But, what about non-traditional advertising? Product placement in movies and television shows is a subtle, but effective, means of influencing the way we think. The next time you watch a movie or television show, pay attention to what the actors are eating, drinking, wearing, driving, etc. Those companies likely paid a lot of money to have their products prominently featured and are hoping to make a return on their investment by influencing your habits. Another way in which we are influenced is through the content of the television programs we watch. Once again, medicine is not immune to this. There are numerous medical shows on television, and even a dedicated medical channel (Discovery Health).

There was an article recently published in the British Medical Journal (The British equivalent to the prestigious New England Journal of Medicine) analyzing the recommendations made by two of the most popular medical talk shows currently airing, The Dr. Oz Show and The Doctors. (BMJ 2014; 349: g 7346). The goal of the authors was to assess the quality and efficacy of the recommendations made by the programs in reference to available scientific evidence, safety/risks, cost, and potential conflict of interest. They did this by randomly sampling 80 episodes from each show and comparing the recommendations made during each show against established medical research and reference databases. The study concluded: “Recommendations made on the medical talk shows often lack adequate information on specific benefits or the magnitude of the effects of these benefits. Approximately half of the recommendations have either no evidence or are contradicted by the best available evidence. Potential conflicts of interest are rarely disclosed. The public should be skeptical about recommendations made on medical talk shows.” In contrast, the authors state that 78% of medical interventions in a ‘real world’ medical practice have evidence supporting their efficacy and/or safety.

So, the take home point is that deliberate marketing and potentially misleading information surrounds us each and every day. This includes information which may skew your thoughts regarding medical care. Although seemingly obvious, the best thing to do is discuss any questions, concerns, or conditions you may have with your physician, rather than deferring to the internet or a popular television program.

Different Spine Surgery Recommendations

In the October 2014 Spine Journal,  there was a fascinating Study presented by Dr. Mroz of the Cleveland Clinic regarding “Differences in the surgical treatment of recurrent lumbar disk herniation among spine surgeon in the United States”.

The study identified significant differences among US spine surgeons,  regarding the use of Lumbar spinal fusion in combination with repeat removal of a disk,  versus just repeating a removal of a disk.  The study concludes:

1. Surgeons in practice for more than 15 years will more likely chose to just remove the disk without fusion.

2. Surgeons with a larger surgical volume will also chose to fuse the spine as well as remove the disk.

Unfortunately,  these conclusions tend to support the stereotype of the “young aggressive surgeon”.

To be fair,  the study did look and compare the results of surgeon preference for surgical management in for first time recurrent disk herniations,  and there was a better consensus that repeat removal of the disk is the preferred method.

The much larger difference was identified when there is a second recurrent disk herniation.

The study was a collection of data via an on-line survey of spine surgeons. Of the total of 2460 surgeons surveyed,  only 445 completed the questionnaire.   Questions identified the geography of the surgeon,  the duration of practice,  whether the surgeon was fellowship trained,  whether the surgeon was in an academic practice,  and the number of spine surgeries performed each year.

Analysis of the data did not show any difference in the surgery preferences in terms of fellowship training,  academic practice,  or geography.

The study demonstrates that surgeons can have significant differences in surgical recommendation for the same set of findings.  For patients,  it certainly confirms the age old recommendation of seeking second opinions about major spine surgery.

My Aching Neck!!!

We have all been scolded at one point or another for bad posture. Well, now more and more evidence is coming out linking poor posture to chronic neck and back pain. Part of the reason for our posture is due to modern society….no, that does not take the blame away from you. Spending a majority of the day in a flexed posture, such as working on the computer, sitting in a car, reading, writing, and watching television leads to alterations of the body’s normal alignment. Your muscles have to work harder in order to adjust for the change in posture and to compensate for the altered center of gravity so you literally don’t fall over. Over time, this can lead to permanent changes on the spine (such as becoming ‘round shouldered’).

One of the things we do seemingly all day, every day, is use our smart phones. An article recently published in Surgical Technology International and featured on the NBC nightly news highlights how much stress this simple task places on our neck. Reading with the neck flexed in the typical 60 degree position, whether on a smart phone or newspaper, places 60 pounds of extra force on the neck. This is equivalent to 6 x10 pound bowling balls or the weight of an average 8 year old. Obviously, the more time you spend in this position, the more stress you place on the neck. More stress will likely accelerate degeneration of the spine and cause pain. Angles less than 60 degrees still do place excessive stress on the neck, so basically any prolonged period of time spent in the flexed position results in increased strain on the neck.

So outside of never reading, writing, or using your smart phone, what should you do? The simple answer is to perform as much of this activity as possible at eye level. Adjust your computer monitor, read with the newspaper up, use a Dictaphone when possible, and read your texts/e-mails/e-books with the device elevated. When your head is in neutral, your neck should be in proper alignment (depending on your baseline posture). Another solution that I recommend is to take frequent breaks (every 20-30 minutes) from activities which cause your neck to be flexed and adjust your posture. This can be as simple as squeezing your shoulder blades together for 5-10 seconds. This simple exercise will not only help improve your posture, but will also strengthen the muscles that support your shoulder blades and upper back.

Yet more proof that your grandma knew what she was talking about…

Non Spine Causes of Sciatica

Sciatica is the pinched nerve feeling in the back that causes back pain with a radiating pain to the hips to the legs.  As an Orthopaedic Spine Specialist,  it is probably the most common complaint of my patients. In the most simplest definition,  sciatica is a pinching of the nerve that goes from the spine into the legs.

Dr. Bennett D. Grimm, MD, and Associates  of OrthoCarolina wrote a wonderful review of the topic in the Journal of the American Academy of Orthpaedic Surgeons.

The review article confirms that the most common causes for sciatica are herniated disks or bone spurs in the back. The sciatic nerve components are pinched within the spine with disk herniations and spine bone spurs.  There are sciatica conditions that are caused by pinching outside the spine.  There are also conditions that cause sciatica complaints not related to the spine.

Non Spine Causes of Sciatica include:

1. Hip arthritis.  Problems with the hip joints including arthritis,  bursitis,  sacroilitis can cause similar back and thigh pains.
2. Reduced blood supply.  Some patients have narrowing of the blood supply in the arteries to the legs.  With activities such as exercise,  or walking,  it may cause pain to the legs.
3. Tumors.  This one usually gets peoples attention.  On rare occasions,  the pinched nerve sensation is secondary to a tumor (benign or cancerous) that grows in the pelvis,  and pinches the nerves as the nerve travels outside the spine canal into the legs.  The Spine bone,  is connected to the hip bone,  which connects to the thigh bone, and so on.  Likewise,  the nerves go from your spine,  past the hips,  into the legs.  A tumor located outside the spine,  can pinch the nerve as it travels to the leg.
4. Peripheral Neuropathy.  Certain medical conditions such as diabetes  causes damage to the nerves outside the spine.  This damage to the outside the spine is Peripheral Neuropathy.
5. Outside Nerve Compression.  As stated above,  the sciatic nerve components travel outside the spine,  into the legs.  Sometimes,  muscles,  ligaments,  and collections of fluids,  called cysts can also cause pinching of the nerve components.   These nerves can also be compressed by  swelling of the tissues from a trauma,  or infection.

Fortunately,  most episodes of Sciatica resolve,  or improve with time.  On the other hand,  increasing pain,  weakness, and numbness may mean a continuing worsening process.  If you have concerns,  please have it evaluated by your Physician.

Fear of Exercise

I have heard numerous excuses, some legitimate and others completely bogus, regarding why people don’t exercise. Very commonly, a specific exercise prescription is part of my treatment plan for patients. As a matter of fact, The American College of Sports Medicine is currently running a promotional campaign emphasizing that exercise is medicine. This has a few important implications. First is that appropriate exercise is an important part of the treatment plan for your condition. Exercise has been shown to help numerous medical conditions, ranging from diabetes to depression….not to mention many orthopaedic conditions. Notice how I said ‘appropriate exercise’. This leads me to the second point about exercise as medicine. Just like any other prescription, it must be followed as directed to obtain maximal benefit and to minimize the potential for harm. Your physician (or other qualified health care professional) has chosen a specific exercise regimen for you based upon your condition, and it should be followed as instructed.

As noted above, I have heard so many excuses as to why patients are not compliant with their exercises that I cannot keep track. One of the reoccurring excuses I hear is because they fear the pain will actually get worse. This is a legitimate psychological phenomenon, and is ingrained into our behavior for good reason. Fear avoidance is a very important lesson that we learn throughout life….such as not touching a hot stove. Unfortunately, this instinct can sometimes prevent us from doing things which will actually help in the long term. As a matter of fact, the particular issue of ‘overcoming the fear of exercise’ has been discussed at national medical conferences and in medical journals. So, it is not just you. The truth is, exercise does hurt. It may initially make the pain worse, but it may not. I tell patients there is a difference between ‘good hurt’ and ‘bad hurt’. ‘Good hurt’ is that feeling of muscle fatigue and soreness after a successful workout. ‘Bad hurt’ is that stabbing pain which takes your breath away or sharp pain in the bones and joints. The ‘good hurt’ in exercise is what triggers the release of endorphins, which is your body’s natural pain killer. If you are unable to differentiate the difference between ‘good hurt’ and ‘bad hurt’, please discuss this with your physician.

Take home point: Exercise should be treated the same way as you treat your medications. It is an important part of your treatment plan which must be followed as directed. If it is not working for you, speak with your physician on how it can be modified to get the results you need.

The Framingham Spinal Stenosis Study

Most people know about the Famous Framingham Heart Study.  The study followed a group of volunteers from Framingham Massachusetts for an extended period of time.  The first group of 5209 volunteers were 30-60 year old men and women enrolled in the study from 1948.  All sorts of measures were documented.  In 1971,  5124 children of the original study group were enrolled.   In 2002,  4095 grandchildren of the original volunteer group were enrolled.  By following these people,  much have been made about the Heart effects of aging,  diet,  exercise,  etc.

In 2006,  3590 volunteers had CT scans of the heart and abdomen for further data collection.    Of these volunteers,  191 consecutive enrollee’s had additional imaging of the lower spine.   From these 191 volunteers,  there has been some interesting data about the prevalence of spinal stenosis.  This is the so called Framingham Spinal Stenosis Study.

This was the demographics taken directly from the paper:

“The study sample included 191 study participants, 104 (55.6%) males and 87 (44.4%)
females. The mean age was 52.6±10.8 (age range: 32–79) and the mean BMI was 27.8±5.0.
This subsample was representative of the whole group of individuals that underwent multidetector
CT scanning (N=3590).”

Relative Lumbar Spinal Stenosis was a 12 mm or less Mid vertebral canal diameter as measured by CT Scan.

Absolute Lumbar Spinal Stenosis was a 10 mm or less mid vertebral canal diameter as measured by CT Scan.

Statistical analysis did not correlate Low Back pain to Age,  Sex,  BMI,  or the presence of Relative Lumbar Spinal Stenosis.  However,  the presence of Absolute Lumbar Spinal Stenosis was associated with corresponding Low Back Pain.  

The Study Conclusions:

1. Congenital Lumbar Stenosis is 4.71% and 2.62%  (relative,  and absolute stenosis)

2. Prevalence of stenosis increases with age

3. In the 60-69 age group,  the rates are 47.2% and 19.4% (relative,  and absolute stenosis)

4. The high prevalence of stenosis in the over 60 population needs to be considered when trying to associate pain and neurologic complaints of the spine.

5. Absolute lumbar spinal stenosis is associated with a 3 fold higher risk of lower back pain.

Published in final edited form as:
Spine J. 2009 July ; 9(7): 545–550. doi:10.1016/j.spinee.2009.03.005.

Risk Factors for Neck Pain

At a certain point,  almost everyone has had an episode of neck pain.  As a Spine Specialist,  I have seen some patterns and I have counseled patients on how to decrease their chances of having recurrent pain.

I sometimes think I am like your Mom,  as I often tell people not to smoke,  eat right,  get exercise and sleep on a regular schedule.  It is a general set of advice that seems to work in almost any medical condition.

But now,  there is demographic data that seems to back up that advice,  at least in terms of neck pain.

a 2014 North American Spine Society paper by Yang, Et al. titled  “Potentially Modifiable Risk Factors For Neck Pain in the US Adult Population” looked at associated variables and its correlation to Neck pain.

The study examined data from the National Health Interview Survey. The Population age  is 18-85.  The time is from 2009-2012.  The Total population surveyed is  122,337.

The data showed the following:

Prevalence of neck pain is 15,22%  (having pain right now)

Risk FActors:

Regular exercise,  is 16% less likely to have neck pain.

Current smokers are 47% more likely to have neck pain.

Sleep less than 4 hours a day s 157% more likely to have neck pain.

Serious Psychological stress is 192% more likely to have neck pain.

Based on this review of the DAta,  Mom was right (again!).

1. Do NOT SMOKE

2. Get regular EXERCISE

3. Get regular SLEEP

4. Try to reduce STRESS

What is the Kinetic Chain?

It sounds like a new kind of line dance, but unfortunately it is not that exciting. I am sure you have heard the song “The foot bone is connected to the ankle bone, the ankle bone is connected to the leg bone…” Well, that pretty much sums up the kinetic chain. Thanks for reading.

Well, I wish it was that simple. The basis behind the kinetic chain is that everything in the body is connected. This is accomplished through an elaborate array of muscles, bones, ligaments, tendons, and fascia (connective tissue). Believe it or not, everything is connected together to keep the body in balance. This is noticed most often in sports related injuries. For example, a pitcher may complain of elbow or shoulder pain, but the problem may actually stem from weak hip muscles. You see when a pitcher throws a ball, he or she uses their entire body to generate the force for the pitch (especially during the ‘windup’ and ‘cocking’ phases of throwing). If, however, the hip muscles are weak a few things may happen. First, the body will be unstable standing on one leg and unable to completely generate full force during the windup and cocking phases. Second, during the throwing phase momentum will be lost due to an ‘unstable’ pelvis. Finally, the pitcher will have to compensate for a weaker pitch by ‘throwing harder’ from the upper body, hence placing more stress on the shoulder and elbow. Make sense, or at least sort of?

Sports injuries are not the only place where the kinetic chain comes into play. Simple back pain is a great example. Sometimes low back pain is actually being caused by knee arthritis. With knee arthritis, your body will alter the normal mechanics of walking to offload some weight and stress from the painful knee. This leads to various changes in your walking pattern, such as limping. These changes will result abnormal movement of the pelvis and lumbar spine. If this occurs for a prolonged period of time and/or in the setting of underlying lumbar degeneration, low back pain can occur….but the actual cause is the knee.

While you may not believe that a butterfly flapping its wings in California can change the weather in China, hopefully you can begin to understand the concept of how an injury in one location of the body may actually manifest as dysfunction in a remote part of the body. This is another reason why sometimes making a diagnosis or developing a treatment plan can be especially challenging.

Patients can determine Spine Surgery Results

YOU can make a difference in your SPINE SURGERY results!  While patients often will look towards the skill of the Surgeon, there are other important factors that will determine the outcome.

Following post operative instructions can have a significant effect on the outcome.  YOU can improve your SPINE SURGERY OUTCOMES by listening to your SURGEON.

At the 2014 North American Spine Society Meeting,  there was a Paper Presentation by the Spine Specialists at Johns Hopkins University titled “Health Behavior Change Counseling: Can a Brief Intervention Increase Patient Activation in Persons Undergoing Spine Surgery?”

To summarize,  the study tried to determine the importance of patients participating and taking ownership for their health and recovery.  The concept of PATIENT ACTIVATION ( “PA-propensity to engage in adaptive health behaviors”) was identified as an important factor in that ownership process.

PA is the measure of the influence of patient factors on health behaviors (like physical activity) on the health outcomes such as continued pain,  disability and function.    It is generally accepted that increase PA is associated with increase compliance to activities,  and thus less disability.

The Hopkins Specialists designed a study by which patients prior to Spine Surgery had a telephone counseling session,  using motivational interviewing techniques to improve the PA amongst the pre-operative patients.    PA pre and post interview was measured using a Patient Activition Measures questionnaire.    The study definitely showed an increase in the PA score after the telephonic interview.

While the study does not show the results of the surgery after the measurements of the PA,  there was a suggestion that the telephone interview increased the PA,  and therefore,  will likely increase the chances of a better outcome.

The bottomline is YOU can CONTROL your SPINE SURGERY RESULT.  Make sure you have a good understanding of your role in the recovery and the activities after surgery.  Successful Spine Surgery is a team approach,  and YOU,  the PATIENT are part of the TEAM.

Tis the Season for Weight Gain

You have said it year after year… “I will not gain weight this holiday season”. But who are you kidding? It is simply the toughest time of year to manage your weight. Because of this, I would like to suggest some simple, but not all inclusive, methods to help manage your weight during the holidays.

1. Exercise: Yes, it is obvious and hard to do with the short amount of daylight and cooler weather, but not all hope is lost….even if you do not have a gym membership.
   1. Since you will likely be shopping at some point during this holiday season, try parking at the rear of the parking lot instead of fighting for the closest spot (as long as it is safe). You will be surprised how many times I see people waiting for a close parking spot at the gym of all places!
   2. Take a 5-10 minute walk during your lunch break…..even if it is just up and down the stairs or around your office building.
   3. Make a deal with yourself: Allow yourself to indulge in a treat, but only after you have gone to the gym or done a set amount of exercise.
   4. Exercise while watching television at home. This is easy to do, even if you do not have any equipment. Simple exercises such as lunges, squats, pushups, and crunches can be performed while a commercial is on TV.
   5. Take the stairs and not the escalator or elevator whenever safe and reasonable to do so.
2. Eat Sensibly: The important part is not to deprive yourself of fun or indulgence, but to indulge wisely.
   1. Eat a regular meal prior to going out shopping. The food court at the mall is filled will tempting fast food choices, which are less than ideal. The same applies to fast food that you pick up along the route between shopping destinations. A full stomach will make you far less likely to consume extra calories while out and about.
   2. Don’t go to a party hungry. If you do, you will likely fill up on high calorie appetizers once you get there to satiate your hunger. Instead, have a piece of fruit or other small, heathy snack prior to going in effort to better regulate your appetite…especially if the party is past your normal meal time.
   3. Try using a smaller plate. This is a mind trick which really works. People tend to consume at least 80% of what is put on their plate. 80% on a smaller plate is less calories than 80% on a large plate, yet your body still thinks you ate a full meal.
   4. When eating hors d’oeuvres, take only 1 or 2 items at a time, especially if they are out on a table buffet style. This way, you will have to physically walk back and forth multiple times if you want more. You will actually wind up eating less because of the effort required to obtain the food.
   5. Chew your food. Duh! No, really. The longer your chew your food, the less you will eat.
   6. Take your time during a meal. The faster you eat, the more you will consume before your body realizes it is full. If possible, put down the fork or spoon between each bite.
   7. Watch your alcohol intake, especially with mixed drinks. Mixed drinks often contain a lot of extra sugar or fat in the form of juice or cream, which adds a lot of calories.
   8. Share a dessert….yes, as hard as it may be, offer to split a dessert with your spouse or friend….especially if you intend on sampling more than one.
   9. Splurge!!!! Yes, you can go all out and have a heck of a great time. BUT, know that you have to accommodate for it. Plan your season accordingly. If you know that your family has an amazing 14 course holiday meal every year that you can’t miss, compensate by eating less at you other holiday gatherings and ideally working out more.

If all else fails, you can make another resolution to loose the weight next year…..but let’s try to avoid that.

Sacroiliac Degeneration

In the 2014 meeting of the North American Spine Society,  there was an interesting paper presentation titled “The Prevalence of Sacroiliac Joint (SI) Degeneration in Asymptomatic Adults: A review of 500 Ct Scans”.  The paper was presented by Jonathan-James Enos, MD,  et al.  

The study looked at 500 Cat scans of the abdomen and pelvis that were performed for other reasons than the pelvic or sacroliac pain.  Patients that had evidence of prior hip or spine instrumentation surgery were excluded.  Patients that still had open growth plates (not yet adults) were also excluded.  Then a chart review excluded patients with prior histories of lumbar pain,  prior hip or lumbar surgery,  prior history of metastatic, inflammatory or rheumatologic disease.

373 patients met the criteria for review.   Average age was 57 years old.  Overall prevalence of SI joint degeneration of at least one joint was 35%.  30% was of the significant or ankylosis (auto fused)  category.    Also, the older the patient,  the more prevalence of both degeneration,  and the severity of the degeneration.

The conclusion was that asymptomatic sacroiliac degeneration is common,  especially in the older population.  The authors of the paper cautioned clinicians in attributing lower back pain solely based on CT evidence of degenerative findings in the SI joint.

For the past few years,  there has been an accelerated interest in performing Sacroiliac joint fusions,  as a simpler,  more percutaneous approach has been promoted.   Unfortunately,  the efficacy of the procedure is dependent on identification of  SYMPTOMATIC Sacroiliac joint dysfunction.  Often times,  it may not be clear that an SI joint degenerative finding really is the source of the pain,  even though clearly demonstrated on diagnostic testing.

The paper again points out that objective anatomic findings do not necessarily mean there is a clinically significant manifestation of the finding.

Is running bad for your knees?

This has been a debate for as long as I have been in medicine, as there are numerous medical articles stating that running is both good and bad for your knees. Theoretically, it makes sense that the repetitive loading and impact on the knees would result in more ‘wear and tear’, therefore accelerating degeneration. Well, at the present time, this does not look like the case. Running may actually be protective for the knees. How is that? Well, let me explain. When it comes to maintaining your body’s musculoskeletal health and fitness, the term ‘use it or loose it’ is a good rule of thumb. Have you ever had a cast on your arm or leg? What did the muscles look like when the cast came off? They were smaller and weaker, right? That is because during the time you had the cast on, the muscles were not being used, so they did what we call ‘atrophy’.

Now, let’s draw a similar analysis to running. It is true that running places increased force on the joints of the lower extremities. This results in the body actually strengthening the joints via various mechanisms. First, the muscles of the lower extremity increase in strength and endurance, which translates to increased stability and decreased chance of injury. Secondly, the bone increases its density to make itself stronger in order to handle the increased forces. Finally, there have been some studies which show that the joint cartilage actually increases in thickness as a result of running.

While this may sound like great news, it does not mean that running will prevent arthritis in everyone, as running injuries do frequently occur. As a matter of fact, running may actually cause more damage to the knee joint in certain people. People who are older, obese, have existing arthritis, and/or have a history of previous knee injury are actually at a higher risk for developing knee arthritis from running than the general population. The jury is also still out regarding what association (if any) high mileage running has on the development of knee arthritis (Note: ‘High mileage’ has been defined differently in different studies, which is why I did not mention a specific number of miles per week here).

So what does all of this mean? Basically, it comes down to being smart when you run. Following an established running regiment, such as increasing the mileage by no more than 10-20% every 10-14 days, can minimize your risk of injury. Engage in a conditioning program to strengthen the muscles of the core, pelvis, hips, and lower extremities. In addition, if you are obese and/or have a history of a previous knee injury, obtain the advice of a qualified health or exercise professional prior to starting any high impact exercise in effort to minimize the risk for further injury or the development of arthritis.

Prolotherapy and Spine Pain

As a Spine Specialist,  there are times when our traditional treatments just have not been beneficial.  In my opinion,  as a Surgeon,  the patients with the very large disk herniations, and with the corresponding physical complaints and findings are the easiest to treat.  Epidural steriod injections are often beneficial.  For these patients,  surgical management is a reasonable option for those who do not improve with medications,  time,  therapy,  or injections.

The reality is most patients do not have those large disk herniations that are so predictable in their effects,  as well as recoveries.

Most people have back and neck pain from wear and tear of the disks,  ligaments,  tendons and muscles.   In the spine,  there are many areas where these various parts can be an issue.  That is why it is so difficult to treat some of these chronic,  or intermittent neck and back complaints.

Assuming there is no dangerous cause of pain  (such as a tumor,  infection,  fracture, etc),  and the traditional treatments such as anti-inflammatory medications, physical therapy,  cortisone shots  and stretching do not work,  patients often turn to so called alternative,  or complementary medical treatments.

One of these treatments is Prolotherapy.

Prolotherapy has been practiced since the 1930’s,  and the concept is contrary to most treatments that are designed to decrease inflammation.  The treatment is based on the concept of proliferation of tissues.  The theory is an inflammation effect will cause thickening,  and strengthening of weakened tissues,  thereby stabilizing the structure.  Conceptually,  the effect appears to make sense.  Many scientists attribute excessive stretching of ligaments,  tendons,  and muscles as the source of some of the pains in the spine.  While it may be a challenge to identify all the ligaments, and structures that are stretched,  if we can treat those structures,  theoretically,  we should be able to help reduce the instability caused by the stretched tissues.  We can stabilize the spine,  and reduce the pain.

Unfortunately,  the scientific data on Prolotherapy is controversial.  Yet,  there are plenty of patients who feel great benefit from the procedure.  If you are interested in the procedure,  understand that it usually takes multiple  needle injections over several months to see if there is a benefit.  Most insurance plans consider the procedure experiment, and will not authorize the procedure (you must self fund the procedure).  You must avoid the use of anti-inflammation drugs after the procedure, as it will negate the intended effect.  There is a chance the procedure may not work.  If you understand all this,  and would still like to pursue the treatment,  please discuss the option with your Physician.  While we cannot say definitively that it will help you,  we are willing to try the procedure if we can identify a ligament,  tendon,  or tissue that may benefit from the procedure.

Depression and Spine Surgery

Unfortunately,  there is a bit of the “chicken or the egg” analogy in terms of the association of depression and chronic pain.   By definition (NIH) chronic pain is a continuous constant pain that is more than three months in duration.  Pain,  in the acute setting,  is a very important response.  While not pleasant (understatement,  I know),  acute pain functions to let our body know there is a problem,  and we should investigate to prevent further harm,  or change activities to initiate healing.  Chronic pain,  however,  no longer is as useful for feedback and can cause unintended negative situations for the body as well as the mind.  One of the negative reactions is development of depression.  Depression can be a serious mental illness manifesting with feelings of hopelessness,  fatigue,  irritability,  insomnia, lack of concentration,  or even contemplation of suicide.  In addition,  it also manifests in aches,  pains that do not improve despite medical treatments.

As you can see,  chronic pain,  and depression are inter-related,  and poses a difficult problem,  especially when trying to predict a successful outcome with surgery.

In terms of Depression and Spine Surgery,  unfortunately,  the science has not been supportive of having Spine Surgery when depressed.  Recently,  at the North American Spine Society Meeting  (San Fransisco, November 2014),  Miller et al  Presented “The Impact of Preoperative Depression on Quality of Life Outcomes Following Lumbar Surgery”.  There was a retrospective look at patients who had lumbar decompression or fusion from 2008 and 2012.  Preoperative pain and depression measures were compared.

The study concluded that worse preoperative pain and depression are associated with less improvement in the quality of life following the Spine Surgery.

This is not new information,  and confirms what we already know.

If you have depression,  and are contemplating spine surgery,  please be evaluated for depression.  Sometimes,  moderating or curing your depression will also cure your chronic back pain.  After treatment,  you should feel mentally better.  More importantly,  you may also be able to avoid surgery,  or have a better outcome if you have surgery.

How Does Radiofrequency Ablation Help My Pain?

You may be familiar with Dr. Shim’s previous blog post on helping to identify which patients may be best suited for a Radiofrequency Ablation (RFA) procedure. The purpose of this post is to elaborate on his previous post, and explain the procedure in depth; hopefully answering any questions you may have regarding the procedure.

Let’s start with a review of how it works. Radiofrequency Ablation is actually used for many things in medicine. I guarantee you are familiar with the science behind it and use a similar device on a daily basis….your microwave. That’s right, your microwave. Although there are differences, the basic premise is the same. Both RFA and your microwave use radiowaves (NOT RADIATION) to heat up water molecules. In the case of a microwave, the result is you have warm food. In the case of RFA, the result is heated tissue. For the purposes of this discussion, we will be talking about nerve tissue. Unlike a microwave which heats up everything inside, the Radiofrequency probe used in medicine only heats up a very small area…..a few millimeters. This is why positioning of the probe is so important, and also why it is a relatively safe procedure. There are also other variables, such as needle size, temperature, bipolar mode, and pulsed mode, which offer various drawbacks and benefits. For simplicity sake, I will discuss conventional RFA in this post.

The first part of the procedure is to see if the procedure would even work for you…..sound confusing? Well, let me explain. There is no reason to do a procedure on you if it is not going to help. Prior to the actual RFA procedure, I will perform either a facet injection or medial branch block. Don’t worry about the details. The purpose of these injections is to twofold. The first is diagnostic to help me….simply, did I identify the correct location and cause of your pain? The second purpose is to help you. The injection is like a trial run of the RF procedure to see not only if it would work, but also how much improvement in pain and function can be expected.

If all goes well, and we agree that the RFA would be beneficial for you, we can schedule you for the procedure. Typically, only one side is performed at a time. The procedure is generally carried out the same way as the facet and medial branch blocks. The difference is that a small wire is passed through the needle. This wire is hooked up to the radiofrequency machine, and is what causes the tip of the needle to heat up and ‘cauterize’ the nerve. Once the needle appears to be in a good place under fluoroscopy (X-ray), I test to make sure that it is exactly where I want it to be. This involves sending a small amount of electricity through the wire, and checking for stimulation and muscle twitching in the arm or leg. Don’t worry, you won’t feel a shock. Typically, it feels like a mild buzzing sensation. If you only feel stimulation in the neck or back, then I am in the right spot. If this stimulation travels into the arm or leg, that means the needle is too close to the nerve root. If this happens, no big deal, I simply reposition the needle until stimulation is ideal. This also serves as a safety factor to make sure I don’t heat up any tissue I don’t want to. Once everything is confirmed to be in a good, safe position, I inject more numbing medication and start the RF procedure. The actual RF procedure takes 90 seconds and typically feels like deep pressure.

After the procedure is finished, I recommend you go home and ice the area in 20 minute intervals. The benefits of the procedure are not immediate. Any immediate relief you feel will be from the numbing medication and not necessarily the RF procedure. Typically, patients report a gradual decrease in pain over the course of 4-6 weeks. The duration of relief typically lasts for 6 months, but can sometimes last for a year. Rarely is the relief permanent, but it does happen. The nerve does slowly grow back, which can lead to the return of pain. If the pain returns to where it started after 6-12 months, the procedure can be repeated indefinitely to help control your pain.

Weather and Back Pain

Winter is just around the corner,  and the cold weather is definitely here.  My patients all complain that they have more pain with the cooler temperatures.  While everyone believes cold weather,  and stormy weather contributes to worsening arthritis pain,  the scientific data can be conflicting at times.

In relationship to work activities,  some population studies have shown an increased incidence of neck and back complaints in cooler weather.

Other studies have not seen an increase risk of back pain with weather changes.

I do know what my patients say.

1. Cold weather makes their back and neck pain worse

2. Increased humidity also increases the pain.

3. Barometric changes  associated with worsening weather is also associated with the increasing pains.

For those patients effected by the above changes,  it is likely the neck and back pain complaints are secondary to arthritis.  Researchers are exploring the possibility that weather change complaints may also have a cultural,  and therefore a psychological effect.  The other possibility is that certain genetically similar populations may have susceptibility to weather related pain parameter changes while others do not.

To give an example,  scientists have seen a trend that certain families will have more back pain and disability than others.  After  reviewing many data sets,  it was determined that there is a family or hereditary component to the development of back pain.    It has also been suggested that some of the disability identified in certain family’s are of a pattern consistent with a learned behavior.      If this analogy is then compared to back pain and weather,  there may be some cultural reasons why some complain of more back pain with the weather changes.

Regardless of the science of weather and back pain,  for those who have back pain,  please make sure to stretch, exercise,  and modify  activities. Thank goodness most episodes of back pain is temporary.  If there is worsening pain,  or if there  is associated numbness,  weakness,  or severe incapacitating pain,  please contact your physician immediately.

BACK FRIDAY!

So here we are,  the Friday after Thanksgiving.  It is traditionally known as BLACK Friday,  the day retailers in the USA become profitable because of the traditional beginning of the Christmas Holiday Spending Season.

Here at Shimspine,  we also call it BACK FRIDAY,  as we get many calls the following Monday about back complaints.  How so you ask?

1.  Christmas Shopping on Black Friday becomes a blood sport.  In the mad dash to acquire bargains,  many shoppers carry excessive bags,  and must manuever around sales displays and other shoppers to hone in on the targeted items.   The excess weight,  and at time unnatural contorsions cause excess stress on the spine muscles,  ligaments,  and bones.  The adrenaline is pumping during the shopping.  Once home,  the minor ache or pain becomes progressively more intense.

2. The tryptophan effect of the the Thanksgiving Turkey results in drowsiness.  The wine adds to the effect.  In the attempt to stay awake to watch all the Football games,  many will fall asleep on the couch,  only to awake stiff and sore from the position.

3. For the more active,  the annual family Football game has its perils.  Fortunately,  few really get a significant injury.  Still,  the middle aged weekend warriors will experience the aches and pains of overused back and neck muscles the following days.

4. For those who do not shop,  there is usually a list of Fall chores that must be done.  Raking leaves,  trimming trees,  and other “honey do” items can be accomplished faster with all the family being home.  Still,  in the rush to finish everything before dinner can result in a few pulled muscles or stretched back ligaments.

During the Holiday Season,  while enjoying family,  friends and activities,  make sure to consider the effects on your health.   Besides tempering your eating,  and drinking,  make sure to get your exercise.  Please stretch your muscles before performing strenuous activities.   Please do not turn your BLACK Friday into BACK FRIDAY!

Doctor's Advice on How to Beat Fatigue After a Meal

We all know that feeling….around 1-2 o’clock in the afternoon. Just as you are returning to work from lunch and trying to get settled back into a routine your brain seems to want to do otherwise. As a matter of fact, it seems like all it wants to do is take a nice little nap. This is a common occurrence, and there are many reasons why this happens. First is the obvious. Are you tired? Not getting a good night’s sleep prior to coming to work can decrease your daily performance. In addition, if your job is physically, cognitively (mentally), or emotionally demanding, your body will become fatigued. Second, from a physiological (which is a fancy way of saying biological) reason, blood flow changes following a meal. Blood is diverted away from muscles and (to some extent) the brain towards the digestive tract. This makes sense, as the body now needs to digest the meal. Unfortunately, this can manifest as fatigue and less than optimal performance. There are also other factors which come into play; such as: the type and size of meal, and your overall physical conditioning. Meals high in fat content take longer to digest than those higher in carbohydrate. Unfortunately, meals high in simple carbohydrates; i.e. sugar, refined grains, and white flour, also result in a sharp increase in the circulating blood glucose (blood sugar). Our bodies respond by releasing insulin to help balance out the blood glucose level (blood sugar level) and store the glucose for future use. All of these factors contribute to what many know as the ‘Post Prandial Coma” or afternoon sleepiness.

Big deal, we all know this…I eat too much and I get tired. But I hate not being able to stay awake for the football after Thanksgiving dinner. So what do I do about it?

One solution is pretty simple……exercise. Yes, this is another blog touting the virtues of exercise. This time, however, you do not have to break a sweat. Sound good? A recent study in Medicine and Science in Sports and Exercise (Vol. 46, No 11, pages 2053-2061) demonstrated that simply standing up from a seated position every 30 minutes can lead to better control of blood glucose levels following a meal. The study was conducted to simulate a work environment, but the scenario applies to being at home as well. The subjects in the study continued to work, but did so from a standing position in 30 minute intervals (30 minutes standing and 30 minutes sitting for the work day). While this is impractical to implement in a typical office setting, the premise of the study is interesting.

The take home point is that a minimal amount of activity, such as intermittently standing up or going for a 1-2 minute walk, following a meal can lead to better regulation of blood sugar and therefore may help to fight off the enticing temptation to take a nap after a meal. While this may sound anti-productive while at work, it actually will result in higher productivity. This is because the time you dedicate to the task will be more high yield and productive than if you stayed at your desk staring at the same document for 5 minutes with glassed over eyes….unless of course, you plan it that way.

Breast Reduction Surgery for Back Pain

Big Breasts can cause back pain!  This is obviously a sensitive topic,  but a common one discussed in many Spine Surgeon’s offices.   Just so it is clear,  Spine Surgeons do NOT perform Breast Reduction Surgery.  We,  however, are asked if the large sized Breasts are the source of neck and or upper back pain.  Breast Reduction Surgery  often requires documentation of medical necessity.  In other words,  a Spine Specialist must often give the opinion that the source of neck and upper back pain is secondary to the disproportionately sized large breasts.

This documentation requires obtaining an accurate history.  The questions can seem embarrassing to some,  but by the time anyone is considering such an operation,  the pain overcomes any issues of embarrassment or modesty.

Most of the time,  accurate height,  weight,  and breast measurement are documented.  Then the history  of the breast development is discussed.  Time is spent detailing when the pains occurred.  Sometimes delicate questions of types of restraining clothing are also discussed.  In addition, the Spine Specialist must document the time and duration of the pain,  as well as the attempts to control the pain with the traditional physical therapy,  weight loss and exercise.

In addition,  to make sure there are not other sources of the pain,  often times diagnostic studies such as MRI’s of the neck , upper back and or the lower back are necessary to rule out other sources of the pain.

As a Spine Specialist,  I am often asked to render these opinions after a person has already seen a Breast Reduction Surgeon.  Some patients are disappointed that I will not just write a document to “rubber stamp” the recommendation.  To me,  I have a duty to the patient to make sure the Breast Reduction Surgery will be a reasonable option to treat the  neck and back pain.  If I am not sure the pain has been properly worked up,  or if I am not convinced the proper counseling has been given,  I probably will not generate that letter.  In the end,  I still would worry that a person would go through a rather difficult Breast Reduction Surgery,  and still have a neck or back pain despite the surgery.  In that scenario,  the large breasts may not have been the source of the Pain.

While there can never be a guarantee of any surgical result,  certain parameters should be discussed, and met prior to making a surgical recommendation.   For Breast Reduction Surgery,  the Spine Specialist should be able to give the opinion that the history was consistent with the Breasts causing the pain,  there is no other explanation for the pain,  and  non surgical treatments have been tried.

What is a Physiatrist?

I hear this question all the time. Usually it is precipitated by a comment like, “Oh, I thought you were a Psychiatrist”, “I thought you were a Physiologist”, or simply just “Huh?” followed by a blank stare.

It is not surprising that most people do not know what a Physiatrist is or even know about the field of Physiatry, since it is one of the smallest specialties in the medical field. Physiatry or Physical Medicine and Rehabilitation (PM&R) started rapidly growing following World War II. The large scale of the war combined with medical advances resulted in an influx of injured soldiers returning home that needed to be cared for. These soldiers suffered from amputations, brain injuries, spinal cord injuries, and general musculoskeletal injuries. Physiatrists were considered the experts in caring for these patients, and helped them return to as close to a normal level of function as possible.

A Physiatrist is a board certified medical physician who has completed a minimum of 4 years of medical school, a 1 year internship, and a 3 year residency program. Some physiatrists continue their training through post-residency fellowship programs, which typically last for 1-2 years. Physiatrists have their own medical specialty boards with several sub-specialty boards, including: Hospice and Palliative Medicine, Neuromuscular Medicine, Pain Medicine, Pediatric Rehabilitation, Spinal Cord Injury Medicine, Brain Injury Medicine, and Sports Medicine. Physiatrists practice in a wide range of settings. These vary from in-patient rehabilitation hospitals to out-patient private practice offices. Many of the team physicians for professional sports and Olympic Athletes are Physiatrists. Physiatrists are also trained to perform nerve testing (Nerve Conduction Studies and Electromyography a.k.a. EMG) tests to help diagnose neurological disorders.

The basic foundation behind Physiatry is to maximize a patient’s level of functioning following an injury or disease. Physiatrists often use a team approach to accomplish this, working with other specialties such as Orthopaedic surgery, Neurology, general medical physicians, social services, and with physical/occupational/vocational therapists. In addition, some physiatrists are specially trained to perform various minimally invasive procedures, such as spinal injections, to help diagnose and treat various conditions.

So in simple terms, a Physiatrist is a physician with expertise in the diagnosis, treatment, and rehabilitation of injuries to the neurological and musculoskeletal (bones, muscles, joints) systems.

Smoking and Back Pain

Smoking increases the rates of back pain.  As if you did not need another reason to STOP!

Scientific research  strongly suggests  a link between smoking and back pain.  If we try to make some common sense to it,  we need to understand what in smoke causes the problem.  We know that nicotine is a strong inhibitor of the bone forming cells caused osteoblasts.  These are  the body cells  that help remodel and heal the everyday microfractures that occur in our bones.  Most scientists agree that the stresses on our bones and ligaments cause minor micro stress fractures in our bones,  as well as minor tears of the micro ligament structures.  Our body has the amazing ability to heal these stresses and remodel our bone to strengthen it (see this video).  But,  with the nicotine effect,  the bone cell that breaks down the bone,  the osteoclasts, remain active,  while the osteoblasts are inhibited.  As you can see,  the nicotine in tobacco has this deleterious effect.  In that process,  it can also be associated with development of  back pain and osteoporosis.

Back pain may be secondary to the blood vessel constriction that occurs with smoking.  We all know that smoking constricts the blood flow to the heart,  causing a potential heart attack.  But,  we also now know that smoking also constricts blood vessels to any area,  including areas that need extra blood flow to repair injuries.  We have all experienced aches and pains of over doing some activities.  Extra loads on our muscles, and bones will cause micro injury.  All athletes experience this on a daily basis, as they are constantly pushing the body to the breaking point.  But,  with the healing properties of the body,  these micro injuries heal,  and with the extra blood supply,  the muscles enlarge,  the bones become stronger, and the ligaments are augmented.  But,  the vessel constriction effect of smoking decreases the delivery of the healing substances.  That is why we know that smokers have poorer healing rates from most surgeries.  Likewise,  when people stress the spine,  and when they smoke,  a minor ache or stress may not heal.  And,  for chronic smokers,  there is data indicating that there is an increased incident of chronic back pain by 30% in smokers.

Another factor in the increased incidence of back pain in smokers may be secondary to the increased general incidence of chronic pain in smokers.  Research suggests smoking changes the bodies ability to cope with pain signals.  In effect,  the pain pathways are not working to the same degree as non-smokers.  Smokers may experience more pain,  to the same stimulus as non-smokers.

Finally,  for anyone contemplating spinal fusion,  smoking has a significant effect on the successful development of a fusion mass.  If smoke,  and are scheduled for a fusion,  please discuss a smoke cessation plan with your surgeon.  Remember,  the nicotine is just as bad in a smokeless product!

In general,  it is accepted that smoking increases the likelihood of developing back pain.  As a Spine Surgeon,  this is the greatest reason why you should STOP SMOKING!

Why is Low Back Pain So Hard to Treat?

Nearly everyone will have an episode of low back pain at some point in their life. Luckily, most of these episodes are self limiting (meaning they will resolve on their own) with little to no treatment. But what happens when the pain does not go away? Why is it so challenging to make the pain better? This blog post will hopefully provide you with a somewhat simple explanation to those questions.

#1. Sometimes low back pain is not low back pain. Huh? Sounds confusing, because it is. One of the challenges in diagnosing and treating low back pain is trying to determine where the pain is actually coming from. Often, it is easy such as when the pain started after feeling a ‘pop’ in the back while helping move your friend’s Grand Piano up 5 flights of a narrow stairway in Manhattan. But what about pain that slowly comes on over the course of months or years? There is a complicated process of degeneration in the lumbar spine, which affects everyone. Unfortunately, some people are more affected than others. Isolated low back pain can come from a degenerative or herniated disc, the facet (spine) joints, soft tissue, ligaments, muscle, sacroiliac joints, hips, stress fractures, etc. Sometimes telling the difference between these is very difficult, as they can cause identical pain patterns. That is why certain procedures may be performed, such as diagnostic lumbar facet blocks. The theory is rudimentary and simple, but it works: If your pain goes away when a specific part of the spine is numbed, then the cause is found. If not, then the physician will likely start looking somewhere else for the cause of your pain. What if the pain is not actually coming from the back? Did you know that other medical problems, such as an abdominal aneurysm, kidney disease, GYN disorders, and colon disorders can sometimes initially present as low back pain? The waters get even muddier when one of the aforementioned conditions occurs in someone with an ongoing history of low back pain.

#2. Okay, so let’s say we found the cause, but why won’t the pain go away? This is also a complicated question to answer. When the pain becomes chronic, typically after 6-12 months, there are certain changes that occur in the brain and spinal cord which can be very difficult to reverse. The neurologic ‘wiring’ literally changes, which results in the continuation of the pain. This is why certain antidepressant and anti-seizure medications may be tried to help with the pain, as they typically work in the parts of the brain and spinal cord which have been ‘re-wired’. In addition, cognitive-behavioral therapy via a trained and licensed therapist or psychologist has also been shown to help fix this wiring problem by using the brain’s own innate power to help reprogram things back to a more normal way. Luckily, there are other factors which are much easier to modify. These include: exercise, weight loss, and smoking cessation. I will comment on the virtues of appropriate exercise and the importance of weight loss and smoking in a future blog, but nevertheless these are very important factors which play a large role in the propagation of chronic low back pain….and they are under YOUR control.

So, then, is everyone with back pain doomed? Not at all, most back pain can be controlled and sometimes even cured. Despite this, however, it is important to realize that your physician does not always have a magical cure to diagnose and immediately fix the pain. It may take some time and various treatments for the pain to improve, especially if it has been around for awhile.

Is a pinched Nerve a permanent problem?

As a Spine Surgeon,  I see people with pinched nerves almost everyday.  Fortunately,  most pinched nerves do not become a permanent problem.  That is why greater than 98% of pinched nerves can be treated without an operation.

Pinched nerves are commonly caused by herniated nucleus pulposus (disk herniation), cervical and lumbar spondylosis  (bone spurs).  The more rare reasons include  fracture, infection,  tumor,  and fat collection (epidural lipomatosis).  For some,  the pinching comes and goes secondary to loosening of the bones and shifting of the bones on one another (spondylolithesis).  Fortunately,  the great majority of the pinched nerves are from the disk herniation or bone spurs.

In the disk herniation,  or bone spur situation,  there is often a temporary,  but significant pain response to the pinching.  Like any tissue that is pinched,  there is a swelling or inflammation process that paradoxically can increase the pain for a certain duration.  Over time,  the swelling goes away,  and the nerve shrinks back to normal.  That shrinking of the nerve is part of the  “unpinching process”.  Science can explain all these points in a most detailed and microscopic description.  The simplest way is to say “the nerve swelling goes away,  and nerve returns back to a normal size”.

In relationship to a disk herniation,  Spine Surgeons now know that the larger disk herniations are often the ones that naturally shrink in size.  The body actually considers the disk herniation as a foreign material,  and attacks the disk fragment,  and it does get degraded down in size.  In addition,  the larger disk herniations are often originally full of water.  Over time,  the water is absorbed,  and the disk herniation fragment will dry up,  thus further shrinking in size.  This contributes to the  “unpinching of the nerve”.

Bone spurs do not go away,  and can and do grow in size.  The nerve usually gets pinched secondary to a combination of the bone spur squeezing the  nerve when the nerve is stretched or pulled.  In the arm,  the nerve bundles from the spine can be stretched when the arm is placed in the extremes of motion,  or when the arm is being stressed by certain activities.  Likewise,  the nerves to the legs are also stretched when the leg is moved in a certain manner.  There was a recent fascinating research performed looking at the location of the nerves in the spinal canal when the extremities are positioned in certain fashion.  There was definite movement of the nerves within the spinal canal,  depending on the position.  If the nerve was then slightly pinched by a bone spur,  it is not hard to understand how that movement will cause further pinching,  and subsequent pain.

Even in the Bone spur scenario,  the pinch is usually temporary,  and the nerve recovers.

As a Spine Surgeon, I know  most pinches do get better with time,  activities modifications,  and medications.  Occasionally,  steriod injections on the nerves are also required to help decrease the inflammation.   A Spine Surgeon is the best person to know that the pinched nerve will be a temporary process.  Unfortunately,  some pinches caused by fractures,  tumors,  infections,  hematoma’s etc may require urgent surgical care to prevent a permanent situation.   Thank goodness,  that situation is less common.

If you have a severe pinched nerve,  there is still a good possibility that may be only a temporary problem.  At the same time,  a Spine Specialist will be the best Physician to determine the best treatment options.  Sometimes Surgery is still a good choice,  if the pinching is severe,  and prolonged.

Personal Activity Monitors

By now nearly everyone is aware that obesity is a major health problem in the United States and other parts of the world. This is due partly to our decrease in daily activity. Technology has rapidly advanced to facilitate our everyday activities. Because of this, we have become more sedentary and therefore burn less calories. Our lack of activity has helped to fuel the exploding market for wearable fitness devices. While initially designed to help track steps taken, calories burned, calories consumed, heart rate, total number of active vs sedentary minutes, and sleep patterns they have also become trendy fashion accessories. You can buy a pedometer for as little as $20 or spend nearly $250 for one that has all sorts of features. You can also compare your activity level to that of your friends and colleagues via various apps for your smartphone or computer.

The scientific name for the device which makes this all possible is called an ‘accelerometer’. This is the same device that senses how you hold your smart phone and adjusts the screen accordingly. Accelerometers have actually been around for a very long time are integrated into many things we use on a daily basis. They have also been used in medical research for many years. A study was recently published in Medicine & Science in Sports & Exercise (Vol. 46, No. 9, pp. 1840-1848) testing some popular activity monitors. The researchers tested the BodyMedia Fit, DirectLife, Fitbit One, Fitbit Zip, Jawbone UP Band, NikeFuel Band, and the Basis B1 Band against 2 devices commonly used for research studies (Oxycon Mobile 5.0 and the Actigraph AG3X) to measure activity level and energy expenditure (i.e. Calories burned). Subjects in the study were asked to perform 13 various activities over the course of about an hour to simulate activities of daily living and basic exercise (running on a treadmill). The bands were compared against each other and between themselves to help determine accuracy and reliability, respectively. In the end, the results demonstrated that some of the devices worked better than others, but generally the bands provided reliable information. As to not endorse any specific product, I will not comment on which devices performed best or worst in the study….sorry to disappoint you.

So what does this mean for me?

In the end, the reality is unless you plan on submitting your data for scientific research, any of the wearable fitness devices will serve you well. Yes, some are more accurate than others. Some do fancier things than others. And, of course, some are more expensive than others. The take home point is that these monitors are generally accurate and reliable, and have been shown to increase physical activity; which is the ultimate goal. So, if using a fitness monitor helps motivate you to get out and do more, then it is well worth the investment, regardless of the brand.

Diabetes and Sciatica

Diabetes comes in two forms.  Type I diabetes (formerly known as Juvenile Diabetes) is secondary to your body not being able to form insulin,  the hormone necessary to absorb glucose,  the sugar carbohydrate that metabolizes to give energy.  Type II diabetes is secondary to your body developing resistance  to the effects of insulin,  therefore causing an elevation of your glucose levels in your blood,  secondary to the inability to absorb and metabolize it.  In both instances,  the build up of glucose causes damages to the cells and structures of the body.

Diabetes and Sciatica are two distinct problems.  The simultaneous development can be a significant source of pain and disability.

In reference to the Diabetes,  the damage is to all the tissues of the body,  including the individual nerves that form the sciatic nerve bundle.  By irritating the nerves,  it can cause numbness,  pain,  and in some instances  weakness.  Why diabetes is usually associated with irritation of the small nerves that control sensation,  it can also specifically effect these larger nerve bundles,  and cause sciatic symptoms.

In the more unfortunate patient,  there is also the component of the more classic sciatica  secondary to the pinching of the nerves (traditionally, andy or all of  the L4 to the S3 nerves).  As a Spine Surgeon,  there is always the concern of a nerve irritation secondary to a disk herniation,  or a bone spur (rarely,  it can also be due to fracture,  tumor or infections).  

Fortunately,  most Sciatica episodes are limited,  with recovery for the vast majority of healthy patients.

In Diabetes patients,  however,  Sciatica can be a more prolonged and persistent problem,  as there is the so called “double crush” phenomena.  The classic Sciatica is secondary to the first “Crush” of the pinching of the nerve by a disk herniation or a bone spur.  The second “Crush” is secondary to the internal effects on the nerves by the excess Glucose damaging the nerve.

Unfortunately,  the predicted outcome for the Diabetes Patient with sciatica is therefore less certain than in non diabetic patients.  

In terms of non surgical care for a Diabetic Patient with Sciatica,  the standard treatments of medications,  therapy,  activities modifications and utilized.  In addition, secondary to the “neuropathy”,  certain nerve medications such as Gabapentin,  or Lyrica may be used.

The concern is for the more invasive treatments.  Epidural corticosteriod injections may offer some benefits,  but there is the potential complication of increasing blood sugars by the corticosteroid.

In relationship to Surgery,  unfortunately Patients with Diabetes are at greater risk for anesthetic complications,  surgical site infections and less predictable pain relief despite a technically perfect procedure.

If you have diabetes,  and sciatica,  please first get your diabetes under control.  Then progress to the more invasive options with caution.  Make sure your Spine Specialist knows about your diabetes condition so they can give you a better assessment of the risks and benefits of any of the treatment options.  

The Advantage of Exercise for Back Pain

This is a followup to my prior blog on Exercise and Back pain.

Common sense tells us that exercise is good for weight loss,  endurance and strength.  Let’s explore some of the research on the topic.

While beneficial,  how do we know it helps back pain?

More and more scientific studies identify the benefits of exercise,  both aerobic and core strengthening.  A summary of many studies show a positive effect of aerobic exercises,  and decrease in reported chronic low back pain levels.  By definition,  aerobic exercises means activities designed to use oxygen.  Examples of aerobic exercises include walking,  cycling,  swimming and jogging.   Obviously,  people with chronic lower back pain are often reluctant to pursue any activities secondary to fear of increasing pain.   Encouragement,  and gradual increase in activity is necessary.  I counsel my patients to plan on initially walking only for 10-15 minutes.  To provide a measure of confidence,  start out slowly.  Walk in one direction for only 5-10 minutes,  then turn around to get back to the start.  Easy victories are necessary to build confidence.  The worst thing to do is to be too ambitious, and cause a significant flare up of pain in the initial weeks of exercise.

There has also been some studies comparing Total Body Resistance Exercises (weigh training,  and use of rubber band type resistance devices) compare to concentrated back extension exercises.  Studies suggests an advantage to the Total Body exercises in obese back pain patients.

Other studies have show the benefit of Core ( lumbar extensor and abdominal muscle) training for chronic low back pain.

How is weight management related to back pain?

I have written a prior blog on this topic.   This is common sense.  If you carried a back pain of 25 pounds around all the time,  it will cause you to fatigue.  If you have back pain,  it will make it that much worse.  Weight matters.  Exercise is an important part of weight management.  The truth is diet is just as essential  as very few can actually lose weight just by exercise.

Is there a positive psychologic effect that plays into the lessening pain?

There is an interesting article Titled “Biological mechanisms underlying the role of physical fitness in health and resilience”.  While the science behind the article is not perfect,  the article suggests those who exercise have emotional resilience,  and can tolerate stresses better.  In my experience this is a common observation.  In my practice,  I have had the pleasure of seeing chronic back pain patients overcome their perceived disability by gradually increasing their physical capacity through exercise.  The strength and endurance felt by the patient increases their confidence in all aspects of their lives.  The patient felt some restoration of control,  in relationship to the pain.  It did cause a positive transformation in attitude.

The Bottomline is Exercise  has physical and psychologic benefits to the Chronic lower back pain patient,  and should definitely be encouraged.  The Science behind that statement can be debated,  but frankly,  we do know that exercise improves aerobic capacity,  and strength.  It is not unreasonable to conclude it then also helps back pain.

What is Elective Spine Surgery?

People are often confused by the term Elective Spine Surgery. The most broad definition indicates a choice to pursue surgery.  So let’s try to define it in a way that everyone can understand.  Naturally,  there may be some nuanced differences among some stakeholders of the definition.  We will try to stay within the mainstream of opinions.

Most importantly,  we must define what it is not:

Emergency Spine Surgery:  There are certain situations where Spine Surgery is an emergency.  Thankfully,  those situations are rare.  In general,  Emergency situations are those instances where delay may cause irreversible harm to your body.  Usually,  that situation means more than just pain.  Emergency Spine Surgery situations are associated with nerve or spinal cord compression that needs relief to give the chance of restoration to normal function.  These situations usually involve trauma,  infection,  or cancer.

In terms of Trauma,  it is usually secondary to a broken spine bone,  or a large herniated disk,  or a pre-existing narrowing of the spine (spinal stenosis) with a resulting significant compression of the individual spine nerve,  or the spinal cord.  The emergency is secondary to loss of the function of the nerve,  and specifically,  the ability to control the muscles associated with those nerves,  or the spinal cord itself.   Depending on how rapid the muscle weakness presents,  surgery may be indicated on an emergent basis.  For the arms,  and legs, weakness secondary to disk herniations,  without evidence of abnormal spine movement (spinal instability),  has an option of waiting to see how the nerve responses to the body’s ability to resorb some of the disk herniation.   To Surgeons,  muscle weakness means the inability to control the muscles secondary to nerve impairment,  not weakness secondary to the pain associated with the nerve irritation.  To patients,  there may not be a difference,  but to Surgeons,  there is a very large difference. That is why you need a good neurologic exam to determine if Surgery needs to be performed.

On the other hand,  muscle weakness associated with a disk herniation and  instability,  with present with a constant irritation of the nerve.  Usually decompression and stabilization is the recommendation.

If there is a broken spine bone  (vertebral fracture) with associated instability pattern,  and muscle weakness,   Emergent Spine Surgery is the usual recommendation.

Pain associated with spine infections,  with progression of weakness is also an indication for Emergent Spine Surgery.  It is important to know that some spine infections can be treated without surgery,  as long as there is no evidence of progressive weakness.

Likewise,  cancer causing nerve encroachment can be observed,  and treated with non-surgical means as long as there is no evidence of muscle weakness or loss.

The nerves to the bladder and bowels are very sensitive.  If there is irritation to these nerves,  it can cause inability to control those functions.  Spine Surgeons call this condition Cauda Equina Syndrome.  While the science is still not completely understood,  there is a general consensus that this situation is considered an Emergency Spine Surgery condition.

Please note that PAIN by itself,  is not considered an Emergency Spine Surgery Condition.  I know that is a source of frustration for many patients,  but we do know that Pain can and usually does improve for many patients.  If there is no evidence of any associated weakness,  and no evidence of a cancer or infection that is worsening,  Pain by itself cannot be the only criterion for Emergency Surgery.

So now that we defined the needs for Emergency Spine Surgery,  What is ELECTIVE SPINE SURGERY?

Elective Spine Surgery is usually a choice made by a patient after trying to deal with the situation for some time.  Usually,  there was come and go period of pain,  discomfort,  tingling,  numbness,  without severe muscle loss.  For scoliosis patients,  there has been an observation period with evidence of  progression of the curvature.  For patients with an instability pattern,  there has been a steady increasing nature of the pain.   Despite treatments such as medications,  injections,  and therapy the symptoms have worsened.  For disk herniation patients,  there has been recurrent episodes of severe pain,  with associated dermatomal neurologic findings.

