|
1. What is Arachnoiditis and is there anything I can do for pain relief?
Arachnoiditis refers to inflammation or injury to the membrane that separates the outer covering of the spinal cord (dura mater) from the surface of the spinal cord (pia mater). Cerebrospinal fluid bathes the spinal cord beneath this arachnoid membrane. Symptoms consists of persistent burning, aching through the day and evening unrelieved by movement or change in position.
Arachnoiditis has been an extremely difficulty problem. Most patients remain symptomatic for a lifetime. A few patients have shown progressive worsening of their condition even to the point of paraplegia. Fortunately this has been a rarity balanced by another group of patients who have shown resolution of their symptoms.
Support has been low impact aerobics, pain medicines including anti-inflammatory drugs, a variety of narcotics, anti-depressants and anti-seizure medicines. Emotional support and low impact aerobics have been elements that have been the most helpful in the group of patients that we have seen. Narcotics have been helpful but have also been problematic in the sense that the patients who rely on narcotics for pain relief tend to need a constantly increasing dosage.
Implants such as spinal cord stimulators or intrathecal narcotic pumps have been useful but have not been a panacea as there are problems associated with these modalities as well. The spinal cord stimulators have been most helpful for patients who have primarily peripheral pain. The intrathecal narcotic pumps have been more useful for patients with central pain that is along the spinal axis. Those types of surgery are associated with problems in the sense that there is tolerance with time and the implants become less effective. There has also been a significant risk of infection with the pumps due to the need to refill the reservoirs intermittently. Of course, these procedures are expensive. Physicians that might be helpful to you would be anesthesiologists who have an interest in chronic pain problems or physiatritst, that is, physicians specializing in rehabilitation medicine.
In the meantime, you can always search for other problems that might be contributing to the pain which might be correctable, in particular, instabilities or residual infections.
Listed below are journal articles on Arachnoiditis you might find helpful.
ARACHNOIDITIS BIBLIOGRAPHY
1. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis.
Orthopaedic Clinics of North America, 27(1):125-36, 1996 Jan.
2. Postoperative arachnoiditis diagnosed by high resolution fast spin-echo MRI of the lumbar spine. Neuroradiology. 37(2): 139-45, 1995 Feb.
3. The long range prognosis of arachnoiditis. Spine, 14:12; 1332-1341 (December, 1989).
4. Neurologic Complications of lumbar laminectomy. Clinical Orthopaedics and Related
Research, 284; 14-23 (November, 1992).
5. Spinal Adhesive Arachnoiditis. Surgical Neurology, 39; 479-484 (1993).
6. Surgical Treatment for Symptomatic Spinal Adhesive Arachnoiditis. Spine, 14 (8), 870-875 (1989) Aug.
7. Spinal Arachnoiditis. Spine 8(5) 538-540 (1983) Jul-Aug.
8. Lumbosacral Arachnoiditis. Spine 3(1) 24-30, (1978) March.
2. 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.
3. 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.
A good reference paperback book is Dr. Augustus White's book "Your Aching Back" published by Simon & Schuster and is available at your local bookstore or you can order it online at www.amazon.com.
4. What is a pseudoarthrosis?
Pseudoarthrosis is a false joint literally. It is a failure of the bone healing process. Motion occurs at the spot where bone healing was to occur. If your pain is due to a nonunion or pseudoarthrosis, the options are to live with it or fix it.
Living with it involves activity modification, aerobic conditioning to increase trunk muscle strengthening, corset during peak activity hours, non-steroidal anti-inflammatory drugs, pain medications sparingly, anti-depressant medicines as needed and a good support system - all depending on the severity of symptoms.
Fixing it would involve instrumentation and autologous bone grafts at the level of the pseudoarthrosis. The possibilities are: anterior/posterior surgery with bone graft using autologous graft; secure fixation with interbody spacers; pedicle instrumentation and interbody spacers; and electrical bone stimulators.
5. What is retrolisthesis?
Retrolisthesis is the relative posterior displacement of vertebra on the one below it. Retrolisthesis is the result of degenerative disc changes. Indications for surgery are based on severity and duration of symptoms and a neurologic deficit rather than on degree of slip. Also, if there is an obvious increase in deformity, surgery is indicated.
The pinch occurs due to buckling of the post longitudingal ligament and narrowing of the spinal canal as a result of displacement of the two vertebra. Treatment initially is activity modification and meds for pain control. If the pain is unrelenting despite best efforts or if a progressive neurologic deficit develops, then surgery may be indicated.
