Search for tag: "spine"

Interviewer: So you or a loved one have opted to have endoscopic spinal surgery rather than one of the more traditional methods. What can you expect on the day of the procedure and afterwards?

We're here with Dr. Mark Mahan. He's an associate professor of neurosurgery at the University of Utah Health. Now, Dr. Mahan, when it comes to endoscopic spinal surgery, what can someone expect, you know, leading up to the procedure, the day after? Where do they start? And what should they be expecting?

Dr. Mahan: The wonderful thing about endoscopic spine surgery is that in, I would say, 99% of the cases, it's outpatient surgery. So that is a little bit of a reframing of what an individual will be expecting, because it's not a traditional come to the hospital, stay there for several days, eat wonderful hospital food, stay in wonderful hospital beds. This is something that you would anticipate going to one of our outpatient locations. A patient would expect to arrive that day. Typical requirements are for, you know, for any surgery are, you know, no eating from the night before, coming in, unfortunately, you know, sort of extra early because we all like to end our days early, and so we try to get started early.

And then you would expect that you're going to be meeting a whole host of new individuals that are going to come in and take care of you. And meaning that we're going to have nurses and others that will come in and check-in and make sure that you're ready. We'll go through a surgical consent. That's an important part for me personally because I want to make sure that everybody understands, ahead of time, both what the surgery entails, what the risks are, what your expectations will be both in recovery as well as long term. And so that we all can meet in a common understanding about what our goals are and what you'd be facing. And then through also about, you know, how to best optimize your recovery long term.

And then after surgery, obviously, these are generally performed under general anesthesia, which is the type of anesthesia where you would have a breathing tube. And so waking up, coming around is usually a time when most people don't remember, fortunately, and then just recovery, make sure that you've, you know, that you're ready to go, you're steady on your feet, that you're eating, you're feeling well, and then we get you back to your car and you can go home.

Interviewer: So how long are you actually in the operating room for a procedure like this?

Dr. Mahan: Typically, it really depends on what the problem is we're seeking to treat. Some of the disc surgeries go really, really quick, like on the order of about half an hour.

Interviewer: Oh, wow.

Dr. Mahan: Now some of the more complex narrowing can be two hours. It really truly depends on what the work that needs to be done.

Interviewer: Now, after the patient is home, what can they expect? We're dealing with pain control, recovery. How long until they're back on their feet, etc.?

Dr. Mahan: Yeah, now, pain control is a particular focus of mine because I really want every individual to really have that smooth glide path because, you know, even though that the endoscopic technique is meant to minimize tissue trauma, it is still a spine surgery. It is still the goal of removing something from your spine. I don't want to make that sound scary, but I don't want to make other people feel like, oh, it's a magical procedure, right? It's not. There's a reality here that we're removing something that's pressing on the nerves and causing pain and discomfort.

And so that you would expect to have some irritation or some discomfort from having something removed from your spine. And so what I do is I do everything I can to possibly minimize it. Number one, endoscopic techniques, minimal incisions, minimal approaches. Number two, often using a lot of numbing medication can really make the recovery much more straightforward. So we'll use a long-acting anesthetic into the muscles of the spine to make them comfortable and relaxed even before we even start doing surgery.

So the first step, block the muscles. Make it comfortable. It also leads to some numbness of the skin where the skin incision is so that that is not too much discomfort. But the block will wear off. So the things that we do is try to, obviously, avoid a lot of powerful pain medications because powerful pain medications can have their side effects and consequences. So we're using things like ice, heat, anti-inflammatories, and then we talk about milder pain medications so that you don't get into the complications associated with strong pain medications.

Interviewer: Now other than the pain management that happens afterwards, when they go home, are they up for a day or two? Are they on their back for a day or two? On their belly? Like, what are you having a patient do to heal up from a procedure like this?

Dr. Mahan: In the majority of the cases, you're doing exactly what you want to do.

Interviewer: Oh wow.

