Back

General Question

1. I have been told that I have lumbar Degenerative Disk Disease. Do I need surgery?
   

   Degenerative disc disease means wear and tear changes in the disc. All of us have it to some degree. Nearly everyone has signs of degeneration of lumbar discs after age 40. Some people show evidence of changes much earlier. Most of us are relatively asymptomatic with these changes. Others have backaches. A few people have severe pain or even nerve compression causing loss of muscle function. These changes are seen on imaging as narrowed disc spaces with osteophytes on x-ray pictures or dark disks on T2 MRI.
   The usual course of treatment is TLC. If there is no relief from bracing, PT, pain meds, anti-inflammatory meds, low impact aerobics (walking and swimming) then fusion may be an alternative. Surgery is indicated for intractable pain or a progressive neurologic deficit.

   Before considering a fusion or any surgery, you should exhaust all non operative methods of treatment. Fusion techniques will vary with the surgeon.
2. Why was I told I must quit smoking before my spine surgery?
   

   Smoking affects the probability of fusion. The statistics involve smokers and non smokers, not ex-smokers. Published studies report a 6 - 8 times higher nonunion rate in smokers. Many surgeons have concluded that for best results patients should not smoke. The surgery can still work in spite of smoking but the probability of failure is higher. The risk of infection is also higher among smokers as is the risk of perioperative pulmonary problems.
   There was a recent article in Orthopaedics Today entitled "Confirmed: Smoking delays bone union" which you might want to read. A Medline search which can be done at your local library or on AOL will provide you with many articles on the subject.

3. Could you tell me what's involved in epidural injections?
   

   An epidural injection is an instillation of typically steroids and narcotics and local anesthesics into the space around the neural elements in the spinal canal. It is widely used for symptomatic relief of back pain.
   In general, this has been a relatively benign procedure with a low instance of problems. Potential problems include injury to the neural elements, infections, unfavorable reactions to the various medications used. There is no necessity for using epidural blocks. The purpose in doing them is to decrease your pain. If your pain is severe enough and you've exhausted other methods such as activity restrictions and anti-inflammatory drugs, it is a reasonable alternative.

   The epidural steroids have given temporary relief, never permanent relief. Headache is by far the most common symptom which occurs about one time in 20 or so.
4. Can you describe the fusion process?
   

   The entire fusion process occurs for over two years. At approximately one year, the fusion mass is about as stiff as it is going to be. However, further microscopic remodeling continues to take place for an additional year. Factors that impair fusions are smoking, excessive motion of the fusion area, deficient bone graft, malnutrition and catabolic states.

5. Will surgery help a cervical spine with degenerative disk disease?
   

   Most people get better with time. Long term outcomes at 10 years are comparable with or without surgery. Surgery is indicated for intractable pain longer than 6 weeks to 6 months or a worsening neurologic deficit.
   Non-operative treatment is avoiding extremes of motion such as overhead work or pillows behind the head in bed. Anti-inflammatory drugs, pain meds, anti-depressants, and steroids are useful depending on the patient. Splinting with a cervical collar may also help.

6. Can you describe what's involved with a discogram?
   

   Discography is a controversial procedure. We find it very useful in our practice.
   The technique of doing a discogram is to sedate the patient, although the patient is still awake, insert a needle into the disc space under fluoroscopy and inject the disc space with contrast material. The purpose is to see the volume of material the disc will accept, the pattern of the contrast material on x-ray image and, most importantly, the sensation of the patient as the injection occurs.
   In general, the injection is painless or is described as a pressure sensation. If the injection reproduces the same discomfort as the patient feels at home, then it is an indication that the level being injected is the source of the pain. If every level that is injected hurts, there is not a surgery to fix it. If no level hurts, then you must look further for the source of the pain.

7. What is the difference between herniated disc and bulging disc?
   

   All discs degenerate as we age. Discs are basically shock absorbers which hold a lot of water. Each disc begins to lose its water and its shock absorber effect starting in the late teens. Degeneration of discs is not necessarily a problem and is frequently a normal process of aging. It is only when a degenerated or bulging disc causes pain does it become a problem. When a disc degenerates to such an extent or a small tear develops in the outer third of the disc, pieces of the disc can move out near the area of the spinal nerves, and that frequently is known as a disc herniation. This can put pressure on a nerve root as it exists from the spine and causes the condition known as sciatica, which is pain radiating all the way down the leg usually to the foot.
   A bulging disc is an early step in the degenerative process of all lumbar discs. As the disc begins to lose its normal water content, it will begin to gradually narrow. This causes the disc to lose much of its "shock-absorbing" effect. This loss of height also allows the outer lining of the disc, called the annulus, to gradually bulge outward as the disc narrows. This process is often compared to an air mattress or a pillow, which would gradually broaden out as it flattens down while losing air. It is rare for a bulging disc to cause significant pressure on the adjacent nerves. A herniated disc, by comparison, occurs when the outer lining of the disc becomes torn, allowing the inner softer disc material to be expressed out of the normal confines of the disc itself and, thus, out pressure on the adjacent nerves. Herniated discs tend to cause "sciatica" or leg pain, due to this pressure on the nerves. A bulging disc usually tends to cause only mechanical back pain, due to irritation of the disc lining itself.

