WebMD chat Treatment for Spine Conditions

Treatment for Spine Conditions

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Moderator:

Welcome to the Pain Management program on WebMD! Our guest today is Robert Pashman, MD, and the topic is “Treatment for Spine Conditions.” Dr. Pashman is a board-certified orthopedic surgeon practicing at Cedars-Sinai Medical Center in Los Angeles. He has dedicated his practice to 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 the North American Spine Society and the Scoliosis Research Society. Welcome back, Dr. Pashman!

Question:

First off, what types of conditions are we talking about when we refer to spine conditions?

Dr. Pashman:

Spine conditions produce pain, numbness, and weakness, commonly in the arms and legs, but also can cause pain any place in the low back. The spine and its pathology can cause problems with nerves which cause pain in the upper and lower extremities. That’s what we’re discussing in terms of spine problems, and it’s a broad, general topic which includes: Infections, tumors, and curvatures of the spine.

Question:

After having spine surgery — rods, cages, screws, et cetera — is the pain ever expected to be completely gone?

Dr. Pashman:

That is an excellent question. I think once the spine has been deranged in some way, either by injury, or even by surgery, that the goal of surgery should be to improve a patient’s function. The expectation of a 100% pain-free result is in my opinion too high. Don’t forget, 80% of the population, without surgery, has low back pain at some point in their lives.

Question:

My dad has four herniated discs with spinal cord compression. Is there any treatment available? He has had no luck finding any.

Dr. Pashman:

The question is, where are the disk herniations at? When you say spinal cord, that would include disc herniations in the neck and upper back If that is true, that the herniation is pressing on the spinal cord, then he needs to be evaluated by a spine surgeon for that problem.

Question:

What is the latest treatment of protruding discs in an otherwise strong and healthy 21-year-old female? Probably the result of years of high jumping — one protruding disk on each side of the spine.

Dr. Pashman:

Protruding discs, per se, do not cause problems, unless they are causing symptoms, such as nerve compression or back pain. Most of the time, disc herniations are self limiting in symptoms with approximately 80% resolving spontaneously in four to six weeks after onset. If the disc herniation is causing continual low back pain or pain in the legs that is not resolved with conservative treatments, such as exercise and certain medications, then certain surgical procedures may be indicated. A complete description of cervical disc surgeries can be found on my website, www.espine.com.

Question:

Should lower back pain radiate from there to buttocks, down to scrotum and rectal area?

Dr. Pashman:

Yes, that can happen, depending on where the herniation is located in the spine. The nerves that innervate the regions you’ve described can be caused by a disc herniation.

Question:

My husband got hit on the head with a beam from 30 feet up. It knocked him to the ground hurting his lower back. A neurologist has been treating him for six months with no help. Tests have shown four bulging disks. When he stands for more than 15 minutes, his legs go numb. What should we do now? He’s on Workman’s Comp but that can’t be his options, rest is not getting him well.

Dr. Pashman:

The answer to your question depends on multiple factors — the magnitude of the disc herniations, the alignment of his spine, and the nature of his symptoms. Without an accurate picture, it would be hard for me to make this diagnosis, or suggest a treatment from here out. If you would like to send the films to me, I’d be happy to review them.

Question:

Harvey asks: Read an article on your web site that deals with back pain and that some of these injections that they put in our backs may also cause a disease of some sort. I have all the symptoms that were mentioned in this article. I lost the web page and wanted to finish it. I had a 360 spinal fusion in 1997. I also found out that my SI (sacroiliac) joint is out of line and I have severe pain in my groin area and burning pain in my lower back over my left SI joint area and down my legs and feet and toes. My doctor tells me everything is all right and the fusion looks good. It has now put me out of work due to the pain. Another orthopedist said I had SI dysfunction. What is this also? Please help. Thank you.

Dr. Pashman:

SI dysfunction after fusion can be caused by multiple factors. It is possible that if bone graft was taken from the pelvis to do the fusion, that this bone graft harvesting can cause sacroiliac dysfunction because of the proximity of the graft site to the SI joint. Also, fusions increase stress at other joints, so it’s possible that a fusion can increase dysfunction. I commonly use an SI joint injection in an attempt to diagnose those types of ongoing symptoms.

