Web MD Chat May 23, 2000: Spine Surgery

MD Chat May 23, 2000: Spine Surgery

Moderator: Welcome to WebMD LIVE! Our guest today is Robert Pashman, MD, and the topic is Spine Surgery.

Robert Pashman, MD, is an orthopedic surgeon practicing at Cedars-Sinai Medical Center in Los Angeles. A specialist in the treatment and research of adult and pediatric spinal deformities, trauma, tumors, and infections and degenerative disorders of the cervical, thoracic, and lumbar spine, he is a member of North American Spine Society and the Scoliosis Research Society. If you have specific questions or are concerned about your health, please consult your personal physician. This event is for informational purposes only.

Welcome, Dr. Pashman! Thanks for joining us today.

Question:

Can a herniated disc heal on its own without surgery? What are the risks of this type surgery?

Dr. Pashman:

We have done extensive studies where people have had disk herniations found on an MRI. Then patients have been rescanned at an interval of seven months to one year in an attempt to try to understand what happens to the disc herniation if no surgery is done. We found that actually discs can get slightly smaller, and that’s because they dry out. We think that although the disc may dry out and get slightly smaller, the disc herniation doesn’t completely go away. What in fact happens is that the nerve roots flow over the disc herniation and don’t bother people. Some people, therefore, get relief from their symptoms without surgery. Some people, though, will need surgery. The surgery that’s employed in my practice is microdiscectomy. It’s a fairly common and uncomplicated surgery with some minor risks involved. There’s a small chance of infection, and a 4% chance of having a new disc herniation through the surgery defect. Patients will usually go home within a day after surgery and usually have an uneventful recovery.

Question:

Why do so many people need multiple surgeries?

Dr. Pashman:

My answer to that would be that spine surgery is very complicated and needs to be done, in my opinion, by people who are well versed in spine surgery techniques and do spine surgery almost exclusively. In my practice, reoperations are usually because of technical problems and not because of new injuries, necessarily. If a surgery is done correctly, it usually does not need to be done a second time. That’s why it is very important to choose the surgeon carefully.

Question:

I’m scheduled to have spine surgery next week. I have osteoblastoma. They will remove the benign tumor together with the T-11, T-12 and L-1. They will replace it will rods and screws and hardware. Is this the proper treatment for that? They did all kinds of tests including an MRI, CT scan, and radiology scan. Do I need a second opinion?

Dr. Pashman:

An osteoblastoma is a benign tumor that most commonly affects the posterior elements of the spine. It can be treated by excision. Because bone is removed from the spine, instability can occur. That’s why hardware, such as screws and rods, is added, plus bony fusion to create stability. If you would like a second opinion online, you can visit me at my web site eSpine.com.

Question:

What do you recommend for herniated disc at T11-12 and L2-3?

Dr. Pashman:

This is an excellent question. As you might know, most disc herniations occur in the lumbar or cervical spine. Disc herniations in the thoracic spine are rarer, or less common, and can present with vague and confusing symptoms. The disc herniation at T11-12, because of the presence of the spinal cord, is more difficult to treat than the disc herniation at L2-3, if surgery is necessary. Then a transthoracic endoscopic removal of the disc may be necessary. In this procedure, a camera is inserted into the chest and the disc is removed with fine instruments. At L2-3, a standard microdiscectomy approach is utilized.

Question:

I recently had a laminectomy and fusion of L-4/L-5 due to a herniated disk and bone cyst wrapped around the nerve. I developed a spontaneous cerebrospinal fluid leak. Although it was repaired during the surgery, it continued to leak and a second surgery was required. I had never heard of that happening. Is that common?

Dr. Pashman:

It is not common but can happen. The covering of the nerves is a thin membrane and can be torn during surgery. When torn, it will leak cerebrospinal fluid. Once the leak occurs, it must be repaired because fluid will continue to leak and may cause headaches, and in rare instances, infection. It is understandable, therefore, that you needed a second surgery to repair it.

Question:

Can DDD (degenerative disc disease) lay dormant, non symptomatic, and with a car accident become symptomatic?

Dr. Pashman:

This is a common scenario. We know that 40% of individuals who are asymptomatic, that have MRI scans, will show evidence of DDD. So that it can lay dormant, and because of some traumatic event, it can become symptomatic.

Question:

I had a laminectomy four years ago at the L4-5 level and it reherniated five months after surgery. I am now at the point where the pain is having an increased negative impact on my life. With the presence of scar tissue, what are the chances of gaining substantial relief from another surgery? Also, are there newer techniques that will improve my chances of improvement long term?

