Continue reading »]]> Surgery for disk herniations

Disk herniations come in all sizes and shapes and they cause all sorts of symptoms.  Some symptoms, such as leg pain, numbness in the legs, and muscular weakness can be improved with surgical treatment, whereas some symptoms, such as back pain, are less likely to improve.  The best candidates for a microscopic discectomy are people with a disk herniation that is causing significant nerve root compression and the patient wants the nerve root pain alleviated.  For example, here are a series of slides from a talk that I give on MRI anatomy of the lumbar spine that demonstrate the different types of disk hernations.  Click on each image to enlarge it to full size and to see the caption…..

This series of images should convince you that there are disk herniations in name only, and those that really need treatment (the fourth slide).  The surgical treatment of disk herniations is relatively controversial, because medical research has shown that if you wait long enough, most people with a disk herniation will improve without surgical treatment.  In fact, it is considered dogma in the US that surgical treatment of disk herniations does not change the LONG TERM outcome, but simply helps patients to get over their pain and return to work faster.  In my experience, most patients WILL get better with physical therapy, medical management, and selective nerve root blocks, and they are able to avoid surgical treatment if they are patient enough.  However, there are those patients that clearly do better with a microdiscectomy and they tend to have the following findings:

1. Their leg pain is worse than their back pain
2. Their pain has been present for at least 6 to 8 weeks without any trend towards gradual improvement
3. The disk herniation is large, a free or extruded fragment, and appears to be causing significant nerve root compression
4. They have tried a course of physical therapy, NSAIDs, and possibly a selective nerve root block and each time the pain has come back.

microdiscectomy technique: a step by step explanation

Continue reading »]]> Anterior Cervical Discectomy and Fusion (abbreviated as ACDF) is a surgical procedure for alleviating the severe pain due to nerve root compression caused by a cervical disk herniations.  ACDF surgery has been routinely performed since the 1950′s and it is a very reliable procedure.  It works best in patients who have an identifiable cause of nerve root compression that has not responded to non-operative care consisting of physical therapy, medical management, and possibly a steroid injection.

First the anatomy.  In this first set of watercolors we see a small segment of the cervical spine.  The white strip in the middle is the spinal cord and the surrounding fluid called the CSF.  The back of the intervertebral disk is flush with the bone above and below, and there is no pressure on the spinal cord.  In the second axial image the spinal cord looks like a white kidney bean in the center of the spinal canal.  The cord is symmetric and there is no pressure on any part of the cord.  In the third image we see a disk herniation.  Some of the shock-absorbing viscous protein in the center of the disk has been squeezed into the spinal canal and it is pressing on the spinal cord.  The fourth axial image demonstrates how the cord is often deformed asymmetrically.  In this case, the disk herniation is pushing on the left side of the spinal cord and the patient is likely to have left sided nerve root pain.

Now the MRI scan.  This is a sequence of pictures of someone with a C6/7 disk herniation on the left side.  The first image is mid-sagittal MRI scan.  This image is a “slice” from the center of the neck and we can clearly see all of the relevant anatomic structures.  If we move over to the left side by 5 mm, we can see the prominent disk herniation at C6/7.  The third image is annotated so that the disk herniation and the cervical spinal cord are more visible.  Please click on each image to enlarge the size of the picture.

Cross-sectional anatomy — the axial slice.  The beauty of MRI scans is that we can use them to look at the human body in any plane.  The three images above are called the sagittal slices, but often the axial images are the key to the diagnosis.  The first image in this sequence is called the reference image.  In this image there is a blue line parallel to the C6/7 disk space.  This blue line is the reference plane for images #2 and #3.  These two images are a “slice” through the center of the neck and they are oriented as if we were at the feet of the patient looking up towards the head.  The anatomic structures on our right are on the patient’s left.  In image #3 I have annotated the disk herniation in order to demonstrate where the nerve root compression is occurring.  In the fourth image, I present an axial image from the same patient, just above the level of the herniation, so that you can see what the normal dimensions of the spinal canal look like.