Dr. Mahan: Yeah, the limitations really come down to if somebody has had a disc herniation, we want to minimize the risk of re-herniation, meaning that another part of the disc fractures out and presses against the nerve roots, which can occur. Other than the disc herniations, I want the individual doing as much as they feel comfortable doing. Oftentimes that sometimes means tempering people. I had one patient the day after surgery he asked if he could go on a snow bike up the mountain. And I was like, it was one of those moments where you have that sort of, you know, common sense questions, like, well, just tell me what would happen if you got halfway up there and you had a back spasm? You had difficulty coming back?

Interviewer: Right?

Dr. Mahan: And, you know, he's like, well, maybe that's not the greatest thing to do today. And you're, like, yeah, the day after surgery may not be the greatest day to go nuts. But people will be walking more. People will be doing more activities. And we want that. We want them to go back to the way that they will choose to live their life.

Interviewer: Now, it's impressive that they are kind of up the next day, or a day or two after their procedure. Maybe a little bit tempered from what they were normally doing. But, you know, not going back up and doing crazy mountain biking, or that snowmobile trip, like you mentioned. But how long until a patient is, you know, all the way healed and sees the most benefit from the procedure, and they're back to normal?

Dr. Mahan: That is an excellent question. And it really is patient-specific. So if somebody had a more profound nerve pressure or nerve injury, and it's been there for a long period of time, meaning that it's going to take longer for their recovery, right? So if you've had a problem that is minor in nature, and it's a short duration, your recovery is going to be quick. If you have a very profound problem that is of long duration, you know, there may be a new normal, even with spine surgery. We can't always erase everything that occurs in time, but you know, we're going to try.

Interviewer: If your loved one is experiencing some sort of serious spine issue, perhaps stenosis or herniated disc, you may be looking into spinal surgery. Now, typically you might be imagining your back being opened up for major surgery, but there's another option that is available.

We're here with Dr. Mark Mahan. He is an associate professor of neurosurgery at University of Utah Health. Now, Dr. Mahan, we're talking today about endoscopic surgery for the spine. Why don't you kind of talk me through exactly what happens with an endoscopic procedure like this and how it differs from say what I as a layperson think when I think about back surgery?

Dr. Mahan: Endoscopic spine surgery is very similar to what people would refer to as traditional spine surgery, meaning that we're the same goals. We're there to decompress the nerves and in doing so with either removing disc fragments or treating narrowing that presses on the nerve roots, but doing it in a much smaller, much less traumatic fashion than previously accessed.

For most of us, the spine is really kind of in the center of the body, so getting there is always an art, to put it mildly. The older techniques, they work great for treating their intended targets, but the problem is, is there's a fair amount of tissue trauma involved with getting there.

And I've been intrigued for quite some time of finding a way of doing that same surgery, but in a way that does not cause the same tissue disruption, tissue trauma, and as a consequence, the same sort of pain or disability and recovery.

Like for so many things in medicine, we stand on the shoulders of others. Other pioneers had really developed using endoscopes previously, starting in about the 1980s, to create the same surgical corridor but through a much smaller opening. So now with the modern surgical endoscopes, we get beautiful illumination. We get beautiful magnification. We get beautiful video representation of the soft tissues in a way that we're able to perform those same delicate procedures, but through oftentimes really small, like 7 millimeters size skin incisions. That's, you know, 7 millimeters means it's less than your nail width depending on your fingers, but somewhere between your index finger. That's how big the skin incision is.

So that also means that that translates it's not just the skin incision size, it's because now you're going to go down with a very narrow caliber set of tools. So the things that you're going to be doing is that you're not going to be opening up as widely. You're not going to be disrupting joints. You're not going to be getting as much bleeding because we're constantly irrigating.

In fact, the operative field never actually gets to see air. There's none of the circulating air even in an ultra sterile OR environment that actually makes contact with the tissue. We're using constant irrigation with sealing. And so, again, it provides beauty and clarity to the surgeon but also minimizes any risk of infection or other bleeding type complication with regard to the surgery itself.

Interviewer: And again, as someone who's a layperson who might be kind of curious about this, how long have surgeons in the medical field been doing this kind of procedure? It seems kind of new I guess to me.

Dr. Mahan: I'd say it hasn't been done at a large volume for quite some time. There were some initial pioneers who were in the 1980s when they were coming out with the initial endoscopes who were starting it and trying it.

