Search for tag: "spine surgery"

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.

Dr. Miller: Surgery for spinal scoliosis. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Darrel Brodke, he's an orthopedic surgeon at the University of Utah. He's also a spine specialist. Darrel, after conservative therapy some patients may not do as well as expected and they end up in your hands again where you may advise surgery. Tell us a little bit about that expectation and what happens.

Dr. Brodke: Patients often with adult scoliosis often caused by degenerative disease, degenerative disc disease, and therefore in a subsequent deformity also have other problems related to that lumbar spine. Specifically low back pain and pain radiating into their legs. They may also have pain with associated numbness and weakness and fatigue. All of that may progress despite non-operative treatment, despite physical therapy, medications, even injections. And it's then that we start to talk about surgical intervention. And surgery often necessitates a big surgery, not a little surgery, and by big surgery I mean surgery that may take many hours and require several days in the hospital and several months of recovery.

Dr. Miller: This is because you're operating on multiple levels of the spine, trying to straighten that curve that shouldn't be there.

Dr. Brodke: Exactly. We're working both on making room for the nerves, decompressing anything that's pressing on the nerves, and then straightening the spine and holding it there with metal instrumentation: screws and rods and spacers.

Dr. Miller: So this is a long surgery, but I imagine the recovery is also long.

Dr. Brodke: Yes. The surgery itself can take many hours. It varies depending on how many levels of the spine are involved and how much we need to do. The recovery, likewise, can vary but usually is on the order of months, not on the order of hours or days.

Dr. Miller: So tell us how you advise, sounds like the rehabilitation after the surgery is a significant part of the treatment. So do you send a patient to just physical therapy or do you send them to a physical therapy physician? Tell us a little bit about that.

Dr. Brodke: Postoperatively we're working with physical therapy immediately after surgery. While still in the hospital, patients are getting up and walking and learning techniques of movement and balance with a physical therapist. Once they leave the hospital, some patients go straight home and can walk as their main therapy and their therapy for the next few months as the bone is healing is walking. Some patients aren't quite ready to go home and will end up in a rehab facility where they work every day with physical therapy until their strength and balance has come around.

Dr. Miller: And that's very intensive

Dr. Brodke: It can be very intensive, several hours a day work in order to get to the point where they're ready to be walking around the home and even outside the home.

Dr. Miller: Now you mentioned you put some hardware in the back and to straighten the spine, I think you use metal rods and hooks and things like that and it sounds kind of daunting and it actually really helps straighten that spine.

Dr. Brodke: Yes, it does sound daunting and it's rather impressive when patients and their families see the X-rays but the screws and rods that we use, mostly made out of titanium today, really help us straighten the spine and hold it there while the spine is healing from the surgery.

Dr. Miller: So the hardware once it's implanted doesn't cause pain. It actually helps prevent it.

Dr. Brodke: Exactly. It helps prevent the pain, it helps hold the position that we want to hold, and it doesn't really hurt long-term either. Most patients don't need their hardware removed. It just goes along for the ride for the rest of however long that ride is.

Dr. Miller: So for our audience, it sounds like a small number of patients would need to have surgery to repair scoliosis. Basically this is a long and complex procedure followed by several months of rehabilitation but at the end of that if everything is going correctly you're going to feel better, you're going to have a better . . . going to have less pain, and you're going to be more functionable with your life.

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Dr. Miller: You've tried physical therapy for back pain, and you're not ready for surgery. What other options are there? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in depth information about the biggest health issues facing you today. The specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: I'm here today with Dr. Richard Kendall. He's a professor of rehabilitative medicine, and he's also the Chair of the Department of Physical and Rehabilitative Medicine. Rich, tell us a little bit about what patients can do prior to surgery. I've heard about injections into the back for those patients who have sort of ongoing low back pain or pain in other parts of their back, but there are now injections that can be tried that might relieve their pain.

Dr. Kendall: So that's true. For people who have not done well with physical therapy program or medications like anti-inflammatories or Tylenol or even opiate medications, epidural injections are a tool for us to use to decrease pain. That's just what they are, they can decrease pain, they don't heal or cure a tissue, but getting rid or decreasing the pain is one option hopefully to let somebody go on, and further function before surgery.

