Advances in Back Surgery -- October 26, 2009 -- Dr. Brian O’Shaughnessy - NewsChannel5.com | Nashville News, Weather & Sports

Advances in Back Surgery -- October 26, 2009 -- Dr. Brian O’Shaughnessy

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TOPIC QUESTIONS ANSWERED by Dr. O'Shaughnessy

1. What are the symptoms of a spine problem?

Spine problems most commonly impact patients in either their neck or low back. The neck is also referred to as the cervical spine, and patients can experience neck pain, arm pain, and numbness or tingling in their hands. Weakness is not uncommon either. When neck conditions get more advanced and there is pressure on the spinal cord, patients can loose the ability to use their hands well, feel clumsy when walking, and have loss of bladder control.

Spine problems in the low back, by contrast, do not cause pressure on the spinal cord. They often result in substantial back pain and leg pain. The leg pain is commonly a shooting pain and can result in a great deal of discomfort. Just like in the neck, weakness, numbness, tingling are also possible.

2. What sort of tests can be done to diagnose spine conditions?

Plain radiographs are often very useful. They tell us about alignment.

I get long films of the entire spine on most of my patients in order to get a global perspective on their spinal alignment.

MRI is very good for looking at the spinal cord and nerve roots.

CT is best used for examining the bone structure.

3. What are the treatment options for spine problems?

The good news is that most patients with spine problems that are not advanced or structurally driven often get somewhat better on their own. I often prescribe an anti-inflammatory agent such as ibuprofen for relief. A short course of oral steroids may be of help in some patients. For low back conditions, epidural steroid injections are sometimes used to help patients get over a bout of leg pain.

Surgery is often used as a last resort or in cases in which there is a structural problem that will not resolve without an operation. In the right hands, spine surgery is often performed very safely with little risk of nerve injury.

4. So far, we have talked about general spine issues; however, you specialize in more advanced problems. Can you explain?

  

Yes. I actually treat all spine conditions from straightforward herniated discs in the neck and low back to highly complex spinal deformities. My specific expertise is in the treatment of spinal deformity which includes scoliosis, kyphosis, and flatback syndrome just to name a few. I perform surgery on both adults and children with these conditions. Not uncommonly, my patients have had several prior spine surgeries and come to me pitched forward and hunched over. They are often in a tremendous amount of pain and discomfort.

5. How do you treat them surgically?

Well, of course, I tailor each operation to each specific patient and their particular problem. No two patients are exactly alike. You have to take into account a patient's age, the quality of their bone, the location of their pain, and their unique anatomy. In complex cases I often need to literally reconstruct their spine and re-align them using advanced techniques.

6. Besides surgeries for spinal deformity, do you have other interest in spine?

Yes, I do. Another passion of mine is spinal tumors. We are able to use techniques from spinal deformity surgery to remove spine tumors with less pain and discomfort for the patient. There is almost nothing more satisfying than to remove a spinal tumor from someone and, in the process, cure their condition and eliminate their pain and suffering.

I am also very interested in pushing the frontiers of minimally-invasive spine surgery. This is something coming into vogue now. There is still a great deal of work we need to do to make it applicable for more conditions. It is not appropriate for many problems in spine, but the development of less invasive ways to treat common conditions is very exciting.

News Notes via www.webmd.com

You know your back hurts, but you may not know why, or what to do about it. Find out how doctors diagnose back problems and what tests may be involved.

  

What Kind of Back Problem Do You Have?

How Do I Know What Kind of Back Problem I Have?

Unless you are totally immobilized from a back injury, your doctor probably will test your range of motion and nerve function and touch your body to locate the area of discomfort.

Blood and urine tests will make sure the pain is not due to an infection or other systemic problem.

X-rays are useful in pinpointing broken bones or other skeletal defects. They can sometimes help locate problems in connective tissue. To analyze soft-tissue damage, computed tomography (CT) or magnetic resonance imaging (MRI) scans may be needed. X-rays and imaging studies are generally used only for checking out direct trauma to the back, back pain with fever, or nerve problems such as extremity weakness or numbness. To determine possible nerve or muscle damage, an electromyogram (EMG) can be useful.