6. What is Scheuermann's disease or Scheuermann's kyphosis?
Scheuermann's Kyphosis means an increase in the normal kyphosis or the roundback that all of us have to some extent. Most people with Scheuermann's disease will have an increased roundback, but no other particular problem. Those folks who have a profound roundback or if the Scheuermann's Disease affects the lower thoracic or lumbar spine are more likely to have discomfort as they age.
Hyperkyphosis may be associated with increased pain in adult years. Growing patients who have an increased kyphosis are frequently treated with bracing which has been shown to have a good outcome in kyphosis, probably better than in scoliosis cases. For adults the treatment is observation, or anti-inflammatory drugs or reconstructive surgery depending on the severity of the symptoms. Exercises for spine extension and hamstring stretching are usually prescribed. However, exercises are unlikely to correct the deformity for an adult. Exercises used for flexible kyphosis are hyperextension isometric exercises and hamstring stretches. If the deformity and pain are severe enough, a few people are treated with surgery to reduce the kyphosis and fuse the spine.
The kyphosis from Scheuermann's syndrome is different from the kyphosis produced from osteoporotic compression fractures in older women, although the two groups can overlap.
The cause of Scheuermann's kyphosis is unknown, but is thought to be due to a growth abnormality of the vertebral body. Diagnostic criteria varies with different experts. Typically patients have a rigid hyperkyphosis with wedging of the apical vertebral segments.
7. 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.
8. What is Spina Bifida?
Spina Bifida is a failure of the lamina to close. The spectrum is dramatic from babies born with open spinal canals to adults with trivial defects seen on x-rays. Most late found defects are trivial.
You might want to visit the web site: http://www.infohiway.com. It lists the various Spina Bifida Organizations around the United States.
9. How are spinal cord stimulators implanted?
Dorsal column stimulators, also called spinal cord stimulators, are useful to treat otherwise intractable pain syndromes.
With the patient awake, the electrodes are placed on the dura - the covering of the spinal cord. Current is passed through the electrodes. With careful positioning of the electrodes using feedback from the patient, the pain signals can be disrupted. The patient reports a buzzing sensation over the portion of the body innervated by the spinal cord track being stimulated. If the surgical trial obtains pain relief, a battery and electronic pack is implanted subcutaneously usually over the abdomen and wired to the electrodes. The device may produce an improved quality of life for months or years.
Potential problems include infection, neurologic injury, disruption of the device by external magnetic fields, the need for battery change, or electrode repositioning.
10. 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.
11. What is spondylolisthesis and is surgery the only treatment?
Spondylolysis is a defect in the pars interarticularis of the vertebra. Spondylolisthesis is the translation or slippage that occurs through this defect. About 5% of the general population have a spondylotic defect or a spondylolisthesis in the lumbar spine. This is the most common type of spondylolisthesis. Spondylolisthesis can also occur as a result of degenerative changes, trauma, tumor, congenital changes or postoperative instability.
The treatment for pain due to spondylolisthesis is activity modification, anti-inflammatory drugs and pain medications when needed. If the pain is intractable or associated with a neurologic deficit, the most common one would be L5 or S1. Problems such as weakness of the calf muscles when tiptoeing or the dorsiflexors of the ankle when walking on the heels or pain and numbness in the big toe (L5) or little toe (S1) may occur.
Physical therapy, isometric exercises to strengthen the trunk, and avoidance of activities that require extremes of motion of the back are recommended. We discourage hyperextension as associated with diving, gymnastics, football lineman maneuvers.
If surgery becomes necessary, the indications would be obvious progression of the slip, intractable pain or neurologic deficit. Reduction is possible.
In our opinion, it is more important to reduce the slip angle than to reduce the slip. The more dramatic the reduction of the slip on the x-rays, probably the more dramatic the risk that was taken with the patient's L5 nerve root. Our recommendation is to accept the reduction of the slip that comes easily at the time of surgery. We do not make a big attempt to fully reduce the slip. It is more important to align the next unfused level, usually the L4-5 level, in a physiologic position than it is to reduce the L5-S1 level. The surgery involves a fusion of the spondylotic elements.
Hospitalization is usually three to five days. Patients return to sedentary activities in the workplace within a month. Most patients get as good as they are going to get within four to six months of the surgery. The recovery depends on the preoperative aerobic conditioning of the patient.