8. How did I herniated my disc?
   

   Some disc herniations occur during extreme injuries, such as motor vehicle accidents, excessive lifting episodes or falls. In those instances, the mechanism of injury is obvious, as pain will often develop soon after the event. However, other patients develop a herniation without an obvious, known trauma. In those instances it is often postulated that the herniation may have developed due to one of several mechanisms. First, a significant injury may have occurred, but was unrecognized at that time. Second, a series of relatively minor injuries may have had a cumulative effect on the disc. Finally, simple progressive degeneration, or "wear and tear" may have weakened the disc to the point of herniation.

9. Can you give me information on lumbar fusions and the usual recovery time?
   

   The indications for lumbar spinal fusions are intractable pain or progressive neurologic deficits due to anatomical changes identified on MRI, plain x-ray, myelogram or discography. The average stay of our patients is four days. Recuperation depends on the definition of recuperation and may vary from a few months to a year.
   Every surgeon has a different postop protocol. We typically try to let patients stand as soon as they would like - usually within a day or so of the surgery. The answers are similar for driving and sitting at a desk. You should ask your own surgeon what his/her protocol is as there is no standard answer.
   Other suggestions for successful lumbar fusions are no smoking; no anti-inflammatory meds; low impact aerobics such as walking and swimming; avoid extremes of motion of the lumbar spine; use narcotics sparingly.

10. My doctor recommended that I have the instrumentation removed from my back. Will that relieve my back pain?
    

    Removal of instrumentation is reasonable any time about 9 months from the surgery. After a few months, the bone begins to heal and the instrumentation becomes superfluous.
    Removal of instrumentation for relief of pain has not been 100% successful. It depends on the source of pain. The presence of instrumentation may be a casual rather than a causal factor. If the pain is directed over prominent instrumentation it would be reasonable to remove it or if the pain is generated from the instrumentation pressing on the neural structures, removal is reasonable. Other potential sources of pain are a pseudoarthrosis or failure of the fusion or other injuries around the fusion level.

11. My doctor told me that I have arthritis of my spine and that I should learn to live with the pain. Is that true?
    

    Learning to live with the arthritis is certainly most commonly recommended, but that need not always mean learning to live with the pain. For example, often a consistent exercise program will significantly reduce or even eliminate the pain. If excess weight is a problem, that may contribute to the pain caused by the spinal arthritis. Sometimes, reducing excess weight will make the problem significantly more tolerable. In some instances, a medication such as an anti-inflammatory drug may provide dramatic relief. (Of course, don't take any medication without discussing with your physician). If the pain does not respond to the above measures, and is of great enough intensity, you may need to be evaluated by a specialist (if you haven't already done so).

12. When is surgery necessary for patients with spine problems?
    

    Surgery is only necessary in a small percentage of patients with spinal problems. Factors that may result in decision in favor of surgery include response to prior treatment, severity of pain, severity of loss of function, severity of neurological problem, degree of spinal damage, degree of neurological threat and prognosis without surgery. Ultimately, the decision to proceed with surgery is a careful and thoughtful decision made between the patient and his or her physician after fully weighing the potential risks and benefits.

13. If I have a fusion does that mean I will never be able to bend?
    

    No, it does not mean you will not be able to bend. Each fusion obviously limits motion at one segment. Therefore, a one or single level fusion would be a relatively small change in biomechanics. However, a multiple level fusion would have much more of an impact on a patients' biomechanics. In general most patients are instructed after their spinal fusion to minimize bending in their spine, using the hips and knees instead so that they minimize the force on the remaining discs.

14. Will fusing my spine cause damage to adjacent area?
    

    There may be some evidence that fusing one segment of the spine may put extra stress at other levels of the spine. This is the main reason that spinal surgeons attempt to limit the amount of levels that they fuse to the levels that are the ones causing the problem. It then will be necessary to follow the patient over a long period of time to make certain that there are not any areas of adjacent level deterioration. The percentage chance of another level degenerating is a subject of some study now in the medical research literature and it is not clear whether or not this adjacent level deterioration is a natural process of aging or if it is truly related to the need for the performance of a fusion.