The decision for surgery is not a limb or life threatening one  (that is more of the Emergency Spine Surgery criteria),  but is secondary to a progression of symptoms.  For some,  the progression is manageable.  For some,  secondary to the natural aging process,  the activities restrictions that naturally result (we do slow down as we get older)  are enough to accommodate the underlying spine condition.

For others,  the spinal condition is such that it is isolated to a specific area,  and Elective Spine Surgery can have a significant positive effect on their daily life activities.    The chances that Elective Spine Surgery can improve your life,  with reasonable associated risks need to be explored by the Patient and the Surgeon.

As of now,  in the USA,  if a Patient can demonstrate that they have tried non-surgical options for their spine problem without success,  and the proposed surgery has a reasonable chance of success,  most insurance entities will still consider the Spine Surgery medically necessary and cover the Surgery.  I have had many Patients assume Elective Spine Surgery means it will not be covered by insurance.  That is not true as long as the prior factors have been met.  1.  Failure of reasonable non-surgical options.  2. The Elective Spine Surgery has a predictable favorable chance of success.

The problem,  of course,  is finding out how to meet the two factors,  as each insurance entity continues to define, and refine each factor.

To Summarize,  Elective Spine Surgery is 1. not limb or life threatening  2. offered after failure of reasonable non-surgical treatment 3. has a predictable favorable chance of success.

If you are considering Elective Spine Surgery,  please consider several opinions.  There are always different options for most surgical situations.  I have personally seen recommendations for very large  multiple level disk removals and fusions with cages,  screws,  and plates in situations that I have only recommended a simple removal of a small piece of bone or disk on an outpatient basis.  Remember that Elective Spine Surgery is not Emergent.  I know you are in pain, but take the time to get to know all your options.   Ask the Surgeon what they would do for their own self,  or own family in a similar situation.  I would also avoid any Surgeon that guarantee’s a specific outcome.  

Introducing Dr. Casey O'Donnell

ShimSpine continues to evolve and improve.  Today,  Dr. Casey O’Donnell joins our staff and adds more Non Surgical Spine and Musculoskeletal treatment options to our Office.

Dr. O’Donnell is a Physiatrist,  or a Physical Medicine and Rehabilitation Specialist.  He has had special training on diagnosing and treating musculoskeletal problems.  From diagnosis to treatment,  he can care for all your non surgical needs.  If he determines you will require surgery,  he is fortunate to be associated with our Umbrella Practice,  OrthoCare Florida.  With over 5o  surgeons,  he will be able to make the referral to a surgeon with the necessary expertise,  and insurance participation.

Dr. O’Donnell has been in private practice  for over 7 years, and joins our team to provide compassionate but competent  musculoskeletal care to our local community.  He participates in most insurances including Medicare.  Please call the office at 813-814-9251 to inquire about an appointment.

The Advantages of Cervical Foraminotomy

I am assuming you have already had the discussion about the need for a neck surgery for a pinched nerve in the neck.  Let us assume you have already failed the standard non-surgical treatments including time,  medications,  therapy and injections.  Let us further assume certain diagnostic tests have isolated the pinched nerves to a specific location,  and a specific nerve.

The decision now is to decide which surgery will give you relief.   Right now,  most of the recommendations are about either removing a disk,  or bone spur,  and then fusing those bones together.  The rationale being that removal of the whole disk will improve the arm pain from the pinched nerve,  but because so much of the disk is removed,  the spine will become unstable,  thus the spine fusion.   The operation is a very common operation,  with high success rates.  It is an excellent option for the proper patient.   A variation of this operation is the same approach to remove the disk/bone spur,  but instead of a fusion,  an artificial disk device is inserted.  This also is an option in the properly selected group.  There are nuanced requirements for patients to qualify.  In my experience,  that can also be a very successful option.

The least discussed option is the title of this blog.  Posterior Cervical Foraminotomy.   The research on this approach also demonstrates good success,  and our experience also is of excellent relief in the properly selected patient.  And that is the point.  In all these scenarios,  the proper selection is tantamount to a successful outcome.

Let’s Discuss the Pro’s and Con’s to the Posterior Cervical Foraminotomy:

Pro:

1.  It is not a fusion operation.  There is no insertion of a bone graft,  or an artificial disk device.

2. The incision is on the back of the neck.  The dissection does not encounter vital structures such as the esophagus,  trachea,  carotid artery.

3. It can be done as an outpatient procedure.

4. Recovery is dependent on healing of the incision site.  There is no need to protect the neck because of maturation of a fusion,  or a risk of dislodging a disk replacement device.

5. Cost wise,  the total cost of the procedure is limited to the surgery facility,  the anesthesia staff,  and the surgical fee.  Typically,  all three fee’s are less than compared to a fusion or an artificial disk device.  The cost of the hardware for fusion,  and certainly the artificial disk device, is a significant expense.

6.  In the properly selected patient,  the results are comparable to discectomy and fusion,  or discectomy and artificial disk replacement.

7.  If there is the need for addtional surgery in the future,  it can be performed with minimal scarring,  leaving all options available for the surgical team.  The more invasive Anterior fusion or disk replacement surgeries will leave more scar formation,  with the associated risks of injury secondary to scar dissection.

Con:

1.  Not all pinched nerves are amenable to this approach.  The goal is to remove the laterally located bone spur, or disk that is causing the pain.  A more central (in the middle) disk,  or spur means manipulation of the nerves,  and potentially the spinal cord to approach the problem.  The spinal cord manipulation is not advised,  and most surgeons will recommend the anterior discectomy to avoid the manipulation.

2. Greater than two levels have decreased success rates.  This is also true of any approach.  But with this more minimalist approach,  some will be willing to try to do more levels.  Be aware the results will still be less likely to be successful with more levels.

3. Body habitus may make visualization difficult.  Obese patients,  and those with large shoulders may make it very difficult to visualize the appropriate level without more vigorous dissection,  and opening techniques.  It may not be an outpatient event.  Also,  depending on the potential visualization difficulties,  some surgeons will advise further non surgical care,  or referral to others.

4.  Dissection of the neck muscles or ligaments (ligamentum nuchae) can be a very painful recovery,  with muscle spasms.  Understand that potential prior to surgery.

5. Dissection around the facet joint capsules can cause the development of spinal instability.

6. There is a rare but serious nerve problem called the C5 syndrome.  The exact mechanism is not definitively known,  but there can be a delayed development of weakness to the shoulder and arm muscles.  Fortunately,  the vast majority of these patients do recover,  but it can occur.  While it also occurs with Anterior fusion and replacement surgeries,  there is a trend of more of these events with posterior procedures.

As in all surgeries,  there are also the standard risks associated with any surgery.

Posterior Cervical Foraminotomy is an excellent option for the properly selected patient.

What is Radio Frequency Ablation (RFA) ?

For certain people,  the source of back pain is the irritation associated with cartilage wear in the facet joints of the spine.  This wear and tear cause the nerves from that particular facet joint to excite,  and causes pain.  The typical pain is a back pain,  that localizes to the lower back,  and buttock,  or in the neck,  the base of the neck,  into the trapezius muscles.  Based on testing such as MRI’s or even CT scans,  the degeneration of those joints can be identified.  As discussed many times in my previous blogs,  the findings on MRI’s or CT scans however,  may not correlate to your spine pain,  as there can still be many sources of neck and back pain.   These studies must be considered with the physical exam findings.  If the pain,  the physical exam findings and the diagnostic studies match a particular pattern,  you can go to the next step,  which I will discuss shortly.

For now,  I want to give examples of when the complaint,  the physical exam findings and testing are consistent with a known pattern,  and when it is not:

EXAMPLE # 1.   Correlation of Complaint,  physical exam and Diagnostic Testing:

Mary is a 40 year old female,  who has developed continued low back pain.  She recognizes the pain is worse in the morning when she first gets up.  When she bends backwards,  it reproduces a pain that radiates to the same area of the buttock on the right side.  Initially,  she had improvement with the use of over the counter ibuprofen,  but with increasing activities,  she has that same reproducible back pain to the right side.  Her physical exam was consistent with irritation to the right lower back along the facets.  Her Family Doctor was successful in ordering a back MRI.  It shows arthritis changes to the right lower back facet joints at L4-5, and L5-S1.

In this example,  Mary has a very consistent back pain complaint,  with a consistent physical exam,  and testing findings of facet arthritis located on the right side,  which is the side of the pain.

EXAMPLE # 2.  Complaints do not match the Findings on Testing:

Joe is a 45 year old male,  who has developed continued low back pain.  He cannot identify a particular pattern to the pain.  He just knows it is there,  and getting worse. There is a significant family history of back pain.   He has been to the ER on several occasions.  He has run out of the medications prescribed.  At times,  the pain is bearable.  When stressed out,  he notices the pain has worsened.  He has had back pain on and off since a work injury years ago.  His physical exam identifies pain to the whole back.  He describes a pulling sensation to the thighs at times.   His family doctor did get an MRI.  It shows disk degeneration findings at every level of his spine,  with a small disk herniation and bone spur at the L4-L5 level.

In this example,  it is not clear what the MRI is identifying other than diffuse degeneration.  It is not clear if the pain is a genetic problem,  a problem specific to the disk degeneration,  a problem from the disk,  or a diffuse overuse muscle issue.

In the first scenario,  injections to the right lumbar facet joints may give relief.  In the second scenario,  any injection treatments may be just a process of elimination,  and any benefit may be a short term relief associated with the cortizone injected into the body.

If there is good relief of pain from the Facet Joint Injections,  then the Physician may have identified the source of the pain,  the degeneration of the facet joints of the lower back .  If there is reproducible pain relief with these injections,  there is a potential for longer term relief by stopping the pain nerve signals from that facet joint.  The nerve  from the facet joint is usually follows a specific route.  If the nerve can be turned off by impairing it on that route,  it can have a  much longer pain relief effect.  That turning off of the nerve to the Facet Joint can be accomplished by the so called RADIOFREQUENCY ABLATION Procedure of the Spine.  Normally I do not use commercial Video’s,  but this video below seems to be mostly educational.

While not all patients are candidates for this procedure,  it has been very helpful for the properly selected person.  Please consider a consultation to see if you are a candidate for the procedure.

Why we have Disk Herniations

Today,  I saw a very rare patient.  Why?  Because he is 40 years old,  and his MRI report read “Normal Lumbar Spine.”   After looking at his MRI,  I came to the same conclusion.  There was no evidence of any disk narrowing,  disk dehydration, or bone spur development.  But he had back pain,  from a pulled muscle.  He probably did not need the MRI to diagnose that,  but that topic is another blog.

In the above picture of a Spine Model,  you can see that there is an entity called the Disk.  The disk is made up of two general parts.

1. The Annulus,  which is the tough outside cartilage wall,  that acts similar to a ligament  (a tissue connecting two bones to one another).  In the most simple of explanations,  it holds the vertebral bones in alignment.

2. The Nucleus,  which is the softer,  initially gelatinous center of the disk,  that gives the disk its shock absorbing properties.  Some will say it is like a very hard,  tough water balloon.  A tough outer skin,  but a watery soft inside that allows it to absorb some stress.

The problem is the disk does not maintain its water content forever.  Inside the Nucleus are special materials called proteoglycans.  At the earlier stages of life,  the proteoglycans absorb water very well,  thus maintaining the water pressure,  and height of the disk.  Scientists have discovered that as we age,  the proteoglycans change,  and cannot absorb as much water.  The water starts to leave the Nucleus.  Our water balloon starts to lose its firmness,  or turgor because of the loss of water content.  The disk height begins to shrink.   With the loss of turgor,  or strength,  there is more motion or slack in the disk.  This allows the vertebral bones to shift more.  This causes stresses to the ligaments,  muscles and tendons surrounding the disk.  It will also cause extra motion of the joints of the spine called facet joints.  With the extra motion,  the smooth cartilage lining starts to wear,  and you start to develop spine arthritis in the joints.  In addition,  the slack in the disk  allows extra motion and stress on the wall of the disk,  potentially causing fissures in the annulus.  Also,  with the extra motion,  the insertions of the disk on the endplates of the vertebra can weaken causing micro fractures of the endplates.  The latest research show that this endplate failure may very well be the real reason disks herniate.  As the endplate gives way,  the softer Nucleus penetrates out along with the endplate.

Of course,  we are over simplifying this topic.  Compound this degeneration with some sort of stress,  and now we may have a  Herniated Nucleus Pulposus or a Herniated Disk.   Incidently,  the concept of degeneration predisposing people to herniations is considered common sense,  but the research has not  yet confirmed this seemingly obvious conclusion.  Nevertheless,  this degeneration process is thought to explain the identification of Disk Herniations in the majority of people over the age of 40.

In the first part of the Blog,  I commented on the rarity of a normal Lumbar MRI in a 40 year old.  I hope the reader now understands why I made that statement.

Why you need to Trust your Doctor

When you have pain,  or when you have medical concerns,  you need to Trust your Doctor.  If you do not,   I suggest you find a Doctor you do trust.  That trusting relationship should provide security,  hope,  and cost savings.

As a Spine Specialist,  I know that a vast percentage of the patients will have pains that will likely improve over time.  For most situations,  I am confident that will happen.  As I have blogged before,  if you take most people with spine pain,  and put them in a black box for three months,  the vast majority will be better when you let them out of the box.  In other words,  people will get better.   As you can see,  many will take credit for you getting better.  To me,  as the Spine Specialist,  I must first make sure you are safe to go into that black box.  In other words,  a Spine Specialist must assess whether a patient can and should give it time before getting more aggressive  (surgical) treatments.  Once the decision to wait is made,  the patient must trust that the Doctor has made the right call.  If there is no trust,  many things can happen. Let’s look at some ideal scenarios:

IDEAL SCENARIO #1

John Smith is a 42 year old healthy male,  who developed excruciating back and leg pain.  There is shooting pain down the legs,  numbness is a specific pattern,  and significant weakness of a muscle  to the leg with inability to walk. John Smith knew of the Doctor from his friends,  and felt confident in the Doctor’s ability.   The Doctor determines the weakness is actual inability to move the leg muscles,  and not just weakness secondary to pain,  or fear of pain.  Because of this finding,  the Doctor orders testing including an MRI at a covered Hospital.  The staff,  understanding the urgency of the situation,  arranges the study immediately.  The MRI  identifies a significant disk herniation to the lumbar spine. The Doctor recommends a limited disk removal procedure that can be done almost as an outpatient.   Urgent disk removal surgery is scheduled, and John Smith has a rapid recovery with restoration of the strength.   John Smith trusted his Doctor,  and followed the recommendation to early surgery.

IDEAL SCENARIO #2

James Brown is a 50 year old healthy male,  who develops excruciating back and buttock.  There is spasms to the back.  He has difficulty walking secondary to the pain.    John Brown is healthy,  and nothing in his history suggests any significant trauma,  or risk for cancer or infection.  John Brown’s physical exam indicates the pain is causing the difficulty with walking,  but there is no evidence of nerve impairment.   His Doctor decides to wait to see if he would get better by prescribing some medications,  and gentle stretches. John Brown trusted his Doctor,  who explained that he will likely improve,  but expect a few set backs while he slowly increases activities.  Because of encouragement by his Doctor,  John Brown accepted that there will be some occasional flare ups initially,  but in the long run,  he would be better.   With each week of followup,  John Brown is improving.  Within several weeks,  John Brown had manageable pain, and was able to return to work,  and gradually return to all activities.  Because John Brown trusted his Doctor’s diagnostic abilities,  he avoided excessive testing,  and trusted that  he would be able to improve despite some flareups.   John Brown’s costs of treatments were confined to inexpensive medications,  and monitoring by his Doctor.

In both these Idea Scenario’s,  Trust in the Doctor allowed focus on improving the pain,  instead of further testing for possibilities and opinions. Costs were minimized.  Confidence in the Doctor’s opinions and treatments gave peace of mind.  Without question,  that decrease in anxiety helps to reduce pain,  as well as fosters an environment that is conducive to healing.  Confidence is an important factor in improvement.

NOT SO IDEAL SCENARIO #3

Joe Smith is a healthy 40 year old with excruciating back and leg pain.  He has the same numbness and weakness as cousin John Smith in Scenario #1.  He finally gets to see the available Physician’s Assistant for the available Doctor,  after waiting for a long time in the office.  Because of the weakness,  the Doctor himself,  examines Joe.  The Doctor orders an MRI,  but the MRI is not authorized, as the Doctor would like the MRI to be done at a specific facility.  With some delay, an MRI is obtained,  showing the large disk herniation.  The Doctor suggests a removal of the disk,  but also a lumbar Fusion Surgery.   Joe had recently seen the articles about the skyrocketing rates of lumbar fusion surgery,  so he and his family are hesitant.  Joe demands a second opinion.  Unfortunately,  it takes time to get a second opinion.  Meanwhile,  secondary to the pain,  Joe develops a dependency on narcotics,  and the weakness to his leg is getting worse.  As time continues to pass,  Joe’s work place puts him on leave,  and financial stresses are additional to his medical stress.  The second opinion Doctor appears to be cautious about his recommendations,  but in the end said  he could have either a removal of the disk surgery,  or the removal of the disk surgery and also the fusion at the same time.  Joe did not ask  what would the Second Opinion Doctor do for Himself,  or his own Family.    Because of the pain,  and weakness,  Joe does get the removal of disk and fusion surgery.  His leg is getting better,  but he is still dealing with the healing pain from the fusion.  His work has still put him on leave.  The bills from the larger fusion surgery are more than he knew about.    He is better,  but he is not happy.

NOT SO IDEAL SCENARIO #4

Scott Brown is a 52 year old male with excruciating back and buttock pain.  Like his cousin James Brown in Scenario #2,  there is nothing in his history that would suggest a fracture,  an infection or a tumor.  Scott Brown has difficulty obtaining a Spine Specialist Doctor’s Appointment,  so he sees his Family Doctor.  The Family Doctor orders x-rays,  which are normal,  and would like to order a Lumbar MRI,  as the Family Doctor does not want to miss any finding.  Scott’s insurance denies the MRI as he did not have adequate treatments defined as medications,  and physical therapy for 6 weeks.    Scott initiates Physical therapy.  While at therapy,  the ultrasound and massage felt good,  but whenever he tries to exercise or stretch,  there is more pain and spasm.   The Therapy Aide recommended he avoid any activity that causes pain, and come in for more therapy.  Scott finally gets to see a Nurse Practitioner at a Spine Institute.  While the ARNP is very nice and professional,  he has yet seen the Spine Specialist Doctor.  By 6 weeks,  he is starting to feel better,  but he is still fearful of doing any activities as it may cause a recurrence of the pain.  He see the Spine Specialist Doctor,  who seemed more interested in seeing if he would be a candidate for surgery.  Because he has had PT for 6 weeks,  and have been on medications,  he now qualifies for a MRI of the Spine.  The MRI shows several small disk herniations to the lower back,  but Scott is now feeling better.  Scott is not sure if he needs to see the Doctor,  but the appointment is made so he goes.  The visit is only for a few minutes and the Doctors says he has a few small disk herniations,  but he does not need surgery now,  but may in the future.  Scott forgets to ask about certain activities,  and he is still not sure if he should exercise,  or return to weight lifting.     The bills start coming in.  The $50 co payment for each therapy visit added up.  He did not expect such a large bill for the MRI,  and the physician’s fee’s for the FAmily Doctor,  the Nurse Practitioner,  and the Spine Doctor has yet to be delivered.    Six months later,  while applying for a disability insurance,  the two small disks that no longer cause any pain,  are causing his policy to be much costlier than he originally hoped.  He is better,  but he is not happy.

As you can see,  in the Not so Ideal Scenario’s,  both people do get better,  but at increased costs,  with future ramifications,  and with some associated disappointments and unhappiness.  There are real world examples that I do see on a frequent basis.  Of course,  if you can choose,  you would want the Scenario where You Trust Your Doctor.

To achieve that  Ideal Scenario, Doctors must gain your trust.  In my opinion,  these factors can help in gaining that Trust.

1.  Price Transparency.  Unfortunately,  only people who pay for all their own healthcare costs know the true costs.  However,  the Doctor,  along with staff should be able to give ball park estimates on the cost of certain procedures.

2.  Timely appointments.  When people are in pain,  the ability to see the Doctor and discuss the concerns is most important.

3.  Adequate time with the Doctor.  While physician extenders are helpful,  when seeing a Specialist,  most patients feel most comfortable spending time with the Doctor.  In addition,  adequate time is necessary to discuss the most important concerns.

4. Appropriate contracting by the Doctor’s office.   If the Doctor underbids their fee,  there is a compelling economic motivation to see too many patients.  If the Doctor does not have the ability to negotiate adequate compensation from a specific insurance plan,  it means (s)he will not have the ability to spend more time with you,  and (s)he will likely hire physician extenders to process more of the patients.

5. Full disclosure about Business Relationships with Therapy,  Surgery Center,  Imaging,  etc.  Patients expect their Doctors to be financially successful.  Afterall,  who wants to see someone who can barely make a living as a Specialist.  Patients,  however,  do not want to know, after the fact,  that you had a financial relationship with any of these entities.  Doctors are required to disclose these relationships.  Signs are usually posted to that effect.  Still,  it is better when a Doctor comes out,  straightforward and lets you know,  and also gives you a choice.

6.  The Physician Version of the Golden Rule:  Assuming the Doctor loves his family,  the Doctor should make the same recommendations to you as he would to himself and his family.  Patients should discuss this philosophy with the Doctor.

7.  Appropriate and on going Staff Training.  Without question,  a happy work environment spills over to the customer.  If a Doctor develops a  friendly,  fair work environment,  that spills over to a better patient experience.   A well run office  also means better care and service to the patient.  That leads to more trust.

8. Willingness to not make the appointment for the Wrong Patient.  Some offices do not do a good enough job in matching the patient with the Doctor.  Doctors are still human.  Not every human will get along with every other human.  If the Staff understands the Patient’s needs cannot be met by the Doctor, the staff should feel comfortable suggesting an alternative office for that Patient.

9.  Understanding that Trust is a two way event.  Doctors must also have some expectations of the patient.  Only when mutual expectations are met,  can there be trust.

10. Happy Disposition.  Some of us are born sad.  But to gain trust,  a Doctor should have a happy disposition.  A smile,  and optimize helps build trust,  even in difficult situations.

The Cost of Healthcare in the USA

Healthcare expenses in the United States exceeds  17% of GDP and over $2.8 trillion in 2012. Yet the Physician fee component of that expense is only 8%.   In this debate over how to  control expenses,  most of the focus seems to be on curbing the Physician fee.   WHY?  Should we not focus on the other 92%?

The truth is the Physicians (8%) do have an effect on the testing,  therapies,  and procedures performed on the patients.     What if the 8% can help reduce the expenses of the  92%?  How would we design that system? Everyone agrees there is over utilization of  testing,  therapies and procedures without any known improvement of overall population health.  How can we get the Physicians to reduce the demand of the patients for unnecessary testing,  therapies and procedures?

What would be a better system to achieve less waste?

The answers to these questions have tremendous ramifications on the USA as a whole.  The rules of economics do not go away.  In the past,  there was the proverbial debate over Guns and Butter.   To summarize,  and simplify,  there is a limited amount of resources.  Society must chose to how to use these resources to serving the people.  The debate is over providing services for welfare,  versus providing security and military power.  Of course,  there is an assumption that there are not external corruption issues that also siphon off the resources,  but that is another story.  The bottomline is excess expenditure on Healthcare can place our National infrastructure, and security at risk.

In the past,  before there was any attempt at government assistance to the population,  people had to fend for themselves.  There was not as much money for healthcare.  Physicians has much more modest incomes,  as few can afford their services.  Also,  the vast majority of  treatments were for infections.  The discovery of penicillin was argueably the most important medical discovery of the 20th century.  Our medical technologies were very modest compared to what we have now.  Prior to the 1960’s,  there was no ICU’s, open heart surgery,  joint replacements,  CT scans,  and MRI’s.   Cancer treatments were modest.  Yes,  life expectancy was also only 69.7  in 1960.  Without looking callous,  the reality is healthcare costs were much smaller,  as there were few medical options,  and few lived very long.

Fast forward to now, and the life expectancy table show it to be 78.7 by 2010. In the 1960’s,  medicare was created,  expenditure on medical research and treatments exploded.  A whole Medical industry including Hospital Chains,  Pharmaceuticals,  Medical Device Companies were developed.  People now have tremendous medical options,  and because of the nature on how the treatments are offered,  can get into a situation where testing and treatments are over utilized.  To explain,  most Healthcare is an employee benefit, or a government sponsored program.  While the individual still has responsibilities for some of the costs,  the majority of the costs tend to be covered by the previous two entities ( a few pay for all their Healthcare,  but that is rare).  Depending on the structure of the Health plan,  there are disincentives to use the healthcare because of a high deductible expense.  The problem is once the deductible is met,  there is then a tendency to over utilize the healthcare services as the deductible has been met.   Also,  at least in the past,  there was an incentive for providers (Physicians,  Hospitals,  Pharmaceuticals,  etc) to provide extra services,  as it improved the finances of the entity.    There is a disconnect on the costs of these treatments to the patients because of the insurance benefit,  or the government sponsored programs.  Clearly,  there is a potential for abuse.  To make it simple,  if the purchaser of the service is also the educated patient,  I doubt that many of these non essential medical treatments would be performed.

So how do we address this Guns and Butter debate in Healthcare?

VALUE ANALYSIS by COST TRANSPARENCY:

Somehow,  we must reestablish the concept of Value,  from the perspective of the patient.  That is very difficult to do,  as there is no transparency on the costs of most Healthcare expenditures.  To clarify,  it is almost impossible for a Hospital to tell you the costs of a hospitalization.  The list price is almost never paid.  There are fee schedules depending on the payer.  There is a different price if you have a government plan,  or a Private health Plan,  or an Auto insurance plan.   Within each of these types of  plans,  there are sub catagories with different fee’s.  This is also a very simplistic explanation to a very complex issue.

In the Physician’s office,  to the Patient,  it is not clear what is and is not a cost associated with the Physician’s visit.   While there is a co-pay or fee for the Physician’s services,  it may not be clear that tests ordered,  therapy,  medications,  etc. also have associated costs and co-payments.  Many of my patients are irritated and confused by the costs.  Some assume that the Physician must be getting a portion of those additional fee’s.  A more cost transparent system will allow patients to make better value calculations.  Once the patient knows the whole costs,  it may be easier to decide not to pursue certain elective procedures.  Also,  once the true costs are exposed,  patients can calculate whether the benefit of the procedure is worth the fee.

PROVIDE PREVENTATIVE INITIATIVES:

For the most part,  the USA has a capitalistic orientation to business.  That capitalism has driven tremendous innovation, and have provide value to the consumers.   The problem in Healthcare is the monetary value to these capitalistic companies is in innovation,  and solutions to problems.  While that is great,  the more efficient use of resources is in PREVENTION of development of these problems.   To make it simple,  if you are a Cancer treatment company,  your company would go bankrupt if there is no more Cancer.   In my opinion,  there is no monetary incentive to promote prevention.  Somehow,  we need to promote healthy behaviors such as weight reduction,  exercise,  smoke cessation,  alcohol moderation,  etc.   Somehow,  we need business entities incentivized to promote healthy behavior.  It also requires a population to take responsibility for its own health.  Currently,  there is very little penalty for unhealthy behavior,  as our current Healthcare still provides care for your deleterious behavior.   Again, not to be callous,  but should Society pay for your treatments for drug abuse,  alcohol induced liver disease,  and smoking induced cancers?   When Society has plenty of resources,  perhaps so.  When Society is having a real Guns and Butter debate,  perhaps not.

RESTORE TRUST IN THE HEALTHCARE SYSTEM:

This will be a totally separate Blog (next one,  I hope).  Many of our Healthcare Expenses are secondary to a lack of trust.  Many medical conditions take a bit of time and patience as the body naturally heals the process.  At least in Musculoskeletal issues,  time can be the great healer.  In a mistrusting environment,  few people will be patient enough to wait to see if there is improvement.  That means more testing,  more evaluations,  more retesting as unrelated abnormalities may be discovered.  It becomes very costly,  and yet,  there is little incentive to rein in these costs.   Our Legal Members of our Society have thrived in this environment of mistrust.   This next statement may get me in lots of hot water with my medical colleagues,  but we too have prospered by this environment of mistrust.   Each time a person does not trust the system,  there are additional evaluations,  additional tests,  and additional costs.  One entities costs,  is another entities revenue.  I am not picking on my radiology colleagues,  but the Defensive Medicine that everyone talks about,  has been an extremely valuable revenue stream to the radiologists.  Afterall,  they draw revenue from reading all the tests.  In a similar vein,  fear of litigation prompts additional interventions,  with additional revenue to Surgeons,  specialists,  and even Primary Care Physicians.  If we spin this back,  and the patient is truly bearing all the costs for all these tests,  and treatments,  then a Trusting relationship with their Physician will result in less expense,  less angst,  and likely better satisfaction.    It will be less cost,  which is the goal.  But we must all understand the ramifications for less cost.  IT MEANS LESS REVENUE for a SYSTEM BUILT TO PROVIDE SERVICES,  not PROMOTE HEALTH.

Why we have Back Sprains / Strains

Most people sprain/strain ligaments and muscles of the back.  The back is a very complex structure.  The main purpose is to support your frame,  allowing safe movement,  while protecting the important vital organs in your abdominal area. The spine is also the conduit for the nerve signals going from your brain to the legs and organs.   The back must be strong,  for protection,  while also flexible to allow movement.  To achieve those purposes,  the back is a complex organization of bones,  ligaments,  muscles and nerves.  Each element has very specific functions, and proper function demands precise coordination.   Because of so many moving parts,  it is actually amazing that we do not have more back pain.  

The muscles of the back are multiple and paired,  right and left.  The Muscles must also be balanced to allow the back to remain erect and coordinated.  As we twist from side to side,  one set of muscles must contract,  and shorten  (concentric),  while a corresponding set of muscles on the other side of the motion must elongate,  in a controlled manner (eccentric).  Considering,  that there are multiple planes of motion  (so called six degrees of motion),   the complexity of the coordination of these muscles become more apparent.    All muscles fatigue with excessive use.  With the fatigue,  these muscles can get overstretched,  leading to the back muscle Strain.

The structure that becomes like a rope,  extending off muscles are called tendons.  The tendon is the extention of the muscle that attaches to the bones.  In the back,  there are multiple small muscles with multiple tendons that insert onto the spine bones (spinous processes).  These tendons can also become frayed or weakened during overuse,  or overstretch.  This stretching of a tendon is also considered a back strain.

In addition to the muscles and tendons,  there are ligaments,  which are rope like structures that connect a bone to the bone.  In the back,  there are multiple paired ligaments that connect boney parts to one another.  Over time,  these ligaments can wear or stretch,  causing the so call back Sprain.

As you can imagine,  all these paired muscles,  tendons,  and ligaments can be a source of pain.   With all the necessary pairing,  and coordination of all these structures,  an overstretch incident can be the source of pain.  With so many components involved,  it would be very difficult to definitely identify which specific muscle,  tendon,  or ligament is the cause of the pain.   In addition,  as these are soft tissues,  X-rays would not be able to identify the cause.  Even with MRI’s,  unless there is a significant tear of any of these components,  the study will not likely pin point the soft tissue pain generator.

So,  when you have back pain,  it is likely secondary to a sprain/strain of one of these muscles,  tendons or ligaments.  While you Physician will also ask questions to make sure it is not something more serious,  the vast majority of back pains are from these sprains and strains.  Also remember,  that as we all age,  these components do wear away.  It is a part of life. Luckily,  most episodes of back sprains /strains do heal with minimal or no pain.

10 steps to Prepare for your Spine Surgery

After making the decision to have Spine Surgery,  the preparation just begins.

1. Notify family members and friends.  Consider how the surgery will effect your family,  and your pets.  Arrange someone to be stay with you the first few days at least.

2. Notify your work.  Finances do matter.  Consider the ramifications of time away from your job,  and find out about necessary paper work.

3. Arrange your home for the surgery.  IF you have stairs, consider making a sleeping area on the first floor.  Decrease clutter from the bed to the bathroom,  and general living area. Remove anything that may cause you to trip,  stumble or fall. Consider removing all the throw rugs.   Prepare your shopping ahead of time.  Arrange for general household maintenance  activities,  or plan accordingly.

4. Plan your routine bill payments ahead of time.  After surgery,  most routine things get disrupted.

5. When scheduling your Surgery,  find out about the financial ramifications.  Call your insurance company to see what is and is not in the plan or network.  Costs that you may or not consider,  but must,  are hospital/surgery center fees,  Surgeon fee,  Anesthesia fee,  laboratory fees,  pathology fees,  radiology fees,  and home health fees.  Please have someone counsel you on your Insurance Benefits,  or discuss the payment for services ahead of time.   Please find out what is and is not a covered service, and what is and is not in your insurance network.  I find patient satisfaction definitely decreases when there is an unexpected fee.

6. Make sure you have a complete inventory of all your medications,  INCLUDING your over the counter medications and vitamin supplements.  Some of those medications can have unintended interactions with the anesthesia,  or cause excessive bleeding.  Your Surgeon,  and the Anesthesia Staff need to know about those medications.

7. Consider the type of surgery,  and future travel plans.  Discuss the anticipated time away from air travel,  vacation,  family  gatherings.

8. Anticipate stress to your relationships.    Your friends and family will likely need to be more accommodating.  It can strain relationships,  and changes roles and family dynamics.  Intimacy issues should be discussed with your Surgeon.  DO NOT BE SHY.  Your Surgeon should be used to discussing this common aspect of couple relationships,  and your Spine Surgery.

9.  HAVE A POSITIVE OUTLOOK on your Surgery.  Without question,  attitude makes surgery  a self fulfilling process.  Cautious optimism is helpful in recovery.

10.  Anticipate some setbacks.   While you should expect a good outcome,  prepare for the “two steps forward,  one step backwards” progress chart.  Focus on the short,  and the long term goals.   Many patients have a bit of a depression prior to surgery secondary to the chronic pains.  Understand that depression may magnify setbacks.  Get proper counseling,  and prepare yourself for minor irritations.

Exercise and Back Pain

When your back hurts,  the last thing you want to do is exercise.  And that is usually a mistake.  Traditionally,  our grandparents were advised to lie in bed, and not move when experiencing back pain.  More and more evidence suggests prolonged bedrest has adverse effects, and unintended consequences of more prolonged pain,  and disability.

Exercise and back pain is a common topic to many patients.   To review,  for the vast majority of the population,  back pain results from a soft tissue sprain/strain of the muscles or ligaments of the lower spine.  Or,  back pain can be the result of irritation of the developing arthritic joints of the spine, called the facet joint.   At any rate,  as long as the back pain is tolerable or not causing nerve irritation,  usually it will resolve, or improve for most people.  Exercise has the potential to decrease the duration of back pain,  or increase the intervals between episodes of back pain.

I regards to exercise and back pain,  my most common advise is to walk.  When you are in extreme pain,  you may not think that is possible.  But I advise patients to just take as many or as few steps for at least 10 minutes twice a day for the first few days of the back pain.  The act of walking does wonders for the body.  It requires you to get up from a seated or lying position.  It requires you to balance and coordinate all your muscles.  And, from the mental standpoint,  it demonstrates your ability to control some aspect of your pain.

In the act of walking,  you must recruit muscles from your abdomen,  your back , and your large muscle of the legs.  If you place your hand on your back muscles while walking,  you can feel the muscles contract and relax with each step.  While you may have back pain,  the act of recruiting those back muscles help maintain the muscle tone and orientation.

If you are feeling better, and can walk at a faster pace,  usually you will find yourself swinging your arms.  Again,  more muscles are recruited.  You can increase your aerobic activities,  and help exercise your heart, and burn a few calories.  Overtime,  the exercise of walking is a low impact,  aerobic activity,  that burns calories, and for the most part does not cost you anything other than time.  And,  it helps restore your core muscles, including your abdomen and your back.

In reference to exercise and back pain,  I also encourage stretching exercises.  under the  For Patients tab on the top of this page,  I have sections titled  Back Exercises, and Neck Exercises.  I find these exercises and stretches are helpful for patients recovering from back and neck pain.

And finally,  in reference to exercise and back pain,  I encourage everyone to be as active as possible.  Yoga,  Pilates,  low impact aerobics, swimming and upright bicycling are excellent other activities.

When experiencing back pain,  I usually recommend against vigorous tennis,  golf, or heavy weight lifting.  Unfortunately,  these activities are associated with more injuries to the back.

The bottom-line, is exercise and back pain are good topics of discussion you should have with your doctor.  Stay active,  stay low impact, and use common sense.

Chiropractic Manipulation Under Anesthesia

Chiropractic Manipulation Under Anesthesia seems to be the latest fad amongst some of the Chiropractic Providers here in the Tampa Bay area.  While the practitioners of the technique tout anecdotal reports from the 1950’s and 1970’s  I was curious to the latest science on the topic.  I must disclose,  that as a Spine Surgeon,  I only see the failures of all the various treatments.  That is because patients only approach someone like me after the  XYZ treatment has failed.  With my skewed population of patients, my opinions on some of the non-surgical treatments may not be balanced.  To give a frame of reference,  I am sure some of the Pain Management and Rehabilitation Physicians may think certain Spine Surgeries do not work,  as the see the failures,  not the successes.  But that is another blog.

In relationship to Chiropractic Manipulation Under Anesthesia,  I have had the opportunity to review video’s of the procedure,  and review the  costs associated with the Manipulator,  the Anesthesiologist,  and the Facility fee.  In my local community,  the standard seems to be a full body manipulation,  done on three successive days.  The procedure is performed under full general anesthesia.  To me,  some of the maneuvers seem rather aggressive,  and I had concerns about potential injury to both the patient,  the Manipulator,  and the ancillary staff that must hold the patient in place while these forces are applied to the neck,  back,  hips,  arms,  legs,  etc.    I have been asked my opinion on the topic,  so it prompted me to do some research.

In my opinion,  the best summary was by Dennis Digorgi, DC,  with a review on the topic.  The conclusion is that there is not enough research to prove efficacy.  A 2014 prospective study of 30 patients did show that 50% of patients did receive some benefit with one session.  But these numbers were very small to make any general conclusions.

Based on these reviews,  most insurance companies consider Chiropractic Manipulation Under Anesthesia experimental,  and not a covered service to the health insurance plan subscribers.

After careful research on the topic,  I would opine that this is a technique that has limited efficacy,  with attached significant expenses.  Before considering the technique,  please find out about the experience of the practitioner and the costs.  If possible,  please ask for references from former patients.

References:

Spinal manipulation under anesthesia: a narrative review of the literature and commentary

Minimally Invasive Discectomy vs Micro/Open Discectomy

References:

1. Cochrane Database Syst Rev. 2014 Sep 4;9:CD010328. [Epub ahead of print]

Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation.

Rasouli MR¹, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R.

http://www.ncbi.nlm.nih.gov/pubmed/25184502

Are Restrictions Post Discectomy Necessary?

After lumbar disk surgery,  there is a common misconception that all future activities must be restricted.  There is more and more evidence indicating that the vast majority of post lumbar discectomy patients can and should be able to return back to all activities.  

Like all things in Medical Treatment.  There is a constant evolution of thoughts and processes.  Thirty years ago,  patients were admitted to hospitals for procedures such as carpal tunnel surgery.  They stayed admitted until the wound was healed.   Now,  select patients are even getting knees replaced on an outpatient basis.

Likewise,  there is a change in post surgical management,  in terms of restrictions.

Traditionally,  post lumbar discectomy patients were placed under protective restrictions.  Some recommended bedrest.  Others restricted any future lifting of any significant weight.  Traditional post lumbar discectomy therapy regimens varied from no therapy,  to delaying therapy for the first six weeks.

Meta analysis of various papers regarding post lumbar discectomy activities restrictions,  and post lumbar discectomy rehabilitation has been essentially inconclusive about the necessity of either process.

Many physicians,  including myself, encourage post lumbar discectomy patients to return back to all activities within 4-6 weeks.  Also,  from the stand point of costs and the need for formal therapy,  most analysis conclude there is no difference in outcomes for post lumbar discectomy patients, with or without formal physical therapy.

By no means am I suggesting Physical Therapy is not helpful for spine patients.  But in terms of improving the patient after lumbar discectomy surgery,  there is no identifiable advantage.  This may make sense,  as the reason the patient had surgery,  the herniated disk ,  has now been removed.  Therapy is no longer necessary to restore the patient back to function.

In terms of activities restrictions,  once the offending disk herniation has been removed,  the irritated nerve now has the ability to recover.  Restrictions are no longer necessary.

Some patients do have recurrent disk herniations and recurrent pains.  Some will blame the surgery for the recurrence of symptoms.  But,  the truth is,  the recurrent disk herniation is not secondary to the surgery,  but rather because the original reason for the first disk herniation is still present.  The tear in the annulus,  and the dessication of  the disk is a continuing process.  Reherniation will occur regardless of the surgery in most situation  ( be aware,  there is a study indication some types of discectomy surgery is associated with increased rates of reherniation,  but most will agree,  the root cause of disk herniations is still secondary to the original cause of the herniation,  rather than a specific technique).

If you are to have Lumbar Discectomy Surgery,  it is highly likely that you will be able to return back to ALL activities.  Ultimately,  however,  you need to speak to your Surgeon to determine if you should get back to everything.  Sometimes,  your Surgeon may have another concern that will necessitate activities caution.

REFERENCES:

 1. Spine (Phila Pa 1976). 1999 Nov 15;24(22):2346-51.

Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions.
Carragee EJ1, Han MY, Yang B, Kim DH, Kraemer H, Billys J.

 2. Spine (Phila Pa 1976). 2008 Jan 1;33(1):33-8. doi: 10.1097/BRS.0b013e31815e3a42.

The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level.

Dewing CB1, Provencher MT, Riffenburgh RH, Kerr S, Manos RE.

Am J Sports Med. 2011 Mar;39(3):632-6. doi: 10.1177/0363546510388901. Epub 2011 Jan 10.

Return-to-play rates in National Football League linemen after treatment for lumbar disk herniation.
Weistroffer JK1, Hsu WK.

3. Cochrane Database Syst Rev. 2014 Mar 14;3:CD003007. doi: 10.1002/14651858.CD003007.pub3.

Rehabilitation after lumbar disc surgery.

Update on Adjacent Segment Degeneration

There remains considerable controversy on the nature of Adjacent Segment Degeneration after lumbar fusion.  To the non-spine surgeons,  the issue is the theory that a fusion operation places more stress on the levels above or below the fusion,  and will lead to accelerated degeneration and subsequent surgery.  In fact,  most surgeons will tell patients about the risk for potential future surgery after lumbar fusion.

The skeptic will say the surgeon is just setting up a biase towards future surgery.   Some will say lumbar fusions are not great surgery,  and the rate of future surgery is so great that the primary lumbar spine fusion surgery should be avoided.   Several studies have showed a rate of additional future lumbar spine surgery after fusion at 10-15% over 10 years in the US population.  Spine surgeons like me,  need some guidance,  so we can appropriately discuss the effects of lumbar spinal fusion,  and the potential for increasing back pain,  and subsequent surgery after the fusion.

Recently,  there has been much interest in the so called Minimally Invasive Spine Surgery (MIS),  and potential benefits of this approach in lumbar fusions.  The major advantage,  according to the researchers on MIS is the sparing of the lumbar multifidus muscle.  It turns out the multifidus is probably the main stabilizing muscle of the spine,  and preservation may indeed also prevent the development of the Adjacent Segment Degeneration associated with lumbar fusion.

The most relevant study regarding was recently published in the August 1, 2014 Spine,  was the ISSLS Prize Winner and is titled “Long Term Follow-up Suggests Spinal Fusion is Associated With Increased Adjacent Segment Disc Degeneration But without Influence on Clinical Outcome: Results of a Combined Follow-up from 4 Randomized Control Trials” and authored by Anne F. Mannion, PhD, et al.     To summarize,  four sites,  representing locations in the United Kingdom,  Norway and Sweden followed patients for an average of 13 years randomized to surgery or non-surgery for painful lumbar disk degeneration.   Pre-operative x-rays were obtained.  The patients themselves had chronic LBP for more than a year,  with the suspected cause of the pain secondary to degenerative disk disease.   Inclusion criteria for the randomization included the use of several disability scales including the Oswestry Disability Index. Long term followup was obtained in 272 fusion patients,  and 92 non-surgical patients.   The results of the comparison of fusion vs non-fusion is another topic.  This paper looked a the effects of fusions on development of Adjacent Segment Degeneration.

X-rays were compared between the groups.  In both groups,  there was development of disk space narrowing.  In other words,  with or without surgery,  both groups had degeneration of the disks that were compared.  The study also showed the disk narrowing of the surgical patients were of a great magnitude.   But after statistical analysis,  there were no evidence that the increased degeneration associated with the fusion patients led to any difference in clinical outcomes.   In otherwords,  the difference in the amount of degeneration between the fusion,  and non surgery group did not cause any more disability or back pain.  Based on the prospective nature of this study,  I can conclude that adjacent Segment degeneration after spine surgery does not lead to more surgery secondary to the fusion.  This may or may not be what Surgeons want to counsel,  but it looks like it is the truth.  Based on latest research,  Surgeons can say  Spine Surgery is always a possibility for any spine patient, but the need for additional surgery  most likely is not related to a prior Lumbar Fusion.

Spine Surgery Risks, Benefits, Alternatives

Currently, we perform spinal surgery on Tuesdays.  About a week or so before the operation,  I ask surgical patients to come to the office to have a discussion about the surgery.  I encourage patients bring a family member for support during that visit,  as we will need to discuss the Spine Surgery Risks,  Benefits and Alternatives.

Our practice is oriented towards elective outpatient spine surgery.  It usually means people have had the chance to let their condition improve with non-surgical means.  To me,  those are the Alternatives.  For at least 6 to 8 weeks,  patients should try to get better without surgery.  There are certain situations where the situation is emergent,  and you cannot wait as there may be irreversible harm.  That is not considered elective spinal surgery.  I am not talking about that situation.   I am talking about people who have disk herniations,  or bone spurs in the neck or back,  that cause pain,  and numbness and weakness, but still manageable,  at least in the short run.  For patients in that situation,  there is a good chance you may get better without needing surgery.   Treatments such as Physical therapy,  Chiropractic Care,  Medications,  cortizone injections,  Massage therapy,  or accupuncture can help you cope with the pain,  weakness and numbness.  The body does have an amazing ability to heal many things,  including disk herniations,  and nerve irritations caused by bone spurs.  Please give these alternatives a try.  Remember that less than 3 % of patients with disk herniations or bone spurs ever actually get spinal surgery.  The odds are in your favor in terms of improving without surgery.

If you are not improving despite the alternatives,  please understand the potential Benefits of the surgery.  In prior blogs I have stated the two main goals of Spine Surgery is to remove a nerve irritation,  and to stabilize an unstable spine.  I encourage you to find out what are the goals of the surgery.  That is the benefit.  If there is a nerve irritation caused by a disk herniation, or bone spur,  the goal is to remove the disk herniation or spur.  As long as that objective is met,  there is a great likelihood you will improve and consider the surgery a success.  For patients with instability,  or abnormal spine movement causing the pain,  the goal is to stabilize the spine.  Usually that is accomplished by fusing the spine.  As long as there is a significant instability,  fusion can have good outcomes.  Understand,  however,  that longer fusions,  with more complexity is associated with poorer results than single level fusion surgery,  or surgery for nerve irritation.

Surgeons usually do not like talking about the Risks,  as Surgeons do not want the patients to worry,  or back out of  the operation.  In my opinion,  the discussion about the Risks is very important,  as the patient needs to understand the potential for a less than perfect outcome.  The biggest risks are that the patient is not satisfied with the outcome.  Then Surgeon must discuss the anticipated results with the patient so they have a good understanding of the expected benefits of the surgery.  A too common scenario is the one where the Surgeon thinks the operation went great,  but the Patient is disappointed.  In that situation,  there must have been a communication lapse as each party has a completely different assessment of the results.  Please make sure you have a thorough conversation about the expected outcome.  Sometimes the outcome is not achieved.  From my experience,  the expectation of the patient may not have been achieved,  although the outcome is consistent with the goals of the Surgeon.

Other risks include complications related to the patient health status,  such as issues with the heart and lungs.  Infections after surgery is a possibility,  especially after the larger operations.

In terms of risks specific to spinal surgery,  the more common ones include flare up of nerve pain,  leaking of spinal fluid,  and residual nerve compression secondary to unidentified disk fragments or bone spurs.

In addition,  with patients who have been on chronic narcotic medications,  and nerve medications,  there is a paradoxic increasing of pain secondary to the pain from the surgical incision and manipulation of the nerve.  This one usually does settle down with time,  although the first few weeks can be tough.

For surgeries requiring metal hardware insertion,  there is always the risk or metal hardware malposition,  breakage and migration.

For fusion surgeries,  there is a chance the fusion may not completely mature.

As you can see,  prior to having your surgery,  please spend adequate time to explore the Risks, Benefits and Alternatives of Spine Surgery.  If you cannot seem to understand those issues,  or if you cannot get an adequate explanation about them,  you might consider post-poning your surgery,  or getting another opinion.

The Hypocrisy of Non-Surgical Care

Of course you should pursue non-surgical care if you have that option.  Surgery should be reserved for emergent life and limb threatening situations,  or in circumstances where there is a well defined goal,  with reproducible results.   We all agree Surgery can be an expensive option.  However,  if you do the value analysis,  it can still be worth the costs.  I have previously blogged about the positive effects of discectomy surgery in the properly selected patient population.  It leads to better long term outcomes,  with increased work productivity.    The media,  and certain Non-Surgical specialties would like to discount the advantages as it helps with the negative narrative about surgery.

Certainly we all agree that there has been excessive utilization of some surgical techniques.   Minimally Invasive Spine Surgery has become big business in the country.  Unfortunately,  as the Marketing arm of these Minimally Invasive Spine Surgery companies take the lead,  it does become more about the profit,  than the outcome.   While increased scrutiny has exposed these companies,  the spill over effect to other Spine Surgery Professionals has created a challenging environment for thoughtful and conservative Surgeons.

The Non-Surgical Care Specialists have also piled on,  advertising about the “radical nature”  of surgery  and highlighting the failures. Some of these Non-Surgical Care Specialists exploit the truth about certain medical conditions.  In regards to Spine Problems,  it is unavoidable,  as everyone will develop some spine degeneration with age.  Also,  the natural history of most initial episodes of pain is that it gets better no matter what.  Because of this self-healing process,  some of the Non-Surgical Care Specialists will take credit for the bodies own ability to heal at least the initial episodes of back pain.

In my opinion,  the most significant Moral Hazard to Non-Surgical Care Specialists is in providing care in chronic degenerative conditions.  The truth is WE ALL AGE,  we all degenerate,  and it will manifest in pain,  stiffness and weakness.  I encourage my patients to accept this fact,  and try to compensate around the edges of the process by exercising,  keeping the weight down,  and being realistic about activities.  Every day,  I have a conversation with someone about their neck and back,  and how they want to be able to do things they did years ago.  As I always say,  there are some situations that warrant a surgical intervention.  It will let you return to being active for your age.  A 60 year old man,  post certain surgeries,  can return back to being an active 60 year old.  It is like the Fountain of Youth,  if that 60 year old was acting like an 80 year old.  But surgery can only restore you back to your age,  not earlier.   For some Non-Surgical Care Specialists,  they advertise their treatments will REVERSE the aging.  We know that cannot be true.  Also,  I have seem many Non-Surgical Care Specialists recommend MAINTENANCE therapy.  In other words,  it does not make you better,  but at least you are not getting worse.  While that may sound reasonable,  the question is why are you doing the same treatments that are NOT MAKING YOU BETTER?  I agree that many will not have a surgical solution.  That does not mean you should continue the same therapy that does not work.  Sometimes you just need to accept that it is what it is.

In my opinion, the greatest treatment scrutiny should be with some of the Pain Management Specialists.  While most are truly there to help and guide their patients,  some are burned out,  and exploitative.  Rather than trying to prevent developing addictions to medications,  and providing counsel on the nature of chronic pain,  some just become a legal automatic narcotics dispensary.  The Medical Governance Entities are concerned about an unwritten deal with the patients.  “If I provide your narcotic prescriptions,  You will let me perform injection procedures that generate income for me”.  Fortunately,  that last scenario only occurs in a small minority of the Non-Surgical Care Clinics.  While some of these practitioners bash ineffective surgical treatment,  they turn a blind eye to their own particular distortions.

The facts are the facts.  Sometimes,  you need Surgery.  Do not let the Hypocrisy of the Non-Surgical Care Specialists prevent you from getting the necessary evaluation.

The Unintended Consequences of a Spine MRI

So,  you have spine pain.  In the USA,  there is a natural tendency to want to get a Spine MRI as soon as possible.  We are in an instant information society,  and it would make sense that we would want to instantly see if there is a problem in our back.

Naturally,  there is aways the concern that the source of spine pain is something very serious.  We have all heard of situations where a MRI identified an unknown broken bone,  an infection,  or worse,  a tumor.   The reality is,  these bad things would have been discovered without a MRI.  By obtaining a good history of the person,  clues such as a recent traumatic even,  severe progressive pain,  developing numbness and radiations,  etc. are the clear signs that something is wrong.  You do not need the MRI to find the problem.  The MRI does help you better define the extent of the problem,  but that is not the same as the MRI will discover the problem.   These serious conditions will be identified by your Physician,  as long as you have established a good relationship with the physician,  and (s)he knows your health history well.  One reason many look for the MRI is secondary to the  lack of trust of the Primary Physician.  That reason may be secondary to the changing nature of medical care.  Our Primary Care Physician is asked to manage a larger and larger number of patients.  Without the individual care,  it is not a surprise Trust is not what it should be.

Media has also changed the way we look at MRI’s.  Most of us follow a sports team,  or a favorite sports athlete.  The instant reaction of Team Physicians are to get MRI’s of players almost immediately after the injury.  We have to remember professional athletes do not look at pain the same way normal people do.  These Athletes will play through significant pain.  MRI’s are used to identify dangerous situations to the players since pain is not a factor to discontinue play for those athletes.  You must remember these players usually are playing with broken fingers,  bruised ribs,  pulled muscles all the time.  The MRI is used to make sure the injury is not limb or career threatening.   In other words,  MRI’s have a very different goal in professional athletes versus us normal people.  Yet,  we think we should have the same treatments as those athletes.  If you go by that standard,  there would be very few “Doctor’s notes” for missing work.  If the MRI does not show a limb or career ending finding,  you will be put back to work.  Be careful  wanting the same standards as the Athletes.  Besides,  there are others reasons not to get a MRI.

Unfortunately,  there are unintended consequences to obtaining a Spine MRI.

1. MRI’s are very costly.  While the costs may vary,  total costs,  including the Radiologist interpretation can average near $1000.  In the USA,  one source indicates there were 7.5 million spine MRI’s performed in the US in 2010.  There has been a concerted effort by both Government and Private insurance to minimize the use of this procedure.  More strict criterion for authorization is coming.  Unless there is a very compelling reason,  most must now show at least 4-6 weeks of conservative treatments such as medications,  supervised exercise/PT or chiropractic care,  and signs of nerve irritation before an MRI is authorized.   Naturally,  you can pay for one out of pocket,  but unless you meet the criterion,  usually, the insurance provider will balk at paying for it.

2. Multiple studies suggest early use of MRI in patients that do not meet the criterion for getting an MRI definitely had increased utilization of additional testing,  and treatments including surgery. Some will question why these patients will receive surgery that may not have been necessary.  The answer is secondary to the nature of surgical opinions.  The default position of Surgeons is to offer surgery.  While the intentions are always noble,  Surgeons do look at diagnostic studies from the perspective of surgical management.  At the time of clinical presentation,  surgery might not be warranted.  The MRI however,  may show what is considered a surgical problem.  The typical recommendation is to give non-surgical means a chance,  however,  if the patient desires,  surgery can be an option.  Once the possibility of surgery has been discussed,  rationalization behavior may lead to surgery,  even though the clinical situation may not be idea.  There are non clinical factors that contribute to the use of surgery.  That is why most will agree that early use of MRI’s in the workup of spine problems can lead to greater surgical frequency.

3.  MRI studies may identify findings that are not related to the pain.  Many findings on the MRI are pre-existing to the complaint,  and can result in treatments for findings that have no bearing on the current clinical situation.  An example is a Spine MRI that identifies a disk herniation on the opposite side of the pain.   Another example is a Spine MRI that identify multiple disk herniations,  but the symptoms are very consistent with impairment of a single nerve root.  In these situations,  the findings are not the source of the problem,  yet some practitioners will continue to offer treatments based on these findings.  This is a corollary  to the point #2.  These findings will be part of the differential diagnosis,  and will likely receive some form of treatment,  even though it is not the source of the complaint.  Currently,  the default position is to over treat the situation,  and cause the many unintended consequences.    A scenario that comes to mind is a patient with a brief episode of back pain,  that resolved,  but the MRI identifies a large disk herniation.  The person is cautioned about activities,  and as a result,  is fearful to participate in work activities,  recreational activities,  and family activities.  You can imagine the ramifications of this reluctance. This is in the face of an otherwise completely normal physical examination.

3.  MRI findings on asymptomatic individuals now document a potential problem.  In terms of the insurance industry,  now that person is considered a risk.  It may result in premium changes for disability application.  It may have a negative impact on a personal injury claim in a future accident.  I know personally on one Physician who had MRI’s of their neck and back under a pseudonym, as that Physician was concerned about the future ramifications of the MRI findings.

The bottom-line is a Spine MRI has consequences that may not be obvious to the average person.  Please consider the unintended consequences before you request your Physician do what he can to try to obtain your MRI,  even though you do not met the criterion.   While it is true various entities are trying to limit the use of these studies,  the effects of a Spine MRI is not just an expense to the insurance company.  It can also start a process that could cause unnecessary treatments,  and risks to you.

As I was finishing this blog,  I came across a recently published article:

In the August 1, 2014 edition of Spine,  there is an article titled “The Cascade of Medical Services and Associated Longitudinal Costs due to Nonadherent Magnetic Resonance Imaging for Low Back Pain” by Barbara S. Webster, BSPY, PA.   To define,  nonadherent MRI means an MRI that was obtained while the patient did not meet the criterion for the MRI.  This study was also done on the worker’s compensation population.  Still the study again showed increased utilization of expensive services,  including surgery despite the patients not meeting the indications.

The Art of Surgery

Not long ago,  I had an interesting debate about Science,  Art and Medicine.  To some,  the discipline of Medicine is only an application of the most relevant  scientific data.    In my opinion, there are many things wrong with that statement.  First of all,  how do we know the most recent scientific evidence is correct?  Many times,  we have later discovered a fallacy in our scientific doctrine.  Second,  while some scientific situations can be reproduced by controlling for all but one variable,  patients always present with many variables.  There are no  scientific studies that have controlled for every variable unique to any one patient’s medical situation.  The scientific method still  derives the best estimate of what should be done in a very narrowly defined setting.  We must realize the recommendations for any one patient is based on extrapolations,  instead of any true scientific data specific to that patient’s situation.

The Goal of a Physician is to provide the best advice, and to utilize the best scientific evidence to formulate a plan for a certain health concern.  It is not as simple as that sounds. As alluded to above, there are often conflicting situations that cause complex interactions.   Some will argue that the science of Medicine has made treatments very algorithmic,  and any qualified Physician should be able to achieve the same outcomes.  If all we needed is a cookbook,  we would just need to train more Cooks,  not Physicians.