12. What is spondylosis?
Spondylosis or degenerative disc disease means wear and tear changes in the disc that cause narrowing of the spinal canal. The narrowing of the canal causes compression of the neural elements which interferes with the function. 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.
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.
A good reference paperback book is Dr. Augustus White's book "Your Aching Back" published by Simon & Schuster and is available at your local bookstore or you can order it online at www.amazon.com.
13. 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.
14. What does "transitional vertebra" mean?
The transitional vertebra means that you have an abnormal articulation at the lumbosacral junction. Our observation is that patients with those anomalies are more likely to have pain. There is no statistical evidence published from a review of radiographs of the lumbar spine that would support that conclusion. Although the abnormal motion segment may induce degenerative changes that would result in pain, the transitional vertebral body alone is not a source of your pain.
15. Can you give me some information on cervical herniated disks?
Neck pain with intermittent numbness and pain in the arms suggest a nerve compression symdrome in the neck which could be a herniated disc. Sometimes the level ca be located by the pattern of the pain and numbness. If the pain is to the thumb side of your hand, it is probably the C5-6 level. If it is to the long finger of your band, it is probably the C6-7 level and if it is to the little finger side of your hand it is probably the C7-Tl level. If you have those symptoms, or symptoms of a myelopathy (more general symptoms related to spinal cord compression) that have not responded to a reasonable trial of non-operative treatment then you are a candidate for surgery.
Most people will not require surgery. The technique for surgery is controversial. The particular procedure involved would depend on the individual pathology and the surgeon's preferences. In our hands it is usually anterior decompression with discectomy or corpectomy and fusion with auto graft - your own bone. Long term studies suggest that the symptoms will get better with time. In general, there has been a fairly high satisfaction rate in patients who have painful herniated cervical disc who undergo anterior cervical fusions.
The usual treatment is time, activity modification such as avoiding overhead work or extremes of motion of the neck and vibratory stresses, occasional use of splinting and traction and pain medicines. Risks involved in non-operative treatment are continued pain. There is a small risk of progression of the neurologic deficit but it is very small.
16. 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.
17. Can you explain what spinal cages are and why they are used?
Spinal cages can mean either struts or threaded dowels. The purpose of either type is to reconstruct the anterior spinal column. The struts such as the Harms cage are usually supplemented with posterior instrumentation such as pedicle screws. The threaded dowels provide a stiffer construct initially and may not require supplemental hardware. We use cages, ramps, interbody dowels and intervertebral bone graft frequently.
The cage is an alternative for other means of supporting the anterior column such as the patient's own bone, typically a tricortical ilium or a portion of the fibula. In some cases, allograft, bone from another donor, is used.
18. What is the "BAK" device?
The BAK device is an interbody spacer that looks like a large screw. It offers the promise of laproscopic application. However, currently many applications are with conventional open dissections. The device works by spreading the disc space apart and putting the ligaments that hold the spine together under tension and then inserting a large titanium screw-like device into the disc space to hold the spine rigid. With time, bone grows through the titanium cage to create a fusion. The best results seem to be with one level fusions.
There are at least three different companies selling similar devices. The cages and bone graft in the intervertebral disc space can be applied either through an anterior approach or through a posterior lumbar interbody fusion approach. The technology is not difficult to apply for any surgeon familiar with the approaches.
19. Can you give some general information on Adolescent Idiopathic Scoliosis?
Scoliosis is a lateral deviation of the normal vertical line of the spine which, when measured by X-ray, is greater than 10 degrees. Scoliosis consists of a lateral curvature of the spine iwth rotation of the vertebra within the curve.
Every patient is unique. No one set of rules fits everybody. For adolescents treatment options are observation, bracing, or surgery. Decisions are tied to the degree of curvature and the amount of growth remaining for the patient. The younger the patient and the more severe the curve, the more aggressive the treatment. If the curve has gotten worse in the last year or is associated with an unacceptable cosmesis, we would consider a surgical recommendation. If the curve is stable and the patient is happy, we would not.
The primary indications for surgery in patients who have scoliosis are progression of the deformity or pain. Cosmesis is also a consideration. Multiple surgical options are available. . They all involve straightening the deformity with a metal rod attached to the spine with screws, hooks, or wires. 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. These procedures involve all the potential complications of major surgery.
The indications for bracing are a curve of less than 40 degrees in a patient who is skeletally immature. After skeletal maturation, the probability of progression is low and bracing is no longer indicated. For curves greater than 40 degrees, the efficacy of the brace is small. There is no statistical proof that any exercise program or activity prohibition or special bed will make a difference in the outcome. For growing patients at risk for progression, bracing makes a difference in probability of progression.