Not all cervical disk herniations need to be treated surgically.  Lots of research has shown that many people will improve over time and their symptoms will spontaneously resolve.  Patient’s who are good candidates for an ACDF typically meet the following criteria:

1. Their arm pain is worse than their neck pain
2. Their pain has been present for at least 6 to 8 weeks without any trend towards gradual improvement
3. The disk herniation is large, a free or extruded fragment, and appears to be causing significant nerve root compression
4. They have tried a course of physical therapy, NSAIDs, and possibly a selective nerve root block and each time the pain has come back.

Anterior Cervical Disectomy and Fusion, for the most part, is now an outpatient operation.  I perform this operation at Monterey Peninsula Surgery Center and the majority of patients go home the same day.

In my hands, my patients do very well with an anterior cervical discectomy and fusion with a allograft and a locking plate applied to the anterior aspect of the cervical spine.  They tend to have immediate resolution of their neck and arm pain, their weakness resolves quickly, and they return to normal activities within 6 weeks.  Using a microscopic surgical technique I am able to visualize and remove the herniated portion of the disk and with an allograft bone I am able to restore normal disk height without using bone from the hip or the pelvis.  For example, here are 2 X-rays from a C5/6 ACDF performed as an outpatient for someone with severe arm pain and a large herniated disk

There are a few side effects after an ACDF…

Will I lose normal range of motion?

One of the most common questions that I get asked is whether the range of motion of the neck will be affected by the operation.  Most patients are concerned about the loss of normal range of motion of the cervical spine if they have a fusion, but this rarely seems to be the case.  In the first place, about 90% of lateral rotation — twisting the head from sided to side — occurs at the level of C1/C2, and this area is never included in a standard ACDF.  Secondly, by the time someone needs an ACDF, usually their spine has developed some arthritis and the range of motion of the disks and spinal segments that need to be fused is already lost as part of the degenerative process.  For example, here are a series of pictures from an active duty US serviceman who needed a multi-level cervical fusion for symptoms of cervical myelopathy associated with kyphosis.  The pre-operative xrays and MRI scans are shown, and the post-operative xray shows excellent correction of his cervical kyphosis.  Clinical pictures taken 3 years after the operation demonstrate that he has a nearly normal range of motion of the cervical spine.

The surgical incision — will it be noticeable?

The surgical incision for an anterior cervical discectomy and fusion runs parallel to the normal lines of the skin in the neck, which are called Langer’s Lines.  The skin in this area is typically relatively moveable and it does not form significant scars.  For example, here is the incision of a patient who has a 2 level anterior cervical discectomy and fusion about 2 or 3 months before this picture was taken.  In this image, the scar is barely noticeable, and with time ti will continue to fade even further.

Swallowing difficulty…

According to the literature, temporary or persistent dysphagia (the medical term for difficulty swallowing) can occur in up to 18% of post-operative ACDF patients, but this is much more common in multi-level operations. Typically, a patient will notice that it feels like something is stuck in their throat, or they can’t swallow pills or meat easily.  If a patient develops difficulty swallowing, the symptoms will usually resolve over time, and while most people return to normal within a few days, complete improvement may take many months. Dyspagia appears to be secondary to local response to traction and manipulation of the soft tissues of the neck since this complication occurred just as commonly when the procedure was performed in the past without the use of a locking plate applied to the front of the cervical spine.

An ACDF — done step by step

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• Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN: Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine.  Part 9: fusion in patients with lumbar stenosis and spondylolisthesis. Journal of Neurosurgery: Spine 2: 677-683, 2005
• Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN: Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine.  Part 11: interbody techniques for lumbar fusion. Journal of Neurosurgery: Spine 2: 690-697, 2005
• Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 22:2807-2812, 1997
• Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73:802-808, 1991

Continue reading »]]> Spondylolisthesis is a medical term that describes an abnormal anatomic alignment between two bones in the spine.  This anatomic abnormality has been around since antiquity, but it was first described in the modern medical literature by a Belgian obstetrician named Dr. Herbinaux in 1782 who noticed that the abnormal alignment of the lumbar spine and pelvis in very severe cases made natural childbirth difficult.  The term spondylolisthesis comes from two greek words: “spondy” (σπονδυλος) which means “vertebra” and “listhesis” (ὁλισθος) which means “a slip”.