Dr. Pashman:

A laminectomy removes significant amounts of bone from the back of the spine, which may create instability. It is possible that this instability has caused you to have more problems at this level. If this is true and you continue to be symptomatic, you might benefit from a fusion at that level. In my hands, using current techniques, fusion is obtainable at L4-5 with 95% certainty, and an equal amount of symptomatic relief. As with any spine problem, the key is making the correct diagnosis for the problem which is causing the pain. Surgery is technically easy. It is important, though, to make the right diagnosis beforehand.

Question:

Have you heard of new intradiscal injections containing glucose, DMSO (dimethyl sulfoxide), and chondroitin?

Dr. Pashman:

I am sure that people are doing these types of things. Currently, there is no large experience with this type of therapy, and it should be approached with significant caution. Sticking a needle into the disc is not a benign intervention. Any infection caused by introduction of a needle into the disc can have catastrophic consequences.

Question:

Any new surgeries to help DDD? I had heard about a thing where they put in a needle type device and heat it up. It is supposed to cook what is left in the disc space. What about replacing cartilage like they do with knees and shoulders now? Thanks.

Dr. Pashman:

This is an excellent question. First of all, the procedure that you refer to is called IDET (Intradiscal Electrothermal Therapy). In this procedure, a thermal probe is introduced into the disc to shrink lax tissue. Although there is a new experience with this type of procedure, large long-term studies have not been done to either prove or disprove its efficacy. If it was my spine, I would use a more conventional treatment until those type of studies are available. At my hospital, I have seen one such catheter from such an IDET procedure broken off in the disc. The second part of your question is one that is very commonly asked. There are two issues which make disc replacement difficult. Number one is that gaining access to the front of the spine requires invasive surgery. Secondly, the spine is a complex biomechanical piece of anatomy. Unlike a hip, which is a ball and socket joint, the disc moves in complex directions with complex forces on it. Although interest internationally has arisen for disc replacement, no final technique is currently employed.

Question:

I have been told that I my fourth and fifth discs have disintegrated. I have stiffness upon getting up from a chair and I do yoga for an hour and a half a week. I stretch in the shower. I am a 66-year-old male and was told by an orthopedist that if I wanted to avoid surgery, I should do yoga. In the morning, I walk hunched over until I gradually straighten up. I hope that my personal question will be of interest to others. Would surgery be beneficial or should I just continue with yoga? Thanks.

Dr. Pashman:

The reason you are stiff in the morning and straighten up as the day goes on is because, most likely, you have osteoarthritis of the spine. We call what you go through an un-gelling phenomenon. It’s almost as if you have to grease the joints to get moving. If yoga, exercise, or anti-inflammatory medication keep you functional, you should avoid surgery. Surgery is only indicated if conservative therapy fails, the patient becomes dysfunctional, or the patient should experience progressive neurological problems.

Question:

I had back surgery three years ago on L4-L5 (discectomy). I still have pain down my left leg and foot. Is there anything else I could try? What will happen if I do nothing?

Dr. Pashman:

It is important that it is established that no other pressure is residual on that nerve. Without knowing exactly what your most recent MRI is, it would be difficult for me to answer that question. In my experience, patients who have recurrent or residual pain after discectomy surgery, either have a missed fragment of disc or instability. Either one can be treated effectively with surgery.

Question:

Aren’t discograms and IDET utilizing needle introductions, which are risky as well?

Dr. Pashman:

That is correct. There is a finite chance of infection whenever introducing a needle into the disc. In IDET, failure to place the probe in a correct position can risk heating a nerve root with disastrous results. Generally, though, discograms done by competent interventional radiologists are fairly safe. The safety of IDET is yet unknown.

Question:

Does a fusion always result in stress and problems above the fusion?

Dr. Pashman:

It depends on how the fusion is done. If the normal curvature of the spine is maintained, and the stabilizing structures between the fused and unfused portions of the spine are not destroyed, it is very uncommon in my practice to have so-called adjacent segment problems above the fusion. Once again, it all comes down to how the surgery is technically done. It is important to have surgery done by somebody who is very familiar with spine reconstruction techniques.

Question:

How long does fusion last? Five years, ten years? And at what age does DDD start?

Dr. Pashman:

If the fusion heals, it is permanent. A fusion at, for example, L4-5 will preclude DDD from becoming symptomatic at the L4-5 level. What a fusion does to the adjacent segments was the subject of the last question.

Question:

Can you speak about the femoral ring used for fusion, that is, success or failure rate?