WE KNOW  EXPERIENCE MATTERS.  Experience gives the Physician the ability to identify when a situation needs to be taken out of the algorithm.   Experience and skill dictates customization of a treatment plan for that patient.  The ability to know when to change out of  the algorithm, in my opinion,  is where Medicine becomes ART.   The ART of Medicine  is why some Physicians have better outcomes than others.

This ART  is why Physicians Train under the guidance of mentor Physicians for many years.  As a Surgeon, in my opinion,  the most demanding Medical ART,  is the ART OF SURGERY.

I am sure the reader knows that diagnostic testing have significantly improved the ability to define the health problem.   For Surgeons,  the testing will define the SURGICAL GOAL. Of course I am greatly simplifying this,  but assume every test indicates the need for the same treatment option. With the known scientific data,  the Surgeon knows the anticipated  effects of the planned surgical approaches.  Still,  there will be unknown subtle anatomic differences,  tissue quality nuances,  and the important variable of  medical co-morbidity factors come to play when a person has anesthesia.  While the goal may be based on science,  how to achieve the goal demands the ART of SURGERY.  What comes second nature,  is  based on practice and  experience.

To make the Analogy,  someone commissioned a Sculpture of the Madonna and Child.  That would be the science,  the Goal.  Make a Sculpture of Madonna and Child.  It took the Artistry of Michelangelo to sculpt the Pieta‘,  that magnificent statute that now sits in the Vatican.    Now it is way too presumptuous of Surgeons to compare themselves to Michelangelo,  but the analogy definitely fits.    The scientific data (the commissioning of the Sculpture) leads to the  Surgical goal.  The Surgeon must now create that surgical goal by artfully,  carefully dissecting into the body to create,  reconstruct,  remove, with minimal harm,  and with safety  to the patient.  A different Artist would not have  created the Pieta’.  Another Surgeon may not have had the same results.

I can remember the first time I had to draw blood on one of my fellow medical students.  It was winter,  in Syracuse New York.  Everyone was wearing a sweater. It was cold.   I had beads of sweat rolling down my neck as I tried multiple times to draw blood from my classmate.  We watched  our instructor again.   I was awed by the artistry of the blood draw technician.  So graceful,  confident,  painless.  When would I ever learn how to do that?

As Surgeons, we open patients to reconstruct their spine,  and return them to function.   We  know exactly where to put the incision,  how to dissect each muscle plane,  how to gently free the damaged and compressed nerves.  We have an internal clock that tracks the cadence of the  operation.  We have a sense of the patients overall status as we move onto the next part of the surgery.   We have instinctively established a back up plan in case situation 1, 2, 3, or 4 is encountered.  We have an exit strategy in case the Anesthesiologist states the Patient’s medical status is unstable,  and we must close immediately.   It is the culmination of science,  skill, and experience.  It is the leadership to orchestrate the whole medical team to positively effect a persons health. It is the confidence instilled in the patient about the decision.  It is the ART of SURGERY.

Who do you want Sculpting the Madonna and Child?

Are you Confident the Provider is using the most up to date Cookbook?

Spine Arthritis

Spine Arthritis has many forms.  The most common is secondary to the natural aging process.  While there are many scientific studies on why we get arthritis,  we have to accept the fact that our bodies are programmed to degenerate over time.  All things wear out over time.  The human body does have an amazing ability to heal injuries, but the process of wearing out continues.  In the spine,  much of the process of wearing out is mediated through the disk.   This wearing out process is called the Degenerative Cascade.

In this process,  the intervertebral disc,  which functions as a ligament,  a spacer and a shock absorber, begins the process by drying up,  or dessicating.   The center of the disc contains proteoglycans,  which binds with water to form a gelatinous cushion within the disc.  Over time,  there are subtle changes to the proteoglycans,  and the water leaves the disc.  Without the water,  the disc,  which originally looks like a hockey puck,  starts to loose the tightness of the outer wall.  The wall starts to bulge,  similar to air leaking out of a car tire.  In addition,  the height of the disk wall starts to shrink.  When the side walls shrink,  the normal orientation of the joints of the spine,  called the facets change,  and the cartilage that lines the joints experience increasing pressure.  In addition,  as the disk wall shrinks,  the ligaments attached to the spine bones,  and the tendons attached to the spine muscles are no longer tight,  but loosen,  allowing increasingly abnormal motions across all the structures.  This directs additional abnormal forces onto all the structures,  and starts causing fraying,  and injury to the cartilage,  bone,  and tissues.   By this process,  you develop narrowing of the spaces that house the nerves,  and for bone spurs secondary to the pull on the bones.  In addition,  the body will try to decrease the forces experienced by the bones by increasing the surface areas of the joints,  thus enlarging and hypertrophying the facet joints.  This is the process of developing  Spinal Arthritis.  Broken bones,  and disc herniations can also accelerate this process.

Other forms of Spinal Arthritis is secondary to auto immune problems,  where the body falsely thinks certain tissues are foreign,  and tries to eliminate these tissues.  That is the process of Rheumatoid Arthritis,  and similar ailments.  This form of Spine Arthritis can be rapidly devastating,  and lead to significant spinal instabilities that may require surgical correction.

Unfortunately,  Spine Arthritis is a common problem to any community.  We can all try to minimize its effects by low impact aerobic activities,  weight management,  smoking cessation,  and activities modification.

If you have increasing pain caused by Spine Arthritis,  please have it evaluated.  For some,  surgery may provide an excellent solution to related nerve compression,  or spinal instability.

Lumbar Synovial Cysts

Lumbar Synovial Cysts or Facet Cysts can be a source of pain to the back.  In most situations,  formation of these cysts are typical of the manifestations of degeneration and arthritis of a joint.  In the knee,  the Synovial Cyst is also called a Baker’s Cyst.  The arthritic condition of the knee causes production of fluid in the knee joint.  Because of the fluid buildup,  sometimes a small opening occurs in the joint capsule,  and a bubble develops with the fluid.  Over time,  the bubble enlarges,  causing the development of the so called Baker’s Cyst.  The Cyst,  is caused by the arthritis and fluid production in the knee.  By definition,  you need some internal joint irritation such as arthritis,  or synovitis to cause the development of the fluid.   This is the exact same process that occurs in the lumbar spine,  leading to the Lumbar Synovial Cysts, or Lumbar Facet Cysts.  In the Spine,  however, the joints are much smaller,  and there are often nerves closely oriented to the facet joints,  thus,  there is potential to develop a pinching of the nerves,  or spinal stenosis.

Saggital MRI view of a Lumbar Synovial Cyst or Facet Cyst

In relationship to the Lumbar Synovial Cysts,  the fluid builds up and escapes the facet joint,  and can either bubble away from the nerves,  or in the more painful situation,   bubble into the space that is normally occupied by the nerves.  In the above featured image,  it represents the Axial MRI view of a lumbar spine,  with an obvious fluid filled cyst emanating from the facet joint.  It causes a well defined “bubble”  that crowds into the spinal canal,  and resulted in nerve irritation.  The facet cyst’s lining is well defined,  and took many months to develop.  Initially,  the cyst may grow very slowly,  and the body can accommodate the subtle pressure on the nerve.  But,  at a certain amount of pressure,  the Cyst can become symptomatic,  and cause both back and nerve pain.

For some Lumbar Synovial Cysts,  movement of the facet joint can increase or decrease the fluid collection within the cyst.  During surgery,  Surgeons can see some of the Cysts located outside of the canal increasing or decreasing in size as we mobilize the facet joints.  I am certain that also happens to some of the cysts located in the spinal canal,  but  not always.

Lumbar Synovial Cysts or Facet Cysts that have two way movement of fluid in the Cysts are potential amenable to injections of corticosteroids.   The  so called Facet Injection can  decrease the size of the cyst,  and relieve some of the pains associated with the mechanical pressure.  In addition,  injections of the corticosteroid also decreases the inflammation associated with the joint arthritis or synovitis.

For other Lumbar Synovial Cysts or Facet Cysts,  there is a ball-valve type mechanism that only allows fluid to move into the cyst,  and not back out.  In this situation,  Facet Injections may still be beneficial,  but  many Surgeons will opine that long term,  only Surgery will solve any nerve compression caused by the Cyst.  Surgical options include removal of the cyst as well as removal of the bone spurs that caused the cyst.  Other options include surgical fusion of the effected facet joint.

Lumbar Synovial Cysts are almost always associated with degeneration,  and commonly occurs later in life.  It is a relatively rare occurrence in Young Adults.

Lately,  I have been asked about development of Synovial Cysts in relationship to Trauma.  In my opinion,  patients with pre-existing facet degeneration can have increasing back pain after trauma secondary to exacerbation of  the underlying degenerative condition.  However,  development of a Synovial Cyst,  by definition,  is secondary to fluid buildup from prior arthritis or synovitis.  While trauma may make  a cyst more symptomatic,  it does not cause a Lumbar Synovial Cyst.  As these Cysts typically present in older patients,  it is more likely that a Synovial Cyst identified after trauma is an incidental finding,  rather than an acute new injury.  In young adults,  the presence of synovial cysts are so rare,  that there needs to be concerned about other underlying medical conditions such as prior degeneration,  rheumatologic conditions,  or other joint inflammatory conditions.   Most Spine Specialists  give a concensus opinion that Lumbar Synovial Cysts are a manifestation of a degenerative process effecting a Lumbar Facet Joint,  and the subsequent development of a Synovial Cyst.  Trauma,  in isolation,  cannot cause a Lumbar Synovial Cyst.

The MRI and Myelopathy

Lately,  I have seen a few patients that have been told they had Myelopathy.  After evaluating them,  I was certain that they have been misinformed about the nature of Myelopathy.  In the most simplest definition,  Myelopathy means irritation or damage to the spinal cord.

The confusion is secondary to the definition of irritation or damage to the spinal cord.  Some will confuse neck pain as irritation to the spinal cord.  Most experienced spine specialists agree that neck pain is a very vague term,  and neck pain can be caused by many other things.  While you may have neck pain,  you can also have Myelopathy,  the neck pain is not the reason you have Myelopathy.  In other words,  neck pain,  by itself does not indicate there is a true spinal cord irritation or damage.

In laymen’s terms,  Myelopathy is associated with measurable weakness to the arms and/or legs,  walking disturbance,  loss of control of your bladder or bowels,  and sensation changes with feelings of numbness or tingling that can be identified by physical examination.

The most common causes of Myelopathy is secondary to bone or disk encroachment onto the spinal cord.  If it happens in a traumatic fashion,  it is considered a spinal cord injury.  Some will say it is the beginnings of being paralyzed by your spinal cord being crushed.  In traumatic causes of Myelopathy,  the presentation is typically rapid,  with identifiable, and measurable weakness,  sensation loss,  walking difficulties,  and bowel/bladder issues.   Usually,  a spinal cord injury protocol is necessary,  with use of high doses of steroid medications,  and testing such as MRI’s and CT scans to see if there is an associated fracture,  instability,  infection, large disc herniation  or tumor that is causing the rapid development of symptoms.  Usually surgery needs to be considered when the patient is medically optimized.

In a more insidious development of Myelopathy,  it is secondary to the slow development of spinal stenosis over time.  The spinal cord is slowly squeezed by the bones and tissues,  until it can no longer accommodate the pressure.    This usually happens in the older population.  Spine Surgeons usually look for specific signs such as the Hoffman’s sign,  or L’Hermitte’s sign to help identify the Myelopathy.  Physical exam findings also include weakness to the arms and legs,  clumsiness in walking,  and coordination difficulties.  In this form of Myelopathy,  it can be monitored,  but most agree that surgical opening of the areas squeezed will give the best chance to prevent progress,  and possibly reverse the effects.

As I stated above,  recently,  I have seen a few people who were told they had Myelopathy.  After evaluating them,  I did not identify any of the above signs,  or physical findings.  The only complaint was neck pain,  with some vague intermittent tingling at times.  In my opinion,  there was no evidence of Myelopathy.  That should have been a great relief for that person,  as most Myelopathy patients need to consider surgery as they are at risk of progression of the spinal cord irritation,  and damage.

After further examination,  the reason the person was told they had Myelopathy is secondary to an MRI finding.   The MRI did show a disk herniation touching the spinal cord.  But,  without evidence of spinal cord irritation,  this does not mean that person had Myelopathy.   There must have been a misunderstanding of the explanation to the person,  or the Physician was not a spinal specialist.   Just because there is an MRI finding,  does not mean you have Myelopathy.  You must have physical evidence of spinal cord irritation,  or spinal cord damage to call it Myelopathy.

As a Surgeon,  it would be great if all we needed is MRI or CT evidence of a Disk Herniation touching the cord to recommend surgery.  It would mean every Spine Surgeon would be incredibly busy fixing all these people with spinal cord irritations or damages.   That is not the case.  You must justify performing risky Spinal Surgery by identifying people who are having objective findings of spinal cord irritation or damage,  not just an MRI showing a disk or bone pressing or touching on the spinal cord. Just having complaints of neck pain,  and complaints of numbness is not enough.  You should have objective physical findings.

On the other hand,  if you truly have Myelopathy secondary to Cervical Spondylosis,  you should consider your surgical options as Myelopathy is a progressive process.  In addition,  secondary to the spinal cord irritation or damage,  you are at an increased risk of having a much more significant Spinal Cord injury by even a very trivial incident like a fall,  or  bumping your head.

The North American Spine Society has produced a nice Vignette about Cervical Myelopathy.

How much Chiropractic Care is Reasonable?

This is a very common question asked by my patients. In the past, I could only suggest the patient speak to the Chiropractor and discuss the costs versus the benefits. There has been some information collected and discussed by the RAND Corporation in the early 1990’s.  Recommendations of Chiropractic treatments varied between 1-5 visits a week,  for 2-24 weeks.    By the mid 1990’s an all Chiropractic Expert panel assembled by Rand Corporation recommended 30 visits for chronic back pain over 14 weeks.

By 2003,  efficacy studies on the effects of Spinal Manipulation on chronic back pain did not demonstrate an advantage over other treatment methods.  There are many ways to interpret that information.  The skeptic will say it demonstrates all treatments are equally not effective.    When analysing the importance of that statement,  we need to understand that up to 40% of patients who receive treatments for back pain go sees a Chiropractor.   Naturally,  in this era of evidenced based medicine,  there is research being done on the  efficacy, costs,  and the appropriateness of duration of treatments.    Recently,  in the SPINE JOURNAL,  the official Journal of the North American Spine Society,  a paper was submitted by Haas,  Et al  titled  “Dose-response and efficacy of spinal manipulation of care of chronic low back pain: a randomized controlled trial“.   The lead author Mitchell Haas,  is a Chiropractic Physician with significant research experience.

400 participants with chronic low back pain were randomized into four groups, and received 0, 6, 12 and 18 Chiropractic Manipulations.   All participants had 18 visits,  3 per week for 6 weeks.  For those who did not  receive Chiropractic Spinal Manipulation on the visit,  they were given light massage therapy,  to provide attention and touch by the provider.    Followup was by phone interview on a 6, 12, 18, 24, 39, and 52 weeks from the conclusion of treatments.

You can read the study for details,  but the authors conclude  the number of spinal manipulations has a modest positive effect compare to gentle massage therapy.  Also,  12 visits has the most favorable results.  The authors also stated that “Even with 12 visits, the contribution of Spinal Manipulative Therapy to outcomes beyond that of a focused light massage delivered by a chiropractor (hands-on control) was a best modest at the 12-week primary endpoint and negligible at the 24-week primary end point”.

The study suggests there is no additive benefit for more manipulations after 12 visits over 6 weeks.  Certainly clinicians may have disagreements with the results of the study.  However,  in the Era of evidence based medicine,  each treatment will undergo efficacy and value analysis.  It behooves the Chiropractic Community to develop studies to explore their recommendations,  and back up the recommendations with scientific, unbiased data.  The payers,  which include insurance, and the government no longer accept just the clinical judgement of the medical professionals.  In the end,  patients can always choose to purchase these services regardless of the scientific data.  Third parties,  however,  are starting to demand evidence of value.

To my Chiropractic Colleagues,  do not run from the coming changes.  Rather,  start doing research and prove the need for your services.  Or,  develop personal bonds with patients so they can advocate for your intangible value.

Outpatient Anterior Cervical Discectomy and Fusion

In times past,  people were admitted to the hospital for the simplest of surgical procedures.  In the 1970’s,  a two week admission to the hospital for a simple carpal tunnel surgery was routine.  People would be admitted  a day or two before surgery to get testing.  Surgery was then performed.  Then,  the patient was discharged when the wound was almost healed.  Fast forward to today,  the patient arrives at the surgery center,  90 minutes before the operation.  the carpal tunnel operation is performed with a form of local anesthesia, with mild sedation.  The patient is discharged from the surgery center within two hours of the operation.  Imaging the cost differences,  the convenience factors,  and the worker productivity issues.

Spine surgery is also becoming more and more of an outpatient surgical procedure.  While simple back discectomy routinely go home on the day of the operation,  there has still been some hesitancy about doing Anterior Cervical Discectomy and Fusion surgery on an outpatient basis.

I will confess that two years ago,  I still admitted patients to the hospital,  and closely monitored them  before discharging the patients the next day.  The concern was about potential breathing problems after the surgery.  There is reports that a small percentage of patients who have this surgery may develop some difficulty breathing.   Usually it is secondary to development of a blood clot,  or hematoma.  The other factor is patients with prior respiratory problems.  Other studies indicate it may also be related to the length of time for the surgery as well as the number of levels being fused.

For the past two years,  I have discharged most of my Anterior Cervical  Discectomy and Fusion patients on the Day of surgery  with much greater patient satisfaction,  and reduced costs.

A recent study by McGirt et al demonstated the efficacy of one and two level Anterior Cervical Discectomy and Fusion Surgery performed on an outpatient basis.  There were no additional complications,  and the cost savings average $7k.

In my practice,  I now assume healthy patients,  without prior breathing difficulties,  and no history of developing hematoma blood clots are scheduled to leave the surgery facility that day.  For others with risk factors,  I will continue to admit overnight.  In my opinion,  this is the right balance between sending everyone home as an outpatient,  versus keeping everyone admitted overnight in the hospital.   I find most patients would rather sleep in their own bed,  and eat their own food.   Only those who have potential risks such as more than one level surgery,  prior neck surgery,  asthma,  use of blood thinners,  or poor medical conditions need to stay as an inpatient.

Returning to Work After Lumbar Discectomy

Back and leg pain cause a significant number of people to miss work,  and lose income.  Many people are worried about their jobs,  and some suffer immensely,  while trying to put food on the table for the family.  In times past,  people worried that back surgery will lead to a permanent disability situation.

Fortunately,  there has been a recent study about this very topic.  In April, 2014  Lane Koenig,  et al  published this article:

“How does accounting for worker productivity affect the measured cost-effectiveness of lumbar discectomy?”

The study basically followed a population of workers and studied the effects on disk herniation surgery on the worker’s earnings as well as post surgery missed workdays.

The results were very favorable to having surgery.

1.  After surgery,  workers missed 3 less days from work compared to workers who did not have surgery.

2. The average earnings for workers who had surgery was $47,619,  while those who did not have surgery was $45,694.  In other words,  those who had lumbar disc surgery earned on average $1,925 more per year.

The authors of the study suggests lumbar disc surgery is effective,  both from the pain relief standpoint,  but also from the standpoint of worker productivity.  Research like this helps establish the true cost effective benefits to surgical management of lumbar disc herniations.

It is perfectly rational to be scared to have spinal surgery.  There are many studies indicating poor outcomes with the larger more complex lumbar spinal fusion surgeries.  But outpatient discectomy surgery is a very predictable procedure.

The bottom line is simple lumbar discectomy surgery in the properly selected patient has excellent outcomes,  and allow workers return back to a productive life.    If you have ongoing sciatic pain from a well defined one or two levels of disc herniation,  please consider seeing a spine surgeon to see if there is a reasonable chance of improvement with surgery.

Why I no Longer Accept Medicare

As of January 1, 2013,  I no longer participated in Medicare.  I was surprised by the reaction of some of the Medicare recipient patients.  Several wrote angry letters and made accusations of abandonment.  Though I had prepared my patients since early 2012, few thought I would go through with it.  In fact a fascinating thing happened.  The established patients made appointments with increased frequency.  By spring of 2012,  I instructed my staff to not schedule any new Medicare recipient patients,  as I did not want any new patients to feel I have seen them just to discontinue a relationship in a few months.

On  that January day,  I was no longer a participant.  I could still see Medicare recipient Patients,  but I must make them sign a document letting them understand I am no longer a participating Physician and the fee’s will be paid by the recipient of the care.   I noticed three difference responses from my Medicare recipient Patients.  Some gladly arranged compensation for my services.  One unfortunate group was not able to afford seeing me,  but took my recommendation to see other physicians who remained on the program.  The third group was very indignant, and angry.

Few realized that I could still provide their surgical services .  Most did not understand that  Medicare will still cover the hospital,  the anesthesia, and diagnostic testing.  The only additional expense would be my surgical fee.  I could still continue to be their Surgeon,  as long as they valued My expertise.

Over time,  I got over my guilt on why I left Medicare,  as in my opinion,  I had sound reasons:

1.  The reimbursements were too low to allow me to provide quality personal care, the kind I arrange for my Family.  Not to say physicians who stay on medicare are not providing competent care.  But if you think about it,  quality,  and competent does not mean the same thing.  I like to use the analogy of Fine Dining versus Fast Food.  Burger establishments provides inexpensive food,   fast,  efficient, with set quality measures to ensure food safety and consistency.  In my opinion,  Fast Food is competent delivery of  food at a reasonable price.  As a consumer,  you know what you get,  and understand what it is.   But,  most will not equate a Fast Food Restaurant as a quality personal experience.  Fine Dining is personalized.  It is not hurried.  The wait staff courteously explain the menu.  The food is customized to the Diner.  For some Diners,  there is an established relationship with the Restaurant,  and the Restaurant Owner cultivates the relationship,  providing extra services to enhance the experience.  While the dining is more expensive than fast food,  the Diner gladly pays,  as the Diner values the experience.   For patients,  most accept that seeing a Physician can be like a Fast Food experience,  except  it is not fast.  But,  I no longer wanted the Fast Food Style of medical practice.  I was determined to become the equivalent of a Fine Dining experience, with timely and personal interactions with the Patients.  Frankly,  Spine Surgery should be discussed with care,  compassion,  and thought.  It should not be rushed,  or hurried.   Most Patients also value that experience,  and many are willing to cover the additional cost.  Patients want to be treated as Individuals,  and as a Cherished Customer.  

2.  I  am not a Commodity.  By definition a Commodity is “ a basic good used in commerce that is interchangeable with other commodities of the same type. ”  How are Surgeon’s considered commodities you ask?   Insurance companies think all Board Certified Surgeons are the same.  Once you meet the criterion,  you are considered interchangeable with any other board certified Surgeon.   Medicare definitely thinks that about Physicians.  Think about this fact; the Surgeon that graduated yesterday from his training is compensated exactly the same as the Surgeon with 20 years experience by the Medicare Fee Schedule.  

I know in the minds of the Government,  and the Insurance Company,  they need to set up a system that can be used to administer to a large population.  On an individual level,  you know that certain Surgeons have more experience and better outcomes in certain situations.  Certainly the Operating Room Nurses have opinions on whom they would want operating on their Family.   In the eyes of the Government,  or the Insurance Company,  there would be no difference.   By this rationale,  everyone should get their hair cut by any Hair Stylist,  after all,  their skills are the same.  Everyone knows that is not true.

3. I did not want to be restricted in the types of surgery offered.    With such reduced compensation,  there is a monetary incentive to perform more complicated and bigger surgical procedures.   To give an example,  the public thinks the average spine surgeon receives $21,000 for a laminectomy procedure by Medicare.  The truth is the actual reimbursement by medicare is about $1000.  While that is still alot of money, that fee includes pre-operative counseling on the procedure,  and up to three months of followup care.   By that level of reimbursement,  most Surgeons cannot provide individualized attention  for each patient,  as the compensation hardly cover the costs.  To continue to provide for those Medicare recipients,  you must do an assembly line, volume business.   You must also structure a practice to identify patients that require the better compensated, but more complex procedures (i.e. larger operations like lumbar fusions),  and you must be able to rationalize offering the more complex surgeries.   Also,  your office administration tends to develop programs that are designed to offer additional treatments such as in office braces,  in office physical therapy,  in office MRI’s,  CT’s,  etc.   I am not criticizing these offices.  There are definite needs for the more complex surgeries in selected situations.  Ancillary services can improve patient conditions.    I am just saying remaining in the Medicare System incentivizes the offices to develop ancillary income streams,  volume processing of patients,  and larger, more complex spine surgery.  I no longer wanted to practice in that system.  I want to continue to offer the surgeries that had predictable outcomes while also providing  personal office time and counseling.  The Medicare reimbursement is  too low to allow me to spend quality time,  and provide the simpler surgery. I want to be able to provide the FOUNTAIN of YOUTH Spine Surgery that I blogged about before.

4.  I want to remain in Private Practice.  There is nothing wrong with being employed.  Many of my Colleagues are employed by a Business Entity and are satisfied by the arrangement.  But I find most employment situations difficult for Surgeons who want to provide a quality personalized approach to surgery.  The Business may not understand the approach,  and find it easier to look at the physician-patient relationship as a buy product of the business transaction.  In business, the main goal is  production,  and efficiency.  In the employment model,  Patients and Physicians are evaluated as units of production,  or units of costs.   The Businesses can sugar coat it in many ways.  The Mantra of ” it is because of the patient”  is used to shape policy and behavior.  But the goal is always the same.   The Businesses are evaluated by the numbers generated.  While some of the intangibles are touted,  it still comes down to the Dollars.    While it is true that the Private Practice Physician also has some of the same pressures,  at least the Private Pratice Physician has ownership,  and can also apply the principle of Professionalism and Medical Ethics while making those business decisions.  The Physician still knows the Patient – Physician relationship is sacred.  That is why seasoned Physicians do not enter into business agreements that compromise the quality of the Patient-Physician relationship.  If the physician cannot get adequate compensation,  then the physician must cut corners,  in terms of time spent,  and counseling rendered.   If the Physician cannot negotiate adequate compensation,  then the physician must rely on volume. With Medicare,  there is no negotiation.  The fees are set.  WE are back to the Fast Food Style again.

If you are a Medicare Recipient,  and are frustrated by your level of counseling,  and access to medical care,  you may have an alternative.  That alternative is to see the Physician who will provide you the value you seek.  You might consider seeing a Physician who consciously decide not to participate in  Medicare.  That Physician will likely cherish you as a patient,  a person, a customer.

The Web Surfer has found this Blog on the internet.  Does the Surfer  know that you can look up Physicians and Surgeons, and find out what they actually collected from Medicare,  and the procedures performed?  While this type of data does not show anything about the quality of care rendered,  in 2012,  the Medicare data confirms that I did not perform  spinal fusion surgery on the Medicare population. While the revenue of $82k is significant,  that was for providing Medicare services for 423 unique beneficiaries.   As a business entity,  some will say that I needlessly terminated relationship with a reliable income stream.  I say I gave up that income stream so I can develop a practice devoted to personalized care,  not volume care.  

Spine Surgery and the Fountain of Youth

Everyone wants to stay young.  But why?  For some,  the appearance is most important.  We have to admit that our society values youth,  energy, and beauty.  In reality,  to feel strong  and vigorous,  and to live an active lifestyle is more important.  Botox may make you look better,  but it rarely allows you to feel younger.

What if you want to Feel Good AND Look Good?

As a Spine Surgeon practicing in Florida,  I see so many recently retired men and women who saved all their lives to enjoy their retirement,  but cannot secondary to severe back pain.   Forget looking young,  these patients want to feel young,  and live life the way they dreamed.  Many have great finances to enjoy an active life,  if only their spine will let them.

Luckily for some,  Spine Surgery can be the Fountain of Youth.

We have to remember that most of the elective surgeries performed on the musculoskeletal system is really an attempt to reverse the aging process.

We develop bone spurs that press on the nerves and the tendons.  We wear out our cartilage to our joints.  The surgeries designed to remove bone spurs or replace damaged joints are really an effort to turn back the clock.

In regards to the spine,  most manifestations of aging are related to the degeneration of the disk,  disk herniations,  and bone spurs.  The herniations and spurs pinch the nerves causing severe neck,  back,  arm or leg pain.  While many of these pinches go away over time,  others linger, and worsen.

For many people,  there may be a surgery that may remove the offending bone spur or disk herniation.  Fortunately,  most of these surgeries are minimally invasive,  with rapid return back to the more active lifestyle.  Spine Surgery can be the Fountain of Youth for select patients.

Please know that I am not talking about the big fusion operations offered by many of the “Institutes”.  The Spine Surgery Fountain of Youth Surgery is usually a removal of a disk,  removal of a bone spur,  or a limited neck fusion operation.  For the most part,  these surgeries are performed on an outpatient basis.   For people who are active,  but impaired by a recent development of pinched nerve,  there may be a solution for your problems.  Consider an appointment with a spine surgeon if you want to return back to activity,  but are hampered by a pinched nerve that has not gone away with therapy,  medications,  injections or time.

While not everyone will be a candidate for surgery,  it can make a significant difference for some. See if there is an option for you. Get back to your life. It can be a game changer.

For Medicare recipients,  I need to let you know I no longer accept medicare in my practice.  The good news is you still have a choice, as an American , to see whom ever you want,  as long as you think the evaluation is worth the fee.  Please read my blog on  “Why I no longer accept Medicare” and you can decide if my style is right for you.

Wine and Spine (update)

Does Wine and Spine have benefits?

Wine lovers have more reason to celebrate!  By now, many have heard about the Mediterranean Diet.  Fruits, vegetables, olive oil and red wine, have shown benefits for reduction of cardiac disease.

But how does Wine and Spine problems relate?  Red wine has been show to contain resveratrol, a naturally occurring chemical in grape skin that is under investigation for multiple positive health effects.  While there are ongoing studies about it’s potential anti-cancer and anti-inflammatory effects,  we are naturally interested in the interaction of Resveratrol, or Wine and Spine effects.

A 2008 Rush University study showed  the promise of Resveratrol in slowing the disk degenerative properties in bovine spine discs.  In plain english, it means cows will not wear out their disks if they drink wine.

A 2013 Chinese study indicates Resveratrol may have potential pain blocking properties.  Wine and Spine pain reduction may be related!?

A 2011 British study comparing the bone density of women concluded wine drinkers had better bone density.

A 2012 study indicates alcohol consumption slows bone turn over in post menopausal women.

A recent MIT study continues to show promise with resveratrol, and now several companies are in the process of making drugs to potential it’s effects.

As a practical point,  I am not suggesting everyone with back pain start drinking lots of wine.  Generally accepted recommendations are only one glass of wine per day for women, and up to two glasses a day for men.  There are plenty of studies indicating that more than that amount will reverse any of the advantages.    And for you college students,  it does not mean you can drink a weeks worth of wine on one night!

But there may be benefits to Wine and Spine.  Anecdotally, many of my patients do agree that with Wine, Spine pain does improve.  There may be the relaxation effect of the alcohol.  There may be the stress reduction effect, that also calms the muscles and the nerves.

There is plenty of on going research about Resveratrol and anti-oxidation, anti-cancer, anti-inflammatory and anti-aging effects.  But don’t assume if a little helps,  why not take more?  Like all things,  moderation and quantity control will be important.  Enjoy your Wine and Spine might improve.  Just be reasonable about it.  And don’t blame my blog if you have too many glasses!

Face Mask Removal is Safer than Helmet Removal

Everyone enjoys loves Football in America.  The SuperBowl is the most watched  American TV event on a yearly basis.  Football can be a metaphor for war,  competition,  and victory.  That is why so many young men risk injury to play the sport.   Injuries are a reality,  and behind the scenes,  there are trained professionals ready to give assistant to the players.

As a spine surgeon,  I worry about the effects on the spine.  Every year,  we witness at least one of two NFL players go down with a spinal cord injury.  Many times,  there are simultaneous concerns about loss of consciousness,  as well as breathing problems for these players.  In that scenario,  the protective helmet and face mask can be a hinderance in delivering attention to the players breathing airway.  In unconscious players,  or with those with a neck complaint,  often there is a dilemma on removing the helmet versus removing the face mask to deliver airway protection.

In the June 2014 Spine Journal,  Erik E. Swartz,  et al designed a study to answer that very question.

22 experienced athletic trainers were enlisted to remove the face mask or the whole helmet (Riddell Revolution IQ and VSR4 helmet. These modern helmets have a quick release built into the helmet) .  A variable of inflation or deflation of the helmet was also investigated.

A six-camera 3-D motion system was used to record motion of the head during the removal,  and for each scenario.  Volunteers were fitted with helmets and pads.

After measuring the motion measurements during both the helmet and facemask removal procedures,   range of motion changes were compiled for each scenario.

The study showed much less motion of the head with the face mask removal.  The study concludes the safest option is to remove the face mask on a football player with an unknown neurologic status.

Erik Swartz, Phd,  personally communicated   “we’re now more confidently able to say that FM removal is safer than helmet removal, what we don’t know is if an airway can be effectively ventilated with the helmet (and chin strap) in place. We did some research this past Spring where it appears the chin strap prevents a seal with a pocket or bag-valve mask. So, if this is in fact the case, depending on the airway adjunct a provider was using they may not be able to adequately ventilate with the helmet and chin strap still in place…”

In this scenario,  the responders must  protect the spinal alignment while ensuring adequate ventilation.  Helmet removal might be necessary if adequate ventilation is not possible with the helmet and chin strap in place.

InterLaminar Decompression and Instrumentation

Spinal stenosis is a very common problem afflicting many people after the age of 60.  It should not be considered a disease,  but rather a normal process of aging.

The degenerative cascade is the process by which the disk degenerates or collapses.  Because of the collapse,  the facet joints of the posterior spine rub abnormally against each other,  causing the bone to enlarge.  For my older patients,  many of you will find that the joints of your fingers have enlarged over time.  That is the same process.  The bones rub against each other,  causing wear of the cartilage.  The bone responds to the pain on the cartilage by enlarging the surface area between the bones.  This enlargement is the development of the widening bones.  In the spine,  this enlarging of the bones will cause pressure on the nerves that travel through the spine.  That is the so called “bone spur”  pinching the nerve.  In addition,  as the disks collapse,  the rims of the disk naturally bulge out.  Some of the bulging can cause some narrowing of the space for the nerve.    The final cause of final stenosis is secondary to the effects of the narrowing of the space by the disks.  There are ligaments called the ligamentum flavum that are normally stretched between the bones of the spine.  With narrowing of the disks,  these ligaments are no longer stretched or taut.  It will cause a shortening, and widening or hypertrophy of the ligament.  This widened ligament can also contribute to the narrowing of the space for the nerve.

Degenerative spinal stenosis is usually a combination of the bone spurs,  the narrowing of the disk,  and the widening of the ligaments covering the spinal nerve.

Traditional treatments for spinal stenosis included activities modification.  NSAID medications.  Exercise.  Recent studies have not demonstrated a usefulness of epidural steroid injections for these patients,  though many still request the injection.

Surgical options depend on many factors,  and not all patients are candidates for surgery.  In general,  the main goal of surgery was to remove pressure on the nerves.  In certain situations,  there is an instability component that necessitates fusion along with removing pressure on the nerve.

In the past 10 years,  there has been more and more interests in so call interspinous ligament devices.  The rationale is that a device designed to stretch the ligaments,  and restore some of the disk height may relieve the spinal stenosis pressure.  The devices have had some success,  but some patients will still require formal surgery to directly remove pressure on the nerve.

As these concepts evolved,  a so called interlaminar device called the Coflex,  from Paradigm spine has been studies for efficacy.  The concept is relatively simple.  A more traditional limited removal of bone and ligaments off the nerve is performed.  then a U shaped device is placed in between the spinous processes,  thus achieving some of the height restoration,  facet off loading,  and opening of the foramen.  In addition,  secondary to the more traditional laminectomy/laminotomy,  the surgeon has direct visualization of the nerves being relieved of pressure.

In my experience,  for the properly selected patient,  this is a very reasonable option for patients with localized spinal stenosis and with low grade instability.

The procedure can be done on an outpatient basis for select patients.   There is no fusion associated with this technique.

Medical Necessity

The concept of Medical Necessity is a legal concept that determines what your insurance company or State and Federal Medical programs cover in relationship to you medical care.  I originally posted a similar page a few years ago,  but decide to post again with some changes.

There are many definitions, but I like the one in Wikipedia. It states:

“Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessity is also used.”

As you can see, the definition is very broad, and because of its simplicity, can be interpreted in many different ways.

What is considered necessary?  While most treatments are necessary,  there are some than are subject to debate.  Fixing a broken bone on a child is considered necessary.  Most cosmetic surgeries are not.

What is reasonable or appropriate?  This is open to broad interpretation.  Factored into this concept is evidence based information justifying the treatment.  In that regard,   some spine treatments have not undergone the rigors of evidence based medical scrutiny.  Some insurance companies will not authorize any treatment that has not undergone this evaluation.  While the public may take great offense to that, there has been instances where conventional wisdom has been proven wrong.  In medicine, we sometimes do it that way because “we’ve always done it that way”.  In a perfect world, we would do it “that way”, because we have evidence to support “that way”.

If you are the payer for the services, you would want to make sure you have evidence to support it. That is assuming the payer is only concerned about the efficacy of the treatment.  In the real world,  payers also want to know the costs of these services and weigh the costs versus benefits.  Lack of evidence can rationalize rejection of treatments for certain situations. For most people who use insurance, they need to understand the rationale used to determine which medical treatments are covered.

Because many of our government sponsored programs are designed to serve an ever increasing population,  the needs of the population is greater than the resources  available.  Because of that fact,  triage must be used to determine the best use of the resources,  for the greatest number of population.  Some would call this rationing.   Rationing has bad connotations.  But it goes hand in hand with the concept of Medical Necessity.

For patients with unlimited monetary resources,  they can look at the evidence and determine if they want to pay for the service.  With the changing medical insurance environment,  even people with more modest means are taking initiative and just pay for services they deem necessary or valuable. With financial means,  individuals can avoid the rationing subjected to the general population.  I am not saying that is good or bad,  but at least for now,  in the USA,  people still have the option of skipping the lines,  the authorization process, and pay for certain valued medical services.  

The cost/benefit ratio is the of concept of Value. For entities with limited resources,  Medical Necessity must also involve a value calculation.  What benefit does that treatment give to the purchaser, at what cost?  This is the calculation made in all purchases. This is where the disconnect in medicine often arises.  If we directly pay for our medical services, then we are the purchaser and we can determine if we are getting adequate value; we can determine whether it makes sense to  purchase this service for a certain cost.  In this instance,  the purchaser is the patient.  This is still a difficult process in the Medical Arena,  since few are equipped with the knowledge to determine what treatment is valuable and necessary for certain situations.

To make matters even more complicated and convoluted,  in Medical care, often times,  the direct purchaser is not the patient.  The direct purchaser is the government or the insurance company, while the beneficiary is the patient.  If you use government sponsored medical care (Medicare, Medicaid), or group insurance as a benefit of employment, you are not the direct purchaser of the care.  While you pay taxes, or work to get the insurance benefits (and even pay a portion of the insurance premium),  you are not directly purchasing the medical care.  Because you do not directly pay all of your care, you may not feel the need to do the Value calculation to see if the medical care is necessary, and worthy of the expense to your overall well being.  This concept is changing a bit  as we are seeing more and more of the high deductible insurance plans.  Even with those plans,  once the deductibles are met,  we see an avalanche of medical use by the insurance recipient.   I am not criticizing this trend.  It is a part of our human nature.

Patients usually follow the advice of the Physician,  but patients often insist on additional treatments or evaluations.  The Physician often complies as an effort to develop better relationship with the patient.   In some instances, Physicians will consider additional testing or treatments, to try to avoid misdiagnosis.  This is called “defensive medicine”  and it does cost more to the system.  The Physician may not consider the costs of such treatments or testing, as it does not affect his Value calculation. The Physician is not the purchaser.  There is no direct cost to the Physician for these tests. In this scenario,  with another entity paying for the tests, there is no incentive to make the value calculation.  The skeptic in us will also realize that in certain situations,  there are monetary incentives for Physicians to order extra tests and treatments.  While all the testing can be rationalized,  you can see how costs can mount without some protocol checks to the system.

Let me give you an example of how this system shields you from making these value calculations on your care.

Many patients now desire an MRI to find out  the source of their headaches, neck pain, back pain, etc.  Evidence based medical protocols indicate many of these MRI’s are not necessary unless there are well defined criteria that indicate the need for these tests.  But many of us demand these tests even though we do not meet these criteria.  WE are angry that the  the test is not authorized by our insurance company and we want it covered.  Often times the vast majority of that cost will be covered by our insurance so we do not know the true cost for that test.  Well,  what if you still want that test, but now it will cost you $800,  out of your pocket for the test?   How many of you would pay $800 for the test, knowing that it will most likely show the normal wear and tear of aging?

As you can see, depending on who purchases the medical care, or administers the care, we have a different way of valuing that service.

Individual patients value security, and as long as it is covered, you want everything done for you, no matter how remotely it will effect you overall health.   While this sounds good, this does come at a tremendous cost.  While most people are willing to pay for their own care, and the care of family, and some friends, most will not be willing to pay for the costs for everyone elses care.

Insurance companies value resource management, and this means minimizing the risk to the collected pool of money so that there is adequate returns for the share holders, as well as satisfaction for the subscribers of the insurance plan.  While some individuals subscribe, the vast majority of subscribers are the large employers who provide health care as an employment benefit.  The goal is to provide the medical benefits while managing the fee’s.  That is why  evidence based, cost effective treatments are promoted, or authorized.  Many insurance companies are also for-profit entities, and they have fiscal responsibilities to their shareholders.  This responsibility may affect some of their decisions.  Much of the Government regulations are designed to safeguard against decisions that may adversely affect delivery of patient care.  As these regulations may effect the fiscal health of the insurance entity, there is always a tension between the needs of the subscribers, to the needs of the shareholders.  Before we say that the needs of the subscribers should take priority, we need to give incentive to the companies to continue to operate.  If there are no profits, the companies will probably stop providing for these insurance services.  If there are losses,  “they cannot make up the difference on volume”, and the companies will close.  If all companies close, can we get by with Government Healthcare?

Governments value Public Heath.  That is why some Governments  with limited resources, will spend much of their Health Care dollars on clean water, food assistance, and sanitation.   How is that Health Care you say?  A Government first must provide adequate infrastructure to make sure the population does not get sick from the water, and has enough to eat so that their immune functions are adequate.  After all, malnutrition and water borne diseases are significant medical issues.  If you have limited resources ( money), then you must first provide for the basics.  That is also the concept of triage and rationing.

Currently, in the United States,  many treatments for the degenerative process is covered by Medicare.  In simple terms, we feel that the treatments for aging are for the most part Medically Necessary.  But that is because we think we have the funds to cover these treatments.  As most tax payers know,  we all pay into a medicare fund collected from our paychecks.  In theory, by the time we utilize Medicare, we should have paid enough into it, so that we are now uilizing our “fair share” of the Medicare collections.  Unfortunately,  the costs of all these medical technologies have exploded.  In reality,  we do not have enough money to cover all these “Medically Necessary” treatments for our future medicare recipients.  Yes, there is fraud, over utilization, and inefficiency waste,  but the fundamental question comes down to what will be determined to be “Medically Necesary” in the future?  We cannot predict that, as it depends on who will define those terms.  It depends on the needs of the overall population, and it depends on how much money is left.  The Government track record on efficient delivery of any service has been subject to much debate.  If you think the record is good, then most likely, you would support a Single Payer system(Connotation for Government Sponsored Care).  If you think the Government track record on delivery of services has been poor, you would  not support a Single Payer System.

The term MEDICAL NECESSITY will be thrown around while the government determines the needs of the population.  The government will determine what has VALUE, and protocols will determine coverage of certain medical treatments and procedures.

As you can see,  the term Medical Necessity can only be defined when you understand who is the beneficiary of the treatment,  who is paying for the treatment, what is the cost of the treatment, and what is the evidence of the effectiveness.

Lets not confuse these terms with ELECTIVE SURGERY. Elective surgery means the procedure may or may not be necessary, but is scheduled by the patient.  In many cases, the elective surgery it is medically necessary. For example, patient may elect to undergo hip or knee replacement as there has been progressive increasing pain to that area. Patient may have originally decided not to pursue surgery. But because of increasing pain, they elect to schedule the operation. Because it is a known degenerative condition, with continued and progressive pain, the procedure (currently by US standards) is considered medically necessary.  On the other hand, cosmetic surgery is also elective surgery. The procedure itself however, is often not considered medically necessary, unless it is for reconstructive purposes.  Please do not be confused.  Elective surgery may or may not be considered medically necessary.  Your surgeon, will submit documentation to define it as medically necessary.  As stated above,  currently, many procedures are considered medically necessary.  But as we run out of resources,  the definition for what is medically necessary may change.

By the way,  I am not editorializing, or suggesting a solution for the current Health Care System.  That is far too complicated a topic and has many tangential issues.  I am not qualified to make such comments.  But I thought we would touch on some of these concepts in medicine.  A civilized nation must safeguard the health of its citizens.  But how to do it with reasonable costs is the problem.

While it is your health,  we must also remember, taking care of your health does require technology, services and expertise.  These things do cost money.  We need to address these costs, and consider how to make these costs manageable for the future.  We need to constantly be thinking about the VALUE of the innovations,  and the reasonableness of the treatment in relationship to the costs and the outcomes.  In Spine Surgery,  we are going through a debate that will likely be transformative in the manner certain surgeries will be valued.  To use rationalization verbiage,  we tried to cure as many spinal problems as possible,  not realizing the cost.  Others will say we performed too many surgery on situations that had a poor chance of improvement and nearly bankrupted the Medicare and insurance system in the process.  I want to believe the truth lies in between the last two sentences.

What is Nonsurgical Spinal Decompression?

At least on a weekly basis,  I see patients regarding second opinions about the so called “Spinal Decompression” therapy.  This is not to be confused with spinal decompressive surgery,  which is an invasive operation to remove bones compressing on the nerve.

From my patients perspective,  Spinal Decompression therapy usually means being strapped into a machine,  and having a programmed force applied to the neck/back which distracts the areas of interest.  The theory is that a negative pressure is applied to the disk and tissues,  which can cause a disk bulge or herniation to retract.

Usually the Spinal Decompressive therapy requires at least 45  minutes of time,  and a program consists of 20-25 sessions over  a 6 to 8 weeks.  The costs per therapy session may not be covered,  and the total fee can be expensive.  On top of that,  the Spinal Decompression is often used in conjunction with other Physical therapy modalities such as massage,  ultrasound, and electrical stimulation.

In the past,  a much simpler,  and less expensive option called traction was utilized to produce many of the same potential benefits.

Unfortunately,  the results of the treatment has yet to be properly tested and defined.   There has been spare scientific evidence that this type of  activity truly causes a negative pressure or suction effect to the disk. As a surgeon,  with patients given full anesthesia,  and muscle relaxation,  it is still very difficult to distract the disks for many patients.  While the patient is awake,  and will normal muscle tone,  it does not appear that a true negative pressure effect can be achieved.

One of the original Spinal Decompression machines was the VAX-D.  Unfortunately,  the research behind its efficacy has been challenged.  Thus far,  I have not identified any research that actually tested the pressure inside the disk of a live subject having the Spinal Decompression therapy.

In general,  I have not recommended this therapy for my patients.  It is an expensive option,  and the research has not proven its benefit to my patients. In certain circumstances such as fracture,  tumor,  osteoporosis and prior metallic instrumentation,  it can even cause potential harm.

While there are plenty of  studies now questioning the efficacy of many types of spinal surgery,  we must also be cautious in recommending unproven, and expensive non-surgical options.

As of now back pain,  neck pain,  and sciatica treatments including medications,  activities modification,  stretching,  and time will help the vast majority of patients.  These less expensive alternatives work the best for  the majority of patients.  If they do not work,  please be cautious in exploring other options,  surgical or non surgical.

Low Back Pain, and Diagnostic findings in 40 year olds

Every day,  I have consultation with patients that have had lumbar MRI’s,  but with mild complaints. Some primary care physicians  use CT scans to identify causes of low back pain. Fortunately,  while there are some findings on the studies,  it is rare to find a truly emergent finding.  Also,  it was rare to find a truly “normal MRI” as most of my patients are in their 40’s and 50’s.   As a Physician,  we often wonder what are the true rates of lumbar MRI findings for the average middle age population.

We are fortunate that there was a study performed investigating that specific concept.

In the May 2005 Edition of Spine,  Per Kjaer published an article titled “Magnetic Resonance Imaging and Low Back Pain in Adults: A Diagnostic Imaging Study of 40 year old Men and Women”

It was a fascinating population study located in Funen County,  Denmark.    Every ninth person who was born in Denmark between 5/27/1959 and 5/26/1960 who also resided in Funen county was contacted by mail.  In other words,  40 year olds at the time of the study.

Anyone with severe disability,  magnetic implants,  claustrophobia,  or inability to communicate in Danish were excluded.  625 subjects were contacted by mail.  413  (66%) agreed to participate in the study.  Each participant filled out a questionaire.   Each participant was also given a lumbar MRI ( .2 T magnet).  The questionaires were tabulated,  and the MRI’s interpreted by a defined group of radiologists.  Interobserver reliability parameters demonstrated a greater than 98% agreement by the reading radiologists.

The questionaire reflected a 69% incident of back pain in the prior year for all participants.   Disk related findings such as herniations,  bulges, disk narrowing,  etc was found between 25% to 74% of the finding per participant.

There was a weak association between hypointense disc signal,  reduced disk height and Modic type changes.

To me,  the take home message from this study are the following:

Low Back pain is a common experience for 40 year olds.

Disk abnormalities at age 40 is very common.

MRI’s are not very specific,  in terms of determining the cause of low back pain.

I did not need  a scientific study to confirm what I already knew as a practicing spine specialist.  But I am glad the science confirmed my conventional thoughts about the topic.

Effects of Delayed Lumbar Disk Surgery

Lately,  there has been lot’s of news about the excessive use of the spinal fusion operation.  Little attention is focused on one procedure that has been demonstrated to help spine patients.  Lumbar Disk Surgery,  or Lumbar Discectomy has been studied extensively.  As a Spine Surgeon,  I am glad to know that in the properly selected patient,  Lumbar Disk Surgery has an excellent potential of improving the patient’s quality of life.

While not 100% conclusive,  there is also data that suggest delay of lumbar disk surgery can be associated with less favorable outcomes. Because the data was collected under the directions of spine surgeons,  and spine surgery centers,  there was always concerns about bias.  Cynics and Skeptics will say  surgeons produce data and studies that justify their rationale for surgery.   However,  there are real life examples of situations where delay in treatment is built into the health system.  We only need to look at the Canadian Health System to get meaningful information about the effects of waiting,  and elective Lumbar Discectomy.

In the December  2013 edition of The Spine Journal,  Quon, et al  presented the article “The effects of waiting time on pain intensity after elective surgical lumbar discectomy”.

The article examined the results of the waitlist concerning access to elective lumbar discectomy  in Canada.  In Canada,  there is an access issue for patients with severely symptomatic lumbar disk herniations.  The article points out that total wait time  “defined as the time from family physician referral to time of service delivery-for orthopedic surgical procedures alone,  increased from a median of 19.5 weeks in 1993 to 35.6 weeks in 2010″.   While true emergent situations can still get the necessary treatments,  elective procedures can expect a wait.

In the study,  approximately 400 canadian patients that fit the criteria for elective lumbar spine surgery were followed, and evaluated for after surgery outcomes.   Variables such as sex,  age,  work status,  smoking,  duration of symptoms and VAS pain scores were recorded.  Physical examination findings were documented.   Waitlist time for surgery was defined as the interval “between the time of waitlist enrollment and the time of having the surgery”.

Of the patients who successfully completed all aspects of the followup necessary to include in the data,  197 were on the waitlist for less than 12 weeks.  94 were on the waitlist for greater than 12 weeks.    Please note that even in the less than 12 week group,  the overall time of pain was still greater than 6 months for 37% of the group.  It was just that once surgery was recommended,  the wait was less than 12 weeks.

After six months after surgery,  the outcomes of the two groups were studied.   Various measurements indicated the longer wait group had less favorable outcomes,  with comparative greater pain intensity.   These findings were also consistent with the findings identified in the Spine Patient Outcomes Research Trial Study.  In that study,  patients with greater than 6 months of lumbar disk related pain  had less favorable outcomes that patients who had surgery before the 6 month time period.

Characteristics of the patients with greater than 12 weeks of  waitlist,  identified a propensity to be male,  unemployed,  receiving compensation,  less likely to have a straight leg raise finding, or sensory deficit,  and more likely to be waitlisted as a nonurgent patient.  By that last sentence,  we must realize the study was  a retrospective review,  and patients were not randomized to the less than 12 week or more than 12 week waitlists.

The authors readily acknowledge many flaws in the study,  including the retrospective nature of the study,  and the lack of randomization.  On the other hand,  this is real life information  based on a healthcare system that makes delay in lumbar disk surgery  a reality.

As a Spine Surgeon,  I will have to agree that waiting too long has potential detrimental effects.  Patients often get physically deconditioned.  Drug dependency is often a common concern.  The psychologic effect of pain leads to depression,  irritability and social relational issues.  Work productivity and/or employment can become another stress.

While this article may not be conclusive,  it does demonstrate the waiting effect on the Canadian population.  It’s conclusions are consistent with other studies about the effects of waiting too long for lumbar discectomy surgery.

PRP Spine Injections

PRP (Platelet Rich Plasma) is slowing being adopted by the medical community,  and will someday become mainstream.   The rationale for use is simple.  By concentrating certain blood derived factors,  you can aid in the healing of injured tissues.  Initially,  these injections were used for professional athletes.  Some research have seen a more rapid return to sports activities for certain conditions.  In the NFL,  the ability to return a player back to the game one week earlier can make a significant impact on the outcome of a game,  and the results of a season.

Now,  it is not uncommon to see PRP being used,  and offered by many clinics.  For some patients,  the injections have had a significant difference in their condition.

What about PRP Spine Injections?  Is that a reasonable option for patients.  Unfortunately,  there has been few studies identifying any benefit to the PRP Spine Injections.  Although,  there are many anecdotal reports of improvement.

A Chinese study of 45 rabbits,  using the annulus puncture method of developing early disk degeneration,  demonstrated arrest or reversal of the Intervertebral Disk Degeneration with use of PRP Spine Injections.

Currently,  various clinics are offering PRP injections,  or stem cell injections into degenerated disks to try to promote healing or reversal of the degenerative process.  To date,  I do not know of any controlled studies that have proven the efficacy of such a treatment.  But,  there is some scientific data suggesting the potential benefit of both applications.

For patients,  the advice is to wait a bit to see the results of  injections therapies into the disks.  In the interim,  ask if your physician can isolate the back and neck pain to the facet joints,  or ligaments.  If so,  prolo therapy  or PRP injections to the facet joints,  and spinal ligaments may have a potential benefits  without the risks associated with experimentation on injections into the disk.

Outcomes from spinal surgery

In my role as the assistant to the surgeon, one of the biggest questions asked by patients who are contemplating spinal surgery is “how successful is this surgery?”  The answer is not as straightforward as some would think.   There are many possible ways to answer this, but to really provide the BEST answer, one must look at the words “successful” and “outcome” individually.

To begin with, there is not one specific definition of success when it comes to neck or back surgery. For some, it is complete relief of their pre-operative symptoms.  Others are looking for improved ability to perform certain activities. Looking at it from another viewpoint as the surgeon, performing an operation in which the procedure goes smoothly, the offending pathology is removed, and anatomic restoration is achieved, defines success to some.

As each of us is inherently different, have a different set of symptoms, are affected differently by a certain disease process or injury,  have differing health statuses, and recover differently, what defines a successful outcome is different for each of us.  Like beauty, success is in the eye of the beholder.

In the world of spinal surgery, some practices quote patients statistics of having a “successful” surgery based on anecdotal evidence from prior surgeries performed and experience.  Some practices collect data from patients by way of patient surveys that are conducted prior to surgery and at various points in time following surgery.  Surveys represent a scientific measurement of various chosen parameters. Many of these have been derived from large studies to determine validity and reproducibility.  The surveys may measure a person’s general health or may be more specific to a disease process.  This is one way we can define a person’s level of disability and functional status. By having patient’s fill these surveys out at selected intervals gives the surgeon a specific way of accessing how a specific treatment (surgery) affected the baseline level of disability and function. Furthermore, using this data, all patients who underwent a specific surgery can be compared. An example of this would be patients who underwent a discectomy for an extruded disc herniation. Using specific metrics, we can define how many patients improved from this type of surgery, a quantitative measurement of how much relief the average patient received, and even how long the effect of surgery lasts.

Going back to the original question “How successful is this surgery?” one must also consider the magnitude of the problem. For example, a patient who suffers from cervical radiculopathy and rates their average pain level a 4 on a scale of 10 in intensity (VAS) may not see as big of an improvement from cervical disc surgery as someone with a constant pain level of 9 out of 10. This does not mean surgery will not be as successful, but points to the fact that indications for surgery are closely tied to outcome.   While skilled surgical technique has obviously a large bearing on the success rate, the final outcome of surgery is largely dependent upon the adherence to strict surgical indications; that is, there must be a strong correlation between the patient’s history, clinical examination, and appropriate diagnostic findings. Not all spinal related conditions have clear cut indications for surgery, and some are controversial.

The other half of the question at hand relates to “outcomes”.  The Merriam-Webster dictionary defines outcome as meaning “something that follows as a result or consequence.”  Patients undergo surgery for a defined reason and what follows is a result, but when is that result defined?   When considering spinal surgery, one must consider the goals of the intervention.  For example, is it to alleviate pain, improve functional ability or both? For some patients, surgery is performed to arrest a condition and prevent worsening disability.  Certain conditions tend to improve more rapidly (or predictably) than others. For example, a relatively young patient who has a drop foot secondary to a massive disc herniation identified on MRI undergoes surgery. From a technical standpoint, a limited discectomy procedure is performed as planned, without complications. Immediate post-operatively, there are only mild improvements in the patient’s motor status.  Was the surgery a success? Advance 6 months later and the patient now has improved strength (4+/5) as compared to the unaffected side. Now, would you consider the surgery a success? The question I am getting at is when is an outcome really an outcome?   With this in mind, it is imperative that realistic recovery rates and potential timelines are instilled in the patient prior to undergoing surgery.