Spondylolisthesis most commonly affects the lower lumbar spine, typically at the L4/5 or L5/S1 levels.  Spondylolisthesis is a very common condition, occurring in about 5% of the population.  The most common type of spondylolisthesis is a degenerative slip that occurs at the L4/5 level.  This type of slip is caused by degeneration of the intervertebral disk and the facet joints which results in an increase in the “sloppiness” of the joint, much like a worn bushing.  Here are two images that depict the changes that occur as the disk degenerates.  The gel-like substance inside the disk shrinks, the edges of the disk become irregular, and bone spurs develop.

Normal

Degenerative

A recent clinical consensus paper was produced by the North American Spine Society that will be referenced throughout this guide, and their version of the “best working definition” of a degenerative lumbar spondylolisthesis is as follows: an acquired anterior displacement of one vertebra over the subjacent vertebrae, associated with degenerative changes, without an associated disruption or defect in the vertebral ring.  The key elements in this definition — anterior slip, degenerative change, and no disruption of the vertebral ring are easy to demonstrate in a typical case of spondylolisthesis.  As the disk deteriorates it becomes less capable of absorbing all of the forces of normal human movement.  Because the joint has increased “play” or “sloppiness” L4 starts to slip forward with respect to L5.  Here are X-rays and an MRI scan of a typical case of a grade 1 spondylolisthesis.  Flexion and extension X-rays are often used to evaluate how much abnormal motion occurs at the level of the spondylolisthesis.

The second most common type of spondylolisthesis that we see occurs at L5/S1.  This condition is especially common in people who have repetitively extended their spine during athletics in adolescence.  The theory is that repetitive hyperextension of the spine during athletics results in a stress fracture called a spondylolysis in a part of the vertebral body called the pars inter-articularis which disrupts the continuity of the vertebral ring.  The lack of a connection between the posterior and anterior parts of the L5 vertebral body allows the L5 vertebral body to slip forwards with respect to S1.  The association between adolescent athletics and this condition is demonstrated by the fact that about 95% of competitive gymnasts and about 35% of competitive football players have X-ray evidence of the stress fracture that may result in a spondylolisthesis later on in life.

This condition usually develops in two stages.  First the patient has an episode of low back pain during their adolescence which is when the stress fracture of the pars interarticularis occurs.  Then as the disk starts to degenerate later in life, they begin to complain of low back and leg pain.  In contrast to a degenerative spondylolisthesis, this type of slip does involve a disruption of the vertebral ring, so this is often called an “isthmic” spondylolisthesis

Symptoms of spondylolisthesis 

Patients with spondylolisthesis complain of low back pain and pain along the course of the nerves that are pinched by the spondylolisthesis.  The narrowing of the normal space available for the nerve roots in the spinal canal is called stenosis.  The back pain typically occurs in the area of the lower lumbar spine and often radiates around the abdomen and into the buttocks.  The location of the nerve root pain depends upon where the slip is occurring and where the nerve roots are compressed.  Nerve root compression due to stenosis is called a radiculopathy: radix is the greek word for “root” and pathos a word for “a disease of”.   Pain and numbness in the legs as the result of a spondylolisthesis occurs in patterns called a radiculopathy that are very characteristic.  The human body is divided into a series of dermatomes which can be visualized as a map of where the nerves travel after the leave the spinal canal.  When the root of the nerve is affected, the entire course of the nerve is typically painful, numb, or the skin in this area is unusually sensitive.  For example, here is a map of the normal dermatomes of the body, and then three diagrams of an L4, L5, and S1 radiculopathy.  Patients with a spondylolisthesis at L4/5 usually have L4 nerve root pain due to compression of the L4 nerve root in the neural foramen.  Patients with a slip at L5/S1 usually have L5 nerve root pain due to tension on the L5 nerve root.  For example, a patient with an L4/5 spondylolisthesis will usually describe low back pain at the base of the spine, radiating into the buttocks, associated with pain and numbness along the sides of the legs, down the front and sides of the calves, with numbness and tingling in the feet.