And you can imagine what using 1980s technology meant kind of dark kind of grainy, not necessarily with the same precision. Things really got a boost I would say in the, you know, the 2010s with the introduction of more modern, you know, high-definition televisions, easier access to those techniques, and then just greater popularity.

So we started seeing that the endoscopic technique was really taking off in Germany, and there there's a couple of key innovations that allowed it to be safe for the spine. So whereas you can think of joints having arthroscopes, those are endoscopes specific for joints, those were a little earlier take on, but they were using really high-pressure pumps and those high-pressure pumps would be dangerous if not lethal in the spine. So we had to really develop lower pressure technologies. You had to develop specific tools sets that were able to do the same sort of meticulous and very detailed work we do with the spine.

We saw that those tools and techniques and instrumentation sets really start about 2010-ish, and so there's a very small fraction of spine surgeons in the United States who are trained to do this, unfortunately, because I think it's the technique that should really predominate. And I do, you know, have the good fortune of being able to go train other spine surgeons on how to do this and adopt this technique, which I really enjoy teaching the other spine surgeons how to do it because hopefully it will become the dominant technique and it's not just a single or specialty practice.

Interviewer: It sounds like this procedure has been getting more and more popular over the last two decades, and you sound confident that it could be the next standard practice for a procedure like this. What is it that you see in this particular type of procedures and what are some of the pros and cons of it that make you think that this is going to be the way that surgery is going to be going?

Dr. Mahan: I really like the fact that it has minimal tissue trauma, which means that it has quicker recoveries. So when you ask about the pros and cons, the certain positive that I particularly love and I particularly enjoy about the surgery is that it provides rapid recovery for my patients. That the next day when I talk to my patients or find out how they're doing, they're describing that they're already back to more activities oftentimes than they were before surgery, which is relatively rare.

When we think about surgery, where most people are like, "Yeah, I've got a down period," and I don't have patients coming back to me with like down periods. They're like, "I'm out walking." I hear reports over and over again. They're like, "I am walking now more like the day after surgery than I was in like the several months leading up to surgery." It is that dramatic as far as differences in outcomes. So that's the most certain person and positive note.

Now, some of the other positives I particularly like, again, its lower blood loss. It has a substantially lower risk of infection. There's a substantially lower risk of a specific complication that occurs in spine surgery and that's spinal fluid in leaks or thecal sac injuries. And that's unique to the endoscopic technique is again, we're using sealing to put a little bit of pressure and create space and so the thecal sac is moved away and so you have less risk of that specific complication.

There are downsides, right? I tell all my patients almost repeatedly, you know, if it's powerful enough to help, it's powerful enough to harm. There are cases where people have injured, you know, individuals with using minimally invasive techniques. Endoscopic spine surgery is no stranger to that.

I would certainly say that I think, in my hands, the complication rate is lower, but it's not it's a freebie. It's not like there are no risks. Secondarily and I think the most of the negatives really accrue to the surgeon. You imagine like if you had to do the same work, let's say it's painting a wall, and you were given the choice of a big paintbrush or a tiny paintbrush, which do you think would lead to be faster endpoint?

Interviewer: It's the big brush, right?

Dr. Mahan: The big brush. It's the big brush. The big brush is going to do something quicker. And so, if you force the surgeon to do the same procedure with tinier tools, it's going to take longer. And the way that the insurance in the United States reimburses surgeons, it's on sort of work product. And so again, they pay you to paint the wall. If you can paint the wall faster, then it can be a choice.

Interviewer: What are the success rates like on a procedure like this?

Dr. Mahan: The success rate on anything in life really kind of depends on what your probabilities of success are. So if I take somebody who has relatively straightforward problem and has a very focal problem that's apparent on MRI and is clear on their physical exam and their description of their symptoms, we're going to have a good success rate whether it's an open technique or an endoscopic procedure.

If it's something that's a little bit more challenging, somebody has multiple problems, multiple medical issues, other interdependencies, you know, things that are going on in their lives that are either participating or motivating the pain, then we're going to be less successful. But so for that, let's take the good situation which is for most people where they are.