Back Pain Tests

Exams and Tests

Medical history

  • Because many different conditions may cause back pain, a thorough medical history will be performed as part of the examination. Some of the questions you are asked may not seem pertinent to you but are very important to your doctor in determining the source of your pain.
  • Your doctor will first ask you many questions regarding the onset of the pain. (Were you lifting a heavy object and felt an immediate pain? Did the pain come on gradually?) He or she will want to know what makes the pain better or worse. The doctor will ask you many questions referring to the "red flag" symptoms. He or she will ask if you have had the pain before. Your doctor will ask about recent illnesses and associated symptoms such as coughs, fevers, urinary difficulties, or stomach illnesses. In females, the doctor will want to know about vaginal bleeding, cramping, or discharge. Pain from the pelvis, in these cases, is frequently felt in the back.

Physical examination

  • To ensure a thorough examination, you will be asked to put on a gown. The doctor will watch for signs of nerve damage while you walk on your heels, toes, and soles of the feet. Reflexes are usually tested using a reflex hammer. This is usually done at the knee and behind the ankle. As you lie flat on your back, one leg at a time is elevated, both with and without the assistance of the doctor. This is done to test the nerves, muscle strength, and assess the presence of tension on the sciatic nerve. Sensation is usually tested using a pin, paper clip, broken tongue depressor, or other sharp object to assess any loss of sensation in your legs.
  • Depending on what the doctor suspects is wrong with you, the doctor may perform an abdominal examination, a pelvic examination, or a rectal examination. These exams look for diseases that can cause pain referred to your back. The lowest nerves in your spinal cord serve the sensory area and muscles of the rectum, and damage to these nerves can result in inability to control urination and defecation. Thus, a rectal examination is essential to make sure that you do not have nerve damage in this area of your body.

Imaging

  • Doctors can use several tests to "look inside you" to get an idea of what might be causing the back pain. No single test is perfect in that it identifies the absence or presence of disease 100% of the time.
  • The medical literature is very clear: If there are no red flags, there is little to be gained in imaging acute back pain. Because about 90% of people have improved within 30 days of the onset of their back pain, most doctors will not order tests in the routine evaluation of acute, uncomplicated back pain.
  • Plain x-rays are generally not considered useful in the evaluation of back pain, particularly in the first 30 days. In the absence of red flags, their use is discouraged. Their use is indicated if there is significant trauma, mild trauma in those older than 50, people with osteoporosis, and those with prolonged steroid use. Do not expect an x-ray to be taken.
  • Myelogram is an x-ray study in which a radio-opaque dye is injected directly into the spinal canal. Its use has decreased dramatically since MRI scanning. This test is now usually done in conjunction with a CT scan and, even then, only in special situations when surgery is being planned.
  • Magnetic resonance imaging (MRI) scans are a highly sophisticated test and, as such, are very expensive. The test does not use x-rays but very strong magnets to produce images. Their routine use is discouraged in acute back pain unless a condition is present that may require immediate surgery, such as with cauda equina syndrome or when red flags are present and suggest infection of the spinal canal, bone infection, tumor, or fracture.
  • o MRI may also be considered after 1 month of symptoms to rule out more serious underlying problems.
  • o MRIs are not without problems. Bulging of the discs is noted on up to 40% of MRIs performed on people without back pain. Other studies have shown that MRIs fail to diagnose up to 20% of ruptured discs that are found during surgery.

Nerve tests

  • Electromyogram or EMG is a test that involves the placement of very small needles into the muscles. Electrical activity is monitored. Its use is usually reserved for more chronic pain and to predict the level of nerve root damage. The test is also able to help the doctor distinguish between nerve root disease and muscle disease.

  

  

Back Pain Surgery

Operative treatments

Depending on the diagnosis, surgery may either be the first treatment of choice - although this is rare - or it is reserved for chronic back pain for which other treatments have failed. If you are in constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function at your job, or to perform daily activities, you may be a candidate for surgery.

In general, there are two groups of people who may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disc, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement. People in the second group are those with only predominant low back pain (without leg pain). These are people with discogenic low back pain (degenerative disc disease), in which discs wear with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.

Some of the diagnoses that may need surgery include:

Herniated discs: a potentially painful problem in which the hard outer coating of the discs, which are the circular pieces of connective tissue that cushion the bones of the spine, are damaged, allowing the discs' jelly-like center to leak, irritating nearby nerves. This causes severe sciatica and nerve pain down the leg. A herniated disc is sometimes called a ruptured disc.