The word satisfaction is also often thrown into the ring when outcomes are discussed. One example that I have seen, is a practice that advertises that 94% of their patients are satisfied with the results of surgery. What does this really mean?  First, based on the way this is presented, means that 94% of patients who underwent any and all types of spinal procedures came away from it satisfied.   It does not necessarily mean that 94% of all patients who underwent spinal surgery are pain-free or even significantly improved.  In fact, it may be unrelated to the patient’s clinical status.  We know that are considerably different success rates and outcomes based on the presence of a specific spinal disease process and type of surgical procedure. Again, there is no specific standard of what defines satisfaction. Many variables that can affect a person’s degree of satisfaction are not controllable by surgeon. Examples of this may include a person’s age, social class, length of hospital stay or even length of recovery.  A person who undergoes a spinal procedure and is able to be discharged from the hospital one day earlier than expected, but still has some degree of pain and other symptoms after surgery, may still be “satisfied” being that many of their expectations have been met or from  great care they received, despite having continued symptoms.  Again, using my earlier example of the patient with a drop foot, some may be satisfied with their treatment even if they still had significant weakness post-operatively knowing that they made the appropriate decision to have surgery as the best chance to improve. Others will remain unsatisfied until such time a significant clinical improvement occurs. The key to this is establishing the expectations prior to surgery.  We can say that satisfaction and the determination of a successful outcome are interrelated yet have distinct meanings.

In closing, from experience and from the medical literature, we know that success rates and outcomes from spinal surgery vary considerably. All patients want to be free of back/neck pain, free of weakness, have full functional ability, good overall health, and be able to perform daily activities without restriction. Success from spinal surgery, in the eyes of the patient, is often determined by achieving an improved quality of life as defined by some of the aforementioned characteristics. While achieving all or even some of these health statuses is not necessarily realistic for some, setting the expectations prior to surgery is vital to achieving successful outcomes.  Tight surgical indications are also included in this. Lastly, when considering outcomes, successes rates must be quoted at specific time intervals. Satisfaction is a separate component when looking at clinical outcomes yet may be tied to the degree of recovery.

– JS. Mazza

The AMA 6th Edition Impairment Guide

When people are injured they can suffer from a permanent change to their body, and have an inability to do certain things.  This inability to do certain things is the definition of a Disability.

Many think the term Impairment means the same as Disability, but that is not true.  Impairment is defined as a physical or mental defect at the level of a body system or organ.  While Impairments can lead to Disability,  that may not always be the case.  To give an example,  loss of certain finger is a definite mpairment.  However,  if the finger is not necessary to do certain activities,  it would not be a Disability for that activity.  Disability is defined as an inability to physically or mentally perform a certain task secondary to a health condition,  disorder or disease.

The concept of an Impairment is important because usually,  the impaired person will seek compensation for the Impairment.  The American Medical Association has developed Impairment Guidelines for that very purpose.   Impairment concepts from the past centuries were used to develop a ratings system.  The ratings system can be used to settle compensation for the impairment.    The goal was to develop a uniform way to define various impairments.  In 1958 title of the first guideline was “A Guide to the Evaluation of Permanent Impairment of the Extremities and Back”.   Over the next 12 years,  12 additional guides for other organ systems were publish in the Journal of the American Medical Association.   In 1971,  a merger of all these organ system guides become the  First Edition of the AMA Impairment Guide.

Since that time,  the Guide has evolved,  and the latest ( as of today June 30, 2014) is the 6th Edition, which was initially published in  November of 2007.

The editors of the 6th Edition acknowledged the flaws of the prior Editions.  On page two,  they outline the prior criticisms.

Taken directly from the 6th Edition Text:

• “There was a failure to provide a comprehensive, valid, reliable, unbiased, and evidence-based rating system
• Impairment ratings dod not adequately or accurately reflect loss of function.
• Numeric ratings were more the representation of “legal fiction than medical reality”

As a spine specialist,  I am naturally more interested in the Spine Impairments.  But there are general guidelines to the determinations of the ratings that I thought relevant to all examiners,  and raters.

1.  Use of the International Classification of Functioning,  Disability and Health (ICF).  This model takes into account the physiology of the respective body parts,  the activity limitation experience, and the participation restrictions.   This model also acknowledges the complex interactions of a person in regards to their complaints,  but points out some can have a measurable impairment without any disability,  while others can experience significant activities limitations in the absence of an impairment.

2. Diagnosis,  history,  physical examination,  testing and functional outcome scores need to be considered.  Self-report assessment tools must be weighed considering the overall presentation of the patient.  We must consider that the self-reporting assessments may over or under report the scores.    The history must identify a consistency of symptoms to the complaint.   Physical exam findings must also be consistent,  and objective clinical testing should correlate with the complaints.

3.  For the patient,  there is a need to Determine the Burden of Treatment Compliance.  In regards to the spine,  and the extremities,  there is already an assumption that there has been compliance and reasonable  treatment prior to rating the impairment.

4. The physician performing the impairment evaluation is to “provide an independent, unbiased assessment of the individual medical condition,  including it effect on function, and limitations to the performance of ADL’s.  Although treating physicians may perform impairment ratings on their patients,  it is recognized that these are not independent and therefore may be subject to greater scrutiny”

5.  “Range of motion is not longer used as a basis for defining (spine) impairment,  since current evidence does not support this as a reliable indicator of specific pathology or permanent functional status”

The AMA 6th Edition Guides to the Evaluation of Permanent Impairment has been in use for the past 7 years.  It is an incremental improvement to the prior Editions,  and in my opinion,  gives more weight to objective findings and consistency of presentation and examination.   No system of impairment measurement is perfect.  Each system is subject to broad interpretation,  but that is why it is called a Guide,  not a Rule.  In the end,  it still comes down to clinical judgement and the objectivity of the Examiner.  Because these ratings are often used in liability litigation,  the Examiners are subject to criticism about their bias,  and lack of fairness.  But,  nevertheless,  the Guides are specific in the nature of the goals of the examination,  and attempts to import scientific consensus by the various Medical Societies to codify the ratings system.

Can I get Too Many Cortisone Shots?

Can I get too many cortisone Shots?

I get that question at least 3 times a week from patients. And, the answer is yes. The answer to how many is reasonable, however, is not well defined.
Cortisone shots are the same as steroid shots and can be used in many body parts. Common areas include the knee, shoulder, hand, feet and the spine. Cortisone shots are a good quick way to try to decrease inflammation caused by arthritis, and swelling. For sciatica, and back pain, many Orthopedic Surgeons use the shots to try to improve the pain.
How much, and how often is really a judgment call of the Physician. Most will agree that the shots should be rarely used on children or young adults, as one of the known side effects is to accelerate or promote degeneration of the cartilage.
In General, some Physicians agree the shots should be used only when needed, and not more often than every 3 months. But, clinical conditions dictate the frequency of its use.

To give an example, in patients with severe knee arthritis, the risks of making your cartilage worse is not an issue. If you had a choice between having a knee replacement, and having more than knee injections  on a more than every three month frequency (providing the injections help), many will choose to have a more frequent injection.
On the other hand, you must always be concerned about the other potential effects of too much cortisone. Common side effects include elevation of blood sugar in diabetic patients, infections from the injection, osteoporosis in women and potential for a more rare, but devastating condition called Avascular Necrosis.
So, before any one Physician will stick to any “rule” about how often a patient can get an injection, the recommendation must be made after consideration for the potential for any of the side effects. Depending on your age, diabetes status, sex, and other health concerns, it may be prudent to have more frequent or less frequent injections. In addition, the results of the injection may prevent a more involved surgical procedure. So that must also be factored. In the end, you need good counseling by your Physician, to decide if the benefits of the injections are better than the risks.

Soccer and Back Pain

Soccer and Back Pain.

We are in the middle of World Cup Soccer 2014,  and there has been some exciting games.  Behind the scenes,  are teams of Physicians trying to prepare the players for the next game.  There will always be concerns of Soccer and Back pain.

While most know about injuries to the legs and hips,  Soccer and Back pain is a reality and a legitimate potential for injury.

Heading a ball is associated with concerns about head concussion.  Another common injury from heading the ball includes neck pain secondary to neck sprain,  and neck arthritis.  In rare instances,  you can get a neck disk herniation by the impact.

During throw-in’s,  the forces to the upper torso  and core of the lower back can be stressed,  leading to injury to the upper and lower back injury.

During running,  cutting direction,  and kicking the ball,  there is tremendous twisting to the lower back,  and sacroiliac joints.  These activities can also lead to back injuries.

To prevent Soccer and Back injuries,  make sure you warm up your muscles with a light jog for 5-10 minutes.  Stretching exercises of the arms,  legs,  neck and torso help limber the muscles and ligaments. 

During training,  make sure to concentrate on building your core muscles as this will protect against injury.

When fatigued,  you are more susceptible to injury.  Work on your aerobic capacity to help prevent being worn down.   It will reduce the risk of  a sprain,  strain or a pull.

For the older players,  if you have neck arthritis  think hard before heading that cross into the goal.  While a goal is exciting,  the potential pain of neck arthritis,  or even worse,  a neck disk herniation should give you pause.    If you are playing the World Cup,  and have that situation,  score the goal,  then call your Spine Surgeon after the Game!

Laser Surgeon says Spine Surgery was a Success. How come I feel lousy?

Unfortunately,  the title says it all.  A dissatifying experience for some spine surgery patients.   It usually comes down to expectations and counseling.

Patients are often too distraught,  or in pain to truly understand the nature of their problem,  and the goals of the planned surgery.  Also,  the constant bombardment of advertising from the many Spine Institutes minimize the seriousness of the condition.  Afterall,  it is much harder to sell a dangerous, risking procedure,  than a routine “everyone had it” procedure.   The reason for the disconnect between the perspective of the Surgeon,  and the perspective of the patient, is usually secondary to a lack of good communication and understanding.

From the Surgeon’s perspective,  the goals of the surgery has been achieved.  The disk herniation has been removed,  or the bone spur has been shaved.  For the more complex procedures,  the implant devices have been properly placed,  and the bones show evidence of fusion.   X-rays and other studies confirm appropriate position.

From the Patient’s perspective, there is still pain,  or stiffness.   The Patient is still not able to do what they desire to do.  It is like the old joke ” So Doc,  after surgery,  will I be able to play the Piano”.  The Doc says “why yes,  after surgery you will be able to play the Piano”.  The Patient says, “Why that’s great, because I have never played the piano before”.   The joke hones in on the fact that there has not been proper discussion about the anticipated results of the surgery.  The “Doc”  should have said,  “after surgery,  you should be able move your fingers normally,  and if you have played the piano before,  it should not be a problem”.  A subtle but meaningful difference.  For Spine Surgery,  some goals are much more predictable.   The Surgeon should be able to discuss the chances of reduction of nerve pain after removal of bone spurs or disk material.  The Surgeon should also caution that residual numbness and pain can be expected.  The Surgeon should also counsel that the Spine Surgery will be limited to certain areas,  and as the Spine has so many other moving parts,  it is still possible that other areas may contribute to further pain,  but the surgery will not address those other areas.  The Surgeon should also address the truth about age and degeneration.  Surgery is designed to return a 50 year old man to the functions of an average 50 year old man.  The 50 year old will be disappointed if the expectation is to return to the activities of a 30 year old man.    As you can see,  these discussions about realistic outcomes can be difficult,  and may lead to some patients cancelling the surgery.  In my opinion,  it is perfectly reasonable reasonable to cancel elective surgery.  For the Surgeon and staff,  cancellation however,  means no recovery for some resources already dedicated for the already planned surgery.  Human nature dictates that some will act to avoid surgery cancellation.  That behavior can lead to the miscommunication about the goals of the surgery and the expected outcomes.

Surgeons always make sure to discuss the potential complications of surgery,  as that is part of the informed consent process.  That discussion can be different from the detailed discussion about the anticipated outcome.

For Lumbar Fusion patients,  there is more potential for dissatisfaction.  Unfortunately,  Spine Surgery for pure back pain has not been as predictable as Surgeons would like.  While the goal for the Surgeon,  which is fusion,  can be predictably achieved,  the goal for the patient,  which is pain reduction is much harder to predict.   In certain situations,  like large disk herniations,  and gross  spine instability,  there is much greater satisfaction and predictability.  But,  for back pain from disk degeneration,  Surgeons are faulted for not preparing patients for continued pain despite a technically correct procedure.

To avoid the spirit of the title to this Blog,  make sure you have a thorough consultation with your Surgeon before you schedule the surgery.  Ask questions about the anticipated outcomes,  the anticipated recovery,  and the anticipated level of function after the surgery.  Ask what is considered a best case scenario after surgery,  the average scenario,  and the worse case scenario.  Competent Surgeons   have the judgement, experience and technical skills to be able to predict a realistic outcome.   Smaller,  less complicated procedures such as simple discectomies,  and single level neck fusion surgeries are much more predictable.  Lumbar Fusion,  and multi-level procedures are less predictable.

As a Potential Surgical Patient, do your home work.  The decision not to have elective surgery is a good one if the goals cannot be obtained.   But,  if the pain is severe,  ask how much improvement can be expected.  Sometimes 50% improvement is still a good goal.  Just remember that afterwards.  Too many patients say they want 50% improvement,  then forget that goal after surgery.   In that scenario,  the Patient may not have been realistic, as the judgement was clouded by the pain.  At that point,  it was important that a Close Friend or Family Member was present during the Surgery Consultation.  That Family Member can help the Patient remember and understand the goals discussed prior to  surgery.

Poor Surgery Outcomes with Narcotics

In the June 2014 issue of the Journal of Bone and Joint Surgery (American edition),  Dennis Lee, MD and colleagues submitted a Paper titled  “Preoperative Opiod Use as a Predictor or Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery”.  The paper discussed an investigation performed at the Vanderbilt Medical Center in Nashville Tennesee.

583 patients,  who had spinal surgery were included in the study.  You can read the details of the study,  but preoperative parameters measured for the patients included use and amount of narcotics,  smoking history,  BMI,  Oswestry or Neck Disability Index scores,  and Zung Depression Scale scores.

The results indicate the use and the amount of preoperative opiod use (narcotics) correlated with worse outcome scores,  disability,  and depression after Spine Surgery.

As a spinal surgeon, this study is a great confirmation of what I have already seen in my practice.  Unfortunately pain is a very difficult thing to measure,  and some patients do have better tolerance than others.  Also,  pain severity can have an emotional component.  To give you an example,  when people are happy,  they just are not as painful.   When people are emotionally stressed,  the pain worsens.

Unfortunately,  there is an unhappy triad of pain,  depression and disability.   Use of narcotics often make this triad worse.  The paper did make commentary on the  exponential increase of narcotics sales from 1999 to 2010 (four fold,  according to the paper).  While the goal of the prescribers may be to help alleviate pain,  the unintended consequences  are multiple.

I have always advocated weaning dependent patients off narcotics,  or at least reducing their narcotics before a surgery.  I noticed patients who have been on chronic narcotics (over 6 months) do have the most difficulty post-op,  and have the poorer outcomes.  Some will say that is because those patients have the most pain, and the more serious problem.  I would argue that those patients may feel more pain.   That does not mean those patients have a more serious problem.   I have noticed most of the poor surgical outcomes are from patients who could not taper their pain medications.  Many claim no improvement after surgery.

It makes you wonder if surgery should be offered at all for those patients,  as the risk for spinal surgery may not be worth a predictably bad outcome.   More things to ponder.  After 21 years of practice,  I am still learning from these experiences.  I am almost tempted to stop offering surgery if patients cannot taper.   But,  then again,  I do not want to eliminate all hope for these folks.  While there are general principles that should be followed,  we still need to treat everyone one and every situation individually.

ShimSpine Vs Laser Spine

Tampa has become a destination city for Spine Surgery,  and I must give credit to all the Spine centers,  especially the ones that tout Laser Spine Surgery.

But,  why are there so many patients coming to Tampa to have the most common of spinal surgeries?  After all,  outpatient,  or minimally invasive spinal surgery is practiced in every major medical center across the United States.

I would suggest that it is secondary to a fantastic marketing effort, and by a better application of Business Principles and Customer Service.

When patients have a spine problem that may benefit from surgery,  it can be a very scary and frustrating process to identify the right surgeon and the right facility.

Also,  when  patients have a spine problem,  they want a surgical solution that lets them return rapidly back to family activities,  friendships, and hobbies.  Unfortunately with the current state of medical reimbursement, surgeons are incentivized to recommend more aggressive and more complex solutions to the problem.  A minimally invasive,  outpatient procedure, using the latest technology seems to be an attractive alternative to the more complex lumbar fusions recommended today by many surgeons.

For the most part,  I agree with the outpatient Laser Spine facilities regarding minimizing the surgical complexity.  In my opinion,  the majority of spine surgery patients are reasonable candidates for some of the outpatient procedures.

But,  I disagree that the use of the Laser is necessary for spine surgery.  The laser is a great marketing tool for the facility,  but it’s efficacy in actually solving the spine problem is limited.  The goals of most spine surgery is to remove pressure on the spinal nerves or spinal cord.  That can be accomplished in a number of ways,  with traditional tools using outpatient techniques for appropriate patients.  Having read the operative notes from some of these Laser Spine facilities,  the traditional tools are still used in every surgery.  Occasionally,  a Laser is used to ablate a few areas,  but,  the Laser itself is not the main event of the procedure.  While the Laser Spine  connection is prominent from the Marketing standpoint,  in reality, the Laser is less used than the traditional surgical instruments.

In the Laser Spine facilities,  there is a fantastic aura of competence and sophistication.  However, there is something missing.  Who decides if Surgery is for me?  Who is doing the surgery?  When do you meet the Surgeon?  Who does the followup care?  Who is the Surgeon?  How long has the Surgeon been in Practice?  Does the Surgeon have Spine Surgery Fellowship training?

As I stated above,  the reason people are coming to Tampa for Spine Surgery is secondary to application of Business Principles.  In some of the Laser Spine facilities,  it is the Business Principle of the Assembly Line.   Phone Operators identify appropriate patients for the assembly line and make appointments.  Non Surgical Physicians will determine that these patients are appropriate for assembly line surgery.  The business office makes sure fees can be processed.  The Non Surgical Physician schedules the procedure to be done by an assembly line Surgeon.   The Surgeon performs the procedure.  Followup is performed by another team of Healthcare Providers, not necessarily Physicians.  If you think about it,  it is like a Tire Kingdom Auto Repair Facility,  except for people with spine problems.  It is very efficient.  It is owned and managed by Business People.  The Physicians and Surgeons are not owners of the facility,  but rather  very highly trained Technicians.  Like all businesses,  I am sure there are incentives for productivity  and increased sales.  If there is a bad outcome,  the Customer Service, and Legal Team handles those details.

It really sounds like a great model,  except,  we are talking about human beings,  not cars.

Contrast that model with a  Personalized Spine Surgery model.  You know your Surgeon.  Your Surgeon determines your surgery needs.  Your Surgeon is the one who is performing the Surgery.  Your Surgeon does your followup.  Your Surgeon owns the practice and provides “customer service”.  In a way,  it is like comparing a Chain Auto Shop to your trusted Auto Mechanic who individually knows you and your vehicle.  That Mechanic may not be easy to find,  but once you find Him/Her,  you know your vehicle is in good hands and you know He/She will do what is right,  not just what gets the bonus.

For Your Car,  you want a Master Mechanic,  not a Master Marketer.  What would you want for YOUR SPINE?

If you are coming to Tampa,  or Live in Tampa, and want a Personalized Spine Surgery experience,  consider your alternatives  and consider ShimSpine.

The Surgeon is not on my Insurance plan. So What!

Nurses should know better.  The other day,  a Nurse made an appointment with me.  Luckily,  she was not a candidate for any surgical management,  but I thought she should see someone about another issue.  It was really to just get an opinion.   She had a great Specialist in mind,  and in fact originally wanted to make an appointment with that Specialist,  but decided against it as this particular Specialist was “Not on My Insurance Plan”.   Her remaining choices were with Physicians,  unknown to her, or a longer distance away. The Nurse spent time rationalizing why she should choose one of the not familiar physicians.  I asked her why she did not want to see her first choice.   Of course she was worried about the cost.  Then,  I asked if  the quality and  reputation of her first choice Physician was worth the expense? It was amazing.  The Nurse never thought about it in that manner.  The answer was “of course that Specialist is worth the expense”.   The Nurse then decided to go ahead and arrange the consultation.  The Nurse forgot she still had that choice. What I found amazing was the initial willingness of the Nurse to see just anyone on the plan.  Of course the Insurance Plan’s physicians are vetted, and I am sure qualified.  But,  this Nurse already knew who would be the Specialist of her choice.   By the very fact that she already had confidence in that Specialist gave more meaning to that Specialist’s opinion.  In terms of costs,  going to the Expert of choice will be a better VALUE as it will avoid the angst of second guessing the not familiar Specialist.  It may also save, in the long run,  as confidence  in the opinion usually means less unnecessary testing. I know Specialist’s visits costs money.  But,  if you have a difficult problem,  or if you are not getting the answers that you think you need,  or if you want to feel confident in the opinions of the Insurance Plan directed Physician,  paying for peace of mind, on Expert Opinion is the best VALUE for your money. And,  just so everyone knows,  Specialists outside your insurance plan are not restricted in the recommendations made as they are free to offer opinions based on their knowledge, and not just what is available and offered on the insurance plan.  Specialists Outside your Insurance Plan can provide an excellent second opinion,  especially for surgical problems.  To follow that logic,  you must consider these factors: 1.  It may be too costly to have surgery from a Surgeon outside your plan. 3. But,  a Consultation is a more affordable expense.   2. Because the surgery will not be performed by this Surgeon,  there will be no conflict of interest in offering the Second Opinion.  3. That means the Surgeon  will only offer opinions on the appropriateness of the various surgical options.  4. The Surgeon can offer a more unbiased opinion about the surgical treatment offered by your insurance plan’s physician.  So to the lament “The Surgeon is not  on my insurance Plan”,  I say “So What!”  For Your health,  or your Family’s health,  is not the opinion worth it? Lately,  I have seen another phenomenon.  A person already has a planned surgery.  While they feel confident the surgery will be a success,  the Surgeon on the Insurance Plan may not have had the time to personally review every detail about the surgery.  While the Surgeon has a good reputation,  the patient just wants confirmation the planned surgery makes sense,  and wants a more individual explanation.    Even though I am not a provider on their Insurance Plan, patients and families still arrange a Consultation to obtain a more detailed explanation of their planned surgery.  These patients see value in an additional Surgical Consultation. Some would like to make this concept of a more personalized approach to medical care an issue of fairness.  But for families and patients who would like a more personal,  and individualized Consultation, the option is available.   Since the vast majority of Physicians and Surgeons  are still participants in most Insurance Plans,  there really is not an issue of access.   But,  if your chosen Specialist is not a participant of your Insurance Plan,  you can still arrange that Consultation.  It is a Value Choice that you can make.  It is a Choice that most forget they always had.

Compulsory Medical Examination

Since I started my practice in 1993, I have also been performing examinations that are now known as Compulsory Medical Evaluations. To those who do not know, it is an examination arranged to evaluate a person with claims of injury from an accident. The causes are usually related to a work injury, a motor vehicle crash, or a fall.

For the person with injury claims, they have often seen several physicians and have received treatments related to the injury. As the patient advocate, these treating physicians will offer every possible treatment. The cost of such treatments are rarely discussed with the injured person, as both the patient and physician assumes that the costs will be passed to the entity that caused injury. Usually, the person with the injury obtains legal counsel to recover costs associated with care, and compensation for the pain. The injured becomes a plaintiff in a lawsuit against the entity that caused the injury.

The entity blamed for the injury typically disputes the nature of the injury, the costs of treatment, and the permanent nature of the injury. The entity obtains legal counsel, or if insured, contacts the Insurance Company to obtain representation. The entity, along with the insurance company will become defendants in the lawsuit by the Plaintiff. It sometimes gets more complicated as the defendant may also hire legal counsel to make sure the Insurance Company is following the coverage of the insurance contract. In the process of defining the injury claims, the legal counsel representing the Insurance Company and the Defendant will arrange a medical evaluation to determine the nature of the injury, the cause of the complaints, the needs for treatment, and any anticipated costs.

As the Injured Person does not chose the Physician who will be performing the evaluation, a set of rules have been set up by the various jurisdictions on how, and when these examinations will be performed. In Florida, these examinations are called Compulsory Medical Examinations (CME).

Unfortunately, these examinations are portrayed in an adversarial light. This can be quite uncomfortable for the Examinee (the injured) and the Examiner (physician). To add to the environment of conflict, some examinations are being conducted with a Videographer documenting every part of the examination. Sometimes, there is also a court reporter transcribing every word of the encounter, as well as documenting the timing of the progression of the evaluation. The examination room can get quite crowded at times. I for one, have sympathy for the Examinee. The poor Examinee is often in a hospital gown, being videotaped while I conduct the evaluation.  And, having reviewed CME evaluations by some of my colleagues,  I can understand how they can be very adversarial.   But I am of the opinion it does not have to be that way.

While I am used to the situation, it can be stressful for some Examiners. Having a court reporter or videographer present does not change my history or physical exam, but,  I am aware of the potential for some subtle inconsistency in my report. When I dictate and organize my report, I am not provided a copy of either the video tape, or the transcription. By the rules, I am not able to record or video the exam. For some of the more complicated situations, reviewing those tapes may have been helpful in reconstructing the history provided by the examinee. Not always, but there are some Attorneys who use those tapes or transcripts to find an “ah-ha” moment, where my recollection of the information may not be 100% consistent with the history or the physical exam. These subtle inconsistencies have not changed my opinions, but the job of the opposing Attorney is to question my objectivity, and I understand why some would exploit these subtle differences.  I understand why some Attorneys feel the video is there to protect their client.  But,  if the Examiner remains objective  and professional,  the video does not have any bearing on the validity of the examination.

For the Examinee, in addition to the inconvenience of being examined by a Physician not of their choosing,  and the embarrassment of being videotaped while being examined, there is the psychologic stress of feeling the Examiner does not believe their complaints. For me, my goal as a CME Examiner,  is to stay neutral and objective. But, in most situations the examinee has been counseled to expect an adversarial attitude. I do thank the Attorneys that advise their clients to be truthful,  and cordial.  It helps the process, and sometimes,  an accurate and complete history can be helpful for the injured.

My protocol is to explain to the Examinee the nature of the visit. I explain my role is to ask about the causes of the complaints, and the relationship of the complaint to a specific event. I ask about the medical treatments, and ask about any future plans. I ask about any similar complaints in the past, or any new unrelated injuries.

I then perform a physical exam of the areas of interest. I usually explain that the Examinee can avoid any part of the physical exam for any reason. As an orthopaedic and spine surgeon, my examination is limited to the musculoskeletal and spinal neurologic findings.

Up to this point, the examination is similar to exams I perform on my own patients. But as the CME Examiner, I cannot establish a Physician-Patient relationship. I cannot offer guidance or directly communicate my opinion. Though my objectivity is often challenged, I am to offer an objective report, based on the history, physical exam, available diagnostic records, and the available medical records. While the face to face time with the examinee may not be very long, the great bulk of my time is spent reviewing records regarding the injury claim. Often times, it requires reviewing tests, accident reports, medical records, employment records, deposition statements, surveillance videos, and recently, social media postings. Then, there is a challenge of writing my opinions, and presenting it in a manner that is understandable. The reports can be as long as 15 pages, and can take a cumulative time of over 6 hours to finish. While the reports are an expense to the group that retained Me for the report, the fees are in consideration of my time.  That time could have been spent seeing consultations,  rounding on patients,  or performing surgery.

I weigh all the information, while formulating my opinion. But, in the end, I know this information will be used by the respective parties to try to come to an understanding. If an understanding is not reached, I will then be asked to discuss my opinions in a format  by which a jury can then decide the objectiveness and validity of my conclusions.

By design, there is a defense orientation of the Compulsory Medical Evaluation (CME). The plaintiff has their physicians rendering opinions supporting the injury. As the CME examiner, at times, I have found that the plaintiff had legitimate and permanent injuries caused by the accident/fall, etc. While I am performing the CME usually for the defense, I am still also asked to maintain my objectivity. Some Defense counselors have been surprised by my opinions supporting the permanent injury claim. But, most defense counselors accept my opinions, and work to resolve the dispute between the two parties. I guess if the Attorney spent resources to obtain a CME, the Attorney is hopeful the opinion would be favorable for their position. But, as the objective CME examiner, that is not always the case.

Interestingly, CME’s are not often utilized by the Plaintiff Attorneys. Strategically, an objective opinion by someone who has reviewed all the available documents would likely be helpful for the injured. But, usually, the plaintiff legal counsel will state that the treating physicians can provide the best evidence of the injury, and the nature of its effect on the injured.  I have seen the Treating Physician, who by definition is the Patient’s Advocate,  being considered a “Hybrid Expert Witness”.  The issue of objectivity is a legitimate concern when utilizing the opinion of the Treating Physician.

As the Treating Physician, you have established a relationship with the Patient. You are the Patient’s advocate. You will do what is in the best interest of the patient. But, that cannot make you objective. It is like asking a Mother to write a letter of recommendation for her Child. A bit of hyperbole,  but everyone will understand the analogy.

Also, most physicians are focused on the complaint of the patient, and not necessary the cause of the complaint. Often times, as the CME examiner, I would agree that treatment is appropriate for the complaint. But, I would not agree that the cause of the complaint is related to the date of injury. Often times, the treating physician is not provided all the background information, or prior records that might show similar complaints in the past. Also, human memory is not perfect, and many times, the recollection of the injured may not match the prior medical records. As the treating physician, often times, you are not provided all the available records before you make your opinions. While your recommendations for treatment may be appropriate, without the prior records, the opinions about the cause of the complaints may not be based on all the known information.

As stated above, often times, costs are not discussed as there is an automatic assumption the Defendant will be paying for the expenses. But what if it is found that the injury was not caused by the accident? As there was no discussion about the costs, and as there has been no payments made directly from the Patient to the Physician, it can  lead to a very awkward situation. The Patient themselves, may dispute the necessity, and the costs of all the prior treatments. Patient and Physician may become adversarial when trying to determine appropriate fees.  To avoid that situation,  both the Patient and the Physicians would naturally  assume the injury is the fault of the defendant,  and therefore the costs will be the responsibility of the defendent.  The treating physician’s opinion can influence whether the defense will compensate for the rendered care.  Rationalization behavior can cause loss of objectivity.

While some will say the monetary incentives also make objectivity difficult for the CME physician, understand the CME physician is being compensated for their time, and the pool of funds available for compensation is not dependent on the outcome of the litigation. Physicians who perform CME evaluations can make substantial incomes. Every Attorney will try to enter the financial information into evidence.  But, over time, only objective CME examiners who can pass the constant scrutiny and attacks on their objectivity can continue to provide such evaluations.  Rules of Discovery allow opposing counsel to obtain information on the financial arrangements of the CME,  and also to discover the prior financial history in relationship with the Examiner and the Attorney,  or Insurance Company.  But, while the CME examiner can offer opinions, in the end, it is the negotiation between the parties that decide the worth of the claim, or the opinion of the Jury that decides the legitimacy of an injury. The Jury also ultimately decides the objectivity of the CME opinion.  And,  while the Jury may factor in the financial incentives for both the CME Examiner and the Treating Physician,  the decision should be about the facts of the situation.  Or as some would put it  “it is about the pursuit of the Truth”.

Given the above analysis, I am of the opinion that the Plaintiff counsel should consider arranging a CME type examination for their injured client. I understand that financially,  the use of the “hybrid witness” may make more sense.  The “hybrid witness'” often does not seek compensation until the conclusion of the dispute.  For simpler situations,  that do not include a surgical option,  the expense of a CME may not make monetary sense.  But,  in a very costly situation,  is a “hybrid witness” with a bias in favor of the injured, the best option?

Many CME examiners have a more conservative orientation towards surgical treatment of injuries. That is why their opinions are valued by the defense. But when the situation is clearly related, permanent, or requires surgery, the CME evaluation can provide the objective analysis necessary to achieve an end to the litigation. If the plaintiff counsel trusts the objective nature of the CME examiner, and truly believes their clients injuries are related to the event, the cost of a CME opinion  will be offset by the value for the injured.

Astronauts and Disk Herniations

Workers must deal with potential injuries associated with their trade.  Common sense dictates that the more manually intense occupations are associated with increased injuries.  While some would argue that disk herniations may be secondary to your genetics,  other studies do show prevalence in certain fields.  While researching for another topic,  I came across some interesting studies on Astronauts and Disk Herniations.

Since the beginning of the Space Program,  there was always great concerns about the effects of space travel on the human body.  As a group,  Astronauts are probably one of the most medically studied,  measured and followed group of any population.  We know that complaints of back pain are common to Astronauts.  And,  it makes us wonder about the true nature of the development of back pain, and its relationship to the  disks.

It is thought that the micro or zero gravity environment allows the disks to elongate,  or increase in height.  Usually,  that is considered a good thing as that also means there is an increase in the opening of the foramen,  or the hole by which the spine nerves exit the spinal canal.  But,  in the zero gravity environment,  this elongation may cause irritation of the small sinuvertebral nerves that are located on the outer aspect of the disk.  Also,  the stretching of the capsular ligaments between the vertebral bodies may also contribute to the pain.

Scientists have tried to recreate a zero or micro gravity environment to study the effects of the environment on the disk material.  One study in 2013 suggests the micro gravity environment may accelerate the degenerative process.

That may explain why the Astronaut Population has a 4 times higher incidence of disk herniations than a matched non-astronaut population.  Others suggest the disk herniation frequency may also be related to the high G forces associated with launch,  and re-entry.

I am not sure how much of this information applies to us normal gravity people,  but some of the hypotheses on why astronauts develop back pain  challenges our theories on why overuse,  or shrinking disk heights promote more back pain.

The Surgeon Recommended against Spine Surgery. Now What?

So your Spine Surgeon recommended against surgery.  There are usually two simultaneous reactions to this news.

1.  Great!  I do not need to undergo the pain,  and anxiety associated with surgery.

2. Now What?  I am still in pain.

As a patient,  you should ask why not?   For most surgeons,  it means the goal of surgery may not be obtainable,  or that further testing did not indicate a successful outcome.  That is the simple answer.  Much more subtle are the reasons surgery may not be successful.  For most surgery,  the anatomic findings are usually a good enough reason to pursue surgery.  But,  in spinal surgery,  there is usually a pain component that is a major reason why patients would pursue surgery.  For the spine surgeon,  predictably removing all pain may be a difficult task.  That is why most Spine Surgeons concentrate on specific obtainable goals.  To give an example,  herniated disks to the lower back are associated with pain.  But, the best predictable surgical outcomes are predicated on finding evidence that the disk abnormality  is the definite pain generator,  and not just an incidental finding.  So,  if a disk is herniated,  and is associated with a defined pattern of nerve irritation (radiculopathy), surgical intervention has a higher likelihood of success.   If your pain pattern is not also associated with a nerve irritation,  many surgeons will recommend against surgical intervention.  Some surgeons use tests such as discograms to try to identify if the disk is the cause of pain generation.  But, the discogram procedure remains a controversial procedure in trying to identify pain,  and it is also known to have risks such as infection,  increase pain generation,  and potential to cause healthy disks to degenerate.  But,  the discogram test is another topic.

Another reason a Spine Surgeon may not offer surgery is that there are too many findings on testing,  and it is not clear which is the source of the pain.  Or,  if all are the sources of pain,  chance for a positive surgical outcome is poor.  An example is an older person who has many levels of disk herniations and bone spurs.  Surgery on just a few of the disks or spurs will not remove all the problems.   Many Spine Surgeons must counsel patients with this situation.   While there is a small chance of improvement,  post surgery, the vast majority of patients remain dissatisfied,  and become another member of the ” I wish I never had spine surgery” crowd.  The analogy is similar to going to the Casino.  Occasionally,  there is a big winner,  but the vast majority of the players lose to the House.  Now with our changing Healthcare environment,  not only does the patient lose by getting a poor outcome,  but it is also a very costly situation for everyone.

The final reason a Spine Surgeon may not offer surgery is based on the expectations of the patient.  I say repeatedly to my 60 year old patients that Spine Surgery has potential to returning you back to functioning like a 60 year old.   What I find is some 60 year olds think the surgery will return them back to be a 40  year old.  Unless the patients are realistic about expectations,  most prudent Spine Surgeons will not perform the surgery, as there will likely be great disappointment in the outcome.  Patients must understand the reality of their situation.  Some residual pain,  numbness and weakness is expected.  The goal is improvement,  not perfection.  If the patient does not understand that,  it means the patient has spent too much time reading the marketing brochures of the various “Spine Institutes” instead of getting real information from competent Spine Surgeons.

Since I have been in practice since 1993,  I can admit I have become more conservative in my surgical recommendations.  Earlier in my career,  I was much more aggressive,  and accepted a 75% success rate.  I rationalized that I was giving more people a chance to get better.  But,  experience can be sobering.  Fortunately,  the vast majority of spine surgery patients do not have life or death situations,  and though many are uncomfortable,  they will still be able to live a functional life if they do not get surgery.   I find that patients that do not improve with spinal surgery actually worsen post-operatively.  In other words,  with that 75% success rate,  I was also making 25% WORSE.    After about 8 years of practice,  I changed my criterion for surgery.  I  limited my  elective spine surgical recommendations to only patients that have at least a 90% chance of success.   I guess that makes me a conservative surgeon.  But,   now,  I am not making a quarter of my elective spine surgical patients worse.   If your Spine Surgeon does not recommend a surgery,  please ask them about their surgery philosophy .  Do  they consider themselves aggressive,  or conservative?  If they are conservative,  you can ask if there is a more aggressive opinion that other surgeons might consider.  When I am asked,  I will refer to other surgeons who are more willing to take the risk along with the patient.  Conservative Surgeons can be faulted  for not offering a chance.  On the other hand,  remember the Casino analogy.

So,  Now What?!   If there are no good surgical options,  do what you can.  Exercise.  Lose weight.  Stop smoking.  Get a more positive attitude.  For the religious,  pray.  If you are going to have the pain and difficulty,  please find a way to cope with the process. There are scientific articles on your side.   Do not lose hope.  Time has been proven to be an ally.  It is hard.  And,  everyone you know will offer advice.  As I say,  “everyone becomes a doctor,  everyone becomes an expert”.  Elective Spine Surgery was not offered because of the factors above.  As a Spine Surgeon,  please do not think I am patronizing the non-surgical patients.  I am just pointing out that there are risks of surgery,  and if the Spine Surgeon cannot offer you surgery,  you can chose to seek a more aggressive surgeon,  or understand that you must do things that will help you cope with your situation.  I know it is a difficult position for the patient.  I wish there was an easier solution.  But,  in the end,  the truth is the truth.  Fine a good support system.   Seek reasonable and less narcotic dependent pain management,  and try to do physical activities that will build your core,  and your function. Do not give up!

Cycling and Back pain

Depending on the source,  it is estimated that at least 39 million Americans rode a bicycle at least 6 times a year.  Demographic trends indicate a greater interest in cycling,  particularly in the middle age years.  The reason for this popularity is surprisingly simple.  It is great exercise, and can be easier on the joints than other forms of exercise.  But,  there is always the potential for injury.  And,  we are not talking about the injuries caused by collision.

For the longer distance cyclist,  the unfortunate truth is that many suffer from some form of neck or back pain.  While the cyclist develops great aerobic capacity,  and develops tremendous leg strength,  often times,  there is also asymmetry muscle development.  That asymmetry can cause inadvertent over stressing of certain muscles.  For hardcore cyclists,  often times,  they do not spend the time on abdominal muscle development, and thus the powerful leg extension muscles can cause excessive stress on the core structures such as the lower spine.    Also,  the position of the rode bike may demand a more forward leaning flexed spine.  Unfortunately for many,  it leads to poor posture on the bike saddle,  with loss of the  normal lordotic curvature of the spine.   Secondary to the position,  many will fatigue and develop lower back discomfort.

Regarding the neck,  often times,  by using the drop handlebars,  it places extra stress on the arms and shoulders,  and also demands a more hyperextended neck position for the ride.  Over time,  this can lead to upper back and neck discomfort.

If you experience these pains,  please be sure to stretch,  and consider a change of position.  Also,  work on developing all the muscles of your trunk,  to avoid the asymmetry as discussed above.   If riding becomes too uncomfortable,  you may consider changing the geometry of your bike by changing the seat,  or handle bars,  and riding in a more upright position.   While they are not the same as a rode bike,  a hybrid,  or a moutain bike will give you a more upright stance.

Cycling is a great activity enjoyed by many.  But,  if you are having pains,  please consider your body mechanics,  and make sure you stretch,  and develop the other muscles of your trunk.

Why Plates and Screws?

So,  your surgeon says you need spine surgery.  And,  it is a surgery that will require hardware,  including plates and screws.  Go to the other blog pages about why the surgery.  Let’s talk about Why Plates and Screws?

For the most part,  plates and screws are used to hold your vertebra still,  or in a certain position.  But that is not the end of the story.  Usually (but not always),  plates and screws are used to help the spine mend together into an optimal position.  The surgeon will then let the natural healing process occur,  and the vertebra will heal or mend together,  ideally in that position.

That healing process of mending two or more bones together is called a fusion.  In simple terms,  you are making two or more bones into one bone.  The fusion process is a surgeon’s effort into tricking your body into thinking the bones are broken,  and therefore must be mended together.

A simple explanation of the bodies ability to mend broken bones is necessary to understand the fusion process.  When a bone breaks,  the natural bony structures are damaged or disrupted.  Small blood vessels course through the bone,  and are therefore disrupted.  It causes chemicals and various hormones to be released into the tissues.  This causes an irritation,  or an inflammation.  There is increased blood flow to the area of irritation,  and the building blocks to repair damaged tissue also arrives via this increased blood flow.  The body has the ability to send “trash collectors” to get rid of the debris, and damaged tissue.  The body also sends “repairmen”  that re-establish the scaffolding to the broken bone channels and blood vessels.  Then,  additional “repairmen” deliver bony substances called osteoid and lay it down on the scaffold.  Over time, the bony substance remodels,  hardens and thickens to the old strength.

In the case of the fusion,  the surgeon will create an environment similar to a broken bone.  The bones to be fused are roughed up,  to allow some bleeding.  Often times,  extra cells that act as the “repairmen” are harvested from the hips to act as bone graft.  And,  because the bones are held into a certain position by the plates and screws,  it will result in the bone healing in the optimal position for that section of the spine.

The science to bone healing is still evolving,  but still,  we have not been able to completely achieve fusion in certain situations  ( smokers,  diabetics,  renal failure,  osteoporosis,  are associated with poor fusion rates).

In terms of plates and screws,  these are still mechanical,  metal devices,  and over time  they will fail.  The best situation is when the bone has successfully mended and fused,  and the plates and screws are no longer necessary.  When the metal breaks (and many times they will),  ideally it has served its function,  and will no longer be needed.

In rare instances,  the plates and screws may begin to back out,  causing problems and will need to be removed.

In even rarer instances,  patients may have an unknown metal allergy and it will cause a reaction that will cause increased inflammation.  If there are any concerns for metal allergies  ( you cannot wear jewelry, rings,  etc),  there are metal allergy tests that may need to be done if you are anticipating us of plates and screws.

Modern plates and screw constructs in the spine are made of titanium,  as it has less image scattering properties if an MRI is necessary in the future.  And,  at least in the Spine,  you can still have an MRI,  without the metal moving secondary to the magnetic  field  ( not so for implants in the eyes,  ears,  brain, and blood vessels).

Plates and screws sound scary,  but in the proper situation,  can be very helpful in maintaining the desired position of the bone after surgery.

Goals of Spine Surgery

As a Spine Surgeon,  I want to give my patients a chance at a successful outcome.  But,   I find some patients to be unrealistic about the goals. So the topic can be broached,  I thought I would share my thoughts on the Goals of Spine Surgery.  As we will see,  there are many considerations to spinal surgery.      As always,  these are my opinions. If you disagree, luckily as the reader,  you have the option of going to another webpage or site!

Before we go into the goals,  we must briefly discuss why you even would consider spine surgery.  In the emergent situation,  you should not be reading this Blog.  You should be getting to an evaluation ASAP.  Fortunately,  the emergent situation is rare.  It usually involves a significant injury from a fall,  or accident.  In other instances,  it is an impending paralysis event caused by infection or a tumor.  If you are experiencing severe pain,  with developing loss of muscle control,  see a physician right away.  This dicussion is not for the emergent situation.

The vast majority of patients who decide on Spine Surgery are people who no longer can tolerate the pain associated with their neck,  back,  arms and legs.  There are also some who have severe associated headaches.  After exhausting non surgical treatments such as time,  medications,  activities modifications,  therapies and injection,  these people often seek a surgical solution.  Please note that I am limiting this discussion on patients that have pain,  but not functional impairment.  This discussion is about Elective Spine Surgery.    And,  often times,  they will get conflicting opinions on the chance for success.  That is because each participant in the surgery may have a different goal.

For the patient,  please have a thoughtful discussion on the definition of success.  This becomes a re occuring theme in relationships between surgeons and their patients.  The Surgeon may be correct in that the reason for surgery has been successfully managed.  But,  for the patient,  the goal, and the definition of success may be different.  Please discuss the expected outcome of the successful surgery from your perspective as the patient,  as well as the perspective of the surgeon.  The surgical goals of the surgeon may have been accomplished,  but the patient may still be disappointed.

To give an example,  I often see patients who are developing cervical myelopathy.  That is a progressive process by which the spinal cord is being compressed in the neck.  It starts as a neck pain,  then progresses to weakness of the legs and arms.  From the perspective of the surgeon,  the goal of the surgery is to stop progression of the process by making more room for the spinal cord.  Making room for the spinal cord is often achieved and confirmed when additional studies are performed.  The patient is aware the surgery was designed to make more room for the spinal cord,  and thus may prevent the long term progression of the myelopathy.  But,  also,  the patients had other assumed goals,  that were not fleshed out in the discussion.  Often times,  patients want to return back to a previous level of function,  WHEN THEY WERE 20 YEARS YOUNGER.  This is just not possible by surgery.  AS I explain to my patients,  the goal of surgery is to give you a chance to get back to age appropriate function.  A 60 year old,  would have a goal to being able to do what an average 60 year old would be able to do.  Unfortunately,  with all the marketing hype on the airwaves and the internet,  the perceived promised goals are often not realistic,  and mostly manufactured by the marketing arm of the various medical entities.

As far as the Goals of Spine Surgery,  the surgeon should also be able to give an estimate on the chances of obtaining a realistic goal.  Again,  if your Goal is to be younger,  it is not likely.  The scenario I often see is the patient that has disk problems in multiple locations.  There is significant pain,  but it is difficult to isolate the pain to one area.  Because multi-level surgery may be necessary,  the chances of a successful outcome is not great.  In addition,  because of the likely added risk of prolonged surgery,  there is also an increased risk of complications such as infections,  anesthetic risks, and bleeding.  In this scenario,  the patient must understand the risk.  This is the part many do not like.  The patient must also understand that sometimes their situation may be such that the risk of surgery, and susequent outcome may not be worth the effort.  The patient may need to accept that their current situation may be better than a bad surgical outcome.

Many do not want to accept that opinion,  and it is understandable.  If they can afford it,  they can get multiple opinions.  At academic tertiary centers,  those physicians may be in a position to manage some of the risks better.  But still,  patients must be realistic.  In very complicated situations,  with a risky profile,  there is still a chance that you will be much worse off after surgery.    As I often say to my patients,  just because it can be done,  does not mean it should be done.  And,  surgery is not reversable.  I am saddened to see patients back after I recommended against surgery.  They proceded,  and now want another opinion on how to reverse the surgery.

In my practice,  I try to limit the Elective Spine Surgery to situations where there is a predictable outcome.  For the most part,  that is lumbar laminectomy/disectomies,  anterior cervical discectomy and fusions,  and on a very infrequent basis,  single and double level lumbar fusions.  There are many talented surgeons that do the much more complicated procedures,  and have helped those patients.  But, after more than 20 years of practice,  I will say that I have limited my practice to only the most predictable procedures,  as those are the patients that have the best chance to return to function,  work,  play and enjoyment.

Back pain as side effect of taking medication

As many new prescription drugs come to market to treat everything from cholesterol to erectile dysfunction, one of the biggest concerns for both patients and practitioners who prescribe these medications are side effects. Some medications do a great job at controlling a specific problem, but are so toxic that they cause others problems. One lesser known side effect of certain medications that is commonly overlooked is back pain. When I say back pain, I am referring to pain that is derived from bones, muscles, joints, discs, and nerves that originate and are part of the vertebral column. Patients commonly take medications to treat back pain, but perhaps a surprise to some, there are many medications that have the potential to cause back pain!

For example, commonly prescribed statin drugs, which are used to treat cholesterol, can cause muscle and joint pains along with numbness or tingling in the extremities. Verapamil, which is used to treat high blood pressure and chest pain also has been reported to cause back pain in a small percentage of patients.

From doing a little research, these are some of the most commonly prescribed medications that list a possible side effect of back pain. I have included the primary reason for taking the medication in parentheses. The mechanism of action and reason for the side effect is poorly understood for many of these. This is not an inclusive list.

Alendronate (osteoporosis)                                             Nicotrol (nicotine cessation)

Ambien (sleep)                                                                   Plavix (blood thinner)

Atenolol (blood pressure)                                                Propanolol (blood pressure)

Bonvia (osteoporosis)                                                       Remicade (reduces inflammation)

Cardura (prostate hypertrophy)                                     Simvastatin (cholesterol)

Crestor (cholesterol)                                                         Timoptic (glaucoma)

Depo-Provera (birth control)                                          Topamax (migraine headaches)

Flomax (prostate hypertrophy)                                      Verapamil (blood pressure)

Gabapentin (neuropathic pain)                                      Xalantan (glaucoma)

Metoprolol (blood pressure)                                           Zetia (cholesterol)

Again, these are some of the most common prescription drugs that patients take. There are over several hundred drugs on the market that list or have had back pain reported as a side effect. Keep in mind that taking one of these medications does not mean you will experience back pain. A small percentage of patients may experience back pain as a side effect. Furthermore, the severity of the back pain may differ considerably from one person to another. As we know, the cause(s) of back pain can be multi-factorial. Recognition that medications do cause unintended side effects is important in helping to identify the source of a patient’s complaints

Diabetes and Back Pain

Yesterday,  I was asked if there is a relationship between diabetes and back pain?   The short answer,  in my opinion is yes.  But just so we can all have a general understanding,  we must first review diabetes and its effects.

As many of you know,  there are two forms of diabetes.  Type I diabetes usually occurs at a young age.  It was formerly known as juvenile diabetes.  To generalize,  your body does not form insulin,  the hormone necessary to absorb glucose (sugar), and transform it into energy.  The glucose levels build up in the body,  and unfortunately,  high glucose concentration causes destruction of your body tissues( As an aside,  just so you can understand the nature of glucose,  sugar cannot spoil.  No bacteria can grow in high sugar concentrations.  In a similar matter,  it can destroy your cells).

Type II diabetes usually occurs with age,  and also has a hereditary component.  The body develops a resistance to insulin,  and will not absorb the sugar, despite the insulin.   Again,  the blood glucose levels increase,  and leads to the destructive cellular processes.

Thus far,  the science is still being explored,  but the cellular distruction caused by higher glucose levels have been shown to be toxic to skin cells,  nerve cells,  skin cells,  smooth muscles,  etc.  In addition,  some studies suggest the higher glucose levels activate osteoblast activities in muscle cells.  In other words,  causes the calcification seen in blood vessels.

In the spine, studies have shown an increased disk degeneration incidence in patients with diabetes.

For Spine Specialists,  we already know that patients with diabetes often develop the so called double crush phenomenon,  where the nerves can be crushed once by the physical pressure of disk or bone pressure on the nerve.  Then,  the second “crush” comes from the high sugar effects on the nerve tissues,  causing the so call peripheral neuropathy.   Demographic studies show that  People with diabetes have associated increased musculo-skeletal complaints.

For spine surgeons,  it is general accepted that patients with diabetes will have higher complication rates and lower success rates.  So in addition to having more disk degeneration, and musculoskeletal complaints,  diabete patients have poor surgical outcomes,  with increased complication rates.

For those who have diabetes,  please do what you can to control your sugar levels,   and monitor your ratio of glycosylated hemoglobin (A1C). You want to minimize the bad effects of a high glucose level.  From the perspective of you spine,  you can help moderate the rate of degeneration,  and subsequent development of back pain.

If you have concerns,  please visit your internist,  or get more information from the American Diabetes Association.

Diving Neck Injuries

Summer is soon upon us.  While it is a great time to get out, and jump in the pool,  lake or ocean,  Spine Surgeons are always concerned about diving neck injuries.

During the excitement,  often times,  people will forget about the dept of the water.  While life guards are on duty,  people are caution about diving into pools.  Designated deep ends are reserved for diving,  and therefore minimizing the chance of hitting the head on the bottom.  But,  every year,  people mistake a shallow area for the deep,  resulting in a tragic miscalculation.

For others,  jumping into a dark water lake, or pond,  or diving into surf also results in a head impact onto a solid object.  For spine specialists,  the concern is a so called flexion-compression spinal injury.  With enough force,  it will cause a fracture of then neck bones,  and loss of structural integrity and stability that protects the spinal cord.  Unfortunately,  that is a mechanism by which some develop a devastating spinal cord injury and paralysis.   In addition,  secondary to the impact, there is also a potential for developing a injury to  the brain.

Like in most spinal cord injuries,  there is a disproportionate representation of adolescent boys and young men.  For you parents,  please warn your children about the dangers of diving into a shallow pool,  or a dark pool of water where the level of the bottom is not known.

If you witness a diving injury,  in the most serious situation,  the diver will not even be able to swim up.  Get the diver out of the water, and call for help.  Initiate CPR,  understanding to avoid excessive movement of the neck.  It is a bad scenario that I hope no one will have to witness.

C5 Syndrome

For patients who undergo cervical myelopathy/radiculopathy surgery,  Surgeons always have concern for developing the so called C5 Syndrome.   Some patients do wake up with weakness to the deltoid and biceps muscles.  Typically, however,  patients will not experience the weakness for a few days after the surgery.  You can imagine the concern for both the Patient and the Surgeon.   A deteriorating neurological situation is an emergent situation.  Usually,  a workup,  with diagnostic imaging is initiated soon after discovery of the weakness.

But,  in the C5 syndrome,  usually,  there is no evidence of any direct neural compression on the diagnostic studies.  In addition,  neuro diagnostic studies such as EMG/NCV’s are inconclusive to the cause of the C5 syndrome.

The cause of this C5 Syndrome has yet to be well defined.  But,  most agree the vast majority of the isolated upper extremity weakness will be associated specifically to the C5 nerve, and corresponding muscle groups.

There is some thoughts to the following scenarios:

1. C5 nerve injury during surgical unroofing of the nerves.  The nerves may also be kinked by shifting bone windows in the so called laminoplasty procedures.  Usually,  the patients do have identified weakness immediately after surgery.   While this explanation may explain patients with a posterior laminectomy approach,  it is difficult to explain for anterior discectomy patients as it is rare to directly expose any of the nerve roots with the anterior approach.

2. C5 nerve root tethering after posterior shifting of the spinal cord after decompression.  Some anatomic studies suggest the C5 nerve is shorter than other nerves.  In addition,  the C4-5 facet joint is more anterior than other joints,  so the cord, and the nerve is oriented more anteriorly before decompression.  After posterior decompression,  the cord does orient more posteriorly.  In that more posterior orientation,  the C5 nerve will act as a tether,  thus causing stretch of the nerve.  This may explain the subsequent development of C5 nerve manifestations.  Again,  this does not explain the C5 Syndrome in anterior surgery.

3.  Spinal Cord ischemia by the tethering effect of the radicular artery to the spinal cord.  Similar to the C5 nerve tethering effect above,  the radicular artery associated with the C5 nerve root, and C5 spinal cord area can be compromised by the tethering effect.  A transient spinal cord ischemia may explain the temporary loss of C5 nerve function.

4. Segmental spinal cord disoder.  Some patients with C5 syndrome have evidence of signal intensity changes on MRI imaging of the C5 areas.  While this scenario may be possible,  it does not adequately explain the unilateral findings on most C5 Syndromes.

5.  Reperfusion Injury of the spinal cord.    Paradoxically,  rapid reperfusion with oxygenated cells may be associated with increased cellular injury,  and decreased perfusion.

Certainly,  these scenarios continue to be investigated,  and conflicting studies have draw conclusions on the validity of the theory.

What we do know is that the vast majority of the C5 syndromes are temporary,  with almost complete return of nerve function for the vast majority of patients.  Still,  Surgeons always have concerns about the development of the C5 syndrome, as it has been reported in up to 5% of patients who had cervical myelopathy surgery.  If you have cervical surgery,  please understand this is a concern,  although the vast majority of patients recover with little residual deficits.

Waddell's Signs

This is a very difficult topic.  It, however is an appropriate discussion,  considering we are in a national debate about healthcare and its costs.

As a Physician,  sometimes we are asked to make judgements on the validity of a patients complaints, and compare them to the physical findings.  It can be an uncomfortable position for some Physicians.  As the patient advocate,  the Physician will give the patient the benefit of the doubt.  But,  if there are inconsistencies,  and yet a Physician makes risky recommendations, despite  the inconsistencies,  the Physician may potentially be recommending a treatment or test that may cause more harm than good.

There are well known disease entities such as Munchausen Syndrome,  where a patient will subject themselves to aggressive and invasive treatments,  including surgery because of a non-physical or psychologic need.    A careful physical exam may identify findings that are not consistent with the reported conditions.  These so called Nonorganic Physical signs are important clues to identifying patients that may have underlying non-physical needs.

In 1979,   the Volvo Award in Clinical Science went to Dr. Gordon Waddell, for his research documented in the following article:

Nonorganic Physical Signs in Low Back Pain, by Waddell et al.

To summarize,  Dr. Waddell identified 5 characteristics of patients exhibiting Nonorganic Physical signs of Low Back Pain.

1. Tenderness.   Does not follow common patterns. To give an example, significant pain with even light touching of the skin. Or wide spread pain to large deep areas.

2. Distraction.   Examples include no pain with distracted provocative moves such as distracted straight leg raise.  Another example is observed normal range of motion or activity, but with testing, significant limitation of muscle strength or range of motion.

3. Simulation.   Pain patterns that do not fit a physical reason. Examples are significant pain with light compression on the skull, or pain with light twisting of the pelvis with patients without hip problems.

4. Regional inconsistencies. Examples of non-anatomic or inconsistent strength or sensation findings during an entire examination.

5. Over reaction.  Examples are severe pains with any movement, excessive gesturing to express pain. The air leak sign.

These 5 signs are now known as the Waddell’s Signs.

As a Physician,  I do not purposely look for these signs.  But,  as a Spine Specialist,  these signs are often easy to identify.  If I have suspicions of a non-physical cause of complaints,  I am more cautious to order invasive testing or treatment.  I am definitely less likely to offer surgical management unless I am convinced the findings and tests identify a life or limb threatening problem.  The workup and counseling can be very lengthy,  costly and at times,  seem adversarial.

For some patients,  they are just anxious, and over react.  But,  if they exhibit many of the signs above,  I would  counsel them on the oddity of their complaints,  and unfortunately,  it means more non invasive testing to make sure we are not missing an underlying more serious condition.  It can get costly for some entity to pay for all these tests.

It is not that the Physician does not trust the patient.  It is that  the Physician does not want to do more harm by recommending a more invasive, potentially harmful, and unneccesary treatments.    Unfortunately,  for all parties involved,  Patient,  Physician,  Family,  Work Place, Payor,  etc., the outcomes and relationships are often diminished during the evaluation for these Nonorganic physical findings.  As a Physician,  we  have a responsibility to consider this possibility in some of our patients.  This scenario does not make the Physician very popular.  It is a scenario that challenges Physician professionalism. But,  it is consistent with our charge to do no harm.