The hormonal relationships we know are that the curves get worse during rapid growth periods - typically the year before and after menarche. At menarche the rate of growth is already showing and the risk of further progression is diminishing. The onset of skeletal and sexual maturity is on the average later - perhaps two years or more - for women with idiopathic scoliosis as compared to the rest of the population. Also, women with scoliosis are at higher risk for osteoporosis than their peers. Menstrual irregularity has not been a feature of idiopathic scoliosis. Breast assymmetry is a frequent complaint related to the rotational deformity of the spine and ribs.
20. 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.
21. What is the current status of artificial disk replacement?
The clinical trials for the SB III Charite disc replacement (artificial disc) study are currently underway at ten sites in the United States. The procedure is an experimental type of surgery in the US. The FDA is allowing a small number of selected doctors to use the SB Charite on a specific number of patients.
The surgical procedure for the SB Charite places an implant using the anterior (front) approach. The disc is removed at the effected level and the SB Charite device is placed into the space. Much like an artificial hip or knee system that relies on metal and plastic to replicate normal movement, the SB Charite is designed to mimic the function of a healthy disc.
22. 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.
23. What is kyphosis and is there any treatment for it?
Kyphosis is an abnormality in the growth of the vertebral bodies (the bones of your spine). The cause is unknown. The result is a kyphosis or roundback. This is because the anterior (front) portion of the spine does not grow as much as normal. In extreme cases, changes in the loading of the spine can result in mechanical pain. In very extreme and unusual cases, impingement of the spinal cord can occur. The diagosis is usually made in the presence of a rigid kyphosis and x-ray findings of wedging of the three apical vertebra and irregular end plates.
Treatment is usually symptomatic. If the patient is still growing, an extension brace is helpful. Exercises for spine extension and hamstring stretching are usually prescribed. In extreme cases, surgery is used to reduce the kyphosis and fuse the spine.
24. What is a laminectomy?
A laminectomy means removal of a portion of the spine bone. The back of the vertebra is called the lamina. Removing a portion of the lamina gives the surgeon access to the spinal canal.
A good reference paperback book is Dr. Augustus White's book "Your Aching Back" published by Simon & Schuster and is available at your local bookstore or you can order it online at www.amazon.com.
25. What is spinal stenosis?
Spinal stenosis means a narrowing of the spinal canal. Some individuals have a lower than normal diameter of the spinal canal that they are born with. Most of us develop spinal stenosis with time just as the joints in your fingers and wrists become larger with age and wear and tear - the joints in the spine do as well. In the case of the spine, this enlargement of the facet joints and the intervertebral joints results in the narrowing of the neural foramina and of the spinal canal.
Most individuals with spinal stenosis live normal lives. In fact, I suspect that all of us over 50 have it to some degree. It is only those patients who have intractable symptoms that have treatment. The usual treatment is activity modification, anti-inflammatory drugs, and pain medications. If the pain is intractable, epidural steroids are frequently used and finally, surgery.
Surgical treatment involves making the spinal canal bigger by removing the bony elements that are compressing the nerves. In our hands, we frequently add fusion surgery in the patients that have siginificant longevity. This is a controversial issue as there is a B difference of opinion. The reason we would recommend a fusion would be that we feel the instability is part of the genesis of the arthritic changes and we find that surgery without fusion, done on the people with significant stenosis, adds to the instability problem by removing a portion of the spinal joints. Lastly, we find that in the long term follow-ups of greater than three years, the patients do better. In general, patients with severe stenosis say the postoperative pain is not a whole lot worse than the preoperative pain as we typically do not operate on folks unless they are essentially housebound before the surgery.
Recovery period depends on the extent of the procedure and the status of the patient preoperatively. For patients who are in good cardiovascular condition, the recovery is relatively brief. In general, the group of patients we are talking about are older and are not in good cardiopulmonary condition. Typically, hospitalization for decompression and fusion procedure would be four to five days with the patient independent for self care but limited in endurance at the time of discharge. Before the patient gets as good as he will get is a period of discharge. Before the patient gets as good as he will get is a period of four to six months. The answers to these questions will vary from surgeon to surgeon. I encourage you to cross check with your surgeon.
A good reference paperback book is Dr. Augustus White's book "Your Aching Back" published by Simon & Schuster and is available at the local bookstore or you can order it online at www.amazon.com.
