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Frequently Asked Questions
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Q: I have been told that I have the diagnosis of lumbar degenerative disc disease. Do I need surgery?
A: Degenerative disc disease is a term that is used when discussing early aging in the spinal discs, even to advanced aging changes in a disc that is the cushion between two vertebral bones in the spine. These changes can happen from wear and tear and normal aging, and most people at the age of 40 have some of these changes. However, degenerative disc disease may also be caused by a trauma, such as an injury or accident. And it can be the source of back pain. Surgery is normally not indicated for degenerative disc disease until most conservative treatment options have been exhausted.
The treatment of degenerative disc disease should start with bringing the load on the spine down to its normal weight-bearing design, which means to shed extra pounds and bring your body's weight down to its normal range. Most women's weight should not exceed 180 pounds, and most men's weight should not exceed 220 pounds. Of course, these recommendations are for persons of average height and body type. Higher weights may still be healthy for persons who are exceptionally tall, have a large frame, and/or a large muscle mass from frequent exercise.
Smoking also affects the aging of the spine and can accelerate the degeneration of discs, therefore increasing the frequency of back pain among smokers. This has been well studied. Treatments consist of conservative care, with proper lifting techniques, physical therapy, chiropractic care and, if pain persists, back bracing, pain management such as injection into the facet joints, epidural steroid injections and radiofrequency lesions into the facet joints also can be used. Trigger point injections and even Botox injections into the musculature of the lower back are also used in the treatment of degenerative disc disease.
If all these conservative treatments fail, a painful test, called a discogram may be performed. This should not be performed initially, as it is invasive. If all the conservative treatments fail, and the discogram is positive for identifying the disc as a pain generator, there are several new treatments that are minimally invasive that are available for the disc. These include intradiscal electrothermal therapy (IDET), coblation or nucleoplasty. All of these treatments are a variety of heating techniques, which can be done within the disc. They are approximately 60-70% successful per disc level.
Older techniques and currently FDA approved techniques of operative care include fusions. The success rate for fusions are slightly higher depending upon the number of levels that need to be fused, these success rates drop. Fusion is done surgically, with the implantation of metal rods, screws and cages, as well as bone grafts, in order to stabilize the spine. Fusions can be done through a variety of approaches, both anteriorly and posteriorly, i.e. from the front or back sides of the body. A combination of approaches may be used in the lumbosacral spine, depending upon the surgical lesions and the patient's needs. Newer surgical treatments that will most likely be FDA approved in 2004 include artificial mobile disc implants. Currently, I am involved in this FDA Stage IV study involving these implants. Some of my patients may be candidates for this treatment as part of the study before it completes final FDA approval.
Q: What is a pseudoarthrosis?
A: A pseudoarthrosis is the unsuccessful fusion of bone. There are several sites in the spine where we attempt to achieve analgesia (pain relief) by the stability and immobility of the spine. This is accomplished through fusion. Although instrumentation, plates, screws, rods and cages are placed into the spine, ultimately what holds the spine is the bone that we place around or within these devices as it grows from one mobile joint to another. Sometimes, fusion does not occur or occurs partially. In these cases, we name this condition pseudoarthrosis. A successful fusion is called an arthrosis.
Pseudoarthrosis is more commonly seen in smokers, diabetics and morbidly obese individuals. Other conditions where pseudoarthrosis is higher is in patients who have had chronic steroid use or have other endocrinologic problems or osteoporosis. At The Spine Institute, we handle complicated spine matters, such as a pseudoarthrosis after a previous surgery. Through the use of special techniques, intraoperatively, as well as the use of special instrumentation and external bone stimulators, we are often able to correct this problem, resulting in a successful fusion.
Q: How do you know if fusion is successful?
A: At The Spine Institute, I follow my patient's monthly with x-rays after a spinal fusion. Through the use of x-ray, we can see if the fusion is successfully healing. If there is any question or if a portion of the body is difficult to x-ray through, such as in the lower cervical spine in patients that are thicker through the shoulder area, often a CT scan is performed in order to assess the fusion. To minimize patient exposure to radiation, CT scans are not normally prescribed.
Q: What are spinal cord stimulators and how are they implanted?
A: Often spinal cord stimulators are suggested by pain management specialists when all structural abnormalities of the spine have been addressed, and there is still pain, or in situations where surgery will not be successful. Spinal cord stimulators are devices that can be implanted percutaneously (way below the skin ?) by a pain management specialist. They are essentially electrodes that are placed (directly?) on top of the spinal cord. When stimulated, they trick the spinal cord and the brain into perceiving signals usually sent as pain and perceiving them as other sensations such as numbness, tingling or perhaps no pain whatsoever. They are approximately 70 % successful. Sometimes when the spinal cord stimulators are found to be extremely mobile, not maintaining their position along the spinal cord, it is asked that we do an open implantation of the spinal cord stimulator. This would involve a small laminectomy, the placement of the leads on top of the spinal cord and then a tunneling of the leads to a generator made through a minimal skin incision in the buttocks or lower abdominal area.
Q: What is spondylolisthesis?
A: Spondylolisthesis is the slippage of one vertebral body on top of another. It is the misalignment of spinal segments. This can occur from a traumatic etiology or from a degenerative etiology, and it does not always necessitate surgery. At times, there are fractures involved. Sometimes these can be healed in a conservative manner without surgical intervention. Often this condition is asymptomatic and becomes symptomatic after a minor trauma. There are several treatment options available for spondylolisthesis, including conservative treatments such as physical therapy, abdominal and low back strengthening exercises, employment of proper lifting techniques, weight loss. More invasive conservative treatments include epidural steroid injections, facet blocks, and trigger point injections. To surgically repair a spondylolisthesis often requires the stabilization of spinal segments and decompression of nerve roots, which involve spinal fusion and usually instrumentation implants in the lumbosacral spine.