15. What are the risks associated with spinal surgery?
    

    Many of the risks associated with spine surgery are the same as with any type of surgery. However, in the hands of a well-trained, dedicated spine surgeon, these risks should be quite low. Surgical risks fall under several categories. There are risks of the surgery itself such as neurovascular damage, hemorrhage, implant insertion error, or anesthetic complications. If an anterior approach is used, there are additional risks to the abdominal structures. After surgery, complications may occur in the early or late postoperative period. Early problems include hematoma, infection, poor wound healing, and pulmonary impairment from the anesthesia. Late problems may occur months later. Recurrent disc herniations and fusion non-unions are examples of late complications.
    All of these risks should be discussed with your surgeon prior to surgery.

16. Does my insurance cover low back surgery?
    

    Obviously, medical insurance is intended to provide coverage for necessary medical treatment. You should always contact your insurance company to discuss the financial issues with them. Pre-approval (pre-certification) is often required. Co-payments and deductibles need to be considered. Sometimes, a second opinion is desired or required. Restrictions may apply. Your surgeon or hospital may or may not participate with your insurance.

17. I hear that men should not have fusion surgery, is this true?
    

    The issue with men has to do with surgery on the front of the spine where the small nerves run that control the ability for normal ejaculation during sexual activity. There is a 5% chance that these nerves may be damaged during routine surgery on the spine performed through an abdominal approach and so men who are still trying to have a family should be aware of this rare complication. It is related to the surgical exposure, not the fusion itself. One approach is to bank sperm before such surgery as a precaution.
    Otherwise, I know of no reason from a mechanical standpoint that a man should not have a fusion just because of the spine mechanics.

18. What are some of the complications associated with fusion surgery?
    

    The categories of risk often discussed include, but are not limited to: neurological injury (loss of function of strength, sensation, bowel/bladder, walking, loss of sexual function), infection, bleeding, lack of relief of pain or increase of pain, spinal fluid leakage, need for further surgery at this or other areas of the spine, failure of fusion, failure of instrumentation (pullout or breakage), risks related to positioning during surgery, risks related to anesthesia, risks of non-spinal medical complications, risks of transfusion, risks related to injuries associated with the approach to the spine (such as when the spine is approached through the abdomen) or death. Remember that the frequency of each risk must be taken in to consideration.

19. How many times will I need to see my surgeon after surgery?
    

    Your surgeon will give you specific quidelines. Usually you will see your surgeon monthly for the first 3 months and then at 3 month intervals for the first year if continued follow up is indicated by your particular circumstances.

20. Why do some surgeons approach the spine from the back and others through the abdomen?
    

    When a surgeon decides to advise surgery for a spinal problem, surgical options should be considered and discussed with the patient. One of many options to be considered by a surgeon contemplating a spinal operation is whether it is best approached from the front or the back. Some operations may even require staged approaches from both sides. Each procedure has its risks and benefits, as well as its advantages and disadvantages. You surgeon should discuss with you his or her opinion as to the best way to approach your problem.

21. What are the risks from going in from the front?
    

    The major risks of going in through the front are the vascular structures (especially the iliac vein). In order to have access to the disc spaces you have to immobilize the aorta and the vena cava. A trained vascular surgeon or a trained spine surgeon can minimize these risks. But that's the major risk. There are many benefits to an anterior approach. But the risks are mostly vascular.

22. What are the risks from going in from the back?
    

    Well going in from the back you don't have a lot of the large blood vessels, but certainly you have the neural elements, which people would think of as the spinal cord. Those are the nerves that allow your body to move. And those nerves are in the way, and have to be careful retracted in order to do that fusion from the back.

23. My doctor said he would be using a bone graph, what does this mean? What is bone graph?
    

    If a spinal fusion is planned during spinal surgery, the surgeon may need to take bone from another location to be implanted into the spine. The bone utilized may be your own bone, which is referred to as autograft. Alternatively, bone from the bone bank (cadaver bone) may be used, also known as allograft. Sometimes, a combination of both would be used. Your surgeon should discuss with you the risks/benefits and advantages/disadvantages of each. The purpose of the implanted bone graft is to promote fusion across the intended bones.

24. Are there any alternatives to having a bone graph taken from my hip?
    

    In some instances, local bone products removed from where the spinal surgery is being performed can be used. Also, sometimes another bone harvesting site, such as rib or fibula (a calf bone), can be considered. In addition, sometimes bone from the bone bank (cadaver bone) can be utilized. The is called allograft bone. Each bone choice has its own advantages and disadvantages.