Is it better to over treat than to under treat?  That question begets a subset of questions such as,  do the unintended consequences of the treatments cause more harm?  What is the less risky choice?  What are the costs associated with over treatment? Who will then bear the costs of the treatment?  Do the patient and family understand the ramification of the choice?  Are the treatments based on consistent physical findings,  or solely on complaints?   Physicians are asked to balance those questions,  as we counsel patients on the next step in their treatments.  Sometimes,  the choice is not obvious in the face of seemingly serious complaints.  But a Physician’s training, and experience often reflect an approach that at least considers the non-organic signs when making recommendations.

Hot Tub Therapy for Neck and Back Pain

Among the many modalities that can be used to manage neck and back pain, the use of a hot tub is usually one of the pleasurable indulgences that many have taken advantage of or have at least thought of. Patients will often ask if there is benefit to using a hot tub.

Historically, the Greeks, Romans, and Egyptians used mineral spas as a form of therapy and relaxation.  As technology has advanced, all types and sizes of whirlpool spas and hot tubs that supposedly offer the same health benefits and more, are readily available today.  While there are very few scientific studies that have been published on this subject, anecdotally some claim multiple health benefits from the regular use of a hot tub.

Using a hot tub or hydrotherapy refers to the use of water to maintain general health or treat a specific condition. Marketing efforts focus on three principles that include heat, massage, and buoyancy.  Moist heat causes blood vessels to dilate thereby allowing for muscle relaxation and decreased blood pressure. This can bring about a temporary relief of muscle soreness and joint pains especially in those who suffer from arthritis and for those who suffer from back spasms. Added benefit can come from spray nozzles or jets that offer a concentrated stream of water to massage specific areas of the back and neck. It has been theorized that this also contributes to improved circulation which is powerful in the healing process. Another positive aspect of hot tub use comes from the principle of buoyancy.  When we are immersed in a hot tub or spa, most of our bodyweight is supported by the water. This can alleviate pressure off the weight bearing joints.  For some, this can allow them to try and obtain greater gains in joint range of motion for stiff and painful joints.

Beyond the positive benefits aforementioned, are there any downsides or reasons one should not use a hot tub or spa? There are a few things that one must consider when considering to use a hot tub. First, you should not go into a hot tub with any open wounds or sores. Secondly, even though it may sound overly relaxing, drinking and soaking in a hot tub is a bad combination!  The use of alcohol can cause dehydration and heat exhaustion leading to confusion and fainting.  If you have a heart condition, you should always check with your physician before using a hot tub.

While I am not advocating everyone to run out and buy a hot tub, the use of one can be beneficial at reducing stress, improved circulation, total relaxation, and improved sleep.

Microdiscectomy Surgery

Today,  we learned Tiger Woods had Microdiscectomy surgery.  So,  what exactly is Microdiscectomy?  In the simplest terms,  it means removal of disc material that is pinching a nerve,  using small incisions and with magnification.  In the United States,  there is an average of 300,000 discectomy type surgeries performed per year.

For the vast majority of patients,  the reason for microdisectomy is PAIN,  despite treatments such as medications,  physical therapy,  chiropractic care, and/or injections.   While some patients have such pain  that they pursue surgery immediately,  the recommended time for non-surgical treatments is 6 weeks.  While a good percentage of the non-surgically treated patients improve,  those that have definite physical examination evidence of a pinched nerve, and a corresponding finding on diagnostic studies such as a MRI can benefit from the procedure.

In general,  the patient will have a small incision ( less than 2 inches) made to the back.  the corresponding back bones are properly identified by x-ray guidance, and the area of the pinched nerve by a ruptured disk is localized.  Usually a small piece of the bone may be removed to allow entry into the spinal canal.  Magnification is used to assist in visualization of the nerves and disk material.   The nerves are identified, and gently deviated away from the pinched nerve material.  Then,  with  use of instruments such as surgical tweezers,  the disk material is removed away from the nerve.

In the properly selected patient,  who has failed non-surgical care,  there is a predicted greater than 90% improvement rate.  Now  in 2014,  the surgery is most often performed as an outpatient procedure.

The post operative rehabilitation is usually focused on maintaining core strength and flexibility.  For some patients,  the nerve pinching has caused specific muscle atrophy, and additional focus may be on those muscles.  By 6 weeks,  most can return back to all activities.  Traditionally,  patients are cautioned against heavy weight lifting, and repetitive bending during those 6 weeks.  Some research suggests fit individuals can return back to all activities.  We have certainly seen NFL athletes return back to the highest level after this procedure.

If you think you need microdisectomy,  please discuss this with your physician.

Tennis and Back Pain

Winter is almost over.  For some,  it is time to get out the rackets and golf clubs.  And,  as a spine physician,  time to go over the some common issues faced by my tennis player patients. Tennis and back pain is unfortunatedly common.

1.  Make sure to  warm up your muscles,  then stretch.  More and more studies indicate a warming up of the muscles by doing a few leisurely laps help heat up the muscles and ligaments.  Then,  stretching of the muscles and ligaments is easier,  and less prone to actually over stretching.

2. Make sure your rackets are properly strung.  Excessively tight strings will cause a strong reaction to impact,  while too loose a string will cause less control, and may in fact cause you to over swing,  to try to impact better control.  Either way,  you get a vibratory force,  or increase your rotational forces,  potentially causing injury.

3. In terms of the serve, a flatter one is less likely to cause a hyper extension injury to the upper back,  neck and back.  If you desire a spin,  you might consider changing to a slice serve versus a kick serve.

4. Make sure you keep limber, and are ready for the rapid actions required of good net play.  Volleys  are fun,  but do not contort your body and place the spine in an awkward position to accomodate more aggressive play.

5. The tennis swing is a rotatory motion.  The effect can cause an unwinding of the natural fibers of the disk.  Make sure you use proper body mechanics and folllow through to avoid excessive jerkiness in the swing.

6.  If the swing continues to cause back/neck pain,  consider getting a lesson,  to make sure your swing mechanics is not the cause of the discomfort.  Tennis and back pain can be controlled with a few changes to your game.

The Data on Obesity and Low Back Pain

The North American Spine Society 2013 Outstanding Paper Winner reviewed the effects of physical activity,  Obesity and Low Back Pain.

In the study,  a cohort of patients were stratifed by BMI,  medical comorbidities,  smoking status and age.  In addition,  each of the patient was provided an accelerometry device that measured activity levels for 7 days while awake.  Admittedly the study did have some flaws in the design,  however the cohort numbers were significant (over 6000 people data base to start) and by the survey,  back pain patients where identified by those who stated the had experienced low back pain in the past three months.

In many respects,  the study confirmed common sense. At the time of the survey,  the normal weight individuals reported LBP during the time of the survey at only 2.9% of the population.  On the other extreme,  11.6% of the ultra obese reported LBP.   There was a correlation between increased BMI and increased reporting of LBP. The results also demonstrated that smoking is consistently the strongest predictor of LBP  across all BMI  groups.  Physical activity was also demonstrated to mitigate the risk of having low back pain.

The study discussion indicates that especially for the overweight and obese,  small increases in a more sedentary activity level,  and less moderate activity leads to greater impact on reporting Low Back Pain.

The take home message is that overweight and obese people need to be counseled on the correlation of obesity and low back pain.  In addition,  this study indicates that exercise,  especially for the overweight and obese can have a mitigating effect on experiencing back pain.

Finally,  a study that actually proved common sense!

Research on Twins and disc degeneration

So,  what if you had a study where identical twins were subject to difference occupations and followed over time to see if there was any difference in the development of disk degeneration?  I think everyone would agree that would be a fascinating study.   If we had just a study,   maybe we will have enough data to answer the question of genetics over environment.  Does increased occupational stresses increase disk degeneration?  Does genetics have a role in the development of disk degeneration?

Well,  in the Spine Journal of January 2009,  Battie, et al  reported on a 1991 Twin Spine Study about a multinational research project that followed twins from Canada,  Finland and the United States.  The study gather data regarding disk degeneration and relationships with occupational exposure,  smoking,  driving and whole body vibrational exposure, anthropomorphic characteristics,  inheretability and the potential genetic nature of degeneration.

The study indicated a significant genetic effect associated with the development of disc degeneration.  For may of the twins,  there was a significant difference in occupational and recreational spinal loads.  Identical twins had different interests,  and had jobs with significant physical demands.  Yet,  the development of disc degeneration was similar in these identical twins.

The study concluded that the conventional wisdom of assuming occupational and physical loading causes disc degeneration was not correct.  The identical twins developed disc degeneration in similar manners despite differences in occupation and recreational exposures.  The study indicates your genetics determine the development of disc degeneration rather than “wear and tear” of life or occupational exposure.

This article was a followup to a 5 year twin study published in 2006.  In that study,  it concluded that in identical twins,  only 2%-10% of the degeneration can be attributable to occupational and physical loading.  The vast majority of disc degeneration is secondary to genetics and similar environmental exposures.

Currently,  there is a significant amount of research being devoted to identifying the genetic markers associated with accelerated disc degeneration, and other musculoskeletal manifestations.  In clinic practice,  at times, we see families that have serial generations with similar findings.  Often times,  we are not sure if the clinical complaints are completely environmental,  familial pattern of behavior, or genetics.  In the future,  we may have genetic tests that may enlighten us to the cause of these familial patterns.

While research continues,  these studies do indicate lumbar disc degeneration does have a significant genetic component.  This information may inflame  the debate on the theories of occupational and traumatically induced disc degeneration.

Cervical Fusions in the NFL

Football is fun to watch, and play.  But,  as a  NFL player,  you are one down away from injury.  Unfortunately,  some injuries can be career ending.   I had previously blogged about the  rates of disk herniations in the NFL.  But, there is not much information about the results of certain surgically treated injuries until recently.  Dr. Joseph Maroon,  MD,  team neurosurgeon for the Pittsburg Steelers did publish a review on the results of  single level Anterior Cervical Discectomy on 15 NFL players from 2003 to 2012.

To summarize the study,  these 15 players had a diagnosis and symptoms of cervical radiculopathy (pinched nerve in the neck).   Each player had a single Level Anterior Cervical Disectomy and Fusion.    13 of these players did return back to play on an average of 6 months from the time of surgery.  The least amount of time to return to play was 6 weeks.  The remaining two players were given the OK to return to play,  but chose to retire.

All 15 of the players remained symptom free of pinched nerve sensations for a minimum of 2 years.

Of the 13 players that did return to play,  5 did retire after an average of 2 years.  The remaining 8 continues to play without any sport related neck complaints.

This is the largest series on neck fusions on NFL athletes.  While we may not apply all this information to the general population,  we can make some general observations.

1.  ACDF surgery has a high rate of decreasing or eliminating neck pinched nerve symptoms in single level surgeries.

2. Successful single level fusions allow people to return to heavy demand activities.

3. For patients with single level ACDF,  timing of return to full activity varies.

4. Athletes returned to play had a normal neurologic exam and full range of motion.  If we use that criteria,  it is a reasonable guideline for all patients.

I have heard the arguement that NFL athletes are highly motivated professionals,  and the monetary rewards make these athletes more likely to return to full activities.  I have also heard that these athletes do not have the same understanding and concept of pain,  and therefore will push themselves to return to activities sooner than others.  While I agree with both of these points,  I also see the same results in normal everyday people.  In my opinion,  Anterior Cervical Disectomy and Fusion still remains an excellent option for the right patient.

Lumbar Fusion Adjacent Level Disease

In the July 2004 Edition of the Journal of Bone and Joint Surgery,  Dr. Ghiselli et al performed a retrospective review on patients that had undergone lumbar fusions by primarily by the Late Dr. Edgar Dawson,  distinguished professor and spine surgeon affliated with UCLA.  The goal was to establish the rate of developing symptomatic adjacent level degeneration that required surgical management.   The journal article details the indications for the fusion procedure.  Most patients had posterior intertransverse process spinal fusion for spondylolithesis,  post-laminectomy instability,  or recurrent discectomy.  Patients excluded from the study included those with history of neoplasm, acute fracture of dislocation,  or were scheduled to have an additional anterior surgical procedure.

Total number of patients reviewed are 215 patients that have had posterior lumbar fusion between April of 1983 to August of 1994.  As we know,  the article was written in 2004.  The surgical procedures included about 50% of the patients that had non-instrumented fusion  ( no plates,  screws or other hardware).

The study concluded that 16.5% of these patients had additional decompression or fusion within 5 years.  36.1% of these patients had additional decompression or fusion within 10 years.    The theory is that these patients developed symptomatic disk degeneration that required surgery at a rate of 3.9% a year.

Of course,  while the study did present some numbers,  this was a retrospective review,  and  the multiple different indications for the primary lumbar fusion was not well stratified.  We do no know if patients that had recurrent disk herniations,  versus patients that had post-laminectomy instability versus spondylolisthesis had more or less numbers of patients with development of symptomatic adjacent level disease.  We do not know if there was a difference of outcome based on the surgical technique utilized (instrumentation,  vs non-instrumentation).   Also,  there was no matched pair of non-surgically treated patients to see if there is an statistical difference in adjacent level disease in non-surgically treated patients.    What if the adjacent level degeneration is not because of the surgery,  but rather,  because the patients who need surgery also are the ones who develop rapid degeneration that would be considered surgically treatable?  The authors themselves stated the limitation of the study is that the endpoint for symptomatic adjacent level disease is the additional surgery.  There can also be a population that develops surgically treatable adjacent level disease,  but chose not to have surgery.  There are too many unanswered questions to conclude the rates and percentages are accurate.  But,  as a spine surgeon,  we do know that adjacent level degeneration is a real issue that must be measured,  and counseling on the potential for further surgery should be discussed with all patients undergoing lumbar spinal fusion.

While some will use this data to discredit spinal fusion,  most clinicians know that spinal fusion still has a role.  Further studies will hopefully give us better information,  so we can inform patients,  families,  insurers,  etc the potential for more surgery in this population.

Stem Cells to Treat Back Pain

Stem Cells to Treat Back Pain

Beyond the standard, traditional treatments for low back pain, stem cell therapy is an alternative approach that is in its infancy but may become a viable treatment option for many.  In simplest form, stem cells are cells that are taken from within the body that can differentiate (develop into specialized cells) to produce more cells. These cells can be targeted to repair tissues within the body including the joints and spine.

Disc degeneration is the process in which the intervertebral discs undergo changes leading to desiccation “drying out” and eventual dysfunction. When this occurs, the mechanics of how the back moves and functions changes.  For a subset of the population, this can lead to chronic low back pain.  From a scientific standpoint, it is believed that once the disc begins this degenerative process, the discs are unable to heal themselves.

Stem cell research in orthopedics is one of the hottest areas in regenerative medicine. In a few small studies that appear in the literature, the use of mesenchymal stem cells to treat degenerative disc disease showed the potential for positive outcomes including a decrease in pain levels. Safety is a big concern and so far, no adverse effects have been noted.

In one of the largest studies to date (phase 2 study), 100 patients were randomized into several groups at 13 sites located in the U.S. and Australia. One group was injected with a higher dose of mesenchymal precursor cells, a second group with a lesser dose of mesenchymal precursor cells, a third group was injected with hyaluronic acid, and the last group was injected with saline. The authors of the study have reported over 71% of those injected with stem cells met markers for efficacy and safety at 6 months.

Some of the unknowns at present include a standardized protocol to develop the cells into the correct type, methods of implantation, survival once implanted, and promoting cell function and development. Even with all of the research that has been done and published, there is still a lack of complete and total understanding of the processes involved in disc degeneration. Without this knowledge, it can prove challenging to develop strategies and treatments to stop or reverse these processes.

One of the other areas and approaches is the use of platelet rich plasma (PRP).  With this approach, blood is withdrawn from a patient, processed and then injected into the diseased area.  The theory behind this is that the stem cells are concentrated in the bone marrow and fat which when injected into certain areas, may help promote healing.   The problem with this approach is that enough stem cells may not harvested to produce the desired effects. Again, there are many unknowns at this point.

At the present time, most insurance providers do not pay for stem cell therapies as it is still considered experimental. While there may be advantages to this type of treatment, it can be very expensive.  The known risks include possible infection and a temporary increase in inflammation following injection

Who Should Have Lumbar Disk Surgery?

We are living in the world of Evidence Based Medicine.  Let’s assume,  there is no other agenda other than trying to find the best ways to take care of known medical problems.   About 15 years ago,  13 institutions pooled their data on Spine  patients,  and followed the results of  both surgical and non-surgical care of specific diagnoses.  Taken Directly from the Dartmouth Medical Center website:

“The Spine Patient Outcomes Research Trial (SPORT) is a 5-year study that looked at 3 of the most common back conditions and compared surgical and non-surgical treatments.  Approximately 2500 patients took part in the study, which was conducted at 13 sites across the country.”

The three diagnoses were intervertebal disk herniations,  spinal stenosis, and degenerative spondylolithesis.  Since the beginning of the SPORT trial,  a significant amount of data was collected and mined.  Surgeons are relieved to know that surgical treatments of these diagnoses has proven to be beneficial, and has advantages over non-surgical treatment in specific instances.  But,  further mining of the data has been used to identify characteristics of patients that would benefit from certain surgeries.  In the January 15, 2012 SPINE article authored by Peason, et al.,   the discectomy treated patients were compared and stratified for the certain variables.   The variables recorded included  marital status, absence of joint problems, worsening symptom trend at baseline, education level, age, worker’s compensation status, duration of symptoms, and an SF-36 mental component scores (MCS) .

In this article,  there were several Key Points that was summarized in the last page:

“Disc herniation patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of specific characteristics.

Being married, without joint problems, and worsening symptom trend at baseline were associated with a greater treatment effect of surgery.

Some characteristics associated with worse overall outcomes were associated with greater surgical treatment effects (i.e., low education, low MCS score, longer duration of symptoms).”

Overall,  it means lumbar disk surgery was a good option for properly selected patients.  It also states that the factors of being married,  not having joint problems and having worsening symptoms had greater treatment effects.  Remember that treatment effects means more comparative improvements.

What intuitively makes sense is that if you do not have any other musculo skelatal problems,  you have greater improvements.  Also,  if the pain is worsening,  surgery has greater treatment effects.  The issue of marriage has been demonstrated to have a positive correlation to successful surgical outcomes in many other areas.  The question is what causes the improvement?  Is it better emotional support?  Is it better home care?

Conversely,  lower education level,  lower MCS scores (emotional, and mental health issues) do not show as great a treatment effect.  Is treatment effects also related to education level, or psychologic factors?

There are currently many studies also looking at the social economic factors and ethnic factors in success of surgical management of many types of surgeries.  Unfortunately,  the Evidence Based research may uncover some uncomfortable trends that could cause cause friction amongst the various communities.    As stated above,  let’s assume there is no other agenda in trying to identify these trends.   Let’s hope “political correctness” will not taint the discussion, and keep the Evidence neutral, and free of any biase.

Back Pain and Traveling

Back pain is inconvenient at best,  life altering at worst.   Still,  with or without it,  we must continue to do what we need to do to participate in the activities of life.  A common question asked by patients concern traveling.  The specific questions asked are, when I have back pain, can I ride on a plane?   Should I be driving with back pain?

Let’s take one question at a time.

If you have back pain,  but must travel by plane,  you need to plan ahead.  Especially if the flight is a long one,  you should request an aisle seat.  That way,  when allowable,   please get out of the seat.  As most back pain sufferers know,  sitting is usually the most uncomfortable position.  Standing up every hour or so allows you to take pressure off the back.  In addition,  the mere act of standing will stretch your muscles, and decrease the pressure on your lower disks.  Also,  as an added benefit,  standing, and walking will allow your circulation to improve,  and maybe will prevent developing a potential life threatening blood clot in your veins.

When taking a plane,  travel light.  Unless you have help carrying luggage,  you must plan to lift the luggage in the overhead bin,  or from the baggage carriage.  While many of your fellow passengers may assist you in some of the efforts,  that is no guarantee.   If you must have certain things at your destination,  you might consider shipping the item ahead of you, so you do not need to carry it.

While it is tempting to fall asleep on the longer flights,  you run the risk of falling alseep in an less than favorable position.  Many back pain sufferers awake with pains from sleeping.  Plane seats just do not accommodate a neutral sleeping position.  Stay awake, and maintain good sitting posture.  While it may be uncomfortable at times,  at least you are maintaining a better spine position when conscious.    As a corollary to not falling asleep on a plane,  please moderate the use of your pain medications and muscle relaxers on the flight for that very reason.

I am not suggesting everyone upgrade to the much more expensive first class seats.  But,  there is more room in those seats, and you may have more freedom to shift in those seats,  when having a significant back pain episode.

Finally,  on the longer flights, some patients find breaking up the flight with a layover makes travel more tolerable.

In the end,  the decision to fly,  and how to fly is ultimately up to you.  But consider the points above if you must travel by air.

Traveling by Car has more options.  If you are having a bad episode,  I suggest you let someone else drive.  If you must drive,  remember not to drive while taking narcotics or muscle relaxers.  Make frequent stops to stretch the muscles.  Consider the type of car seat.  If you have a choice,  avoid low bucket seats, and drive a vehicle that has a more upright, and firmer seat.  Make sure you maintain your lumbar lordosis while sitting, and use a lumbar roll.  If you have a very long drive,  consider breaking up the drive over several days.  Like flying,  consider the weight and type of luggage.

While these suggestions seem like common sense to some,  you will be surprised by the number of patients who have not thought of these issues when traveling.

Treatment for back pain: NSAIDS, Exercise, Injections, and Vitamin D?

 How many times have you seen a physician for low back pain and it was recommended that you take Vitamin D to treat it? The answer for most will be never.  Depending on the nature of your back pain, a combination of physical therapy exercises, non-steroidal anti-inflammatory medications and perhaps a corticosteroid injection is more likely to be offered.

The relationship between Vitamin D and different aspects of health continues to grow. Vitamin D has always been touted for its effect on building bones. Now, several studies have appeared in the medical literature showing a possible relationship between low levels of Vitamin D and back pain.  One notable study published within the last year in Spine concluded that in a group vitamin D deficient patients who were enrolled in the study and were treated with adequate levels of Vitamin D, saw significant improvements in overall pain level. Several other studies have had similar findings. Population estimates for vitamin D deficiency are as high as 80%.

So how is Vitamin D linked to back pain?  There is no clear cut answer to this yet, but there is a suggestion that Vitamin D acts as a hormone and has neuroprotective and immunomodulatory effects. In other words, Vitamin D is vital to normal nerve functioning.  One of the main functions is to regulate calcium and phosphorus. Furthermore, those with low levels of Vitamin D have also have more inflammation.  We know that inflammation makes pain worse, retards healing, and promotes chronic diseases.

While I am not suggesting that low levels of Vitamin D are the sole cause of back pain, it may be one key components that has been overlooked for decades.   The only way to know your Vitamin D level is to have it checked with a simple blood test. This can often be done as a part of your annual physical.

Obtaining enough Vitamin D can be challenging. The best source is natural sunlight. For those who live in the north, some still cannot get enough sunlight exposure even in the summer months. While some foods also supply Vitamin D, getting enough may be difficult.  Additional supplementation (Vitamin D3) is recommended to ensure adequate daily intake of Vitamin D.  As aforementioned, Vitamin D testing is recommended to not only establish your current Vitamin D status, but also to monitor levels with supplementation.

What is myelopathy?

Myelopathy means a compromised state of the spinal cord.  And,  there are multiple reasons for that situation.

The more uncommon reasons are secondary to vascular compromise.  Usually there is compromise of the blood supply to the spinal cord.  Typically,  it is the anterior spinal artery that is effected,  although,  posterior artery (there are two of them) sources are possible.  In the most acute devastating situation,  there is total infarct of the arteries causing ischemia and necrosis of the spinal cord.  Fortunately,  this is a rare occurence,  but if there is and acute paralysis event without trauma,  there is always the concern of a vascular orgin of the paralysis.  Entities such as AVM (Arteri0-Vascular Malformations) about the spinal cord can lead to thrombosis of the arteries,  or rupture of the feeding arteries to the spine.  In other instances,  thrombosis of the major arteries to the brain (carotid,  vertebral arteries) can cause loss of vascularity to the spinal cord vessels.  As stated above,  this can be a rare but devastating consequence of vascular disease, and testing to identify a vascular cause of paralysis and myelopathy will include Brain MRI’s,  MRA’s, and standard brain  angiography.

Other rare forms of myelopathy is secondary to certain antibiotic use in cases of meningitis,  or radiation induced myelopathy secondary to treatments for cancer.  In these situations,  the myelopathy is a side effect from treatments rendered to treat life threatening diagnoses such as spine and brain infections,  or cancer.  In these situations,  the treatments,  while potentially beneficial,  has side effects that can also have a devastating impact on the patient.

The most common reason for myelopathy is secondary to pressure on the spinal cord.  The pressure can happen acutely by mechanisms such as a fracture,  or instability,  or by a large disc herniation compressing the cord.  Or it can also occur by infections compressing the cord, or tumors growing pressure on the cord.

In a more gradual fashion,  such as spinal stenosis,  or ossification of the posterior longitudinal ligament,  the spinal cord will be gradually compressed,  until one day it becomes symptomatic.

The symptoms can be as dramatic as immediate weakness,  inability to control muscles and the bladder,  to a gradual weakening, and clumsiness.

In the acute situation,  it can strike all ages.  Traumatic fracture, instability or disk herniation will present with symptoms in a short time from the time of the onset of the spinal cord injury.

In the more gradual situation,  typically it is found in the older population,  and usually with concomittant degenerative findings such as arthritis and stiffness.

For the more rare cancer or infectious source of myelopathy,  there are also so called constitutional signs such as fevers,  sweats, and weight loss.

As far as treatments are concerned,  some surgeons are more aggressive in the gradual situation recommending surgery, others  will wait to see if the weakness progresses.  In the acute situation, most surgeons agree that the spine will need to be stabilized and the pressure on the spinal cord relieved.  The surgical options depends on the type of compression,  and the presence of a fracture,  instability or a kyphotic deformity.

If you think you have any myelopathy signs,  please discuss your complaints to a physician immediately.  Usually,  the source of myelopathy is located in the neck,  or thoracic spine.

Don’t Just Sit There..If you want to be healthy

Have you ever considered how many hours per day that you sit?   Do not forget to count the time spent sitting while eating breakfast, the car ride to work, perhaps an 8 hour day at the office, the car ride home, sitting at the dinner table, and then reclining in front of the television for hours at night.  Add it all up and some will find that this number is upwards of 15 hours per day! Several published studies have confirmed that many spend nearly two-thirds of their day in a sedentary position.

What is the significance of this?   Sitting is strongly associated with cardiac disease, diabetes, obesity, cancer and early causes of death. In fact one study that included over 595,000 adults showed that there is a 34% greater risk of mortality for adults that sit 10 hours per day.   Even scarier is the fact that we are learning that those who exercise an hour per day are not immune to these risks.  Sitting increases your risks of disease and death even among those who are physically active.

When you are sitting especially for prolonged periods, your body undergoes certain physiological changes in which your metabolism slows considerably. As this occurs, your circulation slows raising your risk for a blood clot. Blood sugar levels and triglyceride levels start to rise.  Additionally, lipid phosphate phosphatase-1 becomes suppressed when you sit. This gene is responsible for the prevention of cardiovascular inflammation and lessens the risk of blood clotting.

As for the effect on the musculoskeletal system and spine, we know that sitting causes muscles to become tight or in some cases overstretched. Sitting puts nearly twice the stress on the spine that standing does.  Changes in your natural spinal curve occur causing the potential for muscle imbalances and abnormal strain on ligaments that support the spine.  The lack of movement also prevents disks from getting nutrients.  This cascade leads to back pain.

Many of us do not have the option of completely changing how we work during the day. Short breaks of standing, walking, and engaging in light activity can make a huge difference with your health.  Outside of the office, there are lifestyle changes that most of us do have the opportunity to make. Back away from the TV! There is an endless array of activities that we you do that do not involve sitting on the couch or easy chair.

The bottom line is that no matter how old you are, how healthy of a diet you consume, and no matter how much you exercise, sitting is not healthy and has the potential to cause many health problems.  The absolute threshold for how much sitting is too much has yet to be determined.   Our bodies were not designed to sit for long periods of time.  Time to get moving…

Repeat Surgery After Cervical Discectomy and Fusion

Traditionally,  spinal surgery  had a bad reputation.  But,  epidemiological studies have demonstrated efficacy of certain procedures.  Recent analysis of the SPORT data indicates that for a matched population of patients with symptomatic disk herniations  there are better long term outcomes for the surgical patient.

Still,  there is the constant fear of spinal surgery leading to additional surgery in the future.  One of the more successful spinal surgeries is Anterior Cervical Discectomy and fusion.  In general, these patients have not responded to non-surgical means,  and therefore elect to undergo the procedure for relief of arm radicular pain.  The success rates are variable,  but the general concensus is improvement of the pain in greater than 90% of the patients.  The concern however, is the long term effects of fusion on the levels above or below the fused level(s).  The development of problems is called Adjacent Segment Disease (ASD),  and with that concern,  there have been a tremendous effort to develop artificial disc replacements in the hope of avoiding ASD and subsequent surgery.  Thus far,  the accumulated data has not been clear about the benefits of artificial disk replacements,  although some studies do show an advantage.  Unfortunately,  other studies do not show less rates of subsequent surgery.   As stated above,  the use of these devices are still too early in its history to know if there is a long term advantage.

But,  the real story is the rate of  developing ASD to the point of having additional surgery.  In the Spine  January 15 2014 article above,  888 patients who underwent Anterior Cervical Discectomy with Fusion over  a 20 year period was followed for the development of surgically significant ASD.  108 had repeat surgery.   That is about  12.2%.  The study also followed these 108 patients,  and about 25% of these patients needed another surgery.

While this is really an epidemiologic  study,  at least in this series of consecutive patients,  we do have some numbers to compare.  We can draw some general ideas about the incidence of additional surgery.  But,  we cannot know if there were other factors that lead to this incidence.  For example,  was the repeat surgery  group of patients associated with a certain type of cervical plating and technique?  Some studies indicate a longer plate that encroaches on the adjacent disk levels can lead to accelerated disk degeneration.  Do the patients with ASD have any other factor such as age,  weight,  medical comorbidities that will effect the development of ASD?

But,  the study is very useful in that I can tell my anterior cervical discectomy and fusion patients,  in general there is a 10-15% incidence of the need for further surgery in the future.   At this time,  I cannot tell them if Artificial Disk replacements can decrease the rate of additional surgery.  But,  there are some compelling arguements to the advance of  artifical disk replacements in younger patients with healthy bone stock.

Skiing and Back Pain

It is winter time in much of the country.  And the statistics indicates  about 11 million people will go skiing at least once this year.   While everyone is naturally concerned about a broken leg,  as a spine specialist I want to share the issues pertaining to Skiing and Back Pain.

There has not been much information about the effects of skiing on the population.  I did come upon a study that asked alpine ski instructors questions about their back.   75% of the ski instructors reported an episode of back pain in their lifetime.   9% admitted to missing over 10 days of work secondary to back pain.   The study concluded that the lifetime prevalence of back pain was similar to the general population,  but the survey responders report a higher lifetime prevalence of back pain  than athletes of many other sports.

Now the reason for the increased lifetime prevalence may be the age of the athletes.  As far as instructors go,  the average age of ski instructors may be greater than other sports,  thus the increased reported prevalence.  But,  I was happy to know that the lifetime prevalence was similar to the general population.

In another study,  young skiers,  before enrolling in an elite ski program had x-rays obtained of their back.  During the two years of elite training, the skiers were observed for back pain.  The overall incidence of back pain among these elite adolescent skiers was 12.5%.  Interestingly,  the pre-enrollment x-rays did show asymptomatic findings of spondylolysis,  scoliosis,  spina bifida occulta, as well as Schmorl’s notes, and posterior end plate lesion.    But,  over the two years,  skiers with severe anterior lesions (lesions that effect greater than a 18% vertebral body height) had significantly more lower back pain that the skiers without these lesions.

After reading this study,  are we to conclude that certain findings are pre-disposed to cause back pain for everyone,  or only elite adolescent skiers?  Or,  as one other study concluded,  in the skelatally immature,  the forward bent position may predispose development of anterior endplate lesions,  especially in the high performance elite young skier.

So,  what is the average recreational skier to conclude with these studies?  The truth is the average skier only ski’s less that 10 days a year.  I do not think that low level of frequency will develop into the bone and spine changing deformities seen by the young elite skier.

But,  there are preventative measures you can take to avoid back pain.  Skiing is both an aerobic and anerobic activity.  Proper core strength will aide in protecting the spine from injury.  In addition,  especially out West,  skiing is an altitude dependent activity.  Because of the greater elevation,  your aerobic capacity will be affected by the lower air pressure.  Without proper aerobic conditioning,  fatigue may not allow your muscles to maintain proper body mechanics.  Fatigue may not allow you to avoid excess loading on your spine.  Also,  due to the cooler environment,  you must spend a bit more time to stretch your muscles and ligaments to avoid injury.  A longer warm up period may be necesary to allow the proper stretching.

To try to avoid injury to the spine,  make sure you work on your aerobic capacity before going skiing.  Build your core strength, and finally,  take a few gentle runs to warm up the muscles,  then go through a good stretching regimen before getting more aggressive on the slopes.

And remember,  once you get home,  because of the fatigue of the skiing,  you may be more susceptible to back injuries until your muscles have  a chance to recover from the stresses of a good ski outing.  Enjoy yourself,  but be safe!  Try not to make skiing and back pain a common occurrence for you or your ski team.

My core is weak and I have back pain: Should I do sit-ups?

One of the most commonly prescribed treatments for generalized back pain is physical therapy.  More specifically, a program to lessen pain while improving flexibility, posture, and provide strengthening are the overall goals of the program. Long-term, we discuss core strengthening to help promote a healthy and functioning spine.  The core represents the stabilizing muscles and supporting structures of the trunk that protects the spine and allows us to do most daily and recreational activities.  It is always great to hear from patients who present to the office and share with us that they have been doing core strengthening exercises.  However, when we probe a little deeper, many are actually doing good old fashioned sit-ups, believing that this is the key component to building strong abdominal muscles (and making their back better!).  Why not have a strong set of abdominal muscles and visible 6-pack to show for it?

So are sit-ups effective at building the core and are they safe for most?  The answer may surprise many.

The evidence is mounting that lying down and repeatedly flexing the spine will only cause further problems. This can result in promoting more rapid wear of the disc associated with repetitive sheer forces. Studies in the medical literature have found that repeated spinal flexion can have adverse effects on the intervertebral discs.  Think about this, we often focus on posture as another aspect of a healthy spine. If someone sits with their back rounded (spinal flexion) and abdomen contracted, is that a normal posture?  The obvious answer is a resounding NO! This is exactly the position that we are in while doing a sit-up.  Furthermore, sit-ups (and crunches) work specific abdominal muscles and the hip flexors but do not work the entire set of core muscles.  We know that when abdominal muscles are strong and back muscles are weaker, the back is more susceptible to injury. So if sit-ups are not good for someone with a “healthy” spine, imagine the potential consequences for someone who already deals with issues related to low back pain. Going back to my introduction, the patient’s we are seeing in the office are not coming to see us because their back is feeling good!

There are many good alternatives to sit-ups that can be done without any special equipment. The bottom line is sit-ups get a big thumbs down in regards to building the core and helping the low back.

Disk Herniations in the NFL

Playoffs are over. Congratulations Denver and Seattle.   On to the Super Bowl!  Whenever I watch the game,  even as an orthopaedic spine surgeon,  I am amazed there are not more injuries. As an aside,  I hope Navarro Bowman of SF has a full recovery.    Considering the size and speed of those players,  you would think there would be an injury with every play.  Sometimes I am asked to consider the bio mechanics of injury.  Back when I was an orthopaedic resident,  we did have training in the biomechanical stresses to the bones,  joints,  and ligaments.  Engineering concepts and force analysis are necessary in developing our instruments and surgical implants.  We all know  mass times velocity = momentum.  Now imagine the effects of 300+ lbs bodies crashing at full speed,  often at awkward angles.  I have heard the arguement about how the NFL athlete’s bodies have been conditioned to accept the hits.  Still,  the tissues,  ligaments and bones are subject to the rules of physics and biomechanics.  Those forces are significant,  yet  the injury rates are surprising less than what I perceived it to be.

In October of 2013,  in Spine,  Dr. Benjamin Gray published an epidemiology paper titled “Disk Herniations in the National Football League”. It was a retrospective review on all disc herniations to the spine from 2000-2012.  The NFL has a surveillance database, and collects information such as location of injury,  player position, activity at the time of injury, and playing time lost due to injury.  It is great information that can be used in Fantasy Football,  only in reverse.

To summarize,  in those 12 years,  there was 275 documented disk herniations.  To put matters into perspective,  there are 32 teams,  with a roster of 53 player each.  At any one time,  that means a total of 1,696 players per year.  Over twelve years,  that turns out to having 275 herniations for 20,352 player-years.  Now,  I know many of the players come back season after season,  but there are statistics on the average length of career in the NFL.  If you are a rookie making the roster,  it is 6 years.  But,  if you include everyone who shows up for training camp,  it is 3.2 years.   If we give it the best case scenario,  where ever player is rookie that makes the roster,  then it means over a 12 year time period,  each position will have only 2 players during that time.  so the player-years calculation becomes 3,392 player-years.  To then calculate the frequency of disk herniations,  it would be  275/3392,  or about a 8.1 % chance that a player in one season will have a disk herniation.  Bear in mind these are my calculations,  and not the ones in the study.   That is a pretty large number.  But,  then  we need to know what happens to these players after they sustain a documented disk herniation.

The data indicates 76% of the HNP’s were located in the lumbar spine,  with the most frequent level being L5-S1. Offensive linemen was the most frequent position injured, with the blocking the most frequent activity.

On average,  there was an approximately 12 game loss ( of a 16 game season)  due to HNP’s,  but even there the statistics were interesting.   If you take the average of all players  (including those who permanently left the game after HNP),  there is an average of  12 games lost to a HNP .  But,  if you take the median,  in other words, of all the players who had a disk herniation,  if you take the player exactly in the middle of the pack of all those with HNP’s,  in terms of time off,   it was only 2 games.  From the players perspective,  if you have a disk herniation,  at least half of the players returned back to play after missing a maximum of  two games.  The players who developed the more significant disk herniations skewed the average to a much higher time away from the game.

Other studies demonstrates 82% of the players return to play for an average of 3.4 years post injury.  And,  in terms of management of disk herniations,  80% of players return to play after surgery,  while 59% of players treated non-surgically returned to play. Peyton Manning is a prime example of a player returning to excellence after neck discectomy and  fusion surgery. 

The authors of this epidemiologic studies acknowledge that the diagnosis of disk herniations on MRI studies may in fact be red herrings and may have been asymptomatic of the disk herniation when presenting with pain.  The 275 herniations may not have been acute, or the cause of the pain on initial presentation.    The database also did confirm that there is an increased risk of degenerative disk disease in high performance athletes.  I will add,  that is consistent with the added biomechanical stresses experienced by these athletic activities.

But,  I find the take home message is that disk herniations occur less commonly than I would think for such activities.  Also,  it is helpful to know that despite finding disk herniations on NFL athletes,  most return back to a high level of competitive activity.  It makes you wonder why some people are so debilitated by disk herniations,  while others can return back to high levels of  activities.  There is a non physical component.  And yes,  I am sure it has to do with compensation (money, fame, ego, etc) and the resulting motivation.

Sex and Low Back Pain

Counseling on Sex and Low Back Pain is sensitive but necessary.  After gaining the trust of my patients,  this does become a common topic.  You could imagine,  it can be difficult to keep a straight face while fielding very graphic and detailed questions.  But,  there has been some research on this very topic  as sex is instinctual, with physical,  pyschological and emotional  components.

What we do know is back pain does contribute to lack of desire,  poor performance, and reduced frequency.  Couples naturally have barriers to having sex.  Lack of time,  too tired,  life stresses, etc.  Adding back pain can cause that one more barrier to reducing physical intimacy.  To some couples,  that can have a lasting effect.    We do not need scientific studies to show that any pain will make physical activities difficult.   But,  never the less,  there has been studies,  based on surveys,  indicating definite decrease in frequency, desire and satisfaction. 

At the same time,  there are studies indicating recovery from episodes of disk herniations,  have corresponding return of sexual parameters.  Some of the studies indicate people return to sexual activities in about 3-4 weeks after successful lumbar discectomy.  Other studies have looked at the rates of sexual dysfunction in people with chronic low back pain.  Population studies indicate chronic low back pain people have higher rates of dysfunction,  but,  even in the group of patients with chronic low back pain,  stratification of the data does show some factors such as younger age,  lower BMI,  lower duration of the condition is associated with higher rates of sexual activity, and function.

In relationship to sexual activity and lumbar spinal fusion, or lumbar disk replacement,  fortunately the data indicates improvement in the sexual parameters in patients who have undergone the surgery.

So,  what is the bottomline?

First of all,  the topic of Sex and Low Back Pain is common to most patients.  Surprisingly,  my patients seem to speak freely about the issue.   In terms of patients with chronic low back pain,  exercise,  weight management, use of NSAIDS, and depression management also improves sexual parameters of desire, and performance.    Studies confirm common sense.  Anything you do to improve your pain,  or strengthen your back can improve your sex life.

For many,  there are certain positions that increase stress on the back, and therefore effects the sexual experience.   Without being too graphic,   certain lying down positions,  or hyperlordotic postures can increase discomfort.   But,  in general,  pain will be your guide to activity levels.

For spinal fusion,  or disk replacement patients,  I would doubt this will even be a possibility in the initial post op phase.  But,  with pain as your guide,  eventual the desire curve will intersect the pain curve,  allowing you to determine the proper time to resume activities.  As stated above,  for simple discectomy patients,  usually there is a 3-4 week delay before activity.  Spinal fusion or replacement patients typically wait longer.

Sex and Low Back pain is a “whisper” topic for many of my patients.  But,  it really is one that is comtemplated,  if not verbalized.   Anything that improves your back pain,  should improve your physical capacity to have sex.   Pain will be your guide.  Learn ways to reduce the pain.

On a lighter note,  headaches are rarely associated with low back pain.

Whiplash, a spine surgeon's perspective

Unfortunately,  whiplash has automatic negative connotations to most people. I hope we can have a civil discussion about this very emotional,  personal, and at times, controversial topic.

Whiplash does have it orgins related to locomotion.  It was first described as an “acceleration-deceleration” motion to the neck  (Crowe, 1928) typically cause by a collision.    In the 1980’s  the complaints of neck pain,  spasms,  headaches were lumped together into a “Whiplash associated Disorder” (WAD),  and researchers have tried hard to define and predict the effects in various populations.

Most physcians agree that the whiplash movement has potential to cause injury.  If the forces are significant enough,  you can find evidence of bone fractures,  ligament tears, and disk herniations.  But,  the Whiplash Associated Disorder (WAD)  is usually associated with soft tissue injuries,  and not associated with any x-ray or MRI defined structural disruption.  And that is why it  is so difficult to get a handle on Whiplash  and its definition.

Often times,  as a physician,  I will see a patient after an auto accident with complaints of neck pain.  My first concern is usually to make sure there is no significant structural issue that puts that person at risk for a more permanent injury.  I need to find out about any associated complaints.  Is there any numbness,  weakness, or reflex changes?  If so,  we may need to be concerned about a nerve irritation caused by a pinching of the nerve.  Is there significant point tenderness to specific bones?  If so,  we need to make sure there are appropriate imaging studies to make sure there are no fractures.  If there are significant increases of pain,  or developing nerve sensations with motion,  sometimes dynamic studies (such as flexion-extention x-rays) are necessary to make sure there are not instability issues.  Is there any associated issues with walking,   or bladder and bowel control?  We definitely need testing to make sure there is no potential castatrophic nerve/spinal cord injury.  And finally, we need to make sure there are not co existing factors such as tumor,  infection,  or osteporosis that makes the forces of the accident that much more significant, causing a more devastating injury.

If in fact any of the more serious conditions exist,  then it is not a Whiplash injury,  but a more significant problem that will likely require more aggressive treatments such as bracing,  injections,  and even surgery.

But,  if the more serious situations are no longer a concern,  and the testing does not show any significant structural problems,  then the neck complaints with associated pain,  loss of motion, and sometimes headaches are considered a WAD.

And,  because the testing did not show any significant structural problems,  that information can be interpreted differently,  depending on your perspective.

As a treating physician,   my biase is to help the patient.  I will always believe the patient unless he or she gives me reason to no longer believe them.  Because there is no diagnostic evidence of injury,  physicians will rely on the patients complaints.  Often times,  this can lead to over treating of the problem.  Unfortunately,  many of the things we offer often do not improve the situation.  To give an example,  we do have an issue with narcotics dependency in this country.  No physician starts giving a patient with complaints of pain narcotics, with the intention of causing an addiction.  But,  we know that happens.  Likewise,  many physicians continue to order physical therapy, or chiropractic care for months,  even though there is no evidence of improvement of that patient with that treatment.  These treatments are potentially expensive,  but as long as someone else pays for the treatment,  patients will typically continue these ineffective treatments.  I guess the question that should be asked is why should anyone pay for ineffective treatment?  I know what some of you are thinking.  But,  let’s pretend there is no monetary gain for the physician that is ordering the treatments.  The question is still a legitimate one.  Why should anyone pay for ineffective treatment?  But,  fortunately,  most do improve their WAD.  It is debated which treatments are really effective.  From my perspective,  use of stretches,  NSAIDS,  mild muscle relaxers, and a combination of PT/DC treatments for up to 3-4 months is reasonable.    Beyond that,  I find it difficult to prove the costs of those measures are worth it.  I am sure many will disagree with that statement,  and I hope they share their justification in a civilized manner.

But as stated above,   the vast majority do improve.  There has been plenty of studies showing factors other than just the physical injury is the cause of prolonged treatment and work absence.  If those factors are apparent,  should they not be eliminated?  Which brings us back to the academic research on the topic.

In 200o,  in the New England Journal of Medicine,  this article was Published:

EFFECT OF ELIMINATING COMPENSATION FOR PAIN AND SUFFERING   ON THE OUTCOME OF INSURANCE CLAIMS FOR WHIPLASH INJURY J. DAVID CASSIDY, D.C., PH.D., LINDA J. CARROLL, PH.D., PIERRE CÔTÉ, D.C., MARK LEMSTRA, M.S C.,ANITA BERGLUND, B.S C., AND ÅKENYGREN, M.D., PH.D.      (N Engl J Med 2000;342:1179-86.)

I know the article was published in 2000.  I know the study was from Saskatchewan, Canada.  But,  the results are fascinating.  As most of you know,  Canada has a national health plan, so there is equal access to healthcare.  Because of skyrocketing tort costs,  the Province of Saskatchewan decided to make auto accidents No-Fault.  There is increased coverage for medical care,  and lost wages (up to $50k/year),  but there would be no awards for pain and suffering.  After inactment of the new No-Fault status,  there was a signficant decrease in the incidence of WAD, and improved prognosis.

What I concluded from the study,  is confirmation of what I already knew.  People do get injured,  but over time they do improve.  A small subset of patients will still complain of pain,  but the vast majority do recover.

Since that time,  there have been multiple other studies indicating the pain and disability associated with soft tissue complaints  is often secondary to issues other that physical injury.  Other studies identify inability of the injured to recall similar complaints or associated complaints in the past.  In fact Dr’s Don and Carragee had a 2008 Outstanding Paper Award on this very topic.  Still,  other studies do indicate a pre-existing degenerative condition does not cause a minor traumatic incident to become a serious back illness. 

As a practicing spine surgeon.  I believe my patients, when they say they have presistent pain after an accident.  But,  it is often difficult to prove why someone still has pain,  and if the pain is permanent,  especially when there is absence of structural findings.  Unfortunately,  we do not have a mechanism to truly measure pain.  And,  we still often cannot find any objective findings on physical examination that can confirm that the pain is present,  and the pain is permanent.

So we are left with this scenario.  As stated in the first line,  whiplash has bad connotations.  Society will think of whiplash as the guy who wears a neck brace immediately after an accident, and trys to draw sympathy or worse.  Society thinks he was the young school kid who always had home work eaten by his dog,  or was always late because of something,  or never could pay back the owed money.  I know,  bad connotations.  Again,  please be civilized in voicing your disagreement to me.

But,  that is why,  in my practice,  I rarely use the term whiplash.  I instead will say the person had a neck sprain/strain.  I would also characterize it as a soft tissue injury.  And,  if I believe the injury is permanent,  I would argue the person had a significant complaint of pain,  immediately after the accident,  with signficant restriction of motion, and documented spasm,  with a consistency of the complaint with documented findings for over a 6-8 month period.  In my practice,  that situation is a rarity.  But,  when it happens,  I too will argue it is permanent,  even though I have no other supporting data other than those complaints.

Should I wear a back brace for a flare-up of low back pain?

As we know, better than 80% of us will get back pain at some point in our life. For some, this will be short lived. For others, the pain and other symptoms may last for an extended period of time.  When we experience a sudden flare-up of low back pain, many are unsure as to how to manage it. Do I take some over the counter pain relievers? Do I use ice or heat?  Should I try and walk or am I just better off laying down?  The biggest issue I see is that most of us do not have time for low back pain to slow us down!  So how do we keep functioning despite back pain and spasms?   The answer for some has been the use of a back brace.  I commonly see patient’s coming in the office wearing a brace or support to manage their symptoms and provide support.

Back braces and supports are usually sold at sporting goods stores, drug stores, and multiple places online. You can usually buy them without a doctor’s prescription.  The cost can vary from somewhere around $20 to several hundred depending on what you buy.

What does a brace actually do?  Normally, your low back is supported by a combination of your abdominal muscles, low back muscles and your core muscles.  If one of these areas is weak or becomes inflamed, your low back may suffer.  The “squeezing” or compression of a brace mimics what strong muscles would normally do. Many patient’s say a brace is helpful to manage spasms or “catching” in their back when they are forced to move and be active.  In fact, a published, randomized clinical trial comparing those who wore a back support while suffering with sub-acute back pain to those who did not wear a brace had significantly better pain scores, functional ability, and used less medication (Calmels et al. Spine 2009).  For a person who is near normal bodyweight and does not have a large abdominal region, a brace can also serve the purpose as a reminder to be cautious and not to do certain activities.

What is the downside to using a back brace?  To answer this, I will use an analogy of breaking your arm and being treated in a cast. The cast is effective at minimizing motion to allow the bones to heal. When we take the cast off 4 to 6 weeks later, the wrist joint is stiff and the muscles are usually sore and weakened.  The same holds true for wearing a back brace too much or too long. The underlying spinal and abdominal muscles will weaken and not function as effectively as they should. The end result is stiffness and soreness to the back.   To avoid this, it has been recommended that you only use a brace for short periods of time when needed. Do not become reliant on the brace there comes a time when the benefits become outweighed by the harm it may cause.

Spinal Cord Injuries

Unfortunately, as a spine surgeon, I have had to deal with spinal cord injuries. Fortunately, it remains a rare occurrence. But, the consequences can be devastating.

The least catastrophic of spinal cord injuries is the spinal cord contusion. In the simpliest term, it is a bruising of the spinal cord, with associated inflammation, and irritation of the blood vessels supplying the spinal cord. As long as the blood flow is maintained, there is a temporary component of the associated muscle weakness, sensation loss, and pain. As long as the integrity of the cord is maintained, there is potential for almost full recovery of the spinal functions over time. Still, in the early stages of a spinal cord contusion, it may not be clear whether it is a temporary situation or a permanent cord injury. For the treating physicians, protocols usually are initiated to decrease inflammation, maintain alignment, and identify the cause. The causes are typically traumatic, but underlying issues such as infection, neoplasm or vascular malfunction need to be ruled out.

The most devastating spinal cord injuries involve a complete mechanical spinal cord transection. Trauma is almost always the cause. Unfortunately, recovery of spinal cord function distal to the transection is no possible. The goal for treatment is to preserve functions of the nerves proximal to the transection. As above, the goals include decreasing inflammation, maintaining alignment and stability of the traumatically injuried structures, and supporting the vasculature of the spinal cord and roots. That usually means a combination of medical management, steroid use, and surgical stabilization. While there are established spinal cord injury protocols, each of the protocols must be weighed in consideration for the many other competing medical conditions that exist in many patients that have spinal cord transactions. Unfortunately, there are often other life threatening injuries also associated with spinal cord transection, and the trauma team must prioritize, based on the condition of the patient at the time of the evaluation. Sometimes, only temporary “damage control” measures make sense in situations of extreme injuries and medical conditions. Fortunately, complete spinal cord injuries are still rare.

There are spinal cord syndromes that are  considered incomplete spinal cord injuries.

Central Cord Syndrome is often associated with older patients that already have central spinal stenosis of the cervical spine.  With a traumatic force (usually  hyperextension) applied to the spinal cord,  these patients will present with weakness  to the arms and sensory changes to the hands, with preservation of function to the lower legs.   It is called a central cord syndrome as it is associated with damage to the central areas of the spinal cord,  with associated vascular compromise and infarction of the central cord.  The central cord usually is associated with nerve fibers oriented towards the arms,  thus the arm weakness.

Anterior Cord Syndrome is associated with a flexion type injury to the neck,  which causes a kinking of the spinal cord in the front as well as disruption of the anterior spinal blood supply.  The front,  or the anterior part of the spinal cord is associated with muscle strength,  pain, and temperature sensation.  In the Anterior Cord Syndrome,  you loose control of your muscles,  but do not feel pain to touch below the spinal cord injury.  You also cannot differentiate temperature.  Interestingly,  because of the posterior (back) location of the nerves for the feeling of touch,  vibration and proprioception  ( knowing where your body part is located in relationship to the body),  you will still have preservation of those functions.

Brown-Sequard Cord Syndrome is associated with a partial spinal cord transection from the side of the spine.  In this syndrome,  below the injury, on the side of the injury,   you lose muscle function,  pain, and tempurature sensation.  But,  because of the way the spinal cord is “wired”, you will still have the feeling of touch, vibration and proprioception on the opposite side of the injury.

Posterior Cord Syndrome is extremely rare,  but as you can guess from the above discussions,  you will loose the feeling of touch,  vibration and proprioception,  while preserving muscle function, as well as the sensations of pain and temperature.

The recovery from these partial spinal cord  injury syndromes can be partial or full.  That is why good spinal cord injury principles of decreasing inflammation,  maintaining alignment and supporting vascular supply is very important.   In the ideal circumstance,  no one will ever have a spinal cord injury.  But,  if there is a spinal cord injury,  hope that it is a contusion, and treat to optimize decreasing inflammation,  maintaining alignment, and preserving vascular supply.

Is Trauma the Cause of Cervical Radiculopathy?

As a practicing orthopaedic Spine Surgeon,  I am constantly asked about the cause of cervical radiculopathy.  From the patients,  I am asked ” Doc,  do you know why I developed this pinched nerve in my neck?”.   And,  since we are now in this environment of medical cost evaluation,  the insurance companies then ask ” Doctor,  in your opinion,  what is the cause of the Cervical Radiculopathy?”  Fortunately for all involved,  the vast majority of cervical radiculopathy ( pinched nerves in the neck) resolve over time,  without significant aggressive surgical intervention.   But,  during the time it takes to recover,  there are usually associated costs.

There are the direct costs of medical evaluation,  and treatment.  These costs do include physician visits,  diagnostic testing, and treatment.  For mild cases,  it means a call to the physician, a few over the counter medications,  and activities modifications until the episode resolves.  In more serious cases,  it means multiple physician visits,  expensive testing such as MRI’s,  expensive and time consuming physical therapy, time off from work.  In the most serious scenario,  it means invasive treatments such as epidural steroids, or surgery.

Then,  there are the indirect costs that are also real.  Time off from work for the patient.  Time off from work for their families and care givers.  Financial costs secondary to income disruption.  Potential longer term issues such as disability, and effects on future insurance eligibility ( health,  disability,  worker’s compensation,  home owners,  automobile, etc).  Fortunately,  the most serious scenario is the least common.  But,  if that is the scenario,  hard questions must be answered.

The physician tasked to answer the questions on the cause of the radiculopathy must weigh many competing factors. In the end,  the opinions offered by that physician may determine which entity will pay  the costs related to that radiculopathy.  In the mild cases,  few will debate or even care who will be responsible for the minimal costs.   But, in the rarer,  but much costlier scenario,  that  physician must consider all the factors,  else that physician’s judgement and credibility will often come under scrutiny.  Some will say,  that physician’s credibility will come under scrutiny no matter what.

In the 1994  Brain article by Radhakrishnan,  there is information regarding cervical radiculopathy that gives physicians information that may be helpful in determining the question of cause of cervical radiculopathy. To summarize,  561 patients from the May Clinic registry had medical information epidemiological survey regarding cervical radiculopathy.  The average age of the patients was about 48 years.   A history of physical exertion or trauma preceded the onset of cervical radiculopathy symptoms on 14.8% of the patients.   A prior history of lumbar radiculopathy was present 41% of the time.  The mean duration of symptoms was 15 days.   A confirmed disk protrusion was responsible for only 21.9% of the radiculopathy.  68.4% of the cervical radiculopathy  was related to spondylosis, disk or both.   A combination of radicular pain,  sensory deficit, and objective muscle weakness was predictors or a decision for surgery.   At followup,  90% of the population was asymptomatic or mildly incapacitated due to cervical radiculopathy.   There are additional points to ponder in this article.  To my interpretation, determiners need to decide if the cause is related to a trauma, or other factors.  With only 15% of cervical radiculopathies associated with trauma,  the burden is on proving if any traumatic  event was the cause.

This type of information should be weighed as physicians, attorneys, and insurance adjustors discuss the cause of the cervical radiculopathy and the responsibility of the costs associated with the radiculopathy.  As for the poor patient,  he or she is only concerned that they have the pain and want a solution to it.  Of course the costs associated with the radiculopathy will also matter.  But,  often,  the patient’s perspective of the cause can be clouded by the pain, and the costs.

The Top 10 for Minimizing or Preventing Back Pain

As we close-out 2013 and enter into a new year, there are top ten lists everywhere ranging from the best songs to the best tech toys.    While my top ten list is perhaps not as exciting as some of the aforementioned,  it is one that ALL of us should consider. In 2013, how many times have you heard someone complain about low back pain?   My top ten list is about ways to minimize or even prevent low back pain. This represents a compilation of various blog topics we have posted throughout the year plus a few extra recommendations:

1.)    Exercise – Many discount this as a means of preventing or treating back pain, but the fact is this is one of the strongest recommendations we can make. Consistency is the key.  Flexibility training and strengthening of the back will help minimize the chances of developing injury to the back.

2.)    Maintaining healthy body weight– Extra body weight especially around the abdomen puts more strain on the back. Many studies have shown that being overweight or obese leads to a greater likelihood of having back and joint pain.  Identify a healthy weight for your height and frame and set a goal to reach the target weight.

3.)    Good posture – Bad posture such as with slouching or stooping can lead to muscular imbalances. You must learn good posture for walking, sitting, standing and lying down positions.