L4 nerve root pain

L5 nerve root pain

S1 nerve root pain

The pain that is associated with spondylolisthesis is variable.  It is often worse with standing and many patients find that the length of time they can walk comfortably starts to shorten as the disease progresses.  We call this finding “limited walking endurance” and it is often an indicator of how severely the patient is affected and how much nerve root compression they have.  Patients who are able to walk for more than an hour rarely need operative treatment, whereas those who can only walk for a few hundred yards before they are limited by back and leg pain will often experience substantial relief once their spondylolisthesis is corrected.  While the pain associated with a spondylolisthesis is usually worse when the patient is on their feet, many patients have a hard time sleeping at night because the nerve root pain keeps them awake.

Xray and MRI findings in spondylolisthesis.

The best test for diagnosing a spondylolisthesis is a lateral Xray of the lumbar spine with the patient standing.  It is important that the patient is standing because there are some slips that return to their normal position when the patient lies down, so they are not apparent on supine X-rays or an MRI scan.  The best test for evaluating the degree of nerve root compression and spinal stenosis caused by spondylolisthesis is an MRI scan of the lumbar spine.

Here are a series of X-rays and MRI scans showing the relevant anatomic finding in a typical L4/5 degenerative spondylolisthesis.  Click on these images to enlarge them to full size

And here are the X-rays and MRI scans of a patient with an L5/S1 spondylolisthesis with bilateral pars defects.

Non-operative treatment of spondylolisthesis

Physical Therapy: While it impossible to reverse the degenerative changes that occur with aging, it is possible to strengthen the muscles that surround the spine.  This helps to stabilize the lumbar spine and will often result in a decrease in symptoms of low back and leg pain to the point where surgery becomes unnecessary.  This type of therapy MUST emphasize active rehabilitation, which means that the patient must work actively to strengthen the muscles of the abdomen, low back, and core.  Massage, hot pack treatments, and electrical stimulation may feel good at the time, but their effects are always temporary and they WILL NOT result in sustained relief.  The type of therapy that we employ emphasizes core conditioning and strengthening and our therapists will instruct you on how to do these exercises properly.  If your symptoms are relatively mild and you are still able to exercise, hike, and play some sports, then often a Pilates or a Yoga program may be very beneficial, less costly, and more convenient than going to a physical therapist.

Medical Management: Non-steroidal pain relievers like Aspirin, Tylenol, Motrin, and Ibuprofen are very helpful in the management of spondylolisthesis.  The medications can calm down the inflammation that accompanies degenerative disk disease.  This often makes it possible to participate in physical therapy with less pain which makes it possible to work harder to strengthen the muscles of the low back and abdomen.

Selective Nerve Root Blocks:  In our clinic we have specialists who perform selective nerve root blocks with injectable medications like Cortisone and Kenalog that are much stronger than the anti-inflammatories you can take by mouth.  These injections are performed in the surgical center and are done using an intra-operative X-ray machine to make sure that the medication is injected in the same area where the nerve root compression is occuring.  In our experience, nerve root blocks are very helpful for patients.  They will often result in a sufficient reduction in pain so that physical therapy is tolerable.  The block may also interrupt the “cycle of inflammation” to the point where the symptoms are manageable and surgery can be avoided indefinitely.