25. What are the differences between bone taken from my hip and donor bone?
    

    Putting the issues of risks of each aside (which is covered below), the main difference between your own bone and banked bone is that yours is "alive". There are still living cells and other factors inside the bone when it is moved from one site in your body to the spine. These cells and factors are felt to encourage bone growth. This process is called osteoinduction ("inducing" bone growth). Both your own bone and the bank bone (cadaver bone) act as a frame or lattice for bone to grow across between spinal bones. This process is called osteoconduction ("conduct" bone growth).

26. I have heard people talk about the pain associated with harvesting bone from the hip. Does this happen to everyone and how long does it last?
    

    There are certain advantages to harvesting your own bone. One of the disadvantages is local pain at the harvesting site. This pain can sometimes be of significant intensity. Most often, it is temporary and resolves during the spinal recovery period. Occasionally, the pain may be of a more chronic nature.

27. Are there any potential complications with harvesting bone from my hip?
    

    The specific potential complications from harvesting bone from the iliac bone would depend upon the amount of bone required to be harvested as well as the portion of the ilium from which the bone needs to be harvested from. Categories of complications typically discussed include, but are not limited to: pain (temporary or chronic), serious bleeding or blood vessel injury, nerve injury, fracture of the iliac bone, infection, abdominal or pelvic injury, injury to the sacro-iliac joint (the joint that connects the lower part of the spine to the pelvic bone) and death.

28. What are the treatment options for Adult Degenerative Scoliosis?
    

    Every patient is unique. No one set of rules fits everybody.
    The usual treatment is conservative (low impact aerobics, non-steroidal anti-inflammatory drugs, pain meds, physical therapy). If it doesn't get better or the patient develops a neurologic problem, the last option is surgery.
    The indications for surgery in adults would be either obvious worsening of the scoliosis as documented on serial x-rays or intractable pain or a progressive neurologic deficit. By far the most common indication for surgery is intractable pain. Before making the assumption that it has recently progressed quickly, we would review the x-rays to document there has been that change. There is no reason to make a rapid decision for surgery. The surgery in the adults are tolerated much better now than they used to be due to changes in the techniques, instrumentation and anesthesia. However, it is still a big deal and the risk and morbidity are greater than for adolescents.
    Multiple surgical options are available. They involve straightening the spine with metal implants and fusing the instrumented portion of the spine. These procedures involve all the potential complications of major surgery. The results of the different systems are comparable. Pedicle screws in this country are used primarily in the lumbar spine. Around the world some surgeons are using pedicle screws in the thoracic spine as well. The most important part of the procedure is not the metal implant. If the bone does not heal in a fusion, the implants will eventually fail. Bone graft is usually added to enhance the probability of a fusion. Sources of the bone graft could be from the rib, from the pelvis, from a bone bank or a bone substitute. Rib resection adds to the cosmetic improvement dramatically by reducing the rib hump. With time, the rib grows back, but in a better position.

29. Is there any treatment for Chronic Pain Syndrome?
    

    The treatment is to look for pain generators that could be treated more directly such as spinal stenosis, spine instability, infection, nerve compression, or discogenic pain. Otherwise treatment is directed at how to make life tolerable.
    An assumption is that you have been through the usual list of pain meds - we usually rotate narcotics every few months as the patient develops a tolerance to any one. Our formulary includes propoxyphene, codeine, hydrocodone, talwin, ultram. The anti-depressants are also useful in this way. We avoid oxycodone, demorol, dilaudid and other schedule II drugs. During acute flare-ups of the pain, steroid drugs either orally or epidurally have been helpful. In desperation cases, epidural spinal cord stimulators or intrathecal narcotic pumps have been useful. Consult an anesthesiologist interested in chronic pain management.
    See if the pain generator can be identified and fixed. If the problem is nerve compression or a mechanical instability, a surgical fix is possible. If the problem is arachnoiditis a surgical fix is not practical. Pain management clinics might be an option. With repeat surgeries, your risk of repeat infections is higher than the rest of the population.

30. I have a thoracic disk herniation. What is the treatment regimen for this condition?
    

    Thoracic disc herniations are relatively rare compared to lumbar or cervical disc herniations. Surgical indications are intractable pain or a progressive neurologic deficit that correlates with the anatomical defect seen on imaging studies. Multiple symptomatic thoracic disc herniations are extremely uncommon.
    Non operative treatment is activity modifications, anti-inflammatory meds, pain control and a search for other causes of the pain. For most people, the symptoms of herniated discs will resolve with time. Surgical options vary with the surgeon from discectomy to discectomy and fusion. Our surgical choice is an anterior discectomy and partial corpectomy to decompress the spinal canal. Reconstruction of the anterior column with bone graft and instrumentation is performed to stabilize the involved segment.