This is, you know, somebody who has singular problems, relatively identifiable things that could fix their problem, and they're going to have an 80% to 90% success rate with a surgical treatment and it's going to be durable. We want to do a simple procedure that doesn't necessarily create problems that need treatment later.

There are some spine procedures out there that cause further problems down the road. This is one of the ones that leaves a person essentially with more or less their native anatomy, their normal anatomy. And so the goal there is that the only thing that contributes to future problems is really, you know, the nature of time and body's ability to resist time but not the surgery itself.

Interviewer: Say that a patient has now received their diagnosis, they know they have one of these spine issues like we've talked about earlier. What is their first step? Say they're listening to this right now and they're intrigued about this procedure, what is their very first step to get more information and maybe even meeting up with someone like you or another trained professional?

Dr. Mahan: One of the things that we want oftentimes in medical practice, and this applies to a lot of things, is that we want somebody to ideally for somebody to come to me or to come to one of another trained practitioners. If they've had a degree of workup, meaning that they've been evaluated, they've been seen by somebody, and that the process has already been started.

For example, a classic thing is that sometimes you have back pain that can be treated with physical therapy, some exercises, some stretching, maybe some modest medications, right? We're talking about like anti-inflammatories and other things that can get you back to recovery that you don't need surgery for. And so both insurance and the surgeons really want to have that evaluated ahead of time so that when you're coming to somebody, it's meaningful. It's a meaningful use of the patient's time. That you're not coming to see somebody who's going to talk about surgery when you don't need it.

And so it's not a waste of the patient's time. It's not a waste of, you know, of resources or other things. So an initial evaluation, maybe some time with the physical therapist, trial of medications. And then if those aren't working and the MRI, which is a critical component of all of our evaluations, because that's where we can come back to saying is an anatomical surgery going to fix your problem.

And so we need a view of that anatomy, and fortunately, MRIs just do such a beautiful job of doing that is that. If an MRI shows that there's a problem, then clearly there's something that we may be able to intervene on and achieve a good outcome.

Interviewer: Wow. So it sounds like it's a kind of newer procedure and you've got to find the right doctor to do it, the right surgeon and you got to make sure that you have done your homework, gotten your imaging and your workups and everything but maybe they're curious about this type of procedure and treatment, where is somewhere where they can get more information?

Dr. Mahan: Well, one place to start would be the University of Utah website. We have a lot of wonderful information there that can give you the breadth because no patient has the same and what no problem is the same either. So there's oftentimes very distinct treatments that endoscopic spine surgery may not be for you. I would love to think that it is, but at the same time, realistically, there are plenty of things that may need to be done and it may not be endoscopic spine surgery and so that's a great resource to go to.

Announcer: Health hacks with Dr. Troy Madsen on The Scope.

Interviewer: What is today's health hack?

Dr. Madsen: Today's health hack is yoga for chronic low back pain. So here we're talking about people who have had lots of issues, who may have been prescribed even opioids for pain, who have looked into surgery. This was a study in "Annals of Internal Medicine," a few months ago, that looked at patients with this type of pain, chronic low back pain. They placed these patients in yoga classes. Other patients, they placed in physical therapy. Other patients, they just gave some education to, some information. Those who were in yoga did just as well as those in physical therapy. They used fewer pain medications, and even a year later, they saw these same results. They were still doing well.

So I think the big take-home for me from this was if yoga works for you, do yoga. If you're having issues accessing physical therapy, because of insurance issues potentially, consider yoga. Or if you're doing physical therapy, talk to your physical therapist potentially about even supplementing that with some yoga classes. It can make a big difference in the long run for a chronic issue that can cause all sorts of problems.

Announcer: For more health hacks, check out thescoperadio.com, produced by University of Utah Health.

Interviewer: Personalizing treatments for chronic back pain. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking about chronic back pain with Dr. Julie Fritz, Associate Dean for Research at the University of Utah College of Health. Back pain seems to be categorically different than other types of pain. Can you talk about that a little bit? How is it different and why is it different?