Q: What is a cervical disc herniation?
A: A cervical disc herniation is when the disc between the cervical vertebrae, the vertebral bodies in the neck, become dislodged. Disc herniation can be asymptomatic, not causing any pain, or it can be severely symptomatic, causing pain or even spinal cord compression. The signs of a herniated cervical disc can range from simple neck pain, trapezius pain, pain into your shoulder blade areas, cervical radiculopathy (pain down into your arms) or spinal cord compression - which can bring on weakness in arms and legs, numbness in hands and feet, tingling sensations, and in the severest cases loss of movement of arms and legs and loss of bowel and bladder function (inability to control your urine or stool). Lateral disc herniations require surgery. Many can be treated by physical therapy and if they are resistant to this, possibly epidural steroid injections can help 50 % of minor disc herniations. Surgery is approximately 95% successful in curing the pain and symptoms brought on by a cervical disc herniation. The most common surgery performed is anterior cervical discectomy and fusion, which is done from the front of the neck. It requires an overnight stay in the hospital. Most patients do not need to wear a collar postoperatively and are able to drive approximately ten days after the surgery and return to work within six to eight weeks.
Q: What is spondylosis?
A: Spondylosis is a word that describes the degenerative changes seen in the spine, both in the cervical spine and in the lumbosacral spine, as well as the thoracic spine (the region in between these two areas, middle back). In spondylosis, we often see the degeneration of discs (the cushions between the bones in the spine), as well as the spurring of some of the bones, as the body attempts to bridge these gaps where the disc is no longer competent. We also see increased arthritic changes in the joints in the posterior spine in response to these aging changes of the disc, where they become larger, the bone becomes greater and more ligaments are laid down. A combination of these processes, including the discs often bulging as they are collapsing can cause tightness (stenosis) of the spinal cord or spinal nerve roots, which can cause pain.
Q: What is an artificial disc replacement?
A: An artificial disc replacement is an implant that will provide mobility in the lumbosacral spine. It is comprised of two titanium endplates with a mobile polyethylene core. It is implanted anteriorly through the abdomen. Its advantage over the currently FDA approved spinal fusion techniques is that it provides and restores mobility to a degenerative disc, which has lost mobility. It also has the advantage of avoiding additional stresses placed on adjacent levels to the abnormal level, which is sometimes found after a fusion operation is performed. Here level refers to the number or location of the disc or vertebra.
There are several models of artificial discs being studied. The FDA is expected to approve the first model by late summer 2004. At The Spine Institute of Southern New Jersey, we are involved in the studies of these artificial discs, and many of our patients are candidates to have the artificial disc placed in the FDA study forum. Currently, when such a device is to be implanted, the surgery must be done at the study center hospital. In this case, Dr. Joan O'Shea travels to New York City to perform the surgery with the team from the Beth Israel Spine Institute. Because of this training and experience, The Spine Institute of Southern New Jersey will be implanting these devices on a regular basis as soon as they are FDA approved.
Q: What is spinal stenosis?
A: Spinal stenosis is simply the tightening of the nervous elements in the spine. It can be present in the neck or lower back or thoracic areas. It can be from a combination of problems or a single problem, such as a herniated disc or overgrowth of ligaments in the spine. In the population over 55, we commonly find spinal stenosis in the lumbosacral spine. This is often caused by normal degenerative changes or arthritic changes with overgrowth of ligaments and bones into the spinal canal, making the space available for the nerve roots smaller. Pressure on the nerve roots causes pain, typically into the legs, especially when walking distances. Bending over shopping carts typically relieves this pain or allows the patient to walk farther, at first. As the disease progresses, the pain may be present in the legs and lower back continuously. At times, spinal epidural steroid injections may relieve these symptoms and may be curative. At other times, surgical intervention is required. Benign cysts that grow off the facet joints can also cause spinal stenosis. Rarely, these can be drained through percutaneous techniques, however, their recurrence is high, and often when symptomatic, they require surgical resection. The overall success rate for spinal stenosis operation in the lumbosacral spine is approximately 85 % in the population over 65 years of age.
Q: What is a laminectomy?
A: The bone covering the neural elements of the spine in the posterior part of the spine, towards what we call the back, is called the lamina. It is a roof of bone that covers the spinal nervous elements (nerves?). Often taking off this bone can help with tightness on the spinal cord or tightness of the spinal nerve roots. Often laminectomies are same-day surgery procedures with minimal blood loss with a high percentage success rate, such as 90-95 % successful.
Q: What is a microdiscectomy?
A: A microdiscectomy is a procedure done in the lumbosacral spine through an incision of approximately 1 inch, depending upon the patient's size; the incision may have to be slightly larger in obese patients. It is an outpatient procedure. That is, a same-day surgery procedure, where the patient goes home the same day of surgery with minimal muscle dissection. The incision is smaller than that used for any kind of endoscopic procedures that are currently being performed. By this procedure, we are able to visualize the spinal elements, nerve roots and remove pieces of discs that have herniated or are ready to herniate from the disc space. It is approximately 96 % successful and causes minimal blood loss, usually less than the equivalent of ½ of a shot glass. There are minimal risks involved, including infection, which is approximately 1-2 %. Most patients have physical therapy the same day. They are usually able to return to work within a month with some sitting restrictions and no heavy lifting restriction during the first postoperative month. If the patient performs a heavy manual labor job, the restrictions may be extended up to six weeks, as physical therapy will be started after the first postoperative month, and work-harding and proper lifting techniques may be indicated.
NEUROSURGERY LINKS
http://www.neurosurgerytoday.org
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