Question:

I have been told I have a mild case of spinal stenosis but not enough to cause scrotum and rectal problems. Are hips joints a source of concern.

Dr. Pashman:

This is a good question. Whenever a spine specialist evaluates a patient for complaints of hip pain, or pain radiating into the groin, a differential diagnosis of hip problems vs. low back problems should be evaluated. Most spine specialists can differentiate problems of the hip with problems caused by spinal stenosis. If, in fact, the diagnosis cannot be made of hip problems based on X-ray or other imaging techniques, a numbing injection into the hip may differentiate the two.

Question:

I feel 60% better since my surgery. Do you think this is normal recovery? Also disks remain at L3, L4; L4, L5; L5 and S1 and cages input with an iliac bone graft. I had rods, cages, et cetera and fusion from L3 to the sacrum.

Dr. Pashman:

It may take up to one whole year to fully enjoy the benefits of spinal fusion surgery.

Question:

For surgery for scoliosis upper and lower, what surgery is the least noninvasive and do you perform this surgery?

Dr. Pashman:

What do you mean by upper and lower? Scoliosis surgery has evolved since the early 1950’s when done primarily for polio. Since that time, the standard has been combinations of hooks, rods and screws to correct the curvature, and hold the correction until solid bony fusion occurs. Most of these procedures were done through the back. Recently, there has been renewed interest in approaching the spine from the front. Screws and rods are placed in the front of the spine to hold the spine and create correction. An excellent example is found on my website, www.espine.com under adolescent idiopathic scoliosis section. More recently, people are attempting to put the screws and rods in using cameras through small holes. This method is yet unproven and will not become generally practiced until more experience is gained.

Question:

What about an S-curve?

Dr. Pashman:

Most S-type curves can be treated by fusing one or the other curve, because the second curve is termed “compensatory.” In patients who have true double major curves, where the whole S needs to be fused, this type of curve is usually not amenable to anterior only surgery, and is commonly approached from the back.

Question:

Are there any surgical treatments for arachnoiditis?

Dr. Pashman:

No.

Question:

Do you perform anterior and posterior endoscopic surgery? Could you elaborate on the procedure?

Dr. Pashman:

This is a very good question. There has been a trend towards using cameras, or endoscopic surgery, to do fusions in the front of the spine. Compared against more widely used methods, in which a small incision is made, and the fusions are done open, the following comparisons can be made: Using an open incision, the surgery proceeds faster, usually with less complications, and is technically easier to do. Fusions done using a scope are generally only applicable in the lumbar spine, to L5 – S1. It is my preference, therefore to do what is called a mini-open procedure. After approximately 600 cases with very few complications, I would have to state that currently, this is the preferred method for doing this type of surgery.

Question:

Can someone end up with RSD (reflex sympathetic dystrophy) after spinal surgery?

Dr. Pashman:

Yes. RSD, or reflex sympathetic dystrophy, is a condition where chronic dysfunction of a nerve : can cause swelling and pain in an extremity. The exact reasons that this occur are unknown, but it is well reported and defined in our literature.

Question:

From what we understand, there is no way to surgically intervene if herniated discs are in thoracic area, is this true?

Dr. Pashman:

Disc herniations in the thoracic area present in complex ways. If the diagnosis is accurately made, and the herniation is causing nerve compression, then the herniation can be approached surgically in multiple ways. The current trend is to place a small camera into the chest and remove the disc herniation this way. Because the chest is a large structure filled with air, it is very amenable to this type of camera technique. This is currently the technique that I prefer.

Question:

What treatments are available for arachnoiditis?

Dr. Pashman:

Arachnoiditis is best treated by a specialist in pain management and, unless it’s associated with gross spinal instability or other nerve compression disorders, it should not be treated surgically.

Question:

Why does degenerative disk disease occur?

Dr. Pashman:

As the spine ages, water is lost from the discs. As the water is lost from the discs, the discs start to have a change in their character and function. This is why degenerative disc disease occurs.