Dr. Fritz: Well, there's a couple things that distinguish back pain perhaps from other pain conditions. One is it's an almost universal human experience. Just about everyone has dealt with some level of back pain, ranging from slightly annoying to completely disabling. So there's a shared experience in it that makes it different than a lot of more rare or less common pain conditions.

The other thing about back pain that really makes it challenging is, in the vast majority of circumstances, we don't have a really good idea of what the cause actually is, what tissues involved, where the pain actually originates from.

So, you know, there's a lot of different structures and tissues in the back, and pinpointing what is causing the pain has proved extremely elusive. And without that, it's a challenge to direct treatment in a way that's going to be effective. And that really makes it somewhat different than a lot of other conditions.

Interviewer: Well, yeah, exactly. I have a friend who's gone through surgery, and yoga, and cortisone shots, and any long list of treatments. And she's basically back in the same position she was a couple of years ago in terms of the severity of the pain. And I mean, would you say that a lot of the treatments that are out there today just aren't effective?

Dr. Fritz: There's certainly a lot of treatments that we should just flat-out stop doing and that really are ineffective, even harmful for patients. And the other reality of treatments that exist for back pain is a number of the treatments, some of which you mentioned, are modestly effective for some people. And the real challenge is figuring out what may work for whom, and there's no magic bullet that works for every patient all the time.

So it's another part of the challenge and the frustration for both patients and providers is there's a lot of individualization that needs to go into treatment, but it's very difficult to figure out what you're likely to respond to and what the next patient may respond to, which may be completely different.

Interviewer: And it sounds like this is kind of the motivation for some of your research. Tell me about what you're looking at now.

Dr. Fritz: Yeah, absolutely. So we have this situation of a number of treatments that have small effects across large groups of patients. And the fundamental challenge that we've tried to address is how to better match treatments to patients, which sounds like a fairly straightforward question, and in some ways it is, but it's proven very difficult with back pain for some of the reasons that we've discussed.

So we try to look at various patient characteristics that might help us decide who's likely to respond to what kind of treatment. And what we found, and many other researchers is that, a lot of those factors that seem at least somewhat predictive are not really specifically related to the pain or the physical injury of the back, but often are related to patients' cognitive and emotional responses to pain, how they tend to cope with pain, what their mindset is relative to pain. And this introduces another level of complexity and trying to figure out the best treatments.

Interviewer: So the idea is that, some people just might be more receptive to getting better and other people are . . .

Dr. Fritz: Well, yeah. I mean, I think we'd say it a little bit differently that whenever any of us experience pain, there's a physical response, and there's a cognitive emotional response to the experience of pain. And that involves our relationship to other people, various other stressors in our life. And all of these things can be positive factors towards resiliency in dealing with pain, or they can tend to lead towards more disablement and more suffering relative to having pain.

It's not a situation where we're talking about pain that's of psychological origin, but of a recognition that all of us have a response when we experience pain that encompasses these domains in our life that get outside of the physical.

Interviewer: As I understand it you'll be looking at different types of therapies including things like mindfulness, which maybe it's something the medical community doesn't routinely turn to when they think about treating pain.

Dr. Fritz: Yeah. Pain conditions like back pain are an area where various integrative medicine approaches, what we've in the past called complementary and alternative approaches, may have a really important role. So in the specific instance of back pain as you highlighted with your example, finding a cure is often challenging.

And many people are left to manage their life with some level of intermittent back pain. And strategies like:

• yoga,
• mindfulness,
• meditation,
• other stress-reduction strategies,

can be really helpful for the self-management of back pain to help people deal with flare-ups that inevitably come, or the experience of pain without having to use physician visits, visit the emergency room, take medication, etc.

Interviewer: And so it's not necessarily about sort of solving the problem or curing the problem, but coping with it.

Dr. Fritz: It is for a lot of patients. We certainly, as providers, seek to cure the problem, to get it to go away and not come back. The reality of back pain is that's often an elusive goal. And as providers, we also have to help give patients strategies to better manage their condition given that we know it frequently tends to recur. That's really what we're all trying to do is help people recover, help people live their lives, and do what they want to do despite the experience of back pain.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research show is on The Scope.

updated: January 30, 2019
originally published: December 12, 2017