4.)    Proper Lifting mechanics – How many times have you heard of someone injuring their low back from lifting something?  It is very common. Risks can be reduced by lifting properly! Lifting objects close to your body, having a strong core and using your legs are several aspects of proper lifting.

5.)    Avoidance of smoking – Smokers have higher rates of back pain than non-smokers! Smoking leads to the build-up of plaques in blood vessels. These same blood vessels are responsible for feeding the bones and structures of the back. Smoking can lead to accelerated degeneration of the spine.

6.)    Avoid prolonged sitting – Prolonged sitting is one of the known risk factors for the development of back pain. Sitting causes an increase in static pressure affecting the discs and overstretch of the ligaments. Good posture, an ergonomic set-up, and frequent change in position is recommended.

7.)    Sleep on your side or back– Avoid sleeping on your stomach as this can affect the neutral posture of your spine.  This can also cause excessive pressure on certain muscles and joints leading to stiffness and pain.

8.)    Eat healthy – As recently pointed out in a recent blog, an anti-inflammatory diet is one of the key components of preventing back pain. This ties in with the recommendation of maintaining healthy bodyweight.  We know that certain foods have anti-inflammatory properties which block pain, reduce inflammation and in some cases even help heal underlying disease processes. Your diet is one of the strongest pieces of the puzzle in minimizing the risk of back pain yet is the most commonly overlooked.

9.)    Vitamin D levels – Evidence in the scientific literature is growing in regards to Vitamin D levels and development of chronic pain. Those with a low level of Vitamin D are at greater risk. Several studies have shown that over 60% of the American population may be Vitamin D deficient. Many have never had their Vitamin D levels checked to know if they are deficient.  The recommendation is to get tested and take a Vitamin D supplement daily.

10.)  Reduce stress and anxiety – Emotion and psychological stress can cause back pain. There are many theories to how stress can cause back pain. A decrease in physical activities can result from excess stress in one’s life leading to weakening of the muscles and deconditioning. Depression and anxiety are often also tied into this. Stress reduction techniques, lifestyle changes and exercise may help reduce stress.

Here is to a great, healthy, and prosperous 2014!

Diet and Back Pain

We often do not make the connection of Diet and back pain.  But,  like in all things,  subtle changes can make a difference.  I have blogged several times about the effects of weight and back pain,  but this blog will be oriented to the type of food,  not excessive food.

In general,  back pain can be secondary to inflammation to the muscles,  ligaments and cartilages of the spine.  So,  the question is,  does food lead to inflammation,  or does your diet contribute to inflammation?  The short answer is yes.

Studies have shown that transfats,  refined sugar,  highly processed grains,  animal fats, MSG, Glutens, and too much alcohol can contribute to increased inflammation to your body.   As in all things,  we should learn to moderate the consumption of these foods,  if not avoiding them all together.

We have also learned that there are certain foods that have an anti-inflammatory quality.

This group includes foods with concentrated  Omega 3 fatty acids.   Great sources of Omega 3 rich food include salmon, herring, mackerel,  sardines, anchovies, trout, flaxseeds, and walnuts.  While lately there has been some strong statements made regarding the lack of efficacy of using multi-vitamins,  fish oil supplements with high Omega 3 is still an excellent choice in trying to reduce inflammation.

Green tea has phytochemicals associated with anti-inflammatory properties.  To be effective, however,  we need to have about 5 cups of green tea each day.

The so called Mediterranean Diet has been associated with decreased inflammation.  That is likely secondary to the use of  olive oil.  Olive oil has been show to have a natural anti-inflammatory effect,  which also helps prevent cardiac disease.

Anti-oxidant rich foods have also been associated with reducing inflammation.  Examples of anti-oxidant foods include  strawberries, blueberries, raspberries, papaya,  cantaloupe, apricots, cherries, plums, and watermelon. Antioxidant-rich vegetables include kale, spinach, broccoli,  cauliflower, squash, pumpkin, bell peppers, sweet potato, and turnip  greens. As a general rule,  color rich fruits and vegetables are often associated with anti-oxidants.

Spices such as  ginger, garlic, cinnamon and turmeric have  been associated with anti-inflammatory effects as well.

In general,  when we say we want to decrease inflammation,  we are actually asking for a way to decrease the aging process.  Inflammation in acute injury is necessary to heal ourselves.  But,  it is apparent that the aging process includes an inflammatory process that promotes scarring, and  breakdown.  If we do our part in promoting less inflammation,  perhaps we can slow the aging process,  which includes back pain from the inflammatory process.

Everything is related.  We must stretch,  exercise,  keep our weight down,  avoid inflammatory activities such as smoking,  excessive drinking, and must eat non processed foods that promote anti-inflammation.  We may stay younger longer, and have less episodes of back and neck pain.

Video gaming, Virtual Reality, and Back Pain

Video gaming, Virtual Reality, and Back Pain

As we approach Christmas day, video game systems are again a hot commodity and popular gift. Several years ago, The Entertainment Software Association published data on the video game industry.  At that time, the industry generated over $25 billion in annual revenues in which more than 70% of American households admitted to playing computer or video games.  One would think that the average age of a game player is in the 18 – 25 year old group, when in reality the average age is 37!  One could argue that being immersed in playing video games has some potential benefits including building of eye-hand coordination, learning strategy, and in some cases enhancing social relationships through online multi-player engagements.   In fact, it has become a form of therapy for some. One of aspects that is commonly overlooked that is associated with intense video gaming is back pain.

When one enters the world of Call of Duty or Grand Theft Auto, it is usually a not a short event! Intense gamers may play for hours (or days!). As we know, sitting for prolonged periods is not healthy for our back.  This type of activity may cause muscular stiffness and soreness that can become persistent and chronic with repetitive activity.  When gaming, most are slouched on a sofa, hunched over in a chair, or leaning over a desk. Posture is rarely ever considered in these situations, but based on the frequency and magnitude of this, back problems can develop. Even smartphones are not innocuous.  Many spend hours looking at a 5” screen with our neck in a forward flexed position.  Beyond postural concerns for gamers, the real dark side is the development of a sedentary lifestyle for some.  Granted, while some of the game systems offer games that encourage exercise or repetitive whole body movements, the overwhelming majority are centered around pushing buttons on a remote control or keyboard. This has the potential to develop an unhealthy lifestyle especially among skeletally maturing adolescents and adults. Several have published about sleep deprivation associated with intensive gaming.  A lack of sleep can lead to several different health concerns including joint and back pain.  A Finish study in the BMC Musculoskeletal Disorders Journal (Makala PT, Saarni LA, et al 2012) evaluated musculoskeletal pain in school children 11 to 16 years old. The authors concluded that use of a computer for 2 or more hours a day increased the risk of moderate to severe intensity pain in different anatomic regions including the neck and back. Other anecdotal reports have also identified that prolonged gaming or computer use may lead to back pain. The actual statistics of this are really unknown and probably unreported. How many children (and even some adults) are likely to complain that their back is hurting frequently from playing video games?  I am sure many would fear the repercussion of having their X-Box One or Play Station taken away!

The bottom line…. We must be aware of the potential physical consequences that prolonged video gaming may cause.  Beyond a discussion about moderation, posture and the need for physical exercise are important especially in developing adolesecents and those who lead a sedentary lifestyle. What use to be hours on end of playing outside when I was in my pre-teen and teenage years, has now transformed into days (and often nights) of non-stop video game action for many.  In virtual reality, we can go unscathed through intense battle with the enemy for hours or run for 200 yards in a football game and not even break a sweat, but back pain is a reality in the real world from exhaustive gaming.

Arthritis Foundation - Jingle Bell Run Tampa 2013

Arthritis Foundation – Jingle Bell Run Tampa 2013

Hi everyone!  While having the honor of sponsoring the Tampa Jingle Bell run for the third year in a row, unfortunately  I was  away for the fun and the festivities today.    But,  I am excited to know that you all have come back to have fun and support this great cause! 

I hope some of you will be kind enough to share your stories about the 2013 Jingle Bell Run as well as any other story related to arthritis,  the spine, and your successes regarding the topic.

Congratulations to Jeff Taylor  and Wibke Rees for being the top male and female finishers of the 5k.

I had members of my ShimSpine team on site taking pictures of this years event that I am sharing below.

Merry Christmas and Happy Holidays everyone!

John H. Shim, MD.  Presenting Sponsor,  Tampa Jingle Bell run. 

Jingle Bell Run Tampa 2013 5k Male Winner Jeff Taylor from Toledo OH

Jingle Bell Run Tampa 2013 5k Female Winner Wibke Rees from Tampa/Germany

Jingle Bell Run Tampa 2013 Race Start

Jingle Bell Run Tampa 2013 Storm Troopers

Jingle Bell Run Tampa 2013 123

Jingle Bell Run Tampa 2013 Team Pajama

Jingle Bell Run Tampa 2013 Race Pic

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Jingle Bell Run Tampa 2013 Race Pics

Shopping and Back Pain

Along with the hustle and bustle of the Christmas Season,  lurks a very common complaint.  Yes,  shopping and back pain is a common occurrence.   During this time,  we do get increased phone calls from patients that have developed increased back pain from activities.  Often times, there are many factors that contribute to this development.

1.  For most of the country,  it is cold.  This contributes to increased frequency of complaints of back pain and arthritis.  While the studies are sparse,  most patients will tell you that the cooler, and damper weather contributes to increased episodes of back pain.  Also,  for many,  the winter is a more dormant season.  Less activity,  less stretching, and unfortunately more pulled muscles and ligaments.  More slipping on wet or snowy walkways.

2. While the holidays bring great joy and happiness,  it also contributes to increased levels of stress and anxiety for others.  Various scientific studies have demonstrated that emotional stresses increase the potential for pain,  or exacerbation of a pre-existing pain condition.  For people with underlying spine conditions,  the emotional stress can trigger another episode of back pain.

3. Let’s face it.  Shopping,  especially during the holiday season,  can become a blood sport, and has physical challenges.  While searching for bargains, or the perfect gift,  it takes physical energy to go to the store, fight the crowds and find the item.  In addition,  carrying bags of different sizes and weights can take a toll on the body and the spine.  And,  while exhausted,  the muscles and the ligaments can suffer from over use.

So,  to try to minimize potential for back pain,  consider these following steps:

1.  Stretch, and warm up your muscles.  Think of shopping as if you are preparing for a long run,  or a competitive game.

2. Pace yourself.  Like a marathon,  an early sprint does not mean you will finish the race.  By  methodically getting through your list,  you will give your muscles time to recover,  and therefore, will be less likely to be over stressed and injured.

3. Make sure you have on proper shoe wear.  Heels may make you look taller and more fashionable,  but comfortable shoes will ensure you minimize the stress on the spine and the other joints of your body.

4. Stay hydrated and fed.

5.  If you are trying to avoid the crowds by doing internet shopping,  make sure you use proper body mechanics and sit upright, and not slouched in your chair.

6.  Have a positive attitude about the Holiday and Christmas season!  And remember the season is about family and religion,  not about commercialism!

High Intensity Zone

In the above  picture,  it demonstrates  T2 Weighed MRI images of a L4-L5 Disk protrusion with increased intensity or an appearance of a lighter area in the margins of the annulus in the sagittal view.  Most radiologists will call this a High Intensity Zone, within a disk protrusion.  In the early 1990’s,  with the increasing utilization of MRI’s,  there was a lot of importance placed on these High Intensity Zone (HIZ) lesions.

Some surgeons also interpreted these findings as signs of significant back pain,  and for a certain duration of time,  patients with these findings were thought to benefit from surgical resection and fusion.  Unfortunately,  the results of surgical management based just on this sign was not  that great.

While the intention was good,  it resulted in questionable results,  at a big cost to both the patient and society.

Now,  the clinical relavance of the HIZ finding is still being debated.  While there are some studies supporting its importance,  most studies have concluded the presence of the HIZ may not correlate to having lower back pain.

In one study,  the presence of a HIZ lesion with associated herniated disk was predictive of pain.  But HIZ in a bulge or a more normal appearing disc was associated with no pain  when utilizing provocative discography as the pain generator.

In addition,  at one time,  it was theorized that the presence of the HIZ lesion may represent an acute finding.  It is now known that these HIZ lesions can be present for years.  That fact unfortunately disproved that theory.

HIZ is often commented and identified by radiologists.  But,  the fact remains, that we still do not know the significance of the finding.

Back pain,  in general is a very complicated diagnosis.  Many studies indicate MRI’s obtained with the first episode of back pain often does not identify any acute findings.   The HIZ finding is still controversial,  and the importance of the finding is still being debated.

Prescription Drugs, Driving and Machinery

In Florida,  you can be prosecuted for Driving under the Influence even while taking prescribed narcotic drugs and muscle relaxers.  In Florida,  many employers perform random drug testing of it’s employee’s, and require drug testing,  for employment.  Most companies now require drug testing when accidents occur with the use of Heavy Machinery.

Why do I bring this up?  As a Spine Surgeon,  often I must prescribe some of these medications.   But,  I always warn that you should not drive under the influence of the medications,  nor operate heavy machinery.  If you read the prescription labels from most centrally acting drugs,  such as narcotics,  or muscle relaxers,  there are also warnings and disclosures to that effect.

While I do know that some of my patients do use the drug and drive or operate heavy machinery,  I want it to be clear that the activity is against my advise,  and may be a violation of the law.

I have know  that some patients who have chronic exposure to the drugs, argue that they are tolerate, and therefore not adversely effected.  Still,  if there is an auto accident,  or a heavy machine operating damage or injury it will be difficult to prove the drug did not contribute to the incident.

To Summarize,  if you take prescription drugs,  do not drive or operate heavy machinery.  While you may have grounds to defend yourself,  if you are involved in a situation,  it will not likely resolve quickly.

DUI does not only mean alcohol.  It can also mean legally prescribed drugs.

WHAT IS THE BEST MATTRESS FOR MY SPINE?

In our spine practice, one of the most common questions that we are asked from patients is “what is the best mattress”. If you think about it, we spend approximately 33% of our life in bed! We know that a lack of sleep can affect our general overall health and cause multiple problems. Sleeping on uncomfortable bed can lead to sleep deprivation (and back pain).

First, to answer the million dollar question about what is the best mattress for your spine, there are no quality, well controlled scientific studies showing that one brand or style is superior to all others. Many of the advertisements we see on TV, in the newspaper, and on billboards would lead us to believe otherwise.  Some manufacturers go as far as having an orthopaedic surgeon endorse their brand to make it look more attractive.

In reality, the best mattress is one that is supportive to your spine.  You have several curves in your spine. An ideal mattress should provide a balance between supporting the curves of the spine and being comfortable to you. This allows your back to “rest” at night after the day’s activities.  Some may take the word “supportive” to mean firm.  This is not necessarily the case. Too firm of a mattress can be equally as harmful as a soft mattress that you sink into.   An extremely firm mattress can cause undue pressure on certain points of the body and cause muscle aches and pains. For those who suffer from hip bursitis, a firm mattress can cause pressure on the hips for those who are side sleepers possibly aggravating the bursitis further.

Finding the right mattress for you can be a challenging task.  You have to lay on the mattress in the showroom to get some sense of comfort level. Some stores do allow you to take it home for a trial period.  Just because it is the most expensive mattress in the showroom does not mean it is the best and most comfortable! We have seen patients spend upwards of $3000 for a mattress only to say they wake up with more back pain after buying it!  Ask questions and educate yourself.  Do not let fancy words like “orthopedic surgeon recommended” or “medically recommended for back pain sufferers” bias your decision to buy a particular mattress.

The bottom-line: If you old mattress is starting to creep up there in years, it may be time to consider buying a new one. It is all about personal comfort!   It is something you will have to sleep on for an average of 8 hours per night for the next 5-10 years, so choose wisely.  Do not let outside factors such as advertising sway your decision. You want to avoid waking up in the morning with persistent back stiffness and for those who already suffer from low back pain, avoid waking up feeling worse. A consistent good night’s sleep is tied largely to your overall health.  The true answer to “what is the best mattress” is the mattress that provides you with the most level of comfort while providing adequate support and allows you to wake in the morning with your muscles and joints feeling refreshed.

Spine Surgery, Then and Now

No matter the era,  spine surgery has always been associated with a certain level of risk.  But,  compared to 50 years ago,  it is much more predictable for certain diagnoses.

Before the 1970’s,  there were many challenges to even knowing whether  surgery would be beneficial.  During that time,  the only diagnostic study was the x-rays,  and myelography.  Unfortunately,  even the myelography test had many hazards,  as larger bore needles were used to insert oil based dye into the spine to identify any nerve compression.  The dye has associated complications such as infection,  allergic reaction,  and scaring of the nerves (arachnoiditis).   These oil base dyes must also be removed from the spinal canal once the study is completed.  It was a technically challenging procedure for the diagnostician,  and a very painful procedure for the patient.

Once spine surgery was determined to be necessary,  typically,  a large surgical incision was utilized to identify the spinal areas of interest. Lighting was often a great challenge,  necessitating the larger incisions.   Early on,  from the 1920’s,  surgeons did utilize blood vessel sealing electro-surgical devices called Bovies, and later bipolar devices to seal the blood vessels,  but the earlier instruments were bulky,  and had issues related to equipment preparation,  and secondary to the potential burning of the tissues,  wound effects.  Also,  because of the nature of anesthesia during earlier times,  there was concern of an intra-operative fire secondary to the electro-surgical devices causing a flameout of the anesthetic agents.

Spine surgery was typically performed from the back,  and for the most part,  surgery was limited to removing disk material,  bone spurs,  and using bone graft from the hip  to achieve a fusion.  As time progressed,  wires were fashioned through some of the bonegraft, as well as the spine bones to try to promote stability which the fusion matured.   For the fusion patients,  body casts were the norm,  and admissions to the hospital would sometimes be for months.  Pain medications,  sedatives,  and tranquilizers unfortunately had many side effects.

Needless to say,  the results of spine surgery was not that favorable.  Even the most famous of Surgeons such as Harvey Cushing, MD  had tremendous complications and even death rates.

Now,  we are in an ERA of MRI’s,  CT Scans,    microscopes,  and medical instrumentation designed to promote more stability after surgery.  We have much better lighting,  and have various agents that aid in controlling blood loss during the procedure.   In the 1950’s Dr. Cloward described the anterior approach to the neck,  that gave surprisingly bloodless exposure to the disks of the neck.  In the 1970’s,  surgeons realized that anterior approaches to the lumbar spine had great benefit for certain situations.  Our anesthesia colleagues have made the process of anesthesia much safer and predictable.  We are now in the ERA of successful minimally invasive techniques, and now many procedures are performed as an outpatient procedure.

Spine Surgery has certainly evolved for the better.   As we go into the future,  more efforts are now being made to better define which patient would benefit from our procedures.  While we have advanced the technology,  the Spine Surgery community is still actively researching the questions of do you need spine surgery?  If you need spine surgery,  which surgery will be the best for your?

Fortunately,  the trend is towards better outcomes,  and better patient selection.

Cervical Discectomy and Fusion Works

The results of Anterior Cervical Discectomy and Fusion are excellent.  I find it strange that I must defend the results,  but we are in a new era of information.  Some would call it mis-information.  If you spend time researching cervical disectomy surgery,  you now see a trend where certain sites are advertising the radical nature of neck fusion.  Other sites are promoting artificial disk replacements for the neck.  Unfortunately,  I think the marketers for the various entities are have introduced their biase to the discussion.

Most spine surgeons will agree that Anterior Cervical Discectomy and Fusion surgery is perhaps the most predictable surgery performed by our specialty.  For the typical patient,  they have had significant arm pain associated with a pinched nerve in the neck.  Despite reasonable conservative care,  the pain has persisted,  or worse,  the arm has developed progressive weakness.  An MRI or CT scan will demonstrate a cervical disk herniation in a level and position that correlates well with the arm nerve pattern (radiculopathy).  Ideally,  the nerves compressed are secondary to one or two disk levels.  The disk herniations are such that a posterior limited foraminotomy or disectomy would not adequately address the issue. For these patients (assuming there is no medical condition that precludes surgical intervention),  Anterior Cervical Disectomy and Fusion has been the traditional,  and most effective surgical option.

Statistically,  Anterior Cervical Discectomy and Fusion surgery (ACDF) has a predictable success rate of greater than 90%.  Success is defined by a significant reduction of the pre-operative nerve irritation, as well as reductions of the associated neck pains and cervicogenic headaches.  For most patients,  by reducing the nerve compression,  over time,  most of the nerve impairment induced weakness to the arm will recover.

By using anterior instrumentation (plates and screw fixation),  fusion of the involved segments typically occurs.  Most complications are transient in nature (horseness of voice,  difficulty with swallowing certain foods,  assymetric pupil dilation, etc).

Today,  about half the patients do have the procedure performed as an outpatient procedure.  Most people can return back to a sedentary level of activity within a few weeks.  Heavy laborers can resume such activities within a few months.

Anterior Cervical Discectomy and Fusion has a very predictable success rate.  The procedure was first utilized in the 1950’s,  and the success rates have been consistent since that time.

I guess the controversy is over the comparison of Anterior Cervical Disectomy and Fusion  with  Anterior Cervical Disectomy and Artificial Disk Replacement.    Being one of the investigators of  an artificial disk device,  I have had the opportunity to compare the results.  For the most part,  the success rates for both of the procedures were essentially the same.  Long term,  we still do not know if the artificial disk will protect the cervical spine from developing adjacent level disease, or degeneration.    And,  we must also understand the nature of these comparison studies.  Usually there is stricter criterion used on the study related patients.  As the physicians performing the procedure are under increased scrutiny,  I will guess that there was more attention to details.  And yes,  usually these comparison trials are performed by higher volume centers.  As with most studies,  the results of the trials are often better than the results of the procedure used by the general public.    What  I can say is the artificial disk does seem to have some promise,  but it is still too early to definitely say it is better than the standard Anterior Cervical Discectomy and Fusion.  Long term,  I predict there will be advantages to using the artificial disks in specific patient populations.  But,  as of now, that has not been determined.

As it stands,  Anterior Cervical Discectomy and Fusion has excellent results,  and it is still the gold standard for the situation described above.  So,  next time you see an advertisement about the radical nature of neck fusion,  or the significant advantages of artificial disk replacements of the neck,  understand you are seeing marketing biase,  not scientific information.

Told you have Degenerative Disk Disease?

Have you been told you have Degenerative Disk Disease? If so, welcome to the club. If you live long enough, you will get it. If you think about it, degenerative disk disease really should not be called a disease, as it is the normal process of disk degradation. It is like saying aging is a disease, which we all know it not true.

So, how does the degenerative disk disease process begin? It really starts almost from childhood. As you develop and grow, the intervertebal disk, does get subject to increasing forces. As we have discussed before, the disk is made of two components, the annulus, which is a tough woven outer structure that contains the softer, initially more jelly-like, full of water, shock absorbing center. With a full of water center, there is enough water pressure to maintain the side walls of the disk. The walls are nice and straight. The disk is also firm. With the height of the disk, and then strength of the well hydrated disk, it acts as a spacer between the vertebrae. Secondary to the space, nerves can easily exit out of the spinal canal in the holes called the foramen. See the diagram above. In the normal disk, there is plenty of room for the nerve to exit out the center of the spinal canal. But, with a degenerated disk, the space narrows, potentially pinching a nerve in the process. The diagram above shows the reddened nerve coming out from one of the narrowed foramen.

What we do not see clearly in that diagram is the side walls of the disk. As we stated above, when the disk is full of water, the pressure in the disk is such that the disk is of a normal height. But, the side walls are also flat. The often used analogy is that of the car tire. When properly inflated, the tire side walls are flat, and the tire is firm, giving a better, more controlled ride. When the disk starts to lose its water content, which is a necessary component of the degenerative disk disease process, the side walls begin to bulge, and the strength and firmness of the disk reduces. In the side wall bulging process, it can also cause further narrowing of the space for the nerve sacs. By losing some of its firmness, it can allow extra motion of the vertebral bones upon one another.

This extra motion causes the facet joints, located in the back of the spine to rub excessively on one another causing development of facet joint arthritis. Also, the extra motion of the vertebra on one another can lead to instability or slippage of the vertebra, potentially causing further irritation of the nerves. This process can lead to what is called degenerative spondylolithesis.

Luckily, the process is usually very gradual. In fact, there are plenty of people who live their whole life without any significant episodes of back, neck or extremity pain, even though their backs and necks may look horrible to a spine surgeon like me.

In general, by age 20 about 15-20% of the population will have some evidence of degenerative disk disease. By age 40, it will be a majority that will have these changes.

And,  unfortunately for most,  degenerative disk disease can cause pain.  The source of the pain can be secondary to the pinching of the nerves,  or the arthritis of the facet joints,  or the related pain associated with the muscles attaching to these joints.  Also,  secondary to the potential development of the spinal instabilities,  the muscles often will need to work extra hard to keep the bones properly aligned and not rubbing against each other,  or pinching the nerves.  This extra work may explain the increasing muscle aches to the neck and back.

Also,  with further collapse of these disks, and reduced heights,  the overall normal body curvatures,  Lordosis, and kyphosis,  can be reduced.  And,  because of the reduction of curvature, and the arthritis to the facet joints,  we experience increased stiffness as we age.    For the more mature reading audience,  I think all these points do sound familiar.

Fortunately,  we usually learn to accomodate these changes,  and we have medical treatments such as anti-inflammatory medications,  muscle relaxers and narcotics to treat the severe episodes.  If necessary,  we can also use corticosteroid injections to accelerate the reduction of the inflammation.  In certain relatively rare situations,  surgery may be necessary to help with the pinched nerves or instability.

Help yourself by doing  the proper things.  Stay disciplined by not smoking,  not gaining weight, and eating properly.  Get exercise, and stretch.

But,  in the end,  we need to accept some of this is secondary to the aging process.   As I discussed with my patients,  it is better than the alternative.

LOW BONE MASS, OSTEOPOROSIS AND BACK PAIN

Is there a connection between having ostepenia or osteoporosis (low bone mass) and having pain back pain?  If you look through the medical literature and do a few Google searches, you will find that the standard answer is there is no association. Low bone mass does not cause pain.  Osteoporosis has always been characterized as a “silent disease”. That is, you will not have any symptoms until you break something! Anecdotally, through the years I have heard a number of different practitioners say that osteoporosis really can cause pain even if there is no apparent break or fracture.  To this, I have seen a number of patients who we have treated for complaints of back pain and have referred them to a rheumatologist to work-up and treat their underlying osteoporosis issues. Several of these patients have come back in follow-up to say their back pain got significantly better after they received treatment for low bone mass. Is this coincidence or is there more to this?

I will say that there is not much in the literature about the association between low bone mass and back pain specifically. Interestingly, I have come across two types of studies that may help answer if an association exists. One of the studies, published in 2012 out of Amsterdam (Hoozemans MJ et al) found an association between low bone mass and low back pain in 30 to 40 year old males.  Another, more recent retrospective study showed an association of low bone mineral density and chronic low back pain in one population (Al-Saeed O. et al).

There are other types of studies that have been published looking at the use of the osteoporosis medications to manage or prevent pain.  Several studies have shown a decrease in back pain with the use of Bisphosphonates and another drug known as teriparatide. Both of these are types of medications used to manage osteopenia and osteoporosis with patients who have significant risk factors.

So is it possible that low bone mass which includes osteopenia and osteoporosis causes microtrabecular fractures which in turn cause pain?  In laymen’s terms, the softening of cancellous bones (“spongy bone”) leads to a fracture or break that we usually cannot see on a standard x-ray.  This can just happen suddenly from normal physical activity.  Your spine is loaded with nerves that allow you to move and feel things including pain. Any disruption to the structures around the nerves can trigger a response. Therefore, even a slight break in the bone can cause a great deal of acute pain.

One could argue that the few studies that have been published about the association of low bone mass and back pain are not well controlled clinical trials and caution must be given when making any kind of concrete opinions about the outcomes.

Going back to my opening question, Is there a connection between having osteopenia or osteoporosis (low bone mass) and having pain back pain?  I think the answer is that the association is unclear based on current evidence.  For decades the medical community has said that back pain really does not come from low bone mass unless you have a broken bone.  While I am not a physician or expert in the field of osteoporosis, but there does appear to be some type of relationship between back pain and having low bone mass.

Latest on Why Discs Herniate

The above image is taken from August 1, 2013 Spine.  It is the title of the ISSLS Prize winning article by Dr. Rajasekaran.  As you can see,  it was a prospective study microscopically analysing disk material retrieved from 181 subjects,  who underwent lumbar discectomy surgery.

Patients selected for surgery met the criteria of being younger than 60 years of age.  Patients also must have no evidence of bony canal stenosis,  or other spinal disorders.  Patients  must have had no prior surgery.  The average age was about 37 years old.   Finally,  patients must also have a normal body mass index.

All surgery was performed by one surgeon,  so there was no difference in surgical technique.  All surgeries were a single level lumbar microdiscectomy.  There was also 724 non operated disc herniations identified that served as controls.

Amazingly,  all of the disk (surgically treated, or non surgically treated)  had diagnostic testing including  plain x-rays,  MRI’s,  and thin slice CT scans at the level of the involved endplates.

Intra operatively,  each disk was carefully probed to see if there was an annular tear.  If a tear was present,  the disk material was retrieved from the tear. If there were no identified tear,  the annulus was carefully incised, so as not to disturb the endplates while the herniated material was removed.

Disk material was then visualized,  palpated,  and then sent for microscopic histologic evaluation.

Interesting Results:

Of the non-operated discs,  84 of 724 had CT evidence of Endplate Junction (EPJ) avulsion.  Interestingly,  104 of 181 operated discs had obvious CT evidence of EPJ.

High intensity zones were present in 25 of the 181 surgically treated discs.  High intensity zones were also present in 41 of the 724 non surgically treated discs.

Of the 18 surgically treated discs with a central HIZ lesion,  interestingly 14 of the surgically treated discs had herniations located posterolaterally,  and not centrally.

Of the surgically treated disc herniations,  70% had evidence of  endplate material present in the removed specimen.

Conclusion:  Endplate Junction failure is a more common cause of why discs herniate.  Because MRI’s are not as specific to bony changes,  MRI’s have missed this prevalent cause of disk herniations.

So,  where does this study lead us?  It appears the concept of a HIZ lesion indicating a annular disruption may not be true.  Discs likely herniate secondary to the failure of the endplate at the junction of the disc.  MRI’s may not identify endplate failures that are associated with disc herniations.  Like all research studies,  it leads to more questions,  while clarifying one question.

Jingle Bell Run, Tampa

For the third year in a row,  we are again honored to help sponsor the Arthritis Foundation’s Jingle Bell Run in Tampa.

We all know someone, or have personally experienced the effects of arthritis.  As a spine specialist,  I see it’s effects everyday,  as many of my patients struggle with the pain and immobility caused by arthritis.

My website was originally created to help patients find information about spine pain.  The vast majority of the caused of this pain is associated with injuries or degeneration,  which eventually leads to arthritis for many of our patients.

The Arithritis Foundation does important work supporting research,  providing counseling and bringing awareness to the issues of arthritis and its effects on everyday people.

Please support the Foundation with your participation, and encouragement.

And,  if you are in Tampa on December 21, 2013,  consider running or walking to support the cause.

The Arthritis Foundation has similar walks in most of the major cities throughout the USA.  Please find a location and go there!  It is fun,  it is good for you,  and you are supporting an organization that is there to support you!

Loss of Cervical Lordosis

As a practicing Orthopaedic Spine Surgeon,  I often get back x-ray reports indicating “Loss of Cervical Lordosis”.   As most of my patients are highly educated,  they often will read that report, and will come to discuss the finding.  So,  I thought I would share my comments on the topic.

As some of you may know,  Lordosis is the curvature of the spine in the sagittal plane  ( simply stated,  the side view),  by which the front portion of the curve points to the front of the body.    Humans typically have  four curves when viewing the spine from the side.  Going from the head,  the first curve is a lordosis curve from the skull to the lower neck.  Then,  there is a compensatory curvature in the opposite direction (kyphosis) from the lower neck to the upper back.  Then,  there is another Lordosis curve from the upper back to the lower back.  Finally,  in the tailbone,  there is a reverse curve (kyphosis).  When you measure the effects of the four curves when standing,  in general,  you have a situation where the head is then balanced over the pelvis, and the center of gravity of a normal person will be positioned  directly in the center of the body.  With that effect,  when standing straight up,  your body will be balanced over the center of gravity,  and there will not be the forces pulling you, or pushing you in any direction.

But,  when we have irritations of parts of the spine,  it can cause this natural gentle curve to straighten.  Often times,  when people have irritation to the neck muscles,  an x-ray or MRI can show loss of the normal lordosis.

For most normal humans,  without any degeneration of the disks,  fractures,  or symptomatic disk herniations,  these muscle irritations do improve and usually,  the lordosis does return.

But,  if we have progressive disk degeneration, or a break,  or arthritis,  the lordosis may decrease, or reverse permanently over time.

So,  when I review an MRI or x-ray, and I see reversal of lordosis,  it does not necessarily mean it is a new finding.  If the advanced degenerative findings are present,  loss of lordosis is expected.

Other factors to consider when discussing Lordosis,  especially in patients without significant pain,  is a positional nature of loss of lordosis.  X-rays and MRI’s can be taken when lying down.  In that scenario,  the position of the neck can cause the image to look like a loss or reversal of lordosis.

Also,  in relationship to the lumbar spine,  sitting MRI’s often will show a loss of lordosis.

In summary,  loss of lordosis can and usually is associated with irritation of the muscles causing loss of the normal curvature.  Muscle irritations can be caused by disk herniations,  muscle sprains, and fractures.  But,  true structural  permanent loss of lordosis is usually secondary to advanced degeneration,  or structural changes to the bones, and disks of the spine.  In rare instances,  humans can be born with a loss of lordosis.

Assistant of the Orthopaedic Surgeon

As a patient, when you go into an orthopaedic surgeon’s office for your appointment, it is usually not the surgeon that first greets you and brings you into the examination room.  You are often asked a barrage of questions about why you have come in and often are asked about your medical history. So who is this person that is asking you all of these questions and what are their credentials?

There are many different allied health providers who work with orthopaedic surgeons. To help you understand some of the differences, I am going to start with separating these individuals into two categories:  Mid-level practitioner and Support Staff.   Mid-level practitioners are Physician Assistants (PA-C) and Nurse Practitioners (ARNP).  These providers work under a physician and often seen patient’s for routine follow-up visits, order/review diagnostic tests, prescribe medications, and recommend various forms of treatment. The PA and ARNP professions are licensed by the State.

The second category I mentioned is support staff. This includes a whole host of different allied health providers. These include Orthopaedic Assistants (OA-C), Surgical Assistants (CSA, CSFA, SA-C), Athletic Trainers (ATC), Nurses (LPN, RN), Orthopaedic Technologists (OTC), and Medical Assistants (MA).  Out of these professions, Athletic Trainers and Nurses are licensed in Florida and most other states. Orthopaedic Assistants (also known as Orthopaedic Physician’s Assistants) are licensed in some areas of the country, but not Florida. Surgical Assistants are licensed in a handful of states. Licensure defines what a particular professional is able to do. Those that are not licensed fall under different state laws in which the supervising physician is responsible for what activities they may perform. In general these individuals provide support to the physician to help with all aspects of patient care. Since these individuals are the assistant of the physician, many patients commonly refer to them as “Physician Assistant”.  From a legal standpoint, this is not technically correct.

Education, training and overall level of knowledge for all of these professions does vary considerably.  The only profession listed that offers comphrensive training, strictly in orthopaedics is that of Orthopaedic Assistants.  These individuals are trained to work with orthopaedic surgeons in both the clinical setting and in the hospital. Many of the other professionals mentioned learn orthopaedics while working on the job after they complete formal schooling.

So the big question that is often asked is “who is the best assistant and most qualified for an orthopaedic surgeon”? There is no one correct answer to this question.   Most physicians desire a well-trained, competent individual who can provide superior patient care.  As a patient, if you broke your arm, which of the above named allied health professionals would you want to place you into a cast? To most, the answer is “it does not matter, provided that individual has the appropriate training, experience, and really knows what they are doing”. A good personality also goes along with that answer!

Next time you are go to see your orthopaedic surgeon, I encourage you to ask the allied health professional who is assisting you about his/her credentials.  As a part of the office team, it is often this individual that helps direct your visit with the physician and provides you with patient education, information, and helps enhance your overall experience.

What is Radiculopathy?

Often times,  physicians use a lot of terms freely with patients,  assuming the patients know what the word means.  Radiculopathy is one of those terms.  In the most simplest terms,  it does mean a pinched nerve in the spine.   It is important to know that radiculopathy really means pinching of the nerves as the nerve leaves the spinal sac. The medical community calls these individual nerves nerve roots.   Because of the close proximity of the nerve root to the spinal sac,  often the cause of radiculopathy is a crowding, or compression on the nerve by  structures closely located to the spinal column.

Those structures are often  bones,  vertebral discs,  ligaments,  and fat tissue.  And,  as we will discuss,  each of these can cause pressure, or compression on the nerves causing this pinched nerve radiculopathy.

But first,  we must define the function of these nerves as they come off the spinal sac.  For my patients,  I explain that each nerve is like an electrical wire  that goes from one part of the body to act as the electric signal to another part of the body.  With these nerve “wires”,  a signal from the brain,  through the spinal cord,  to the nerve will go to a specific part of the body,  and control muscles, and sensation.  As physicians,  we know the typical pattern of responsibility of each nerve root.  to give an example,  the L4 nerve root is associated with quadriceps muscle strength,  the knee reflex, and sensation to the media or inside of the calf.   Through feedback to the brain from these nerves “wires”,  the brain can adjust the rate of use of each muscle or body part.  Part of the feedback includes pain,  so the body can avoid situations that can harm the body.   If you think about it,  it is an amazing coordination of information, and fine control of may moving parts, that allow us to do something as simple as walking.    The nerves that come off the spine sac,  go out the bone holes in the spine called the foramen.  The nerves usually assemble into bundles that travel a certain distance together in the arms,  and legs.  These large nerve bundles form the so called brachial plexus in the arms,  and eventually split off into the 4 main nerves call the axillary,  radial,  medial and ulnar nerves.  Likewise,  in the legs,  the nerve bundles are the femoral nerve and the sciatic nerve.    As you may guess,  these large nerve bundles are composed of several individual nerves that exist the spinal sac.  To give the example,  the sciatic nerve is usually composed of the nerve roots  from L3 to S3.  This is a very simplistic way to look at the nerve anatomy,  but it will then help you understand radiculopathy.

When one of the nerve roots are irritated,  it can cause a corresponding irritation to many of the functions  associated with the larger nerve bundle .  Also,  since the individual nerve root is irritated in radiculopathy,  any additional stress on the large nerve bundle such as pulling of the nerve bundle ,  will cause an increase irritation of the individual nerve root.   To give an example,  if a L4 nerve is irritated, and you then pull on the sciatic nerve by raising your leg  (the Straight leg raise test),  it will cause more pain to the l4 nerve root,  and cause a pain down the leg in the distribution of the L4 nerve sensation pattern.

As stated above,  the structures closest to the spinal sac, and nerve roots are usually the cause of radiculopathy.  Disk herniations, and protrusions can cause irritation of the nerve roots.  As the disk material pushes outside it normal confines,  it will cause pressure on the nerve roots  potentially causing nerve irritation.  Interestingly,  while some people are very sensitive to this irritation,  some people have nerves that can accommodate this pressure without any significant effects.

As we age  the ligament encasing the spinal sac,  the so called Ligamentum Flavum often will hypertrophy, or thicken.  In that process,  it can also be a source of pressure on the nerve roots.

As the facet joints of the back of the spine wear out due to age,  often times they enlarge,  forming the so called bone spurs that potentially entrap the nerve roots as they exit the spinal canal through the foramen.

Though not common,  some patients have hypertrophy of the fat in the epidural space,  causing Epidural Lipomatosis which can also lead to nerve irritation.

Sometimes,  due to arthritis in the facet joints,  a fluid sac forms outside of the facet joint,  causing pressure on the nerve roots.  These fluid sacs are called Synovial Cysts.

Lastly,  we are very dependent on the patients history,  in order to determine if the source of radiculopathy is secondary to  Vertebral Fractures,  Spinal Infections or Spinal Tumors. Luckily,  these are rare causes of radiculopathy,  but a vigilant  physician will also consider these possibilities  during the discussion with the patient.

Most radiculopathy causes can be treated without surgery.  But,  if the symptoms persist,  or progress,  surgery may become an option for some patients.

Discectomy Surgery Results are Good

Lumbar Discectomy surgery has good results.  And,  spine surgeons should not be shy in discussing the known rates of success.

First,  let’s assume the patient considering surgery has already had all the usual non-surgical treatments such as medications,  therapy,  injections,  chiropractic care, activities modifications,  etc.  Let’s also assume at least 6 weeks have passed since the initial onset of the pain. Finally,  let’s assume the patient has diagnostic studies such as MRI’s or CT scans that demonstrate a disk herniation that has the location and symptoms that correlate with the disk herniation.  The symptoms are back pain and associated leg weakness, numbness, and reflex changes consistent with the nerve irritated by the disk herniation.

In  this scenario,  assuming a relatively healthy person,  there is a 90 to 95 % chance of a successful outcome .    That means greater than 9 out of 10 of properly selected patients will have improvement of their leg pain and back pain.   The vast majority will be able to return back to their previous level of activity before the disk herniation.

But,  there is a caveat that must be mentioned.  While the vast majority will be better,  there will still be an occasional episode of back pain,  and when closely examined,  there may always be a small area of numbness.   The reason for the numbness is secondary to the disk herniation process.  No matter what, and even if there is no surgery,  the nerve has been irritated, and during the healing process,  a small amount of scarring will develop on the nerve.  While no longer painful,  the nerve can still have residual effects from the scarring.  That effect is most evident by loss of sensation.

In regards to episodes of  back pain after discectomy,  some of that pain will be secondary to the normal degenerative process associated with disk herniations.  Even if you do not have surgery,  the disk is now damaged by the disk herniation.  Even if you do not have surgery,  your disk will further degenerate,  and we know that disk degeneration can be associated with episodes of back pain.  In rare instances,  the disk degeneration can cause so much pain,  that further surgery may be necessary.  But, as stated before,   disk degeneration is a process that occurs when you have a disk herniation.   Discectomy surgery is designed to remove the disk material irritating the nerve.  In my opinion,  in most lumbar discectomy procedures,  any post operative degeneration is more likely caused by the natural degenerative process associated with disk herniations,  and not secondary to the surgical procedure.

I thought it important to share the fact that lumbar discectomy surgery in properly selected patients,  has good results.  Lately,  we are seeing efforts by many entities to limit access to certain spinal procedures such as injections, and  lumbar spinal fusions.  I for one,  agree that there is over utilization of the lumbar fusion technique. Lumbar fusion clinical improvement results are not that great.   But  let’s be careful in not lumping all surgical outcomes into the non-effective category.   Lumbar Discectomy surgery definitely works for the properly selected patients.  We as a community must be ready to defend this option for our patients, and to our patients.

What causes disc herniations and how can I prevent it?

What causes disc herniations and how can I prevent it?

In our spine practice, I am often the first person to talk with patients about their orthopaedic and spine problems during the course of their visit.   Through our educational website and during consultations, Dr. Shim has presented a wealth of information on how we manage and treat disc herniations.  As an allied health professional who works with Dr. Shim, I spend a fair amount of time educating patients about Dr.Shim’s recommendations and findings. The big question I am often asked is “what caused my disc herniation”?

In simplest form, the disc is essentially the shock absorber for your spine.  The disc is composed largely of water and proteins. As we age the water content decreases (“desiccation”) and the protein responsible for the structural integrity, elastin, chemically changes.  The true causes for some of these changes is not well understood. The disc loses its elasticity and cannot tolerate the same type of loads in mid and later life than it once could. When there is increased pressure on the disc (such as with bending, coughing, and heavy physical activity), the center core (“nucleus”) can get pushed toward the outer margins of the disc.  As the disc loses its elasticity, its ability to keep the nucleus contained decreases and may result in the jelly like nucleus being pushed out of the disc. Some refer to this as a “slipped disc”.  In other words, a herniated disc.

Disc herniations in the lumbar spine (low back) are much more common than those in the cervical spine (neck).  Disc herniations can develop for a number of reasons with the most common described above.  In the case of normal wear and tear, repetitive loading on a disc that is aging can result in a herniation. Keep in mind that not all disc herniations cause pain or symptoms!

As many also suspect, a sudden traumatic accident can also cause a disc herniation.  Car accidents and falls can lead to one or more disc herniations.

In general, we know that there are a numerous activities which can cause increased pressure on the spine and therefore raise the risk of a disc herniation:

– Frequent, repetitive lifting

– Smoking

– Excessive bodyweight / Obesity

– Bending or working in awkward positions

– Prolonged sitting

– Accidents / Injuries

– Coughing / Sneezing

Based on what I have discussed here, I think most would agree that it is nearly impossible to truly PREVENT a disc herniation.  There are some factors that we can control and some we cannot.  Knowing what you can do to help yourself and MINIMIZE your risks for a disc herniation is the key.

Does Lumbar Spinal Fusion work?

Spine technology continues to evolve,  despite the background debate on the cost and efficacy of spine surgery,  in general.  Since the early 200o’s,  the spine surgery community has been closely scrutinized by the government, and the payers of spine surgery services.

While still being debated,  there is no question that the utilization of the lumbar spinal fusion technique has seen a significant increase in the US.  Unfortunately,  for all that additional surgery,  there is very little data to support any improvement of the general health of the population.

Basic questions are still to be answered.  Does lumbar spinal fusion improve the outcomes versus simple discectomy and decompression?   When do patients with spinal stenosis also improve their outcomes when decompression is coupled with fusion?  When selecting lumbar fusion techniques,  which ones are effective?  When does utilization of cage devices in front of the spine improve the general outcome of  the fusion?  Does artificial disk replacements in the lumbar spine provide a predictable alternative to fusion?  Can our society justify the cost of spinal fusion  for certain patient populations?   Obviously,  these questions are being asked,  but the attempts at a clear answer to most of these questions often are biased by the “questioners”, or the “answerers”.  The cynic will answer  ” the insurance companies, and the government will prove that spinal fusion is not necessary”,  while “the surgeons and the device manufacturers will demonstrate the great improvements of function resulting from spinal fusion”.  I suspect the truth is somewhere in between.

So,  what do we know?  Let us assume the patient has exhausted non surgical treatments, and has  healthy enough physiology to withstand the anesthesia, and positioning required of the surgery.

In general,  it is accepted that lumbar spinal fusion works in the following scenario:

1.  One and two level spondylolithesis with evidence of instability, and stenosis.

2.  Lumbar fusion works for multiple recurrent disk herniations at the same level.

3.  After necessary aggressive decompression,  which necessitated destruction of a whole lumbar facet joint,  fusion prevents development of instability.

4.  Gross instability defined by radiologic parameters,  including increasing translation on flex/ext views,  or angular instability on these same views can benefit from stabilization.

To be objective,  these factors decrease the likelihood of a successful outcome:

1.  Smoking decreases fusion rates.

2.  Obesity leads to longer operative times,  with increased complications and potential for infections.

3.  Patients with psychiatric diagnoses such as depression,  bipolar syndrome, and anxiety disorders have poorer outcomes.

4.  Underlying litigation,  including disability determination,  workers compensation issues, and liability claims are associated with poorer outcomes.

5.  Multi-level diffuse disease also leads to less predictable lumbar spinal fusion outcomes.

While many patients are having significant back pains,  the option of spinal fusion should be reserved for patients that have the best expectation of a successful outcome.  If you are contemplating such a  surgery,  make sure you explore all your options before making the decision.

Percutaneous Discectomy

What is Percutaneous Discectomy?  Just the words themselves seem intimidating.  But,  in the most basic form,  it means a large bore needle is placed into the disk,  and either a suction device, or a disc vaporization device is used to remove disk material from the end of the needle.  usually,  a very small incision,  or a small needle puncture is all that is visible after the surgery.  I am sure we have all seen the advertisements on the airplane magazines of a person strolling on the beach,  with a small bandage on their back.  That advertisement is usually used to promote the percutaneous disectomy procedure.

Percutaneous Disectomy has many pseudonyms.  It has also been called Laser Disectomy,  or Plasma Disk Decompression.  But,  the techniques always remain the same.  Usually,  the patient is sedated, but not completely asleep.  Using x-rays guidance,  a small gauged needle is placed carefully in to the disk, and confirmation of appropriate placement in two planes  (AP, and Lateral).  Because the patient is awake,  surgeons can avoid placing the needles too close to a nerve.  Once appropriate needle placement is confirmed.  The needle is used as a cannula to guide a small working channel to the disk.  As I explain to patients,  effectively a small straw is placed over the needle, and then inserted into the disk.  After the straw,  or working channel is confirmed as being in the disk,  instruments then can be passed into the disk to remove disk material that is thought to be causing the pain.

As far as instruments are concerned,  there are many different systems that can be utilized to remove the disk material.  Some systems have endoscopes,  or camera lens introduced into the channel,  allowing visualization of the removal of the disk material.  Some systems use lasers or radio frequency energy to evaporate the disk material.  Others use suction devices, as well as mechanical resection of the disk material.  Not matter which device is used,  the goal is always the same.  Removal of disk material that is thought to be the cause of pain.

Unfortunately,  the outcome of the procedure has not been as predictable as most surgeons would like.  That is because often times,  it is not certain that the offending disk material has been adequately removed.   While the center of the disk can be debulked,  it can be difficult to know if the nerve pressure has been relieved.  While certain systems do allow visualization with a camera,  the learning curve to that technique can be steep,  and few operators have been successful in reproducing visualization of disk removal on a constant basis.

While complications are rare,  they do occur.  The most common failure,  however, is inability to adequately relieve the nerve compression pain.

As a late by product of the procedure,  we now know that placing large bore needles in disks can cause more rapid degeneration of the disk,  and therefore contribute to a more rapid development of back pain for some patients.

As of today,  this procedure is offered by some spine surgeons.  But,  if you are interested in this procedure,  please discuss the pro’s and con’s with your surgeon.  Please have your surgeon discuss the expected outcomes,  and also discuss further treatment options if the surgery does not result in improvement of your pain.   And,  most importantly,  before you pursue any surgery,  make sure you have adequately exhausted all the non-surgical options before pursuing surgical care.

The Best Medicine for Bone Health

In my previous blog I discussed bone health. I wanted to share with you some of the findings from our bone health screening program.  In the last 3 months, over 60% of those patients who were recommended to have a Bone Density test (DEXA) have had evidence of osteopenia, or even worse, osteoporosis, and did not even know it.  A majority of these patients are their early 50’s (one was in late 40s). We have even had a male in his mid-50s whose DEXA scores revealed osteopenia.  Some of these patients had multiple risk factors for the development of low bone mass while others had very few. For many, this was their first bone density study!  The one commonality I have seen is that all of these patients say “I do not want to have to take medicine for this.”

As a part of a bone health work-up, we also recommend Vitamin D testing. Without adequate Vitamin D levels, your body will not process calcium. Over 50% of those patients that we have screened or sent for screening have come back with low Vitamin D levels. Having testing done early enough can identify help identify potential problems whereby treatment often amounts to some lifestyle and dietary changes. Many of us are reluctant to change our lifestyle especially if we do not “feel” like anything is wrong with us. Waiting until later in life or failing to address the findings makes it more difficult to manage poor bone health.

Keep in mind that that there is not one specific single cause for loss of bone mass. There is not a common reason why all of the patients discussed above developed osteopenia.  At the same time, there is not one magical pill we can take for this.  The basic treatments that have been previously discussed are dietary changes including the use of calcium and Vitamin D3 on a daily basis, a sound nutritional diet and physical exercise. Keeping in mind, for some patients, this is not enough! There are other underlying medical issues that need to be addressed.

A few years ago, I became acquainted with a well-respected physician (and great resource) by the name of Dr. Richard Cohen. His company (Core4nutrition.com) focuses on improving the quality of health and sports performance. One of the concepts I have learned from him and truly believe in is that many of us take a variety of supplements thinking that we are doing ourselves good. In reality, many of these supplements are synthetic and we may be taking too much of one thing and not enough of another. This is often the case with calcium (too much) and Vitamin D (not enough).  It is about pairing the right factors and the right amounts to create a synergistic effect (putting it altogether is better than the individual components by themselves).  When we do this, we can improve our health dramatically (in this case bone health).  My point with this is that I cannot stress diet (including appropriate supplementation) and exercise enough to prevent poor bone health.  Regular testing (DEXA scan and Vitamin D levels) are the tools we use to tell us how effective our regimen is.   This is considered primary prevention and is the BEST medicine we can offer.

Sciatica

Sciatica.  What is it?  The truth is,  most people will, or have experienced  it already.   Amongst the physician reading population,  it also has other names such as lumbar neuritis,  lumbar radiculopathy,  or lumbar neuralgia.  But,  to the rest of you,  it is the “pinched nerve” problem associated with the lower back, with a shooting pain, numbness or tingling associated with irritation of the sciatic nerve.

Sciatica is the result of pinching of a component of the sciatic nerve.  In the Image above,  it demonstrates that the sciatic nerve is composed of multiple branches of the nerves coming off the lower back.   Most scientists agree it is composed of the specific nerve branches of L4 to S3.

Each of these individual nerves deliver electrical signals and information to specific muscles, reflexes, and areas of sensation.  To give you an example,  the L4 nerve is typically associated with the quadriceps femoris muscle (which allows you to straighten your knee),  feeing of sensation to the front of the thigh, and inside of areas of your foot, and controls your knee reflex. Irritation of any of these individual nerves can, and often will result in pain.

If you have sciatica caused by pinching specifically the L4 nerve,  it may effect any or all of the above areas.  But,  a word of caution,  as any individual body may not exactly follow the textbook pattern,  and may also have built in redundancy.   That is, some people have some nerves that control more areas than what our anatomy textbooks will suggest.

Because the sciatic nerve has so many components, any one individual nerve involvement can cause pain.  At the same time,  because of some of the built in redundancy,  irritation of one specific nerve,  while resulting in pain, or numbness, will still allow you to be functional.

There are multiple causes of sciatica.  We often associate it with a “slipped disk”, or a herniated nucleus pulposus.  The shock absorbers between the vertebrae wear out, and can rupture,  causing pressure on the individual nerve as it exits the spine to form the sciatic nerve.  Another cause is development of bone spurs,  that gradually, over time,  enlarge, and cause the pinching and irritation of the nerve.

There is still plenty of  ongoing research regarding how and when does a pinch actually cause any of the pain,  tingling, numbness and weakness that is so often associated with sciatica.  The confusion lies in the fact that many people have significant nerve pinching on diagnostic tests,  yet,  they have absolutely no effects from that pinch.

In our current cost conscious healthcare enviroment,  science and government are trying to determine how to cost effectively deal with the problems associated with sciatica.  We know that most people do not need surgery to treat sciatica.  We also know that surgical treatment of sciatica can be quite costly, and with some risk.  If we can determine why most people really do not have any associated symptoms with pinching of the nerves,  maybe, we can come up with more cost effect, and rapid treatments for this common problem.

If you have sciatica that lasts more than a few days,  or, if you have sciatica that is causing profound weakness, or inability to control your bowel or bladder functions,  please report these complaints right away.  In rare instances (cauda equina syndrome),  you may need urgent care,  including surgery.  But,  for most instances of sciatica,  it usually does go away,  or become tolerable.  But,  get proper counseling to make sure your sciatica is not something more serious.  For more information,  please go the Spine Animations link (Under For Patients), and click on Spine Conditions for a nice animation produced by Understand.com.

Can Herniated Disks be treated without surgery?

The answer is Yes.  And you know that to be true.  Let’s take a poll.  How many of you have been told you already have a “pinched nerve”,  or a bulging disk or “slipped disk”?  If  you are older than 35,  more than half of you will answer in the affirmative.  And,  statistically,  less than a few percent of the population has ever had spinal surgery to correct that herniated disk. So,  it is pretty evident that most Herniated Disks do not need to be treated with surgery.

But,  I must be fair to the reading audience of the Blog.  Because you are reading this Blog,  you are already a select group that likely has interest in this very topic.  Maybe,  you have the so called “pinched nerve” feelings, or sciatica.  Maybe you are confused by all the choices you see regarding treatment for your discomfort.  Maybe,  you are being told surgery is the only solution.

Without boring you with all the science,  ( you can go to PubMed to research this very topic)  statistics are on your side.  There are plenty of studies indicating herniated disks do improve,  shrink, and heal over time.  And,  this is without surgery.   The evident suggests the pain and discomfort associated with disk herniations are caused by two general factors.

1. When the disk material escaped the margins of the disk,  there is usually a release of various chemicals from the disk, that causes inflammation around the area of the herniation.  This inflammation, by design caused the body to send  cleaning elements that clean up and clear the chemicals as well as remove the injured disk material.  When this inflammation subsides,  the pain also lessens.

Also,  when the disk material escapes, or herniates,  the normal blood supply and nutrition that feeds this disk material stops.  This piece of disk will begin to shrink away, or is taken apart by the body.  There is plenty of evidence that shows the largest disk herniations, and the most extruded pieces are the most likely to dissolve or disappear over time.  There are MRI studies of non-surgically treated disk herniations that do shrink and go away over time.  If  you think about it,  it really makes sense.  A large disk herniation is usually associated with healthier, well hydrated disk material that displaces.  Once this health disk material loses its blood supply, and nutrition,  it will more rapidly dehydrate and shrink away.

2. A herniated disk can cause mechanical pressure on the nerves.  Most anatomy studies indicate the outer layer of the disk,  called the annulus fibrosis has nerve sensors located next to it.  When a disk ruptures,  these nerve sensors are irritated causing the pain signal to be activated.  In addition,  secondary to the inflammation caused by the chemicals above,  the nerve continues to be irritated.  But, as in the above discussion,  the chemicals and injured tissues are removed.  During that process, the nerve irritation caused by the disruption of the annulus also dissipates.

There is also the mechanical effect of the disk herniation causing pressure on the nerve sac.  If you spend a little bit of time understanding the anatomy of the nerve sac (thecal sac,  or dural sac),  you will be able to see that pressure on the sac may or may not cause nerve irritation.

Whoever designed the thecal sac was a genius.  I use the analogy of a garden hose to explain how it works.  The Thecal sac is like a garden hose, with water within the hose.  Also,  within the hose are individual strands,  that are the individual nerves going to various muscles and structures.  The nerve strands float freely in the  “garden hose”, until they exit out of the hose to its respective body part.   If you indent this hose,  it does not necessarily mean that indentation will mean a pinching of a nerve.   Also,  within the protection of this garden hose,   the nerve can float freely,  even when the garden hose is bend, or stretched.    That is why our nerves are usually not pinched when we bend our spines while reaching, bending or twisting.

But,  on occasion,  you can have a herniated disk that indents the thecal sac enough to cause nerve irritation,  especially when you bend or move.   That is why,  with certain disk herniations,  specific activities such as sitting,  reaching,  twisting, sneezing, etc.  will cause an experience of  “bolt of lightning” down the leg (or arm, in the case of a neck herniated disk).

But,  as above,  this impression on the sac, and the nerve can diminish , and shrink over time.  That is why most disk herniations can be treated without  surgery.