Question:

My son (33 years old and overweight) has myotonic dystrophy. He has some neck pain and went to an orthopedic surgeon who did an MRI (magnetic resonance imaging) and noted two herniated disks (C5/6 and C6/7). Surgeon wants to operate (anterior laminectomy, I believe). My son is not a trooper when it comes to pain management. My concern is about the surgery in general, especially in light of his disease. What are the complications, recuperation time, et cetera and if he lives alone, how will he take care of himself while convalescing?

Dr. Pashman:

In reference to the procedures and recuperation time, the answer can be found on my website, www.espine.com under cervical discectomy. The issue of complications with someone with myotonic dystrophy may be unique to his particular condition. Certain patients who have muscle dysfunction can have a higher rate of a problem called malignant hyperthermia. These things should all be discussed with their doctor and anesthesiologist prior to surgery. It would be interesting to speculate that the weakness in his muscles have caused increased mobility in his spine, which in turn could lead to the disc herniations. But, it is absolutely critical that he be checked for scoliosis, because disc herniations in the neck, myotonic dystrophy, and scoliosis, can frequently occur together.

Question:

What is the likelihood of disc pain years after scoliosis surgery that did not exist before surgery? What is the likelihood of disc degeneration, and how much of both pain and degeneration is attributed to the surgery and is there any post operative treatment?

Dr. Pashman:

Excellent question. We know that the incidence of pain in the low back correlates proportionately with the levels at which the scoliosis fusion ends. For example, a patient who has a fusion to L4 may have a 60% to 70% chance of having low back pain after surgery, whereas a fusion that ends at L5 has a much higher chance. In short, the more free vertebrae below a scoliosis fusion, the less chance of having spine generated pain subsequent to surgery.

Question:

I was diagnosed with spinal stenosis and degenerative disc disease in September of 1999. In November 1999, I underwent bilevel anterior cervical fusion. The results have been somewhat disappointing. I recently had a post-surgical MRI that showed a protrusion on the left. I still have considerable pain, but my surgeon seems to think that this is all in my head. I am not able to work and my surgeon has advised me to apply for medical disability retirement even though he thinks I am fine. This seems to be rather a contradiction of opinions. I am at a loss. What options are available to rid me of the chronic pain that I am in.

Dr. Pashman:

I suggest you get a second opinion. This can be obtained through the internet at www.espine.com. This is an excellent question.

Question:

Dr. Pashman, should people be wary of second opinions given out over the Internet?

Dr. Pashman:

The only thing that is missing from an Internet-based second opinion is physical contact with the patient. In this situation, most useful Internet second opinions are provided under the following conditions: That a patient has already seen a qualified spine practitioner, that the diagnosis has already been made through physical examination and imaging studies. It has been my experience that useful and accurate second opinions can be obtained by obtaining the patient’s history, all of their imaging studies, and speaking to them on the phone. If a patient does not have a diagnosis for their problem already, they should be skeptical of the outcome of an online second opinion.

Question:

My son has had three lumber punctures and there was no fluid. They said they would try again in a few days. Why would they not be able to get any fluid?

Dr. Pashman:

This occurred because the needle was not put in a position to get the fluid out. I guarantee you that the child has fluid because the lack of fluid, or CSF (cerebrospinal fluid), around the brain and spinal cord is incompatible with life.

Question:

Does that mean the doctor did not know what he was doing?

Dr. Pashman:

No. People have to realize that doctors have very difficult jobs. Many times, fluids are difficult to obtain for any number of reasons. I do not think that inability to get a positive puncture in any space in the body totally reflects a physician’s capability.

Question:

I am a 48-year-old male with a 65% curvature. Eight to 10 years ago, it was 50%. What is the likelihood of this curvature continuing?

Dr. Pashman:

Adult scoliosis progresses at approximately one degree per year. Since you have already shown that your curve is progressive, there is a very high likelihood that it will continue to get larger. I would suggest you consult a spinal deformity expert because most progressive curves of this magnitude will require surgery for control.

Moderator:

We’ve reached the end of our show. Thank you so much, Dr. Pashman for joining us again!

Dr. Pashman:

Thank you, once again, for having me in this forum.