Spinal stenosis: the narrowing of the spinal canal, through which the spinal cord and spinal nerves run.

It is often caused by the overgrowth of bone caused by osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but also to numbness in the legs and the loss of bladder and/or bowel control. Patients may have difficulty walking any distances and may also have severe pain in their legs along with numbness and tingling.

Spondylolisthesis: a condition in which a vertebra of the lumbar spine slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause not only low back pain but severe sciatica leg pain.

Vertebral fractures: fractures caused by trauma to the vertebrae of the spine or by crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back pain, but it may also put pressure on the nerves, creating leg pain.

Discogenic Low Back Pain (Degenerative Disc Disease): Most people's discs degenerate over a lifetime, but in some, this aging process can become chronically painful, severely interfering with their quality of life.

Following are some of the most commonly performed back surgeries:

For herniated discs:

Laminectomy/discectomy: In this operation, part of the lamina, a portion of the bone on the back of the vertebrae, is removed, as well as a portion of a ligament. The herniated disc is then removed through the incision, which may extend two or more inches.

Microdiscectomy: As with traditional discectomy, this procedure involves removing a herniated disc or damaged portion of a disc through an incision in the back. The difference is that the incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disc through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar. It appears to take about the same time to recuperate from a microdiscectomy as from a traditional discectomy.

Laser surgery: Technological advances in recent decades have led to the use of lasers for operating on patients with herniated discs accompanied by lower back and leg pain. During this procedure, the surgeon inserts a needle in the disc that delivers a few bursts of laser energy to vaporize the tissue in the disc. This reduces its size and relieves pressure on the nerves. Although many patients return to daily activities within 3 to 5 days after laser surgery, pain relief may not be apparent until several weeks or even months after the surgery. The usefulness of laser discectomy is still being debated.

For spinal stenosis:

Laminectomy: When narrowing of the spine compresses the nerve roots, causing pain and/or affecting sensation, doctors sometimes open up the spinal column with a procedure called a laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the spine and removes the lamina and any bone spurs, which are overgrowths of bone, that may have formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.

For spondylolisthesis:

Spinal fusion: When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal fusion, two or more vertebrae are joined together using bone grafts, screws, and rods to stop slippage of the affected vertebrae. Bone used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.

Although the surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body. With donor bone, there is a slight risk of disease transmission or rejection. In recent years, a new development has eliminated those risks for some people undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate bone generation, eliminating the need for grafts. The proteins are placed in the affected area of the spine, often in collagen putty or sponges.

Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.

For vertebral osteoporotic fractures3:

Vertebroplasty: When back pain is caused by a compression fracture of a vertebra due to osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and inject a cement-like mixture called polymethyacrylate into the fractured vertebra to relieve pain and stabilize the spine. The procedure is generally performed on an outpatient basis under a mild anesthetic.

3 Used only if standard care, rest, corsets/braces, analgesics fail.

Kyphoplasty: Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine following fractures due to osteoporosis. Kyphoplasty is a two-step process. In the first step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the second step, he or she injects polymethyacrylate to repair the fractured vertebra. The procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.

For Discogenic Low Back Pain (Degenerative Disc Disease)

Intradiscal electrothermal therapy (IDT): One of the newest and least invasive therapies for low back pain involves inserting a heating wire through a small incision in the back and into a disc. An electrical current is then passed through the wire to strengthen the collagen fibers that hold the disc together. The procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDT is debatable.

Spinal fusion: When the degenerated disc is painful, the surgeon may recommend removing it and fusing the disc to help with the pain. This fusion can be done through the abdomen, a procedure known as anterior lumbar interbody fusion, or through the back, called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is successful in about 60 to 70 percent of cases. Fusion for low back pain or any spinal surgeries should only be done as a last resort, and the patient should be fully informed of risks.

Disc replacement: When a disc is herniated, one alternative to a discectomy - in which the disc is simply removed - is removing it and replacing it with a synthetic disc. Replacing the damaged one with an artificial one restores disc height and movement between the vertebrae. Artificial discs come in several designs.

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