26. Can you explain the microdiskectomy procedure?
Microdiscectomy means a small incision perhaps up to an inch long and visualiation of the surgical field with an operating microscope.
Microdiscectomy has been relatively successful. We employ it in our practice. Assuming that you have an accurate diagnosis in the sense that the anatomic defect seen on the imaging corresponds well with your neurologic defect and pain pattern, the probability of you having relief from your pain is high. This does not return the disc to normal but removes a portion of the compromised disc. The wear and tear of degenerative changes present will continue.
There are risks involved in any procedure including microdiscectomy. The particular risks involved other than the general statement of risk to life and limb are injuries to the structures that live close to the operative site such as the nerve roots to the lower limbs, great vessels to the lower limbs, risk of infection and risk of arachnoiditis.
Most patients are home from microdiscectomy in 24 hours, back to sedentary work in a week, back to moderate activity in a month, return to vigorous activity in 3 - 4 months.
27. What is a myelogram?
A myelogram is an injection of contrast material into the spinal canal in the space where the spinal fluid is. The purpose is to evaluate for neuro compression. Pain varies from minimal to moderate from patient to patient. Side effects are infrequent - range from headache due to CSF leak to rarely, seizures, to allergic reaction to the contrast material. With any invasive procedure there is risk to life and limb. In some cases, MRI is a good alternative.
28. 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.
29. 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.
30. 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.
31. What is ankylosing spondylitis?
Ankylosing spondylitis is a chronic inflammatory disease that is best described as symptomatic sacral iliitis. That is, all patients have x-ray findings in the sacroiliac joint. Typically the pain starts as an insidious onset in the third decade in the low back and gradually climbs up the spine. Men tend to have more classic x-ray findings of sacro-iliitis - squaring of the vertebral bodies and eventual ankylosing or spontaneous fusion of the vertebral bodies together. While the incidence of ankylosing spondylitis is equal between the sexes, the diagnosis is often delayed or confused in women because the x-ray findings are not as typical and often involve skip lesions - that is - areas of the spine that may not be involved. There is an association with a particular gene which is detected in blood tests called HLAB 27. This is occasionally used as a confirmatory laboratory test. A diagnosis is typically made by listening to the patient's history and physical findings as well as x-ray findings. Treatment is largely supportive - that is, anti-inflammatory drugs, occasionally pain medicines and encouraging the patients to work on spinal extension. Complications that can occur are hyperkyphosis with ankylosis such that the patient is stuck in head down position. In extreme cases, the changes can involve the peripheral joints - typically the hips or shoulders although other joints can be involved as well. Involvement of other organs is also common, in particular, the eyes which is described as UV- itis and the lungs which have been described as a pulmonary fibrosis. Because of the restrictive elements caused by the ankylosing of the thoracic vertebra and ribs, the addition of pulmonary fibrosis can be devastating.
We recommend that patients with ankylosing spondylitis not smoke which seems to further accelerate the problem. Cardiac changes have also been reported but have not been a prominent feature in the series of patients we have seen clinically. Most patients live productive lives with relatively normal life spans. The severe problems are seen in only a minority of patients.
32. Would you comment on the pedicle screw issue?
Pedicle screws, in our opinion, are an effective way to treat nonunions, spine instability, deformities, tumors and trauma. We use them routinely. They are safe in some surgeons' hands. There is certainly the potential for catastrophic complications in their use. In the hands of a spine surgeon however, the risk of a nonunion is dramatically reduced and the changes of success are dramatically increased by using them. We have no hesitation in recommending them to you. Pedicle instrumentation represents the current state of the art.
The FDA does not approve or disapprove surgeries. The FDA supervises the manufacture and sale of the implants. Why or why not the FDA approves devices is a mystery to most of us in medicine. The process has some scientific, political and economic considerations. Surgeons frequently use implants for off label uses such as using aspirin to prevent heart attacks even though the label says the purpose of the drug is to reduce fever and inflammation.
33. What is spondylolysis?
A defect of pars interarticularis or spondylolysis, is a crack in the pars mainly related to repetitive micro trauma over a period of time. This injury is prevalent in weight lifters and gymnasts. Spondylolysis is present in about five percent of the population. Some ethnic groups have a much higher rate.
The treatment would be conservative at first with exercise, physical therapy and bracing. If the pain is intractable and does not respond to conservative measures, surgery is an option.
| 