Dr. Miller: So what exactly is an epidural injection? Where does that go on the back?

Dr. Kendall: The epidural space is the space around your spinal cord, and it's in the middle of the safe protection of the bones of the spine. It's a nice protected space that's filled with fat that we can put in some steroids and some Novocain in that can really help reduce inflammation as well as reduce pain.

Dr. Miller: Is this a difficult procedure or what does a patient expect when they come in to have this done?

Dr. Kendall: Honestly most of our patients expect the worst, but when we come in, we finish the procedure, and they say, "Wow, that's it? Are you kidding me? That's easier than the dentist." So . . .

Dr. Miller: That's pretty easy. If it's easier than the dentist, that's pretty easy.

Dr. Kendall: The thought of somebody poking a needle in your back is somewhat anxiety provoking but we do them with a lot of Lidocaine, and numbing under X-Ray guidance so most people really experience very little symptoms.

Dr. Miller: What are you injecting into that space that actually reduces the pain?

Dr. Kendall: We put in two medicines. One is corticosteroid or cortisone, and that gets rid of the inflammation. It'll sit in the fat cells for about two weeks around your spine and get rid of inflammation. The second is just a Novocain or a Lidocaine which is an anesthetic, and it'll numb those nerves and areas for several hours.

Dr. Miller: That lets you know that you're probably making a difference. I mean if the Novocain is working in the area where the back pain is emanating from, you'll know you're at the right place I guess, right?

Dr. Kendall: Yes, many people will be pain free when they leave. Some people that's only for four, five hours. However the Lidocaine does sometimes essentially stung the nerve if you will, and people's pain does disappear for much longer afterwards depending on the diagnosis.

Dr. Miller: How effective is this in reducing pain? Is it 80% effective, 50%, 30%? What's the story on that for patients that might be considering an epidural injection?

Dr. Kendall: Well in certain conditions, it can be very effective with disc herniations and people with radiculopathy or pain down the leg from that disc herniation. If you take all patients who could be surgical candidates and you do the injection, 60% of them choose not to have surgery because their pain improves significantly with the injection, and they choose to just not have the surgery because they're doing better.

Dr. Miller: So a great option to may be postpone or prevent surgery.

Dr. Kendall: So a great option for more than half the people . . .

Dr. Miller: That's great.

Dr. Kendall: . . . to really decrease pain, get them on, and avoid a surgery that lays you up for a few weeks or more.

Dr. Miller: Now can you have repeated injections if necessary or is there a limit on the number of injections one can have?

Dr. Kendall: There's not an actual limit, however we usually say three or so a year would be the most we would consider. Some people, it does take one or two injections to really get rid of that leg pain that they have and avoid the surgery. However if we do two injections and your pain comes back within a week, then actually surgery is probably a much better choice.

Dr. Miller: So you do these under imaging, and that helps direct the shot into the area that needs to be infused I guess.

Dr. Kendall: We do these all under X-Ray guidance, so we know exactly where we're going, we know exactly where the needle tip is. We inject a little bit of contrast die to make sure we're not in a nerve or a blood vessel. So overall these are very, very safe injections.

Dr. Miller: Now how would a patient find a physician that would be qualified to do these kinds of treatments? I don't think they necessarily need to go to a surgeon per se, do they?

Dr. Kendall: No, in fact most surgeons don't do these epidural injections. Most are non-operative either anesthesiology or physical medicine rehabilitation physicians. Most people who are pain board certified have done significant amounts of injections, and finding a physician who specializes in back pain and pain will certainly have enough training to do these.

Dr. Miller: Now last question is, if the injection is effective, how long could someone expect to have the effect last?

Dr. Kendall: Most of the time, I tell people until they do something that irritates their back again, it's really not easy for us to say a time frame. It's mostly until you bend funny again or slip or shovel too much snow or do something again that may irritate that disc again.

Dr. Miller: I'm assuming you'd also have them follow up with exercise therapy and physical therapy as another modality to continue to strengthen the back and prevent further injury.

Dr. Kendall: Yes, we always have our patients continues with their exercise program throughout this even before and afterwards just because that's going to decrease the likelihood of you flaring it up again.

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