But,  a word or caution.  In certain specific circumstances,  surgery is definitely necessary.  If the disk herniation causes significant impairment where by you cannot control your bladder or bowels,  it is an emergency.  If you are soiling yourself because of lack of control,  stop reading this Blog and call your Doctor immediately.  You may have something called cauda equina syndrome and you need evaluation immediately.

Also,  if you have progressive weakness you should also be evaluated immediately.

It is rare that anyone has the above situations,  but  those are the absolute immediate evaluation and surgery situations.

For the rest of people with disk herniations,  the need for surgery is secondary to continued pain.  If you do not get better with 6-8 weeks of non- surgical treatment, and the pain is not tolerable,  surgery is a reasonable choice.  But,  if you can,  allow your body to fight the disk herniation, and diminish the pain.   Please contact your physician if you have questions about your options.

Lumbar Discectomy

Why Lumbar Discectomy?

Most people have heard about lumbar discectomy surgery for slipped disks (herniated disks).  And,  the attitude to the surgery has changed.  Not too long ago,  the conventional wisdom was that any back surgery had uniformly poor results, and the chances of a positive outcome was not that great.  But,  times have changed, and the forces of marketing has turned this once feared surgery to a “band aide operation”, with expected routine results.

For patients who must have this surgery, confidence in a favorable outcome  is good for the patients emotional state.   But,  secondary to the marketing techniques of many of our “Spine Institutes”,  some patients have lost the healthy respect that should be given to any surgical procedure.

Having said that,  we do know that in the properly selected patient,  the results can be very favorable.  The key words are “properly selected”.

In general,  patients that have lumbar discectomy surgery usually fall into two categories.

The first group of Lumbar Discectomy patients are the unfortunate individuals that develop excruciating leg pain,  with rapidly progressive weakness, and in true emergencies,  lose the ability to control their bowels and bladder.  Without getting too detailed,  it means their legs cannot support their body, and they buckle,  not from the pain,  but from true lack of ability to control the muscles.  In terms of the bowel or bladder, loss,  it is not constipation.  It is true loss of control where people will start to soil themselves.  In this situation,  surgery is usually done on and urgent basis.  If you think this is what is happening to you,  stop reading this Blog and call your doctor immediately,  or go to the emergency room.  Fortunately,  for most Lumbar Discectomy patients,  this is not the situation.

The second group of Lumbar Discectomy patients often present with a significant pain,  but it is not associated with a progressive weakness, or loss of bowel or bladder control.  But,  even with time,  physical therapy,  medications, and injections,  the disc herniation does not stop hurting.  For these patients,  after having the proper workup including x-rays and MRI’s,  a surgeon may suggest lumbar discectomy surgery.   A good outcome is associated with disk herniations that follow a predictable pattern of nerve irritation.    To clarify,   although you may have a disk herniation,  it may not be located on the right area to cause your complaints.  If that is the situation,  surgery may not help your situation.   A prudent surgeon will consider further treatments, or even other nerve type test before considering surgery in that situation.

In the best case scenario,  a person would have continued pain from a defined disc herniation, with a corresponding pain pattern,  numbness pattern or weakness complaint that is consistent with the nerve(s) entrapped by the herniated disc.  If this person fails conservative treatment,  there is a high likelihood of a successful outcome if surgery is performed.

There are other factors that also weigh into the decision, and the likelihood of a successful lumbar discectomy surgery.  A healthy normal weight person has a better chance of an uneventful and successful outcome.  If you start adding in other factors such as multiple levels of disc herniations,  obesity,  diabetes,  and other medical problems,  the risks do go up, and the outcome prediction does go down.

But,  in a relatively healthy person, with a well defined disc herniation,  Lumbar Discectomy is an excellent choice.  And,  no matter what specific technique,  as long as the disc is visualized, and properly removed,  the outcomes will be predictably good.

Bone Health Testing: Is it necessary and when?

In orthopaedic and spine surgery practices, most of the focus has always been on secondary and tertiary prevention. That is, we try to treat various diseases of the musculoskeletal system after they become apparent and before they become a big problem. In some cases, patient’s come into the office with identified problems that have been ongoing and our focus becomes more on rehabbing and reducing the effects of the problem.

What if we could lessen or even avoid the onset of certain musculoskeletal diseases before they become apparent? This is known as primary prevention. It is the same reasoning behind going to your internist for a yearly physical to try and prevent problems before they start!

One of the areas that we like to focus on is bone health.  Bones play a vital role in forming the human skeleton, protecting organs, and allowing us to perform weight bearing activities. The strength of your bones are derived from a combination of collagen (“connective tissue”), calcium and phosphate.

Bones are constantly in a state of remodeling. Early in life, bone forming process are greater than bone resorbing (“removing”) processes. This constant state of remodeling is based on the body’s attempt to maintain calcium levels.   For most, we stop building bones somewhere in our early 20’s. This is a point where bone formation and bone resorption is nearly balanced. Peak bone mass starts to decline after age 30. In fact, when we perform a Bone Density test (DEXA SCAN) one of the results given is the “T” score.  This is a measure of how your bone density compares to that of a 30 year old. There are many factors which can cause bone density to decline in time. Some of these are genetic and many are environmental.  For example, one of the common treatments we use in orthopaedics are cortisone injections. We inject a “steroid” into a joint or muscle to decrease inflammation. The problem that exists is that too much cortisone can cause the body to decrease new bone formation and increase bone breakdown leading to weaker bones.

Going back to my earlier point about how bone remodeling is triggered by the body’s need for calcium, without enough Vitamin D, our body cannot absorb calcium.  There have been many published articles suggesting that over 60% of the population is vitamin D deficient.  It has also be theorized that taking calcium supplements while having low vitamin D levels can lead to calcification of arteries that lead to heart and kidney conditions.  Your body stores a majority of calcium in your bones. When you do not consume enough calcium, your body will use that calcium that is stored in your bones. As you can imagine, when this occurs, your bones can become brittle.

There are various recommendations on the internet and in the medical literature about how much calcium and vitamin D to take. Which recommendation is correct? This question has yet to be answered. The one thing we do know is that calcium and Vitamin D derived from a healthy diet is the best and safest for your body.  There are potential risks in taking too much calcium or Vitamin D from supplements.

The key to managing your bone health is knowledge. Having your bone density tested early in life (30’s and 40’s) may help identify the onset of declining bone strength early enough so that something can be done about it without having to resort to prescription medications to treat osteoporosis later in life. The same holds true for Vitamin D testing. The proper combination of diet, exercise, lifestyle, and vitamin supplementation (calcium and vitamin D) started early enough has the potential to lessen or diminish the onset of some musculoskeletal diseases.

From a financial perspective, consider this. Many insurance companies will only pay for a bone density test for women who are post-menopausal or have other medical conditions that necessitate the need to have the bone density checked. Most do not pay for a bone density study for healthy 30 and 40 year olds.  Vitamin D testing may or may not be included with your annual physical lab work.  Consider this, bone health testing usually costs $100-$200. The costs of prescription medication to treat low bone density starts at around $200 per year. If you had the option of paying $100-$200 now for bone health testing to detect your current status and help your physician recommend some lifestyle changes to minimize the risk of bone loss or had the option of paying $200+ per year for the first line of drug treatment for osteoporosis (that may or may not work and has side effects) from age 50 on, what would you chose?  I might add that $200 per month does not cover the costs associated with treatment for broken bones (remember bones become brittle with osteoporosis).

Primary prevention of some bone related diseases can be achieved through early testing and lifestyle changes. For most, there is an out-of-pocket cost to this, but that cost is far less than a lifespan of treatments for poor bone health.

–          Jason Mazza, M.Sc, OA-C, CSA, SA-C, OTC, CCRC

Degenerative Disk Disease

What is Degenerative Disk Disease?

It is a  process that essentially means the spine is aging.   In my opinion,  it should never had been classified as a disease, as it affects all of us, if we live long enough.  In one of my earlier blogs,  I reviewed medical research that demonstrated that disk disease or degeneration has been identified in young adults at a great rate than originally thought.

So what is this process?

Before we discuss degenerative disk disease,  we must first understand the function of the disk.  The disk is a soft tissue that serves as a shock absorber,  allowing the stacked bones called the vertebrae to remain oriented  next to each other,  without breaking due to the forces.  The disk also acts as a ligament, that allows the the vertebra to move, bend, and twist, while maintaining its shape and function.  And finally,  the disk acts as a spacer,  so the nerves can exit out the vertebral canal, out the holes called the foramen, without causing undue pinching of the nerves as they exit.

In the diagram,  you can see the anatomy of the vertebrae, and see the relationship between the vertebral bone and the disk.  If you could imagine,  the disk allow the proper space to be maintained within the foramen.  You can see how important this relationship will be, in order to avoid excessive pinching or stretching of the nerves.  The disk height is also important in maintaining the proper relationship of the facet joints.  With any change in the disk height,  it will effect all these relationships.

In the degenerative disk disease process,  the disk begins to lose its water content.  The process actually starts early in life.  The disk in essentially make up of two components.  The outer part of the disk is called the annulus.  It is a woven firm cartilage layer that contains the second part of the disk called the nucleus.  The nucleus is soft, and early in life, gelatinous in consistency.   To make an analogy,  it is like a jelly donut,  where the “bread” outside is the annulus, and the “jelly” inside is the nucleus.

To clarify the statement above,  the “jelly” loses its water content, and the “jelly’ becomes firmer, and less fluid.  In addition.  Due to the loss of water content,  the disk height starts to shrink, or narrow.  Disk narrowing leads to foramen narrowing,  thus potentially causing pinching of the nerve.

Disk narrowing also changes the orientation of the facet joints, causing potential abnormal rubbing of the facet bones against another.  This can lead to the enlarging of the bones by the rubbing.  This is the beginnings of the so called facet arthropathy.  This is the “bones spurs” pinching the nerve.

Also,  as the disk narrows,  the sidewalls of the disk bulge out,  similar to the car tire sidewalls bulging out as air slowly leaks out of the tire.  This bulging can potential also cause the pinching of the nerve.

Also, as the disk narrows,  it allows the vertebra to move more than when the disk is at normal height.  Again, it is like the car tire, that is not fully inflated.  There is more movement, or bounce.  This extra movement can cause increased wear of the annulus, and potentially  making rupture of the annulus, and disk herniation more likely.

The degenerative disk disease process is  progressive, and ultimately can cause symptoms such as back pain,  nerve pinch pain, and stiffness.  This is actually the process that is occurring everyday to everyone.  This is the process of spine aging.   Fortunately,  most of the time,  the pain associated with the process is temporary, and not severe.

Pinched Nerve

Think you have a pinched nerve?

A pinched nerve is a common experience for most people over the age of 35.  Usually, it is associated with pain,  burning, or a tingling sensation to either the arms or legs.   While the pinching can occur out the spine, in conditions such as carpal tunnel syndrome, most of the time,  it is associated with a compression of a nerve within the spine.

In the Above diagram,  it demonstrates the effect of a disc herniation pinching a nerve in the neck.  The disc material physically compresses the nerve as it goes outside the canal.  The pinched nerve causes the associated pain,  burning, tingling and numbness.  In more severe situations,  the pinching will also impair the muscle movements associated with that particular nerve,  causing weakness.

While initially very painful,  a pinched nerve usually does improve and heal over time.

For mild situations,  your physician may recommend activities restrictions,  use of gentle massage and therapy, and an anti-inflammatory medication (if you can tolerate them).  For most patients,  the episode of the pinched nerve is often hard to pin point.  It may be caused by a certain activity.  It may be caused by a very innocent movement,  or a cough or a sneeze.  In some cases,  it may be secondary to a heavy lifting or a twisting event.  In these situations,  the nerve will initially become inflamed by the situation.  But,  gradually,  overtime,  the inflammation goes away.  Most recommendations are designed to reduce the inflammation.  That is why most physicians recommend anti-inflammation drugs (if you can tolerate them), ice, and time.    Fortunately,  this is the typical pattern of most pinched nerve events.

For more significant events,  there may be associated severe pain, and a history of a specific event such as a heavy lift,  or an accident. Usually,  the pinched nerve presents itself quickly, and there is a good history of the associated pain,  burning, numbness or tingling to a specific arm or leg.   Usually in the scenario,  as long as there is not significant weakness associated with the pain,  or no loss of bodily function of bladder or bowel control,  the same treatments above are recommended.  And,  even in the most severely pinched nerve, there still is a good chance the nerve will recover with time.

But,  in a minority of pinched nerve events,  the situation becomes more progressive, with time.  If the pinched nerve is also associated with progressive increasing pain,  increasing weakness, or losing of bladder and bowel function,  this can become an emergent event.  If the physician has concerns that this is becoming a progressive problem,  the pinched nerve needs further diagnostic evaluations, and may ultimately require surgical intervention.  Fortunately,  the need for surgical intervention is necessary for small percent of all patients.

Neck Pain

Do you have Neck Pain?

Unfortunately, neck pain affects a large number of people, and the causes do not always seem obvious.   Most of the time,  it will be a self limiting process and will improve with time.

Explanations of neck pain include arthritis, which is a degeneration of the bones and joints in the neck bones.  The cartilage wears away, causing the bones of the neck to rub against each other.   There are small nerve fibers located underneath the cartilage, and it signals pain.  Any extra movement causes increased signaling.  That is why the body will act to prevent these motions.  Along with the pain signals,  often, there are inflammation effects at the location of the degenerated bones.  It cause a natural swelling of the area.  That will cause an increased inflammation of the muscles and the tissues around that area.  This also results in the nerves signaling pain.   Over time,  in most instances,  the body will naturally decrease the inflamed areas, and there is recovery.  To help the process along,  physicians can recommend medications such as anti-inflammation drugs, and muscle relaxers.  As in all medical situations,  sometimes there are side effects associated with these medications,  therefore cautions and warnings are always necessary with any intervention.  Simple remedies such as ice to the inflamed area,  gentle massage, and activities modifications can also help with the process.

Neck pain can also be secondary to a pull to the muscles or ligaments in the neck.  As above,  this pull or sprain to the muscles causes an inflammatory reaction.  And,  most of the time,  with the same techniques as listed above for arthritis,  the pain from the muscle/ligament sprain/strain will resolve over time.

In more serious situations,  neck pain can be secondary to a more significant cause such as a pinched nerve from a disk herniation, or bone spurs.  In this instance,  there is neck pain along with associated nerve pain specific to the nerve that is pinched.  Usually,  it means a shooting, radiating pain to parts of the arm.  There may be associated weakness of specific muscle groups as well as numbness to specific areas of the arm.  If the pain is severe, or the weakness is profound,  you should consider contacting your physician to make sure it is not a more serious condition.  In rare instances,  the process may not be reversible without medical intervention.

Not to alarm anyone,  but it some instances,  neck pain can be caused by more serious conditions such as a broken bone,  an infection or a cancer.  If you have severe pain after some traumatic injury such as a fall, or an auto accident.  You should contact your physician for an evaluation.  If you have a history of prior cancer,  fevers, or sweats, or other significant medical conditions such as diabetes, or immune-compromise,  you should also contact your physician for an evaluation.

In rare instances,  the pain is also associated with loss of muscle strength,  inability to walk, and/or loss of control of your bladder and bowels.  In this instance,  you should contact your physician immediately,  and if there is and concern about the seriousness of the complaints,  go to the Emergency Room for an evaluation.

Fortunately,  in most instance of Neck pain,  it is not a serious condition, and will improve with the above mentioned treatments, counseling and time.  But,  if you have concerns,  your physician can counsel you on the possibilities as well as offer advice on how to prevent recurrences,  or how to minimize the length of time of each episode of neck pain.

Back Pain Again?

We do not have time for Back Pain.

But,  unfortunately,  there is a good chance we will all experience back pain sometime in our lives.  The good news is that most episodes of back pain are not serious and resolve over time.

But,  physicians are always on the lookout for more serious causes of back pain.  Not to alarm the reader,  but your physician will usually ask questions trying to see if you have any reason to suspect the more serious causes.   Typical questions asked are:

1.  Have you had a serious fall, or injury?  If yes,  there will be suspicion for potential break to the bones,  or a significant traumatic tissue injury.  Depending on your complaints,  your physician may order diagnostic tests such as x-rays or MRI’s.  If not,  these tests may not be necessary in the short run, as you may improve,  and not need them.

2.  Do you have any history of cancer?  Unfortunately, people with a prior history of cancer may have back pain secondary to recurrence.  If you do have this history, and the pain does not improve within a few days,  you should consider followup with your physician.

3.  Are you experiencing fevers, sweats, or chills?  In rare instances,  this could mean an infection causing your back pain.  People with prior histories of other infections,  cancer, diabetes or any immune compromise disorder need to be aware of this possibility and should contact their physician.

4.  Are you experiencing inability to control your muscles,  or lose control of your bladder or bowels?  This is sometimes very embarrassing for patients to discuss.    But,  if you are definitely losing control of your bodily functions and soiling yourself,  you need to contact your physician immediately,  or go to the emergency room for an evaluation.  Sometimes back pain is a side effect of a significant nerve compression in the spine.  The nerves can be permanently irritated causing permanent loss of muscle strength, or bodily function.  While some functions ultimately recover,  the nerves to the bladder and bowels are more sensitive and need urgent evaluation to determine the  cause of the lack of control.  If it is a nerve compression,  aggressive measures including surgery may be necessary.

Fortunately,  most episodes of back pain do not have the associated problems above.

More typically,  a person does not really even recall exactly what caused the back pain.  It can be something as simple as reaching for your shoes,  or twisting in bed.  Many people describe back pain  in terms of “wrenching the back”, or lumbago.  Often times back pain is associated with a listing to the side,  or spasms with restriction of motion.  In the end,  as  long as you are not experiencing excruciating and progressive pain,  you can usually wait, slowly stretch,  take over the counter medications such as tylenol, and ice the area until you recover.

If  however,  the pain lingers for more than a few days,  a visit to the doctor may be beneficial.  Often times,  your doctor will obtain a detailed history, and once it becomes apparent there is no significant concern,  will counsel you on stretches,  medications,  mild muscle relaxers,  ice, and time.  It can be frustrating,  and we know we do not have time for back pain,  but time will heal the back.  Then,  your physician will counsel you on ways to prevent recurrence, or  techniques to reduce the duration of back pain.

In the end,  for most people,  back pain will resolve.  To prevent or minimize future episodes,  you should speak to your doctor about preventative techniques and regimens.

HIgh Intensity Zone

What is a High Intensity Zone?

In relationship to the spine,  it is a term that has been used on and off for the past 20 years.

Initially described by Drs’ April and Bogduk in 1992,  it is a  MRI finding  identified on a specific sequence called T2.  A High Intensity Zone (HIZ) is defined as an increased white signal in the margins of the disk annulus.   Dr.’s April and Bogduk  opined that it represented  an acute annular disruption, and thus a source of pain.  In the study (hyperlink above),  presence of this signal intensity was  associated with a painful grade 4 annular tear, and therefore, a reliable marker for back pain.

Armed with this information,  many physicians utilized this sign as an indication for potential spinal fusion surgery.  Unfortunately,  the increased surgical rates did not yield better clinical outcomes. In plain English,  this finding did not mean surgery would help.

In the December 2000 Article in Spine, by Dr. Carragee,  the author wanted to compare the results of discography in patients with and without the findings of these High Intensity Zones (HIZ). His study concluded the following:

“The presence of a high-intensity zone does not reliably indicate the presence of symptomatic internal disc disruption. Although higher in symptomatic patients, the prevalence of a high-intensity zone in asymptomatic individuals with degenerative disc disease (25%) is too high for meaningful clinical use. When injected during discography, the same percentage of asymptomatic and symptomatic discs with a high-intensity zone were shown to be painful.”

This study was awarded the 2000 Volvo Award for Clinical Studies.  And,  this study may have identified why the clinical results of surgical management of HIZ lesions was less than predicted.

Since these early studies,  there have been numerous studies on this topic.  Some studies compared the “acuteness” of these findings.  These studies suggest a HIZ lesion cannot be used to determine the recentness of the findings.  In other words,  HIZ cannot determine if the findings just developed, or was there for several years.

Other studies have even disputed the clinically significance of discography itself.

Not to be an alarmist,  but recent studies suggest the act of disography on a normal disk  (control level) will cause that disk to degenerate at a faster rate that if it had never have the study.

With all these controversies at hand,  a prudent clincian needs to determine if the information is relevant to the individual patient.  The clinician must also weigh the risks of the diagnostic procedure versus the benefit of the information.

In patients that are considering spine surgery,  the great unknown is whether the findings on the studies are the true cause of the pain or dysfunction.  That is because there is such a high prevalence of these findings in asymptomatic people.   The surgeon,  along with the patient, and yes,  the payors of the procedure ( it is not always the patient) must determine if the information from tests  is causing the condition of the patient.   Everyone must assess the risks,  benefits and potential for a positive outcome.

And,  unfortunately, these rational decisions  must be formulated with a patient is in alot of pain, with significant frustration, and fear of uncertainly. Sometimes,  the severity of the situation may sway the group to make a risky decision that may not be the best one.   In the end,  it will always come down to a calculated risk.  Better clinicians know when to take that risk, and for which circumstance.  Better clinicians weigh the information, both scientific and clinical, to make the best decision.

Disk Degeneration in 21 Year Olds

During my training,  it was assumed that the average adolescent or teenager should have normal disk anatomy. It was assumed that  Disk herniation/degeneration was a rare occurrence in that population.  But,  at that time,  technologies such as a MRI scanner was relatively new, rare and expensive.  We did not have the capability to test to see if our assumptions were correct.

Now,  at least in the United States,  we do have more technology available to study these assumptions.  In the past 8 years,  there has been significant numbers of studies looking at back pain in our teens and young adults to see how back pain correlates to diagnostic studies (mainly MRI’s).

First,  there were studies about the incidence of lumbar disk abnormalities in elite 17 year old  (on average) asymptomatic tennis players. It turns out that 84% has some abnormalities to the spine,  although not all specific to the disk.

Additional studies identified degeneration at high rates for teenage gymnasts, and football players,  with and without symptoms.

There are more studies that now look at the general public.  A recent study followed a population that was born in 1986 in Finland.  The data collection included Lumbar MRI studies on 558 people (325 female, 233 male) taken when the age was approximately 21.  54% of this population had evidence of disk degeneration.

After further examination of the Data,  this Finnish study concluded “High BMI at 16 years was associated with lumbar DD at 21 years among young males but not among females. High pack-years of smoking showed a comparable association in males, while physical activity had no association with DD in either gender. These results suggest that environmental factors are associated with DD among young males.”

Obviously,  more studies need to explore the natural history of disk degeneration in our teens and young adults.  However,  from these studies,  information suggests disk degeneration is much more common amongst this population than formerly thought.  And,  based on lack of symptoms on many of those examined,  we still do not know why some hurt, and others do not from the disk degeneration process.

Epidural Steroid Injections And Compression Fractures

Epidural Steroid Injections have been used to treat patients with both herniated disks as well as for patients with spinal stenosis.  In addition,  the same steroid compounds have been used by physicians to treat arthritic conditions of the spine, via the so called facet joint injection.

Most prudent practitioners have always cautioned the patients that there are still associated risks with any invasive treatments,  and that includes these spinal injections.

Last Year,  2012,  our nation unfortunately witnessed one of the potential complications with administration of these injections.  The FDA,  CDC, and the new media was busy tracking the unfortunate development of infections cause by contamination of the injected compound steroid.  Many patients suffered significant infections, causing serious medical conditions including death.  On  a daily basis,  my patients did ask if I used the cortisone from the specific Compounding Pharmacies.  I assured them that I used a different brand, and there had not been any association with my brand of choice to the contaminated vials of cortisone.

Still, as per protocol,  patients that undergo these injections are told of the risks including, but not limited to infection,  nerve irritation,  blood sugar elevation,  water retention, effects from steroid use, etc.

With patients that have a history of osteoporosis, or risk factors for osteoporosis,  I often have the discussion that these injections have potential to make there bones weaker.  Well now,  unfortunately,  we have information that does suggest there should be a concern for use of the epidural steroid injections  secondary to osteoporosis and development of compression fractures.

In the Journal of Bone and Joint Surgery,  June 5, 2013 issue,  Dr. Mandel performed a retrospective review on patients that received epidural steroid injections.  Then,  he found a matching group of patients with all the same medical conditions, and complaints, except they did not have the epidural steroid injection.  Dr. Mandel found that each successive injection increased the risk of compression fracture by a factor of 1.21  after adjusting for covariates.

Certainly,  this is a retrospective review, and not a blinded control study,  but the conclusion suggests exposure to steroids from epidural steroid injections may carry a greater risk of fragility fractures than once thought.

The take home message is that physicians and patients should approach this option with more caution.

Dermatome Patterns

Dermatomal Patterns help physicians define nerve radiculopathy patterns.  Most neurologists/spine specialists  accept certain associated sensation, muscle strength, and reflex changes patterns to specific nerve roots.

L5 radiculopathy is typically associated with weakness of the extensor hallucis longus muscle.  That is the muscle that allows the great toe to point upwards.  L5 radiculopathy also follows a dermatomal pattern associated with the front of the foot.  There are no reflexes associated with L5.

SI radiculopathy is associated with weakness of the gastrocnemius muscle.  That is the muscle that allows a person to step on their tip toes.  S1 radiculopathy follows a dermatomal pattern  associated with the outer heel, and back of the calf.

But, as physicians,  we know that there can be considerable overlap in the sensation changes associated with each of these Dermatomes.

In the above study published in  SPINE,  the authors mapped out the distribution of pain and pins and needles patterns in patients with known disk herniations causing specific entrapment of either the L5, or the S1 nerve.

After mapping the sensation patterns of these patients,  the authors came to the conclusion that patient report is an unreliable method of identifying the anatomic source of pain or paresthesia by nerve root compression.

The results read “There is a substantial overlap of the dermatomes with most patients indicating pain or pins or needles in more than the dermatomal area.  In addition, the distribution of pain and pins and needles did not correspond well with dermatomal patterns.”

Clinicians know this statement to be true.  As I explain to patients,  “I guess your S1 nerve did not read the anatomy book”,  as the pattern was not consistent.

In my opinion,  dermatomal patterns are helpful to establish  the presence of a radiculopathy.  But, as the author concludes,  these dermatome patterns do not always exactly follow the pattern.  But,  while I appreciate the fact that there is deviations of the dermatome patterns,  what I do look for is a pattern.  For patients that have global pain to one extremity,  it is likely that that global loss of sensation,  or the pain is secondary to non-dermatomal issues such as neuropathy,  cord compression,  or non-physical matters.

Cervical Instability

What is Cervical Instability?

In the above x-ray series,  it demonstrates movement of the vertebral body of C6 on C7.  On Flexion,  the posterior corners of the vertebral bodies line up.  But,  with extension,  there is a 4.3 mm movement of the C6 body posterior (towards the back) to the C7 body.  The accepted criterion for cervical instability includes a motion of greater than 3.5 mm’s.

In these same X-rays,  we identify another known criterion for cervical instability.  On comparison flexion-extension x-rays,  instability can manifest by excessive “fishmouthing” of the disk space.  In the above images,  we can see that when the neck extends, the disk space opens.  When the disk space angles are measured,  it opens to 14.6 degrees.  When the neck bends forward or is in flexion,  the end plates are essentially parallel.    Instability is established by a angulation of greater than 11.5 degrees on comparison flexion-extension.   

So, the question becomes, when should we suspect a cervical Instability?  First, lets assume these people have already been worked up to make sure there is no fracture, tumor, infection or significant disk herniation.  Then, let’s assume these people have already had the usual initial treatments such as physical therapy, chiropractic care, and medications.

1. In patients with chronic neck pain,  who describe increasing pains with specific motions, flexion-extension x-rays can help define the instability.

As a side issue,  I am sure there a some patients that become instable with rotation as well.  Unfortunately,  we do not have good established criterion on how to define a rotational instability, and we do not have a good test, that does not subject you to significant radiation dosing.  In theory,  we can have baseline CT scans of the neck,  then as the person to rotate the neck to see if there is excessive facet subluxation on rotation identified by the CT scan.  But, now that we know there is a certain radiation risk to CT scans,  I do not know if the risks for the scan will justify the test for rotational instability.  And, as discussed above,  criterion for rotatory instability has not been established.

2. Patients who have had a recent trauma, with concerns of disruption of the liagments and supporting structures in the neck.

3. People with Rheumatoid arthritis have risks of developing instability secondary to the auto immune effects.  Continued neck pain should be evaluated for instability.

There is a problem, however with flexion-extension x-rays.  Sometimes,  people have such neck stiffness and pain, with spasms.  In that scenario,  people will not allow the neck to flex or extend.  We cannot get enough information to assess instability.  To this point,  often times,  during an operation,  when people are relaxed due to the anesthesia,  we often identify a instability pattern by direct observation of the disk level, or by obtaining imaging during the operation.

Cervical Instability is a potential serious issue, and can lead to significant problems.  Minor instabilities can be treated with exercise and therapy.  But,  significant instability usually require surgical management.

Discograms

Discograms have been used by spine specialists for purposes of diagnosis.  Unfortunately,  there is controversy about the relavence of the procedure.

In the ideal circumstance, this discogram procedure provides a means to identify the source of back pain.  If a physician believes the procedure is an effective diagnostic tool,  discography is ordered, and it will help isolated the pain to the specific disk that is examined.  Then, surgical management of that specific disk will result in pain relief.

On the other hand,  some practitioners believe the discogram test has significant potential to confuse the situation, yielding unreliable information about the sources of pain, and should not be used for surgical selection.  Also,  because there are certain inherent risks to the procedure,  and based on  lack of diagnostic efficacy,  the test should not be administered.

But, the question remains on why we would even consider such an invasive procedure for our back pain patients.  The rationale for discography, or a discogram is based on the concept of the pain generator.  As we have discussed in our many previous blogs,  often times, diagnostic testing of the lower back yields multiple areas of findings.  It is truly rare to find a “normal lumbar MRI or CT scan”  as the natural disk degenerative process happens to all of us.  In fact,  many studies do demonstrate that the vast majority of disk degeneration findings such as disk degeneration,  disk protrusions, disk herniations, and disk osteophytes/bone spurs are often asymptomatic, and not the cause of the back pain.  On the other hand,  for some patients with severe pain,  not responsive to non-surgical treatments,  sometimes spine surgery, most likely fusion will be recommended.  Because there is a certain uncertainty to the efficacy of the lumbar spine fusion procedure,  discography was utilized to see if the particular disk that is scheduled to be fused would be the cause of the pain.

The discogram procedure is basically a needle procedure, by which needles are placed within the disks of the presumed pain generating disks.  Then,  the needles are injected with fluid to see if the insertion of the fluid will reproduce the pain.  There are subtle technical concerns,  and some physicians go in great detail about measuring the pressures of the disks, and also injecting dye to see if there is evidence of advance disk degeneration, or dye leakage to the surrounding areas.  Followup CT scans are often utilized to examine the dye pattern.  But,  in my opinion,  if there is any useful information, the best information is obtained by the response of the patient to the injection.  If the injection totally reproduces all the pain associated with the primay complaint,  then the discogram study for that particular disk is considered concordant (or consistent) with the initial complaint.  Based on a concordant response, a physician my recommend surgery.

The problem lies in how people respond to the whole technique.  Some patients have so much pain, that it is difficult to say if the test itself is meaningful.  Also,  the test requires the patient to tell us if the pain of the injection truly represents the primary pain.  There is a subjective component to the test, and you are assuming complete truthfulness in the response.  Finally,  there have been some studies indicating a concordant pain response can still be associated with resolution of pain without surgery.

Finally,  there is the risk component.  Unfortunately,  some patients do have bad pain experiences by the test.  Also,  there is the potential for an infection to the disk.  Also,  there are some studies that suggest discograms can actually cause healthy disks to start the degeneration process.

To summarize,  it would be wonderful if discograms give perfect results and can predict the cause of pain.  But,  that is not always the case.  And, there is risks associated with the procedure.

Personally,  I still use discograms on a very selective basis.  But, I, like most treating physicians,  do not have hard data supporting why I use discograms for my specific indication.

Do Disc Herniations Cause Pain?

Do Disk Herniations Cause Pain?  The answer is maybe.  There has been plenty of research on this topic, and while the exact mechanism of pain can still be debated, in general most agree the cause of pain, discomfort and radiations are secondary to three factors:

1. Chemical irritation.  When a disk herniates, the soft inner component of the disk, called the nucleus will penetrate the outer wall of the disk ( the annulus) and allow certain components of the disk to spill out.  These components include enzymes,  cytokines, and other chemicals that have certain effects on the surrounding tissue.  To make an analogy,  the materials can cause a “chemical burn” effect on the tissues, causing the body to react by mobilizing an inflammatory reaction.  These chemicals are currently being investigated in detail, hoping to find a quicker way to collect, or dilute or deactivate these reactions,  therefore, potentially decreasing the pain and other effects caused by this “chemical burn”.

2. Direct nerve irritation of certain specific nerves.  Located near the outer fibers of the  annulus, are the so called sinu-vertebral nerves.  Most spine researchers agree that these nerves have potential to generate pain when irritated.  With disk herniations, the annular disrupts, and has potential to irritate this nerve. The pattern of pain is not always classic, but irritation of the nerve can lead to spine related pain and discomfort.

3. Mechanical pressure on the nerve sac, or the actual nerve.  Who ever designed the spine did an wonderful job protecting the nerves and the spinal cord, while still allowing motion.  The spinal cord, and the individual nerve fibers in the spinal canal is incased in  the dural sac.  To make an analogy,  the dural sac is like a garden hose, and within the water filled hose, are individual nerves or the spinal cord, floating within that cord.  Normally there is room within the dural sac, so that stretching, bending, and some compression of the sac will  not cause direct compression on the spinal cord, or the individual nerve.  But sometimes, the stretch, or compression is significant enough to cause irritation onto these individual nerves, or the spinal cord itself.  As stated above, the fluid filled dural sac usually has enough space to allow movement for the individual nerves or cord within the sac.  But, significant disk herniations,  fractures, or other causes of significant compression can cause actual entrapment of the nerves or the cord.

By these three mechanisms,  we can usually explain the rationale for treatments prescribed for symptomatic disk herniations.

1. NSAIDS, ESI’s and steriod medications are designed to decrease the inflammation caused by the “chemical irritation”.

2. Narcotic medications can also dull the pain associated with the irritation of the nerves, or inflammation of the tissues.

3. Physical therapy can relax the inflamed muscles, and strengthen the core muscles, preventing further pressure on the annular disruptions.

4. Activities modifications can also protect further inflammation, or prevent further annular disruptions.

5. By decrease the pain,  the patient can give the body time to decrease the inflammation, eliminate the chemicals, and allow the herniated fragment to dehydrate and shrink away from the cord or the nerve.

6.  If, however, the pain is too severe, or if there is further development of weakness, surgery can be a reasonable and effective alternative.

Risks Associated with MRI Scans

What are the risks associated with MRI Scans?

From a practical point of view,  there are few medical risks.  MRI’s do not utilize radiation.  Unless there is use of a dye,  it is completely noninvasive. Most patients can tolerate the procedure well.

But, certain patients do have some medical risks associated with MRI Scans.  If you have had any metal device implanted in your brain, or heart, such as cardiac stents,  brain aneurysm clips, or coils,  or metallic implants in your ears or eye,  you should avoid MRI’s as the magnetic forces can potential cause movement of these devices.

In addition,  some metallic implants such as pace makers, defibrillators and implanted pumps can malfunction with the magnetic forces.

Finally, in terms of medical Risks associated with MRI Scans,  some patients cannot tolerated the confined space and react badly with claustrophobia.

But,  some of the other risks are not necessarily medical in nature.

If you are in the process of applying for disability,  some policy underwriters will use the prior history of MRI testing as a risk factor, and may cause increase to your premium.

If you have been in an auto accident, a prior history of MRI testing of certain areas may subject you to scrutiny regarding a pre-existing condition.

Finally,  from the pure statistical standpoint,  we know that most people will have MRI evidence of structural abnormalities to the spine, and the knees and shoulders.  Many of these structural abnormalities can be completely asymptomatic, and not necessarily the cause of any pain or discomfort.  But,  once you have an MRI,  and an abnormality is identified,  there is a much greater likelihood you will have surgical management for that finding,  even if you have complete recovery of your pain from the time of the MRI study.    The reason is not that aggressive surgeons will recommend surgery for the problem.  The reason is that you, the patient, will assume any future pains are secondary to the finding on the MRI.  Over time,  you may request surgical management of the finding,  even if the complaints are not completely consistent with the findings on the MRI.  So,  even if your original surgeon will decline to offer the operation,  you can usually find someone who will perform the surgery.  I am not suggesting the second surgeon performed an unneccessary surgery.  But,  I am saying the original surgeon will likely suggest waiting for it to improve (as it has in the past),  while the next surgeon,  not understanding that history,  will offer the surgery.   The outcome can still be excellent,  but, there is a chance that waiting a bit longer may have also corrected the underlying complaints.  Controversial statement,  I know.  But, I see this everyday.

So,  before you get an MRI of your body,  please discuss the necessity of the MRI with your physician.  Not only can the study be expensive, and cause some complications for certain patients,  but it can also result in higher incidents of surgery, even if you get better.   And,  don’t forget the part about ramifications if you apply for disability or if you are involved in an accident.

Recurrent Herniated Nucleus Pulposus

Statistically, Recurrent Herniated Nucleus Pulposus occur more commonly than hoped. When you have a Herniated Nucleus Pulposus,  the outer fibers of your disk, or the annulus has weakened allowing a tear, and subsequent rupture of the soft nucleus material out of the disk.  We can debate the cause of the weakening of the outer annulus,  but usually, it is a combination of wear on the crosslinking fibers for the outer fibro cartilage, combined with forces placed within the disk causing the softer inside (nucleus) to rupture, or herniate outside the fibers of the annulus.

In most instances,  even with a large disk herniation,  the pain can subside without surgery.  The nucleus material that ruptured tends to dessicate, or dehydrate causing less pressure on the nerve elements over time.  Also,  the initial release of potentially pain generating materials from the disk gets absorbed, also lessening the pain.  But,  the disk, unfortunately, is now changed.

While the torn fibers of the annulus tries to repair itself,  the scar formation sealing the tear is never as strong as the original annulus.  It becomes a potential weak spot, and there is a concern for recurrent disk herniations through that same area of tear and scaring.

This Recurrent Herniated Nucleus Pulposus rate remains similar for both surgically treated, or non surgically treated disks, as the scaring of the annulus remains the same. Some of the so called surgical failures are actually patients that suffered from a Recurrent  Herniated Nucleur, Pulposus,  and not necessarily because of failure of technique.   Recently,  there has been some effort on annulus repair , with sutures.  While there is some promise, the long term data is still not clear.

Recurrent Herniated Nucleus Pulposus can be treated similar to the initial disk herniation.  Activities modification,  use of medications,  physical therapy and steroid injections are usually prescribed.  If there is no improvement,  surgery can also be an option.

In the circumstance of Recurrent Herniated Nucleus Pulposus in a patient who had prior surgery at the same level,  sometimes a more aggressive surgical option, which includes removal of most of the disk and fusion may be recommended.

If you suspect you have a Recurrent Herniated Nucleus Pulposus,  please contact your physician to see what can be done to decrease your symptoms.

Cervical Neck Fractures

CT Scan of Cervical Neck Fractures:  Facet fracture and fragment in Foramen Transversalis

Cervical Neck Fractures are a common presentation associated with severe neck pain after trauma.

Unfortunately,  Cervical Neck Fractures commonly present after sports or recreational activities.  Common causes include diving accidents,  football collisions,  and racing activities.  Because of the activities involve, the Cervical Neck Fractures occur in a younger and more active population.

Sometimes the presentation is obvious,  as there is significant pain, with corresponding arm radiations and pain.  In the more severe cases,  unfortunately,  there may be a spinal cord injury, with long term disability ramifications.

But, in many cases of Cervical Neck Fractures,  often the only presentation is pain.  In the CT scan above,  the patient was involved in a bike accident,  but the only complaint was neck pain.  There was no presentation of arm weakness or numbness.  But,  the history is one of a fall off a bicycle landing on the neck with immediate pain.  The patient actually walked into the Emergency Room.  But,  because of the history of trauma, an x-ray raised suspicion of a Cervical Neck Fracture.  The CT scan confirmed the diagnosis.

If you have severe neck pain after a traumatic event such as a fall, a motor vehicle accident, or forced twisting maneuver,  please  discuss the complaint immediately with a Physician.  If the suspicion is there, further testing, initially with x-rays may be warranted.  If there is no evidence of a fracture,  but the suspicion is still strong,  often times, a Physician will consider further testing such as flexion extension x-rays, or CT scans to the neck.  In regards to neck fractures,  CT scan often demonstrate the fracture better than other tests such as MRI’s.

In our senior population,  unfortunately Cervical Neck Fractures are also a concern.  Because our older population have a high rate of osteoporosis,  the Cervical Spine is prone to fractures.  Because of the frailty of the bone,  any complaints of neck pain,  even with trivial trauma should be evaluated for potential Cervical Neck Fractures.

While many Cervical Neck Fractures can be treated non-surgically with a collar,  if you have a break,  you need to be evaluated by a physician who can determine whether the break can heal without sequela,  or if it should be stabilized to prevent a more significant event such as paralysis, or chronic pain.

Anterior Cervical Discectomy and Fusion Results

How are the Results for Anterior Cervical Discectomy and Fusion?

General consensus by most surgeons and patients report a 95%-98% success rate in terms of relief of arm pain.  And, that statistic is very important for everyone to understand. Cervical Discectomy Surgery is successful for ARM PAIN.  Unfortunately,  that does not mean neck pain, or Headaches.

Just like any procedure, surgical or not,  the success is determined by proper selection of the patient.  For Cervical Discectomy patients,  the ideal candidate is a healthy, normal weight adult,  without any significant arthritis of the spine,  that has an isolated single disk herniation, located to one side with corresponding arm pain,  weakness, numbness or tingling that does not respond to the usual conservative treatments or time.  With no other  sources of pain,  medical risks, and anatomy concerns,  this patient would be predicted to   have an excellent result with improved arm pain also all the time.  Unfortunately,  most patients do present with other issues that may factor into a less than ideal outcome.

Anterior Cervical Discectomy and Fusion can improve neck pain, and headaches,  but the rates of success specifically for those two problems are not as predictable.  The reason being the causes of both the neck pain, and headaches are very difficult to exactly define. In terms of neck pain,  it can be secondary to arthritis of the facet joints of the neck,  with corresponding pain caused by rubbing of the arthritic joints.  While fusing that level may alleviate some of the neck pain,  usually, cervical facet joint arthritis is diffuse,  so you run the risk of still having neck pain despite fusion to one or two levels, as the third or fourth level may still be the cause of discomfort.  If you have neck fusion for facet arthritis,  please make sure you have investigated all the potential other cause of neck pain, and ask if your surgeon has isolated the neck pain to the specific levels of fusion.

Cervical Discectomy and Fusion for Headaches can equally be challenging.   While it is true that neck pain can cause headaches, and that nerves of the back of the neck can cause headaches,  it is difficult to associate all your headaches specifically to one or two areas of the neck.  As a great secondary effect,  after a patient has Cervical Discectomy and Fusion for arm pain,  often they notice improvements in neck pain and headaches.  But,  the predicted outcome of headache and neck pain relief is not as accurate as the prediction in improvement of arm pain, tingling and weakness.

Cervical Discectomy and Fusion surgery has excellent results in terms of relief of arm pain, tingling, weakness, and numbness.  However, its success with decreasing neck pain and headaches are not as predictable.  While it often does cause relief of the headaches, and neck pain,  please discuss your concerns about the headaches and neck pain before you have the surgery.

The best outcomes occur in patients that understand the goals of the surgery.  Cervical Discectomy surgery has excellent predicted outcomes in terms of arm pain.  But you the patient need to understand its other effects on other concerns.

Cervical Selective Nerve Block

What is a Cervical Selective Nerve Block?

For people with arm pain and tingling secondary to a pinched nerve in the neck,  most of the time, the pain does get better.  But for a small but painful minority,  the pain remains constant despite all conservative treatments.

For those people,  your Doctor may offer injections of cortisone to the neck.  The rationale being,  the cortisone will help decrease the inflammation on the nerves.  With reduction of inflammation,  the pain, tingling and numbness may improve.

These injections have many names, and many forms.  Cervical epidural steroid injections.  Cerivical Nerve Block.  Cervical Facet Injections.

The effects of the cortisone is secondary to its very potent anti-inflammation effect on tissues.  Any nerves or tissues that are swollen can potentially decrease in size with the cortisone effect.  Remember that cortisone is a steroid, and some forms naturally occure in the body. But, with concentration of the steroid (cortisone), most tissues will decrease its inflammation.

In addition,  by delivering a solution near the area of inflammation or injury,  the fluid can help dilute the various concentrated enzymes,  and painful substances that are causing the irritation in the limited spaces of the spine.

Cervical Selective Nerve Block have one more function.  In certain situations,  there may be confusion as the cause, or location of the nerve compression or “pinched nerve”.   In the more typical situation,  a person has physical findings and MRI evidence of multiple pinched nerves.  As we try to isolate which of these nerves are causing the pinch,  we can use Cervical Selective Nerve Block to differentiate the pinch nerves identified on the MRI versus the pinched nerves that are actually causing the pain.    As some of you may know,  many times,  nerves can be pinched, but not have any associated pain, numbness or tingling.

In the process of Cervical Selective Nerve Block,  the physician will direct a small needle next to the nerves of interest.  Then,  usually one at a time,  as close as possible to an individual nerve,  a small amount of a fluid similar to novacaine, along with a small dose of cortisone is delivered onto the nerve.  Then a certain amount of time passes to see if the Cervical Selective Nerve Block causes improvement of the pain and discomfort associated with that particular nerve.   Then, a second, and possibly a third nerve is injectioned to see if the nerve has improvement with the Cervical Selective Nerve Block.  The key is to deliver a very small amount of the novacaine/cortisone fluid to each nerve so that it will only effect that nerve.

With the results of Cervical Selective Nerve Block,  the cause of the pain can be isolated to the truly affected nerve.  This sometimes makes a significant difference in determining the type of surgical procedure necessary to correct a chronic and severe pinched nerve in the neck.    This technique can also be utilized in the lower back as well, with associated sciatica.

Though the process sounds a bit intimidating,  Cervical Selective Nerve Block can help isolate your problem, and improve your surgical outcome.

Cervical Foraminotomy

What is Cervical Foraminotomy?

In my prior blogs,  we discussed cervical radiculopathy,  or in simple terms,  a pinched nerve in the neck.  Usually,  there is associated pain, numbness and tingling corresponding to the distribution of the pinched nerves functions.  As we discussed before,  these nerves can have a distribution of sensation called dermatomes, as well as corresponding associated reflexes, and set groups of muscles.

Causes of the pinching of the nerve are usually from disk herniations,  and bone spurs.  Unfortunately,  but rarely,  it can be caused my more serious problems such as fractures, infections and tumors.  In general, however,  most episodes of cervical radiculopathy usually resolve with non-surgical means.  But for a certain percentage of patients,  surgery will become the only treatment that will give relief.

Cervical Foraminotomy is one of the options that can provide surgical relief in that patient population.

In the most simple explanation,  Cervical Foraminotomy means removing the bone spurs that cause the pinching of the nerve.  The incision is made from the back of the neck, and the bone spurs from the arthritic facet joints are partially removed.

Cervical Foraminotomy can also be combined with removing of a disk herniation that is located in an accessible location in the spine.  The surgical judgement call involves  determining which cervical disk herniations can be approached through the opening created by the cervical foraminotomy.  If the disk herniation is located too far to the middle of the spine,  it requires retraction on the spinal cord to properly remove the disk fragment.  The key is to minimize any pressure on the spinal cord during removal of the disk.  If the location of the disk necessitates excessive spinal cord retraction to retrieve the disk,  the better approach may be to remove the disk from the front.  That procedure is the Anterior Cervical Discectomy and Fusion surgery.

Sometimes,  even with posterior Cervical Foraminotomy,  there remains residual bone spurs, but with improvement of the space for the nerve,  there is still favorable reduction of the pain.

While performing Cervical Foraminotomy,  the surgeon must assess the facet joints of the neck to see if there is stability of the joint.  If the joint is not stable, and allows excessive motion,  this can also lead to nerve pinching.  Also,  if certain instances,  more bone than orginally planned must be removed,  with a high risk of developing instability.  In those scenarios,  a Posterior Cervical Fusion may also be performed at the time of the surgery, or at a later staged time.

For properly selected patients,  with isolated nerve entrapment from posterior bone spurs,  Cervical Foraminotomy is an excellent option.

Cervical Radiculopathy

What is Cervical Radiculopathy?

it means you have a pinched nerve in the neck.  In the above image,  it demonstrates the most common cause of Cervical Radiculopathy,  a herniated nucleus pulposus.

Other causes of cervical radiculopathy include bone spurs,  fractures,  infections and tumors.  Fortunately,  most of the time,  the causes are not as serious as the latter three.  But, your doctor will always be thinking of those possibilities if you are not making improvement.

What are the common complaints associated with Cervical Radiculopathy?

Usually, it begins with complaints of neck stiffness or pain,  followed by numbness, tingling or radiation to the arms and hands.   Because the nerves irritated can cause weakness to the muscles of the shoulders,  elbows, hand and wrist,  the certainty of the diagnosis not always clear.

What are the other possibilities other than Cervical Radiculopathy?

In General,  your history is most helpful to identify the diagnosis.  But, your Physician usually has a so called Differential Diagnosis, when confronted with patients with possible Cervical Radiculopathy.  Other possibilities include:

Shoulder Rotator Cuff problems.

Brachial Plexus problems

Carpal/Cubital Tunnel syndrome

A type of neuropathy

How do you diagnose Cervical Radiculopathy?

After obtaining the history of the problem,  your Physician will then perform a physical examination.  Does the history indicate a potential trauma, that may cause a fracture or a disk herniation?  Do you have a prior history of neck pain, and is your age such that bone spurs are likely?  Have you had any recent infections,  fevers, sweats?  Have you had any complaints that make cancer a possibility?

On physical examination,  your Physician will usually perform a neurologic examination, and a musculoskeletal examination to try to differentiate nerve problems, versus muscle and joint problems.

Then finally,  if warranted,  your physician my order tests,  including x-rays or MRI’s (not always the first visit) if your symptoms are severe, or are not improving.

What are the Treatments for Cervical Radiculopathy?

As long as there are no concern for infection, tumor, or progressive neurologic deficits,  most episodes of cervical radiculopathy are treated initially with conservative options such as medications,  exercises,  Physical therapy, or chiropractic care.  If you do not respond to these treatments,  further workup, including x-rays or MRI’s may be necessary.  Depending on the findings,  you may be offered more conservative care,  spinal injections,  or as a last resort surgical management.   If you are suffering from complaints that are consistent with Cervical Radiculopathy, and you do not improve, or worsen in a short time, please call your physician for an evaluation.

Cervical Myelopathy

What is Cervical Myelopathy?  By definition, it is any functional change of the spinal cord.  Usually, it is caused by pinching of the spinal cord by bone spurs, disk herniations, or a combination.  In the above MRI,  the red circle identifies changes in the spinal cord (see the different coloration) in a man with complaints of progressive arm numbness, weakness and pain.  He had prior cervical surgery,  but the spinal stenosis continued to manifest as Cervical Myelopathy.

Common Cervical Myelopathy complaints include arm pain, and tingling, a heavy feeling to the legs,  difficulty with brisk walking, and an electrical sensation from the neck to the extremities.

As Cervical Myelopathy progresses,  it can lead to a very weak, and awkward gait,  bladder and bowel disturbances, and eventually, difficulty with coordination of the arms and legs.

While Cervical Myelopathy is usually a slow progressive process,  it can be associated with rapid deterioration of function.

If you have neck pain, with tingling to the arms or legs,  you should at least discuss the complaints with your physician.  If there is any concern for myelopathy,  usually diagnostic studies such as cervical MRI’s or CT scans will identify the problem.

Cervical Myelopathy treatments varies to the findings on the Tests, and must consider your overall health.

If the diagnostic studies identify mild spinal compression, the Cerical Myelopathy can be observed, and monitored.

On the other hand,  if you have rapid progression of your complaints, Surgical intervention usually is necessary for Cervical Myelopathy.  The Surgical techniques include removal of the disk or bone spurs from the front of the neck,  with anterior discectomy or corpectomy with fusion.  Sometimes,  the findings call for a posterior cervical laminectomy, or laminoplasty.  Sometimes, the bone spurs require such significant bone resection that you will require posterior fusion along with the decompression.  Sometimes,  the spinal cord compression is such, that it requires both an anterior and a posterior procedure to adequately decompress the spinal cord.  All the surgical interventions must also consider the medical condition of the patient, as a majority of patients who have myelopathy are typically older, and have other medical issues.

Cervical Myelopathy has potential to cause a significant permanent spinal cord injury, so if you have any of the above symptoms,  please discuss the situation with your physician.

Obesity and Spine Surgery

Obesity and Spine Surgery is a sensitive issue.  The March 1 issue of Spine does tackle this issue by comparing the results of surgery for obese patients to normal weight patients. Not surprisingly,  the results do show a difference, with patients in the obese catagory having inferior rates of success compared to the normal weight patients.

The good new, however, is that Obesity and Spine Surgery can still yield improvements to the patients.  But,  a higher BMI (body mass index= Weight in kilograms/ height in meters squared) was associated with greater odds of dissatisfaction after surgery,  and according to the study,  inferior results at the 2 year followup.

Overall satisfaction of surgery at 2 years, was 67% for normal weight patients  (BMI<25).  64% in over weight patients (BMI 25-30), and 57% of patients who are considered obese (BMI>30). Statistically,  there was a definite difference in the outcome comparing the normal weight to the obese patients.

Surgical intervention was for patients with Lumbar Spinal Stenosis.  Data was from the Swedish Spine Registry, with more than 80% of the total surgical procedures for degenerative lumbar disorders included.  The population includes 2633 patients.  The study was not clear about the exact nature of the surgery,  but surgical interventions most likely are laminectomies, with some fusions.

The whole concept of Obesity and Spine Surgery is controversial.  While we think it is common sense that Obesity would be associated with increasing low back pain,  the data has been conflicting.  Not every study has demonstrated this correlation.

The authors of the study does discuss some of the short comings of the study.  But, concludes obesity is a factor when trying to stratify a patient population that might benefit from Lumbar Spinal Surgery.    The study actually does not demonstrate a great overall success rate for any of the lumbar surgeries, as even in the normal weight group,  satisfaction was only 67%.

Still, the study did confirm a common consensus  opinion,  which is Obesity and Spine Surgery,  while at times necessary,  can result in inferior success rates for patient satisfaction.

Neck Fusion Surgery

Is Neck Fusion Surgery radical?  Browsing the internet,  I have seen some commercial sites suggest Neck Fusion Surgery is very extreme, and often times unnecessary.  That of course is the opinion of the writers of those advertisements for the commerical sites.  I do not know for sure,  but most likely, the writers are not spine surgeons.

In the properly selected patient,  Neck Fusion Surgery has a very high success rate, with very satisfied patients.

In our practice,  patients who elect to have Neck Fusion Surgery typically have these following criteria:

1.  Usually, the patients have neck pain with arm radiations.  There are usually associated complaints of arm pain,  numbness and tingling.

2.  Diagnostic studies usually reveal a Cervical Disk Herniation, Cervical bones spurs (spinal stenosis), or evidence of instability of the cervical spine.  Those are the most common indications for Neck Fusion Surgery.  Less often,  but still common,  the studies can reveal a fracture, infection or tumor.  In that scenario,  often surgery needs to be performed on an urgent basis.  If you have any of the last three problems, you should have evaluation immediately, so as to avoid a potential permanent problem.

3. If you have progressive weakness, or increasing pain despite non-surgical care,  then you are a candidate for Neck Fusion Surgery.  In some instances,  the location of the disk herniation or bone spur may be accessible by a posterior neck decompression surgery called a foraminotomy.  In this situation,  you can remove the cause of the neck pain and arm pain without surgery.  But your surgeon will be able to discuss why you would or would not be a candidate for this lesser surgical option.  In general,  if the location of the disk herniation or bone spur is more towards the midline of the spine,  it can be risky to move the spinal cord to remove the spur from the lesser foraminotomy procedure.

4. One and two level Neck Fusion Surgery has a better predicted outcome than three or more levels.  If you need more than two levels,  please discuss the rationale for the multiple levels.  In my practice,  we try to avoid more than two levels,  but, in certain instances such as multiple levels of disk herniations or spurs,  you cannot avoid the additional levels of surgery.

5. Patients are counseled not to smoke.  Neck Fusion Surgery has a higher success rate in patients who do not smoke.  Smoking is associated with higher rates of non-union,  or failure of the bones to successfully unit.

Neck Fusion Surgery is very successful in the properly selected patient, and has a much higher satisfaction and outcome than lower back fusion surgery.  Please do not assume neck fusion surgery and lower back fusion surgery have the same results.  If you have significant neck pain, with corresponding nerve compression pain limited to one or two levels,  Neck Fusion Surgery can be a good treatment option for you.

Artificial Disk Replacement

Have you been told you need an Artificial Disk Replacement?  Usually,  it means you have had neck or back pain, and have not improved with conservative treatments.  Assuming you have had appropriate treatments, but still have significant pain, artificial disk replacement may be an option for you.

But,  there are certain questions you need answered before having the artificial disk replacement procedure.

1.  Is it for my back or my neck?   Of course there is a lot of research being done on this subject.  I can say that often times,  you can find research supporting almost every position.  But, in general,  the general trend supports the theory that cervical (neck) artificial disk replacement has better outcomes that lumbar (back) artificial disk replacement.  Again,  there are many theories on why,  but the most common sense way to look at this is in terms of the original reason why we have  disks in the first place.  Disks are structures necessary to allow our spine to move our bodies, while allowing a conduit for our nerves to get from our brain to the respective body part.  As you know,  these nerves allow you to control your body functions including your muscles,  and ability to feel things.  The disks are the flexible part of your spine that allows movement, while protecting the nerves.  The disks act as shock absorbers, spacers and ligaments.

The disks in the neck need only to support the weight of the head,  But,  the disks to the lower back, must support the whole body, as well as take the stresses associated with movements of the legs.  In plain English,  the lumbar disks see alot more stress, and forces than the cervical disks.  That is why there is much more back pain than neck pain.  In this same line of discussion,  cervical artificial disk replacement is often more successful than lumbar artificial disk replacement.

2.  Are the facet joints of that particular level normal?  When you perform a standard artificial disk replacement,  you are replacing the disk structure to the front of the functional spine unit.  But,  we need to understand the motion associated with the disk, also must be coupled with motions of the two  facet joints on the back of the functional spine unit.    If you have deteriorating facet joints, or pain from those joints,  artificial disk replacement may not be your best option.

3.   Is the procedure covered by your insurance?  Artificial disk replacement is still considered experimental, or is a non-covered benefit for certain insurance companies.  Also,  not all the artificial disk replacement devices have received FDA clearance.  Please make sure you understand these issues in reference to your particular recommended artificial disk replacement.

4.  While there is some supporting data,  long term (greater than 15 years) data is still lacking.  Make sure you understand your options should the artificial disk replacement procedure is not successful.