Dr. Pashman:

I use many femoral rings in my practice. To date, I have had no infections, and no rejection phenomenon. Once again, the importance of any surgery is how it is technically performed. In my practice, I take the disc out, distract the space widely so that the graft, that is, femoral ring, is placed under compression. This also restores the natural curve to the spine. Using this technique, I have had excellent results. To reiterate, it is rarely the device that changes the result of surgery. It is how these devices are applied to a patient’s individual situation. Every patient should be treated individually.

Question:

What would be recommended for a person with the following X-ray results? Lumbar spine: Severe narrowing of all the intervertebral disc spaces and this is associated with subchondral sclerosis and marginal osteophyte formations. There is moderate scoliosis convex to the left side. The facet joints are somewhat narrowed and sclerotic. Thoracic spine: All disc spaces are narrowed and there are scattered marginal osteophyte formations with anterior bridging. The findings are compatible with diffuse moderately advanced degenerative disc disease and degenerative spondylosis deformans.

Dr. Pashman:

Thank you for forwarding your radiology report. You have multiple level age-related degeneration of your spine. Many people have similar problems and can be treated with physical therapy and anti-inflammatories. Surgery is only necessary for those patients who fail conservative therapy, and are dysfunctional from their symptoms. Although your disease is not life-threatening and will not reverse with conservative therapy, your symptoms may adequately be controlled with exercise and certain types of medications.

Question:

I have spinal stenosis and it is very painful. Is an operation the only and best treatment for this condition? I have had cortisone injections with not much success. Also, what can I do about the pain? Thanks. Is there an alternative to surgery for severe spinal stenosis?

Dr. Pashman:

Spinal stenosis is typically treated with steroid injections and in certain instances, physical therapy. If spinal stenosis produces nerve compression, which causes pain in the buttocks or legs, especially with walking, neurogenic claudication, then surgery, in my opinion, is a technically easy and gratifying procedure for both the patient and the spine surgeon.

Question:

Can you tell me what myofascitis and spondylosis are? I am told I have these two and disc degeneration in my lumbar spine. Thank you.

Dr. Pashman:

Myofasciitis and spondylosis are terms spine surgeons rarely use. They do not refer to specific problems. Disc degeneration in the spine is very common and may or may not cause symptoms.

Question:

Do you perform or recommend transthoracic endoscopic surgery? What other options do I have?

Dr. Pashman:

Transthoracic endoscopic surgery can be used for any one of a number of problems. I use it in the following situations: A thoracic disc herniation, or in scoliosis when anterior disc removal is necessary to make the spine looser, so that correction of the curve can be more easily accomplished. It is especially useful in children with large curves. If patients require major reconstruction, such as tumor removal, or removal of an infection, I elect to remove a portion of the rib and do what is termed a mini-thoracotomy.

Question:

I know everybody is individual, but can one truly get the pleasures back in life after spinal surgery?

Dr. Pashman:

Many people in the news have had spinal surgery, Scotty Pippin, Joe Montana, and many other high level of athletes. Spinal surgery is effective if the surgery is done technically well for the right diagnosis.

Question:

Regarding your statement, it is rarely the device that changes the results, have you heard negative feedback with the use of BAK cages other than poor imaging?

Dr. Pashman:

In terms of the BAK cages, in my practice, I prefer to use allograft instead of titanium cages for the following reasons: one, it is easier to image patients postoperatively with allograft, donor bone. Secondly, I fear that 25 to 30 years after a patient has titanium implanted into their spine, as their bone loses density, they may have an increased chance of fracturing around a non-pliable metallic device. I have made the decision for many of my patients that using a bone graft instead of titanium, which would be incorporated would, in fact, preclude this complication.

Question:

Another moderator on WebMD, although an orthopedic surgeon, is very anti-surgery for all but the most extreme forms of back pain. You seem to be advocating surgery for more problems. In your experience, can exercise cure back problems like stenosis or sciatica caused by pressure on the nerve?

Dr. Pashman:

If the nerve is truly being compressed, and is causing nerve compression symptoms, and has not spontaneously resolved with conservative therapy, then surgery in many instances can help. What I see most commonly is that those physicians who do not advocate surgery under most every condition will commonly lose that patient to follow up and will not benefit from an understanding of how surgery can improve a patient’s symptoms.

Moderator:

Before we let you go, Dr. Pashman, can you please give some guidelines as to what to look for when choosing a spine specialist?

Dr. Pashman:

Spine surgery and disorders of the spine have become the realm of a new discipline, which is the spine specialist. In most every geographic locality, there are doctors who restrict their practice to disorders of the spine. They may be orthopedic surgeons or neurosurgeons. In most instances, disorders of the spine are best treated by these physicians. I predict in ten years a new discipline separate from orthopedics or neurosurgery will evolve, which will be practitioners of spine surgery.