5.  Based on my personal experience as a Spine Surgeon,  cervical artificial disk replacement shows good promise, and I am hoping long term data will show that use of these devices will decrease the development of adjacent level disease.  Lumbar disk replacement has been very successful in the hands of a few of the most  experienced artificial disk replacement surgeons.  If you are considering a lumbar artificial disk replacement,  consider seeing a surgeon with the most experience in your community.

Epidural Steroid Injections

Should you get Epidural Steroid Injections?      It depends on the rationale for the treatment.  In my practice,  I use Epidural Steroid Injections for both treatment as well as diagnostic purposes.  The research for these injections have been significant, but the conclusions by the various authors have been very different.  If you must know,  there is controversy on the efficacy of the treatments.  Traditionally,  epidural steroid injections have been seen as a reasonable treatment option for patients with back pain and sciatica. But, now in the era of “cost effective” medical care,  the clinical benefits are measured against its costs to the system.  And,  as we know from the recent experience of contamination of the medications,  measured against the risks associated with epidural steroid injections.  A simple search of the internet will reveal many articles on the risks and benefits of the procedure.  Based on my experience,  epidural steroid injections definitely have a role in the treatment of patients with back pain and sciatica.

In theory,  epidural steroid injections benefit the patient by delivering corticosteroids to the areas of inflammation.  The steroids have a known anti-inflammatory effect, and will decrease the swelling to the tissues upon contact.  In a very simplistic way,  by decreasing the swelling,  the affected nerves in the spine will no longer have as much irritation.

Some practitioners also inject a volume of saline associated with the steroids,  and theorize that the volume of saline also flushes the area of painful chemicals that also lead to the inflammation.

In my practice,  I use epidural steroid injections when a patient has a sciatic, or nerve inflammatory complaint.  I believe the epidural steroid injections can help decrease the inflammation, and therefore reduce the pain.

For diagnostic purposes,  if the epidural steroid injections give even temporary relief,  it usually confirms that there is an irritant to certain nerves.  Based on temporary improvement, surgeons may consider the patient an appropriate candidate for surgery, as many practitioners use the so called transforaminal technique to try to isolate the specific nerve that may be causing the irritation.

There are certainly risks to the procedure, but in general,  epidural steroid injections can provide pain relief for certain patients, and can help isolate the cause of the spine pain.  Please discuss the details of the procedure with your physician.

Before you have Spine Surgery

“Before you have Spine Surgery……..”  there should be a discussion on the risks, benefits, and alternatives.

I see patients for surgery second opinions almost every day.  Naturally,  the patients are in pain, and often have some weakness.  But,  I am surprised on how many patients have not truly explored their alternatives.  So,  here is a list of things you should consider Before you have Spine Surgery.

Before you Have Spine Surgery,  have you discussed the findings with your physician?  Patients that do well with surgery typically have three factors that must be present.

1. The physical findings are of a consistent pattern.  That means there are a corresponding set of findings that are consistent with the presumed diagnosis.  To give a good example,  a person may have a large L5-S1 disk herniation as the diagnosis.  On the physical exam,  there is evidence of irriation of the L5 and S1 nerves.  The areas of numbness correspond to the proper skin areas.  There are reflex changes consistent with those nerves.  There is a pattern of weakness consistent with the nerves.  There are positive so call provocative signs, indicating nerve entrapment.    Examples are the straight leg raising signs, and a extended position when sitting.
2. The diagnostic testing are consistet with the diagnosis.  In other words,  the MRI or CT scan identifies findings consistent with that particular nerve compression pattern.  Also,  the diagnostic testing confirms isolation of the findings to that particular nerve compression.  Unfortunately  for physicians,  a difficult decision occurs where there are multiple findings on MRI’s and CT scans.  While there are multiple findings on the diagnostic test,  the physical exam does not demonstate corresponding physical findings.  In this situation,  there is risk that surgical management may not improve all the complaints.
3. The patient has given non-surgical alternatives an appropriate amount of time to work.  In extreme situations, such as progressive weakness, loss of bowel and bladder function, acute fractures,  or the presence of infection or tumor,  surgery may be emergently indicated.  In most situations,  however,  non-surgical  treatments often do improve the situation.  Options such as medications,  therapy,  chiropractic care,  acupuncture, steroid injections, and massage can and do improve the situation.  There has been many studies on the efficacy of each of these alternatives.  While not all studies prove the efficacy of each of these modalities,  I personally encourage patients to pursue any and all non-surgical treatments for at least 6-8 weeks. Before you have Spine Surgery,  you must feel certain that you have given the non-surgical treatments a chance to work.  Only then, can the patient be properly psychologically prepared for surgery.

Before you Have Spine Surgery,  you must also be certain that you have a good understanding of the nature of the surgery.  Your surgeon should discuss the operation in detail.  You must feel confident that you understand the necessity of the surgery, and prepare for the outcomes,  both good and bad.

Before you Have Spine Surgery,  you must prepare your home for the recovery period.  Make sure you have adequate help at home for the initial recovery period.  Prepare your bedding, and make sure your bed room is moved to the first floor if you have a mult-story home.

Before you have Spine Surgery,  you must consider the financial implications of the operation.  While your health is important,  it still takes monetary resources to arrange surgery, and provide for your needs during recovery.  Make sure you have adequately made arrangements with your work place,  and  you have document the needs so your insurance policies can properly execute surgery authorization,  short term disability,  temporary parking, etc.  It will be much easier to deal with these issues before the operation.

Before you Have Spine Surgery,  get in the best physical shape possible.  I know most of you are in too much pain to do any exercise,  but EXERCISE ANYWAY!  While specific parts of your body may hurt because you need surgery,  the other parts can still be completely functional, and need to be in it’s best shape.   After surgery,  while there is immediate improvement to certain areas,  you will have some pain and weakness because of the incision.  If you are in better shape,  you will be able to recover faster, as you do not have to deal with a de-conditioned body as well as recover from the pain of surgery.  To give an example,  our professional athletes bounce back much faster from surgery.  That is because they are usually very motivated.  But, also, because they are in good shape  even before the operation.

Finally,  Before you Have Spine Surgery,  make sure you are confident in your surgeon.    I know some of you go to certain surgeons, as they are the only ones on your plan.  I am sure all the surgeons are qualified.  But,  it is clear that the confidence of the patient often leads to better outcomes.  If your surgeon does not give you that confidence,  maybe you should consider finding one that will give you that  feeling.

Did the Accident Cause the Disk Herniation?

Did the Accident Cause the Disk Herniation?

That is a frequent question asked by many patients.

The answer is a definite maybe the Accident Caused the Disk herniation.

As a practicing orthopaedic spine surgeon,  I have seen many patients with complaints of pain after an auto accident.  In my community,  I have also been asked to evaluate patients in Auto accidents by attorney representatives of  insurance companies. The question is,  Did the Accident Cause the Disk Herniation?  If so,  are the treatments appropriate?  A corollary, which is also common, is did my work injury cause the Disk Herniation?

Everyone involved in the situation would like a definitive answer to that question.  Unfortunately,  often times the answer is not so simple.  To  answer, I usually need to ask other questions of the patient, and confirm that the medical records support that answer.

How old is the patient?  After the age of 40,  there is a 50/50 chance that the patient already has a disk herniation.  The disk herniation may have occurred long ago, and may have been completely pain free for a long time.  MRI’s will demonstrate the disk herniation but it is rare that signs of acute disk herniation will be present.   Those signs such as edema around the disk herniation,  or hemorrhage by the nearby tissue require such a force, that usually, there are also other associated injuries or complaints.  With those findings, it is easier to say the disk herniation is new and associated with the recent injury.  Unfortunately,  Most MRI’s will not show those findings, therefore, at a certain age, the disk findings by themselves are common, and therefore not conclusive of a newly formed disk herniation.

What findings are on the MRI? Can the findings determine Did the Accident Cause the Disk Herniation?  Regarding disk findings on MRI,  disk bulges secondary to disk dehydration is usually not  an acute finding.  Neither is evidence of osteophytes, which are bone spurs associated with degeneration.  At one time,  physicians put alot of weight on the so call High Intensity Zone, which usually indicated the presence of a tear in the outer part of the disk,  which is called the annulus.  Now we know that these High Intensity Zone lesions can be present for years,  and therefore do not necessarily mean a new disk injury or herniation.  As stated above,  findings of edema and hemorrhage are rare, but if found, do indicate an acute event.  If not found,  you still cannot say the disk herniation is not acute,  but you cannot say by image it is acute either.

When did the pain start? Can the timing determine Did the Accident Cause the Disk Herniation?  I find this to be a very important question.  After the accident,  in my opinion, a person that had an immediate, or within a few hours development of neck or back pain, with developing arm or leg is more likely to have a disk herniation associated with the accident.  There are disk herniations associated with just back and neck pain only,  but usually, for a disk herniation to become symptomatic, there is an association with nerve irritation, or as we physicians call it,  radiculopathy.  Once in a while,  I will see a person involved in an accident, but with no real complaints of back or neck pain.  After some time,  usually greater than a few weeks,  they may develop some neck or back pain. For what ever reason,  they get a MRI, and since they may be in the over 40 population,  the MRI does demonstrate a disk herniation.  While this person is convinced the disk herniation was caused by the accident,  in my opinion, it is difficult to relate the disk herniation finding to the accident after such a time delay.  In addition,  the person usually does not have the corresponding radiculopathy findings consistent with that particular disk herniation.  The timing is very important.  There is no dispute that there is a disk herniation.  The question however, is not that there is a disk herniation, but did the Accident Cause the Disk Herniation?

Has the person ever have similar complaints in the past? Can prior complaints determine if the Accident Cause the Disk Herniation?  The answer is maybe.  Back and neck pain is a part of life.  Most people  have had a pulled neck or back muscle with activities of life.  That is why there are so many terms for a back ache.  Lumbago,  sciatica, pulled back,  wry neck, crick in the neck,  kink in the back, etc.  Minor neck pains and back pains are common and expected.   In my opinion,  there is a difference between a minor neck or back ache experienced rarely, and a constant chronic neck or back condition that required constant treatments by a physician, chiropractor or therapist.  If you  have an accident, but have recurrence of the similar prior chronic condition,  it is likely that the accident flared up a pre-existing problem.  But,  if the accident caused a new set of complaints shortly after the accident, and even though you may have had a pre-existing condition, there is a definite change of complaints,  the accident may cause a new change to the disk, the accident may have caused the new disk herniation.

Can a prior identified Disk Herniation become symptomatic after an Accident? In my opinion,  there is that possibility.  I have seen circumstances by which a person has had a test long ago demonstrating a disk herniation.  Then for a long period,  there is no pain associated with that disk herniation.  But, after an accident, there is a quick development of significant pain with corresponding radiculopathy.  The pain does not improve or go away.  In that scenario, Did the Accident Cause the Disk Herniation?  The answer would be no.  But,  the accident did cause a permanent aggravation of a pre-existing condition.  So in that circumstance,  the accident did cause a pre-existing condition to become a permanent injury.

Can the Energy of the accident determine if the Accident Cause the Disk Herniation?  I am not a biomechanics expert,  so I am told that a low energy fender bender will not likely cause a disk herniation.  While I think that is the general case,  in the end,  it comes down to history of the development of the pain and the nature of the pain.  Some patients are very frail, and some are predisposed to getting injured with minor forces.  In some instances,  It is my opinion that a low damage, low energy impact can still cause disk problems.  It comes down to the history and clinical presentation.

In the end, as a practicing orthopaedic surgeon,  after reviewing all the history, and all the records, and after looking at the MRI’s and other images,  my conclusions are based on the entirety of the information.  And I can say I have been wrong when trying to answer Did the Accident Cause the Disk Herniation?  It does come down to the credibility of the history when the records do not match.  I know there are some people who just cannot explain their pains properly, or did not go to the hospital immediately after the accident because they hoped the pain would go away, or was afraid of the costs.  Unfortunately,  their recollections may not match the evidence, and because of that,  the history is wrongly discounted.  I can say I may have been wrong with my conclusions in that scenario.  In another scenario,  I believed the history, and the records were also consistent with an accident related disk herniation.  But,  to my chagrin,  that person also had surveillance video’s showing the person performing exceptional physical feasts immediately after the accident, or after my evaluation.  My opinion about the significance of the disk herniation was likely wrong.

The bottom line is the answer to that question is not always straightforward.  Did the Accident Cause the Disk Herniation?  It depends on the factors discussed above.  It also depends on the credibility of the historian, and the otherside would argue, the biase of the person answering the question.

Disk Surgery

Have you been told you need Disk Surgery?   Unfortunately, that is a common situation faced by many patients that suffer from back pain with radiating,  shooting leg pain.

In extreme situations,  such as severe weakness, or loss of control of bowel and bladder function,  assuming the disk is the cause of the problem,  you will need urgent Disk Surgery.

But, in most cases,  you should at least try some non-surgical treatments.

Treatments usually include rest for a few days ( not more than 2), medications, physical therapy, and/or chiropractic care.  Usually,  by 6 weeks,  many patients are feeling better.

If there is still pain,  before disk surgery,  some physicians will offer steroid injections, either locally,  or in the epidural space.  There are plenty of articles on the efficacy of all these non-surgical treatments.  For the most part,  you should try at least 6 weeks of something before you consider disk surgery.  The reason is that a large percentage of patients can improve without disk surgery.

But,  if you  are considering disk surgery,  there are factors associated with better outcome.

1.   The disk herniation causes reproducible leg pain,  and certain leg movements cause a shooting sensation to the foot.  In this scenario,  the disk is definitely pressing on the nerve, and as you move your leg,  you are pulling on the nerve,  causing pain.   This is what physician’s call a straight leg raise sign.  It usually is associated with good leg pain relief by  disk surgery.

2.  The disk herniations are localized to one or two levels, with the  pain  findings corresponding to the distribution of the nerves at the disk level.   Nerves typically provides electrical signals to corresponding area of skin for sensation,  a certain reflex, and a certain pattern of muscle movement.  This distribution of sensation is call the dermatomes. 

To give an example,  the S1 nerve, typically irritated by a L5-S1 disk herniation, will cause numbness to the outside of the foot, weakness of the gastronemius muscle, and weakness of the ankle reflex.

Patterns of leg pain, weakness and numbness that follow the distributions of the affected nerves predict good success with disk surgery.

3.  There are patient factors that increase the likelihood of successful disk surgery.  Fit individuals that was in good physical shape before the operation typically recover faster from disk surgery.  Factors that increase the likelihood of complications or prolonged recovery includes obesity,  smoking,  diabetes and cardiac disease.  I am not judging anyone.  But,  it is possible to control some of these factors.  If you want a better success rate of disk surgery,  consider these negative factors.

4.  Proper attitude is important to disk surgery.  While patients must be informed of the risks,  once it is decided to have surgery,  the attitude must be a positive one.  A Patient’s motivation to be active, and do the right exercises and rehabilitation is a very important factor for a sucessful disk surgery.

5.  Adequate preparation of the home and family for disk surgery is necessary.  You must plan ahead on who will care for your day to day needs immediately after disk surgery.  Financial concerns must be handled.  Families and friends must be willing to help in the post-operative few weeks after the disk surgery.

To summarize,  the results of the properly selected patient for disk surgery is excellent.  In fact,  the SPORT (Spine Patient Outcomes Research Trial) data is very encouraging, and demonstrated that for an equally matched set of patients,  the surgically treated patients had slightly better outcomes than the non-operatively treated patients.  But the results must be closely  scrutinized.  The patients that chose surgery had failed non-surgical treatments as outlined above.

In my opinion,  you should always try non-operative treatments if you can.  But, if you fail, and have the good factors outlined above,  the chances of a successful disk surgery is excellent.

BEST Spine Surgeon in Tampa Bay

WHO is the BEST Spine Surgeon in Tampa Bay?  That answer should be a simple one.  It is the physician who will be operating on YOU.  Having been in practice in the Tampa Bay area since 1993,  I am happy to say that there are many excellent spine surgeons, and many of them are both my friends as well a colleagues.   The BEST Spine Surgeon in Tampa Bay is the one that make you feel the most comfortable.

There are general guidelines that you should consider.

1.  The  BEST Spine Surgeon in Tampa Bay should be Board Certified by the American Board of Orthopaedic Surgery,  or the American Board of Neurologic Surgery.

2.  The BEST Spine Surgeon in Tampa Bay usually had fellowship training in the Surgery of the Spine.

3. The BEST Spine Surgeon in Tampa Bay has hospital privileges.  While many procedures  are now done on an outpatient basis,  a prudent physician always prepares for the rare situation that may arise.  In urgent circumstances, a hospitalization is necessary.  A surgeon that does not have hospital privileges cannot care for the emergent situations that happen after hours, and on the weekends.  Best Surgeons of any kind always prepare for this contingent situation.   Surgeons that do not prepare for the unexpected, are not the BEST Surgeons.

4. The BEST Spine Surgeon in Tampa Bay will have at least 5 years of practice experience.  I am not saying the new, recently fellowship train physician is not competent.  Often they have excellent training, and may be more up to date in some of the new techniques.  But,  like anything else,  experience matters.  In my opinion,  you get better and wiser with each year of practice.  The steepest learning curve is in the first 5 years.  I do not think I need to explain this  in more detail.

After those 4 parameters are met, there are more intangible factors that will determine if your surgeon is the BEST Spine Surgeon in Tampa Bay.

1.  The Best Spine Surgeon in Tampa Bay usually will develop a good trusting relationship with you and your family.  Usually,  there is at least a few visits (for elective surgery) to first obtain an proper physical exam, as well as a review of all pertinent history of your problem.  Then, there is a detailed review of all the diagnostic tests.  Often,  non-surgical options will also be pursued.  During these initial visits,  either you will trust that physician to make the right decisions, or not.

2. The Best Spine Surgeon in Tampa Bay will discuss your surgical options in simple terms and in great detail.  Questions will be answered.  Risks, benefits and alternatives will be discussed.

3. The Best Spine Surgeon in Tampa Bay also understands that his/her staff is very important to the process.  The Surgeon will make sure to hire and train friendly, competent and compassionate staff.  The staff will do as much as possible to minimize your anxiety about the surgery.  That includes helping you navigate the visits to the hospital or surgery center,  visits with the anesthesiology team, coordinating post operative instructions, as well as inform you about the insurance and cost issues.

4. The Best Spine Surgeon in Tampa Bay will also respect your time, and will make efforts to see you on time for all your appointments.

In the end,  The Best Spine Surgeon in Tampa Bay is the one that will do your surgery. Why?   Because,  this Surgeon has met all the critical points we discussed above.  The bottom line, is you like this Surgeon, and feel confident he is well trained,  has experience, and will go the extra mile to improve your problems.  The Best Spine Surgeon in Tampa Bay will treat you like (s)he will treat his/her family.

Neck Pain Treatment

Are you interested in Neck Pain Treatments?  Obviously, you have neck pain.  Your physician must now figure out why.

Initially, your physician may ask a series of questions about the pain:

When did the neck pain start?

Is there any associated trauma, such as a fall, accident, or altercation?

Was the development of pain gradual, or sudden?

Does the neck pain have associated numbness, tingling or weakness to the arms, hands, or legs?

Have there been any associated changes in your bowel or bladder function?

Has there been prior history or similar complaints?

Has the pain improved or worsened?

Is there any prior history of cancer, diabetes or infection?

Is there any recent history of fevers, chills, sweats or unexpected weight loss?

By these questions, your physician can determine the likelihood that the pain is a typical presentation of a neck sprain, or manifestation of neck arthritis.  But, depending on your answers, possibilities include a broken bone, an infection, cancer, disk herniation, or bone spurs causing nerve entrapment in the spine.

Without history of a recent traumatic event, or suspicion for an infection, or cancer, usually, the treatment includes use of activities modifications, ice, use of medications, and home exercises or physical therapy.  Chiropractic care can also be considered.  The majority of neck pain episodes respond to these less invasive treatments.  On average, by 6-8 weeks, most episodes of neck pain will improve.  Usually, testing such as x-rays or MRI’s are not necessary.

With suspicion of a fracture, usually x-rays are ordered.   Please remember, however, that there is a small but real radiation dose with each x-ray.  If there is concern for instability or loosening of the spine bones, special flexion and extension views will be obtained.  If the x-rays do not demonstrate a break or instability, usually the pain can be treated with the above regimen.  And, similar to the above, most will improve.

For patients with complaints of arm and leg radiations, if there is no improvement within a 4-6 week time period, or if there is increasing weakness of the arms and legs, usually further diagnostic tests are necessary.  MRI’s demonstrate excellent visualization of the muscles, disks, ligaments and nerves.  MRI’s can identify disk herniations, disk bulges, and nerve entrapment.  MRI’s can also identify infections or tumors of the examined area.

With certain patients that have metallic implants (cerebral clips, corneal implants, recent angioplasty, etc, MRI’s cannot be performed.  In this circumstance,  depending on the  presentation,  a physician may order a CAT scan,  or a myelogram followed by a CAT scan.  These tests will better define any fractures or bone spurs, and with the myelogram, any nerve or spinal cord entrapment.  With any CAT scan study, however, there is a very large radiation dose.  The use of CAT scan therefore must be justified, considering the radiation risks.

If the cause of the neck pain is secondary to nerve entrapment from disk herniations, and there is no improvement with the above therapies, more aggressive measures such as steroid injections are offered.  In rare instances, surgery may be the only remaining option.

If the cause of the neck pain is bone spurs, or arthritis, and without improvement with the above therapies, steroid injections to the facet joints may be beneficial.  Surgery may also be an option for arthritis causing nerve entrapment.

Please seek medical attention if you have persistent neck pain, and especially if it causes numbness, tingling or weakness.

Does my Doctor Own his Private Practice?

Does my Doctor own his Practice?  This may or may not be important to you.   When you are hurting, and need help, it is probably the last thing on your mind.  But,  if you are carefully weighing your options, and seek a solution to a chronic condition,  perhaps you should answer that question.  Is a Private Practice Better?

There is no question that the whole medical community is changing.  While our government strives to provide healthcare for the population, it is trying to balance the costs with the outcomes associated with the delivery.  With an aging and expanding population, the costs of treatments have placed a significant burden on the finances of the country.  To fulfill promised access to healthcare, the physicians are seeing more and more patients, while juggling with the increased complexity of medicine.

Every patient must be properly evaluated.  Then, ordered diagnostic tests  and consultations must be reviewed.  Then treatments initiated and monitored.  With each iteration of technologic advancement,  the complexity of the process increases.  Coupling this increasing complexity with an increasing aging and expanding population, leads to large volumes of patient encounters,  tests, and results.  Anyone can see that the potential for error also increases.

To combat errors,  the government increases regulations in hopes that it will be able to minimize the risk to the population, and prevent inappropriate or fraudulent behavior by the providers of healthcare (Doctors,  HMO’s. insurance companies,  Hospital’s etc.)

For the physicians,  the burden of providing care to an ever aging and expanding population becomes larger with each year.  Unfortunately,  our Medical Schools are not producing enough physicians to accommodate this growing population.  In addition,  due to the higher costs associated with delivery of care,  the government has been trying to decrease costs by decreasing unit reimbursement for certain physicians and procedures.

Cost of practice to individual physicians continue to increase.  Now with the increase regulatory demands,  many have found it difficult to maintain their own private practices.  It is estimated by 1014, that up to 75% of physicians will be employed.

So HOW DOES THAT MATTER TO YOU?

Because, in the end, your physician is also a human being.  While most will say that it does not matter how they are paid, and  they will  deliver the same excellent care,  the nuanced edges of care will change depending on your employment status.

Employed physicians often do not have the burden of running the practice,  but because they are now an employee, they will comply with the terms of their employment.  As they are no longer the owner,  they can lose some of the drive to go the extra mile for certain situations.  I am not saying this always happens.  Often times,  employed physicians are excellent in every way.  But, there is always that potential.

Having said that,  employed physicians must still provide a positive return for the employer.  In our current situation where there are too many patients, with few funds to provide for their care,  there may be incentives (both good and bad) to increase patient visits,  or other treatments to provide this positive return.  In the worse case scenario,  physicians may have incentives to treat too many patients at a time.  There is potential for poor patient satisfaction.  I guess the analogy is like in retail where you will go to the “big box store”  for a bargain, knowing that there will not be the greatest customer service or individual knowledgeable  attention.  But, in certain circumstances,  you are willing to pay more for individualized attention, and custom care.

So Why is Physician Ownership of their Practice Better?

It may not always be.  If the private practice physician is struggling with his costs, poor with his contracts, and awful in staff training,  then maybe that physician should work for someone else.  If a physician feels he is underpaid, and overworked, usually you can see it in his/her staff.  If you go into an office, and the staff is  always rude, and the waiting room always looks like pandemonium, the practice will likely be struggling with the above situation.  The staff learns its attitude from the management and the owner.  This physician owner is struggling, and unless there are changes,  he/she will not be able to deliver a satisfactory environment for the patient.

But,  there are private practices that do a good job in providing caring and competent care.  The staff is friendly, and caring.  The waiting room is never over flowing.  The physician stays on time, and respects your time as much as you respects his/hers.

The difference in these private practices is the confidence of the physician owner.  This physician usually will not accept horrible insurance contracts that forces the physician and staff to see a tremendous number of patients to generate an income. With appropriate fee’s and contracts,  patients will be scheduled timely, and appointment schedules will be on time.  With appropriate fee’s and contracts,  the office will be able to develop an atmosphere of individual care.  This physician will also not tolerate patients that are always late, or disruptive to the office.  This physician only accepts patients that value the opinion of the physician, and in turn will provide appropriate opinions, in  timely professional manner.  This physician will recognize the hard work of the staff, and encourage collaboration, not conflict.

The bottom line is in the well run private practice,  because fee’s to the physician are reasonable,  they do not have to schedule 40 patients per physician/day.  Because the offices tend to be smaller,  there are less administrative costs,  and will better contracts, there are less regulatory pressures (regulatory pressures are associated with the high volume, less reimbursement plans, usually run by the government or surrogates).

And,  if the private practice physician does not deliver the above,  usually they cannot get the better contracts, or the fee’s.  So the poorly run practice are now closing and going to the employment model.

For the above reasons,  it may MATTER IF YOUR PHYSICIAN OWNS HIS PRACTICE.

How Common are Disk Herniations?

Surprisingly,  I am rare asked  questions about frequency of disk herniations.  But the answer is, it is very common.  The better question is, “Is the disk herniation seen on the MRI the cause of my pain?”.  The answer to that question is maybe.

Research has demonstrated that findings of disk protrusions, disk hernations, and disk degeneration are very common finding in most people over the age of 50.  Because of these findings,  we often find ourselves blaming our pains on these disk anomalies.  While that may be true, in other scenario’s, it is not the case.

In fact, there has been studies on the incidence of these findings in our more active, or athletic population.  Surprisingly,  some studies have shown the incidence of advanced degenerative disk problems is not different from our less active population.

MRI’s have been very commonly used.  Without editorializing on the necessity of using this test,  we now have more and more information on the incident of spinal conditions in our population.  It turns out that there is a plurality of patients that have disk protrusion/hernation/degeneration.  Likewise,  we know that within your life time,  there is an 80% chance that each and everyone of us will have an episode of back pain that will limit our abilities to work,  and change our lifestyles for at least a few weeks.  But,  we still may not know if you back pain is caused by the findings on the MRI.  Usually, you will need a detailed examination to determine if the back pain is more that a pulled muscle, versus a significantly pinched nerve.

So,  when you have an episode of back pain,  while it is not a consolation at the time,  please understand that is an common experience by most of humanity.

But,  in rare occasions,  this back pain can be a more serious problem.  If you have severe pain, with associated weakness of the legs,  numbness, or loss of control of your bladder/bowels,  you must discuss this situation with your physician immediately. In the worse case scenario,  you need to be emergently admitted to the hospital for testing, and possible surgery.

If you do not have the above,  sometimes your physician may recommend some medications and gentle exercise or physical therapy.  But,  if you do not make improvement within a few weeks,  you should consider getting  further evaluations by a spine specialist.

Thankfully,  most episodes of back pain, and disk herniations usually can be managed with medications, activities modifications and therapy.  If you have questions,  please contact your physician.

Spine Technology

I started my practice in 1993. Since that time, there have been significant technologic changes in medicine.  Spine Technology has experience significant advances.

The whole medical experience has changed. I think for the most part better, but some will argue differently. In the 1970’s-1980’s, patients were routinely admitted to the hospital for very simple procedures. Patients would spend 5 days in the hospital for a routine carpal tunnel release.

Now, in some outpatient surgery centers, patients are in the facility by 6:30 am, and discharged by 9:30 am. Patients were routinely admitted to the hospital to have diagnostic testing. Now, most go to a diagnostic center to obtain an outpatient MRI, CT scan, or other tests. Major surgeries required prolonged admissions, often for a week or more. Now, patients are discharged within a few days, but have visiting home health services.

In the area of spine surgery, there has been significant improvements in fusion rates, and diagnostic protocols.

Clearly, the addition of metallic instrumentation improved the rates of fusion for lower back surgery. At one time, use of pedicle instrumentation (metallic screws) was very controversial. I can remember the news media demonizing this technique. But now, it is an accepted technique for spinal fusion, and has been shown to improve fusion rates in certain situations. This technological change has improved certain situations.

Likewise, we have better abilities to visualize anatomy compared to the past. We now take MRI technology for granted. But in the past, it was difficult to image problems like disk herniations without subjecting the patients to a painful procedure. We have since evolved from the days of the painful oil based myelogram dyes. MRI techniques show the anatomy with great detail. With the proper strength magnet, and technique, most spine related anatomy is well visualized, with minor discomfort to the patient. Claustrophobia aside, there is little risk to the MRI test.

As far as surgical options,  surgeons are getting better and better with minimal access, and outpatient oriented spine surgery techniques.  For the right patient, with the right anatomical problem,  the surgery can be performed successfully, with rapid recovery.

Additionally,  there are newer spine instrumentation and hardware, including minimal access fusion products, artificial disk replacements, and percutaneous decompression techniques.

But, and there is always a but,  utilizing all this technology still is secondary to the following principles:

1.  Has the patient had a proper diagnosis?  As many of you know,  MRI’s and other diagnostic testings are almost too good.  Often times,  tests demonstrate the natural wear and tear process.  Often times,  this wear and tear is completely asymptomatic,  or non-painful.  Is the source of the pain really identified by the testing?

2. Has the patient had adequate attempt at non-surgical resolution?  Have you given options such as medications,  therapy, injections, and activities modifications a try?  In certain instances,  emergent surgery is your only option.  If you have loss of the ability to use your muscles secondary to paralysis,  lose bowel, or bladder control, or have progressive pain, infection or cancer,  you may not have any other choice.  However, if you do not have a limb or life threatening problem,  most patients will try non-surgical options first.

3. Are the goals of the surgery obtainable by the intervention?  If you have nerve compression,  the goal of the surgery should be to relieve the pressure on the nerve. If you have an unstable spine segment,  the goal should be to stabilize or fuse that segment.  The surgery,  whether using the newer technology or not,  should be directed to achieve the goal.

4. Does the patient have the ability to tolerate the surgery?  unfortunately, some patients have other issues besides the spine.  If there are significant medical problems such as heart disease,  diabetes, obesity,  infections,  etc,  surgery may not be the best option.  You need an evaluation by your other physicians, if there is concerns about the ability to survive the surgery.

Technology has definitely improved the recovery period, and outcomes for certain procedures.  But in the end,  you must be the proper patient for these techniques.  Each patient is unique.  Each surgery will have its nuances.  Please discuss these issues with the surgeon before pursuing surgery.

Back Pain After Golf

Do you have Back Pain after Golf? Our practice is in Florida.  And Florida has a great number of golf courses, and players.  On an almost weekly basis, I will see a patient that hurt the back while playing golf.  For many players,  golf is their only form of exercise.  So why do so many players hurt themselves?

The answer lies in the mechanics of the golf swing.  It is not an natural activity,  and it places tremendous force on your shoulders, back, hips and knees.  And,  on an average round,  you will make that motion at least 200 times ( practice swings, etc).

The human body is made to do repetitive motions.  The act of walking is an example of such motions.  Also,  depending on your trade,  you repetitively use your arms and legs in the same motion for a certain duration of each day.

But the golf swing requires a twisting motion foreign to the day to day motions of your body. For this reason,  you may be at more risk for injury.  Without getting into the hardcore science and biomechanics,  the golf swing generates high torque forces on your muscles, ligaments and disks of the spine.  These forces can lead to injuries of the associated anatomy.

To minimize the chance of injury, consider these following steps:

1. Warm up and Stretch.  The best way is to limber up the muscles with a brisk walk.  Then go through a stretching routine that stretches the muscles attached to the neck, shoulders, lower back, hips and knees.  Also stretch the heels.  All these areas are necessary for a good swing.  All these areas can be hurt.

2. Go to the Range.  Hit a few short irons before taking out the driver.  Do not just “grip it and rip it”.

3. Take golf lessons.  We all know that the good players have smooth almost effortless swings.  Good swings also give less stress to the body.

4. Play from the appropriate tee box.  This advise is hard on the guys.  But,  if you tee off from the whites, you do not have to try to kill the ball to put it out on the fairway.  Smoother swing,  less stress on the body, and better score.  Let the pro’s play from the back tee.  Save your back and play on the tee made for your level of the game.

5. Buy appropriate sized equipment for you.  Certain clubs may increase your risk of injury.  You do not have to pay a fortune for clubs.  There are alot of discount and used golf equipment stores.  You need advise on the length,  shaft material, club head size, etc.  It can make a difference.  Go to  an informed golf shop for the details.

Even the pro’s commonly have back injuries.  If you ever have the opportunity to go to a pro tournament,  you will see that there is always a medical tent.  Usually,  there is a trainer, physical therapist or a chiropractor on site.  Back pain known to almost all the pro’s, especially on the senior tour.  All of the pro’s do have a pre swing stretching and warm up regimen.  For us weekend players,  we must do the same.

Do I need a MRI?

That is a very common question asked by many of my patients.  And, the answer is “It depends”.  I know that is not very satisfying, but I will explain.

MRI stands for Magnetic Resonance Imaging.  There are very scientific and exacting descriptions of the study, but I will try to break it down into the most basic form.  I apologize in advance if my explanations are too simple for some.

Basically,  a magnetic field is generated and passes through an area.  That area is where we place patients body parts.  The magnetic fields get distorted by the objects in that field. The MRI machine identifies the distortions caused by the various body parts.  Muscles,  ligaments,  bones, discs, fat, fluids, etc. cause a specific known pattern of distortion.  The machine then uses these distortion measurements to reconstruct an image of the body part that caused the distortions.

Please understand that the MRI image is a reconstruction of the body part based on the measured causes of the magnetic field distortions.  As accurate as most MRI’s can be,  there are still technical factors that make some images more representative than others.

How you ask?  High magnet field MRI’s can increase the sensitivity of the study.  Open MRI’s (the ones claustrophic patients want)  tend to use lesser magnets,  and as some of the distortions  are not captured due to the configuration.  Also,  depending on the technique utilized,  the representative slice of the image is an average of the distortions over the width of the slice.  It can influence the ability to identify subtle findings.  Also,  there are different techniques of calculations that concentrate on finding fat density or water density, and the time to capture the distortions can increase or decrease.  All these factors play a role in the specificity and sensitivity of the studies.  While MRI machines are getting stronger, and better,  there are still suble variabilities.  While in general, obvious findings are rarely missed,  more minute findings can be a challenge to some MRI machines.

There are also patient factors as well.  You need to stay as still as possible in the study.  Any metallic object in your body may have potential to distort the image.  Some metallic objects in your brain,  eyes, ears, heart etc., can cause a problem for you during the test.  Please let your physician and the MRI facility know you have these implants.  Sometimes,  you risk harm to yourself, or the implant by having the study.  Finally,  your body habitus may not allow the magnetic field to uniformly penetrate the tissues.  Obesity can be an issue for lower field MRI’s.

As you can see,  there can be some variability based on the factors discussed above.  To be complete,  I am only discussing the more obvious differences.  I am sure my radiology colleagues and the manufacturers will have many other points to contribute to this discussion,  but I leave that to them.

So,  let’s get back to the original discussion.  Most patients seem to want to get an MRI.  But, the question is why?   Should having pain be the only criteria?

MRI’s help to identify infections,  non displaced fractures, ligament problems,  muscle issues, disk issues and tumors.  They give more details then x-rays, and in combination of certain dyes, can also be helpful in identifying blood flow issues.  It truly is a very helpful tool.

But,  while it can identify all these issues,  it can also lead to unneccessay treatments and worries. How so you ask?

Let me tell you of a common scenario I see nearly every day.

Mr. X, who happens to be good friends with his Family Doc, has had back pain for three days.  He has never experienced it before.  At 42 years old, he does remember have an occasional minor back stiffness in the past, but now,  he is really hurting bad.  He does not remember how he got the pain.  But now, he finds it difficult to work, or drive. The Family Doc  pulls strings with his insurance company and gets authorization for a  MRI of the Low back.  The MRI shows some  bulged disks to the lower back.  But, by the time he has a followup visit to discuss the findings,  he is feeling much better.  In fact,  he is almost normal.  Family Doc did recommend physical therapy, but the $50 co-payments for each visit is a non starter.   Family Doc then advises him  to take advil, and do home stretches.   He is advised the disk bulges seen are typical for everyone after 40.  After 10 days,  he is all better.

One month later,  Mr. X gets his bill from the MRI company.  While the MRI has been authorized,  the co-payments are still significant.  Then a few weeks later,  he also gets another bill from the radiologist that read the study.    Mr. X is no longer so happy with his Family Doc buddy.

A few months later,  Mr. X is applying for a disability policy, just to protect his family, just in case.  Now Mr. X has to report that there is a history of a back disk bulge in his history.  There are ramifications of this diagnosis while applying for his disability policy.

In this very common scenario, ,  the MRI did not add to the improvement of his back pain.  It has however, cost Mr. X money ,and difficulty with obtaining a disability policy.

Now, we have all heard horror stories of how a delay in obtaining an MRI missed a very serious condition.  But,  I have found that very rare.  The above scenario is much more likely.

To avoid either of the above scenarios, most practitioners follow established clinical guidelines.

1. MRI’s are ordered for the respective body part if there is high suspicion for infection, significant neurologic compromise or tumor.  This means MRI’s are ordered for suspicion of the above problems,  not just because you have pain.

2. Without history of severe trauma,   significant neurological changes, or strong suspicion of infection or cancer,  alternative treatments including medications,  therapy, and observation are more appropriate.  If the pain does not improve despite these treatments,  MRI’s will likely be authorized after a reasonable period of treatment.

3. By following those principles,  Physicians can avoid over utilization of the studies, with their unfortunate consequences, as well as appropriately order the studies to identify potentially life threatening or limb threatening problems. By following these guldelines,  Managed Care Entities are much more likely to authorize the studies for you.

4. If patients insist on having the MRI, despite the above concerns,  they can always pay for their own MRI’s.  With most patients enrolled in a managed care plan,  the guidelines must be met to obtain authorization for the managed care entity to pay for the study.

5. Unfortunately, it does come down to money sometimes.  And,  it comes down to YOUR MONEY, not the Managed Care Entity’s Money.

6. Some of you are irritated that we Physicians are so beholden to the Managed Care Entities.  The fact remains that you signed up for the Managed Care Entity, or was provided the Managed Care Entity as part of your Compensation Package.  As you are seeing the physician through this arrangment,  the physican and you  have agreed to the Managed Care Entity’s guidelines.  If YOU,  the patient would pay directly for your MRI’s, then you can also have the study anytime you want. But, if you want the Managed Care Entity to pay for the study,  you have to follow the agreed upon guidelines.

What Information Do I bring to the Office Visit?

Often,  when you make an appointment to see your physician,  it is because there is a concern, or a new pain.  I have noticed many patients will arrive to the office, then get frustrated by the process, because they left key information at home.  So,  here is an easy check list for things to bring or things to do before the visit:

1. For New patients, download the New Patient Information Forms and please fill out before the office visit.  You will need to have these documents filled out before we will see you.

2. For Followup patients greater than 6 months from last visit, or a new problem please download and  fill out the Patient Update Forms.  This will also allow the office to speed up your time in the office.

3. Please bring us a list, or the actual bottles of  your current medications.  We do not want to inadvertently prescribe a medication that my have a reaction.  We also do not want to accidently duplicate your prescriptions.  Please also provide us with the phone number or address of your pharmacy.  We now use electronic prescriptions for most medications (this does not include certain narcotics, or some mail order medications).  But,  we still need to know where to send the message for the medications.

4. Please go to the x-ray, MRI, or CT scan facility and bring the actual images of the tests ordered.  As orthopaedic surgeons, we need to look at the actual images.  Although the reports are also important,  the most important information is the actual images, as sometimes the report description may not be interpreted the same way by individual physicians.

5. If there has been prior opinions rendered on your medical condition,  please provide the prior medical records from the other physician.  Sometimes,  these records provide information that may be helpful in formulating our opinions about your condition.

6. If you have been in an auto accident, or a work injury,  make sure our office knows about the situation.  Depending on the circumstance, we may no not be able to see you without authorization, or disclosure about the situations with the various insurance entities involved. Unfortunately  in these situations,  without this information,  there may be significant confusion on determining the responsible party for the costs.  In the worst case scenario,  you may be responsible for the costs, as well as the costs of any diagnostic studies ordered.  If you are not prepared to assume these costs,  please notify our staff about the situation, so they may investigate, and try to determine your responsibilites before the visit.

How Come my Doctor did not order an X-Ray?

That is a question often asked of me and my staff.  The better question is “Why should you get an X-ray for back pain?”

The answer to that question is “It depends.”

I know.  you want a better answer.  But,  there is a logic to the response.  The most important determining factor on the need for x-rays is the HISTORY.  By telling your Doctor the reason for the visit, your Doctor will determine if there is a benefit to ordering the X-ray.

Let me give you a hypothetical scenario.  What if you are a healthy 30 year old man,  with no history of back problems.  Yesterday,  you helped a friend move into his/her new apartment.  During the move,  you felt a bit sore, but  after your friend offered a thank you beer,  you felt fine.  This morning,   you experienced a mild back ache.  Should you see a doctor and get an x-ray?

I think most people would opt to give it a bit more time to see if the soreness will naturally go away.  99% of the time it will.  The answer to the question is NO, you do not need to see your Doctor or get an X-Ray.

In the second hypothetical scenario,  You are a 65 year old woman with a history of osteoporosis (brittle bones), and you tripped and fell on your front porch.  You have immediate sharp pain to the middle of the back.  You have pain whenever you inhale, and it is difficult to walk without pain.  In this scenario,  you should certainly contact your physician, and if he/she is not available,  you might consider making a visit to a walk-in clinic or an emergency room.  By history,  there is a strong potential for what is known as a compression fracture. If warranted, your Doctor may get an x-ray to confirm or rule-out this possibility.

By these examples,  you can see how the history is very important in determining the needs for tests such as x-rays.

X-rays should be ordered if there is suspicion of  a broken bone, a dislocation, or in rare instances,  as a screening test for potential cancer or infection.  Beyond those problems,  spinal x-rays rarely help in the diagnosis or treatment of the typical episodes of neck and back pain.

I know many of you will say,  “But my doctor discovered I had spine arthritis with the x-ray.”  The statistic is that after 40, almost all of us will have some evidence of arthritis of the spine based on x-rays.  The better question is,  does the x-ray discover of spine arthritis change the treatment plan for the average patient?  As you can guess, the answer is no.

Often times,  x-rays will demonstrate the early disk degenerations and bone spurs of aging.  I like to make the relationship of balding or greying hair.  We all get it eventually.  The x-rays findings of degeneration of the spine is like the visual effect of seeing our greying or balding hair.  It happens.  You cannot reverse it.    And,  just because you see arthritis on the x-ray, it does not mean that the arthritis is the cause of your neck or back pain.  Face it.  X-rays for neck and back pain are not helpful in the vast majority of patients.  X-rays should be reserved for situations where we suspect a broken or dislocated bone.    Even in the face of infection or cancer,  the x-ray is just a general screening tool, and if there is strong suspicion,  more that just an x-ray is necessary.

The usual scenario that I see as a spine surgeon is the patient has back pain.  The patient has expectation of testing, so the x-rays are ordered by some one.  By the time I see the patient,  often times the pain is vastly improved, and the patient needs some basic counseling on exercise,  use of NSAID medications, weight management and smoking cessation.  The x-ray usually did not reveal anything other than arthritis.

Every once in a while,  there will be a patient that has a significant finding, unrelated to their back pain, discovered on x-ray. That patient will point out how that x-ray discovered the problem.  But the truth is,  that problem, if significant enough, will be discovered anyways.

So why am I trying to convince you that x-rays are not always necessary?  Because there are also risks of x-rays.

X-rays of the lower back subject you to the equivalent about 80 chest x-rays.

X-rays findings can often lead to costly and time consuming over-treatment of findings.

X-ray findings can also mislead you on the real diagnosis.

If you have neck or back pain, give your Physician a thorough and accurate history of this episode of pain.  Then he/she will determine the need for additional testing.  If the pain does not go away within 4-6 weeks,  it is likely that your physician will refer you to a specialist, or order screening tests to make sure you do not have a more serious condition.  But,  if your Physician  does not order an x-ray immediately,  maybe it is because your Physician thinks it will go away, without subjecting you to all the risks of an x-ray.  Maybe your Physician is not  testing you on purpose.  Maybe your Physician thinks the risks of x-rays are not necessary.  Maybe your Physician is just being a good Physician.  Ask him/her about it.

Management of Bone Loss

Were you aware that as we age we produce fewer hormones which can cause us to have reduced bone and muscle mass? This can lead to degenerative conditions such as osteoporosis, which can lead to extreme loss of bone mass. In order to preserve and maintain optimal bone mass it is important to participate in weight bearing exercise, such as brisk walking, racquet sports and yoga. It is important to perform strength training, even with light weights at least 2-3 times per week. This stresses our bones and muscles to stimulate bone growth. Isotonic Vitamin D with K supplementation is also something to consider, up to 1000mg per day to promote normal bone density. Adequate amounts of D with K helps to promote adequate absorption of calcium. If we keep this in mind, we have a much better chance of healthy strong bones as we age. For questions about this Isotonic Supplementation please give us a call at 813-814-9251.

Lisa

Relief of Back Pain: The choices we make

“My back is killing me…” As an orthopaedic spine practice, this is something we hear every day. It is usually followed with “You have to do something for me.” Everyone wants Relief of Back Pain!
We have an arsenal of “tools” that we use to treat back pain including various types of medications, spinal injections, physical therapy, and in some cases referrals to outside specialists. Our real focus is on giving you the information you need to take control of your back. These modifiable factors include managing your weight, refraining from using tobacco, daily exercise, and having the right diet. Many patients discount these recommendations as they think that this is not taking care of their immediate needs.

Instead of being reactive to having recurrent episodes of miserable back pain, why not take a proactive approach to reduce the risk factors that may cause a lot of your problems to begin with? Everything comes at a cost. Would you rather pay a $35 co-payment to come in for an office visit periodically plus the cost of anti-inflammatory medication costing $15-$20 per month plus a course of physical therapy at a cost of another $35 per visit for 10 visits? In the first month, you would have spent nearly $400 on treatment related to just back pain. If your pain continues further treatment at a higher cost becomes necessary.

The other option is to focus on improving your overall health to minimize your risk of chronic joint and muscle complaints, lower your risk of cardiac disease, and diabetes. In the long run, you will spend far less financially and have something to show for it if you were to take this approach. When I say this, I am not just talking about taking a slew of vitamins and exercising every day. The type of nutrition we get (that includes vitamin supplementation) has a huge affect on how we look, feel, and perform. Many of you may be familiar with the line of supplements that we have been carrying, Nutrametrix. This is a good option for some who want somewhere to begin or want to treat a deficiency in your diet. However, there is much more to “being healthy” than just taking supplements.
As an orthopaedic spine surgery practice, we are experts at providing you with the treatment you need for your neck and back problems. We utilize the expertise of other specialists as a part of a multi-disciplinary approach to improve your health. One of the experts that I have been working with is named Dr. Richard Cohen. He is based on west coast of the U.S… I have consulted with him numerous this past year. His company Core4Nutrition is all about helping you perform at your best and really taking a hold of your health. I can personally attest to the few supplements he uses in his program and can tell you what a profound difference his Core program has made for me. You are not just taking supplements and hoping they are really doing something for you. The unique aspect of the Core program are periodic assessments which look at several different markers of health. Deficiencies in one or more areas can then be addressed on an individual basis. Core4Nutrition also offers nutritional counseling services and a wealth of good information on how to improve your well being.
By taking control of your diet and health, you can lower overall inflammation in your body and lessen the likelihood of suffering from chronic conditions. The cost of this program is far less than you would pay for ongoing treatment in our office and you will feel great!! We rarely advocate a specific product or service, but this is one which I definitely want to share with you. Just like everything else in life, the Core4Nutrition program is not for everyone. Results will vary. It is for those of you who REALLY want to take charge of their health and be proactive. I encourage you to visit their website http://core4nutrition.com/ or give them a call.

I opened up this blog with saying that patient’s frequently say “you have to do something for me.” in regards to relief of back pain.  You can have choice A which includes injections, medications, and surgery or you can chose choice B which includes taking control of your own health and modifying those risk factors which promote back pain. Choice B is much less painful and much cheaper in the long run.

Are you carrying an extra "backpack"?

Weight loss is a difficult thing to discuss.  As a physician,  I am always worried that somehow, the patient will be offended by this discussion.  If I talk to some of my Primary Care colleagues,  some have stopped bringing this topic up, as some patients have gotten upset enough to “fire” them,  or even worse,  report them to the State Regulatory Body for insensitivity.  As a physician,  I am not judging you.  I need to bring this up for discussion, as it is part of my education and counseling protocols.  You cannot help yourself improve without understanding the causes of some of the pain.

America, and many parts of the world is experiencing an epidemic of obesity. And  Yes,  obesity is associated with increased back pain!

Many of my patients come to the office looking for advice.  Most would like to avoid surgery.  Most will not be a candidate for surgery. So what can you do to help yourself?

Instead of having a discussion on weight loss,  I like to discuss things in the following manner.

Have you ever carried a 20 pound backpack all day?  Have you carried it despite having knee pain, hip pain or BACK PAIN?  Didn’t it feel much better when you took that backpack off?  Well,  your extra 20 pounds of weight is like carrying the 20 pound backpack.  (As an aside,  there is good information that heavy backpacks can lead to pain for children).

I know you have heard all the reasons to lose weight.  It will help with diabetes.  It helps control blood pressure.  It decreases demand on your heart.  But, while those things are good to control,  usually, you do not have pain directly from diabetes or high blood pressure.  And, by the time you have heart related pain,  it may be too late.

But back pain is a good way for your body to remind you to keep the weight down.  Will losing weight get rid of all the pain?  Probably not.  But,  it will definitely help.  Besides,  you have all the benefits described above, plus, you look better, feel more confident, and therefore may also feel less depressed.  And,  just so you understand,  depression is associated with increased pain.

Losing weight has all sorts of benefits.  If you are more than 10 pounds overweight,  please discuss the situation with your primary care physician.  They can help you lose weight appropriately.  It is a lifestyle choice.  I have heard all the “pundits” saying it is a now an access to good food, and a societal issue.  While there may be some truth to this,  in the end, it comes down to personal motivation and choice.  Please help yourself, and keep the weight down.  Your Spine will appreciate it.

Do Not Smoke!

80 % of people will have back pain sometime in their life.  Often, I am asked how can I avoid having back pain.  Unfortunately,  we cannot avoid the natural wear and tear to our bodies.  Just by living,  you will wear out your joints, bones and ligaments.  In addition,  some of us will cause injury to our joints, or muscles by a traumatic event.  But there are factors you can control.  The most common one is smoking.  Do not Smoke!

Your cardiologist does not want you to smoke, as it leads to heart disease, and puts you at risk for heart attacks.  Your oncologist does not want you to smoke as it leads to increased rates of cancer.  These are significant issues, but usually, people will not stop smoking until they have a event  that causes them to stop.  Cancer, and heart attacks are one of those events.

As a spine surgeon,  I want you to know that smoking also increases back and neck pain.

How you say?  The nicotine in cigarettes cause constriction of blood vessels.  That is why you can have a heart attack.  But,  blood vessels supply oxygen to your muscles,  ligaments and disks.  Blood vessels suppy nutrients to these same areas.  If you do not have oxygen or nutrients,  these areas suffer damage.  SMOKING causes damage to your neck and back muscles, ligaments and disk.  This concept has now even made it to the general media.  The following link is from the news agency Reuters: http://www.reuters.com/article/2010/01/08/us-smoke-back-idUSTRE60755G20100108

Often times,   smokers will cough.  The internal forces associated with a cough is significant and causes potential damage to these structures.  Anyone with a history of a pinched nerve, or severe back pain will tell you that they brace their back or neck before a cough or a sneeze, as it causes severe pain.  Although not studied well,  it is my opinion that the smoker’s cough also contributes to degeneration of the above structures.  In addition,  secondary to constriction of the blood vessels,  smokers cannot repair the damages to the structures like non-smokers.

Lastly,  there is clear evidence that smoking affects surgical outcomes.  For all surgeries,  secondary to decreased blood flow,  you heal slower, and potentially have increased rates of wound problems and infections.  Specifically in spinal fusions,  a good blood supply is necessary to promote bone healing and fusion.  Without this blood supply,  often times the fusion does not happen, resulting is a potential suboptimal outcome.  The following links to a medical article about smoking and fusion. http://www.ncbi.nlm.nih.gov/pubmed/3824072

The bottom line is DO NOT SMOKE!  You get heart disease, cancer and a bad spine!  Don’t wait until you get these to STOP!

Neck Fusion Surgery?

When do you need Neck Fusion Surgery?

So,  your Doctor recommended neck fusion surgery.  While that recommendation comes as a welcome option to some of you,  most patients are too overwhelmed by that recommendation to ask the proper questions.  So, lets go through my rationale for offering such an option.

First,  you must be a proper candidate for the procedure.  That means you have the three most important criterion for successful outcomes:

1. You have clear signs of nerve compression.  I know you all have pain,  but do you have a specific pain pattern?  Do you have neck pain, with arm radiations?  Do you have numbness to certain parts of your hands and arms?  Do you have weakness to specific muscles?  Do certain motions such as extending your neck, or rotating the neck cause a shocking sensation to your arms and hands?  Do you feel better by lifting your arms overhead?  Do you have associated severe neck pain with headaches?  If you answer yes to many of these questions,  your complaints are consistent with nerve compression in your neck.

2. Do you have a MRI or CT scan that shows nerve or spinal canal entrapment?  Your diagnostic studies  should identify a disk, or bone spur (or in rare circumstances, a tumor or infection) causing compression of a nerve or spinal cord, with complaints  that are consistent with nerve compression.

3.  Have you failed nonsurgical treatments?  That may include activities modifications,  medications,  physical therapy, and nerve blocks.  Despite these treatments,  you continue to complain of the above.

In addition, to predict whether you would do well from surgery, your surgeon must then assess these factors:

4. Does the nerve compressions isolate to a few levels?  One and two level surgeries have a high success rate.  But,  more levels of involvement make positive results less predictable.

5. Does the patient have a reasonable medical history?  In otherwords,  are you health enough for surgery?  If you have significant heart disease,  pulmonary disease, diabetes,  prior history of cancer with radiation therapy to the neck, significant obesity, etc., the medical risks must be weighed before surgery is offered.

6. Does the patient have a realistic expectation after surgery?  Patients are often in so much pain,  they do not comprehend the risks of the surgery or the expected outcomes.  In regards to neck fusion surgery,  properly selected patients do have excellent outcomes,  but guarantees are never made. The risks need to be discussed in detail with the patient, and the patient needs to know about the expected post surgery recovery issues.  Often times, there will be some residual numbness and tingling,  neck stiffness, hoarseness of the voice, and difficulty swallowing solid foods for some time.  Fortunately,  these are usually temporary findings,  but a certain percentage of patients will always have some residual effects.

And finally,  how does a Surgeon decide to do a fusion versus just a “removal of bone spurs or a disk?’

7.  Your surgeon will look at your MRI’s/CT scans to determine the location of your problem.  Often times,  if you have a significant disk herniation,  or if you have bone spurs in the middle of you spinal canal causing entrapment of the spinal cord or nerves,  the safest approach is to remove the whole disk from the front of your neck ,and then perform a Neck Fusion Surgery.  By going from the front of your neck,  your surgeon can safely remove the disk herniation, or bone spur without having to manipulate your spinal cord.

But, if your main problem is a small disk located in the foramen or most outside portion of the disk,  or bone spurs formed from the facet joints of the neck,  a posterior foraminotomy or disectomy can be done safely without manipulating your spinal cord.  Please discuss these options with your surgeon.  But please do not say ” Dr. Shim’s Blog said blah blah blah”.  Your surgeon may get offended.

Laser and Back Surgery

What the deal with laser and back surgery? This is a common question we are asked by patients.

Our answer to this question is “Not much” . The laser is a tool that has been used in surgery for over 35 years. Many associate the use of the laser as ultimate fix all as its use has been widely marketed in other specialties including eye surgery, dermatology, and even dentistry. For some procedures the use of the laser has been an invaluable tool to remove soft tissue with precision. In spinal surgery, the use of the laser is controversial as no clear benefit when compared to traditional surgery has been shown. This is especially the case when considering surgery to remove spinal stenosis (bone). Remember that there is no surgery that is completely risk free and noninvasive. Surgery should always be the last treatment option regardless of the approach used.

As for the specific use of laser and Back surgery,  there is definitely a marketing aspect to its use.  The goals of spine surgery remain the same for almost every situation.  If the nerve is compressed,  the goal is to eliminate the cause of compression. That goal can be achieved with many techniques.  Traditional techniques include removing the disk material by direct visualization.  By utilizing small knives, and curets, the compressing material is mechanically removed off the nerve.  The compressing materials can be soft and gelatinous, like the soft nucleus of the disk,  or firm like crab meat with the annulus.  In the situation of spinal stenosis,  actual bone spurs must be removes.  Sometimes,  it requires use of micro-chisels and high speed burs.    In my experience, there is no substitute for direct visualization, for safety and effectiveness.  The laser sounds like an attractive alternative,  but it is not as precise as the other techniques for spine surgery.  Lasers are widely used in eye surgery, and for ablation of softer tissues. Lasers work well in uniform tissues, that have a predictable reaction to the laser energy.   But in the spine,  the variability of structures causing compression on the nerves make laser use too unpredictable.  To decompress the spine,  often the surgeon will need to remove bone, then ligament, then fat, then disk material or additional bone.  As the laser has different impacts on each of the materials,  there is potential that use of the laser will cause  unintentional damage to the nerves.  If you are considering Laser spine surgery,  please discuss the technique with you surgeon, and consider getting a second opinion.

Nutritional Supplements

We are happy to be carrying the Nutrametrix line of Isotonic supplements in our practice. Isotonic means “same pressure”. When mixed with the appropriate amount of water and taken on an empty stomach, these powdered supplements become Isotonic, which allows the solution to readily pass through the stomach, into the small intestine and have 90-95% absorbtion into the blood stream. If you have any questions about these great products, please give us a call 813-814-9251 or check out the hyperlink to the left under Nutritional Supplements.

Lisa