Narcotic Pain Medications: In our experience, using narcotic pain medications on a daily basis for the treatment of the pain associated with a spondylolisthesis is a bad idea.  Because spondylolisthesis is a condition that tends to worsen with time most people who start taking narcotics find it very difficult to stop.  The use of narcotic pain medications for an open-ended diagnosis in which there is not a defined point in the future when we know that the pain will spontaneously resolve is a dangerous situation.  For example, if a patient has a fracture, we know that the pain will subside once the fracture heals.  However, with a spondylolisthesis, because there is not a possibility of spontaneous correction, the patient will continue to perceive a need for narcotics on a regular basis.  This quickly leads to tolerance as the medications become less effective with time and their routine use becomes habit forming.  For more information on my philosophy about the use of narcotic pain medications, click here.

The North American Spine Society’s consensus statement on non-operative care for spondylolisthesis is a follows: The majority of patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits will do well with conservative care. Patients who present with sensory changes, muscle weakness, [or a short walking endurance] are more likely to develop progressive functional decline without surgery. Progression of slip correlates with jobs that require repetitive anterior flexion of the spine. Slip progression is less likely to occur when the disc has lost over 80% of its native height and intervertebral osteophytes have formed. Progression of clinical symptoms does not correlate with progression of the slip.

Surgery for spondylolisthesis

Here is what the North American Spine Society has to say: Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical and interventional treatment.  In our clinic we agree with this statement.  What this means to us is that patients who have symptoms that can be clearly attributed to their spondylolisthesis should first be educated about their condition.  Next they should consider physical therapy and lifestyle changes that we believe are associated with improvements in back pain.  If they continue to have pain they should consider a selective nerve root block to temporarily reduce the inflammation in the nerve roots — as long as this is seen as a bridge to making physical therapy more tolerable.  Surgery should only be considered when the patient has continued symptoms that do not improve with physical therapy or medical management.

Our technique for the surgical correction of spondylolisthesis is designed to achieve four goals

1. relieve the nerve root compression that is causing pain and numbness in the legs

2. stabilize the unstable spinal segment that is slipping

3. improve the alignment of the spinal canal

4. provide the patient with a durable solution that will improve their quality of life for years to come.

While there is a great deal of debate about the best surgical technique for the treatment of spondylolisthesis, the NASS clinical guidelines do state that surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis…and that …decompression and fusion is recommended as a means to provide satisfactory long-term (greater than 4+ years) results for the patient.  For example, on a recent Spine Surgery Board Certification Examination administered by the American Academy of Neurological Surgeons, the following question was asked: A 47 year old dentist presents with a 5 year history of intractable low back pain refractory to several courses of physical therapy and numerous medications.  He has recently developed bilateral L5 radiculopathy.  MR imaging demonstrates grade II anterolisthesis of L4 on L5 with resulting L4-5 central canal stenosis and bilateral neuroforaminal stenosis. The BEST treatment option is:

1. dorsal column stimulator
2. anterior lumbar interbody cage fusion
3. laminectomy and pedicle screw fusion
4. epidural steroid injection
5. laminectomy with facetectomy

The correct answer, according to the AANS, is #3.  Here is their explanation: This patient has failed reasonable attempts at non-operative management and has an anatomical abnormality that corresponds to his clinical symptomatology.  Surgical correction is the best option.  Decompression alone in the presence of spondylolisthesis in a relatively young patient is associated with a high incidence of progressive listhesis and worsening pain.  Stand alone anterior lumbar interbody fusion procedures are contraindicated in the presence of more than a minimal spondylolisthesis.  Placement of translaminar facet screws requires the presence of lamina.  Posterior decompression and fusion, especially with interbody techniques, is associated with better patient outcomes than any of the other treatment options listed.

Here is a series of pictures from our operating room during correction of a spondylolisthesis of the spine…

Here are a series of x-rays that demonstrate the correction of spondylolisthesis with a decompression and fusion of the slip performed in our clinic in Monterey, California.  You can click on each of these Xrays to enlarge them to full size.

L4.5 degenerative spondylolisthesis repaired with an L4.5 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L5/S1 isthmic spondylolisthesis repaired with an L5/S1 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

Continue reading »]]> In this gallery of images we go through a microdiscectomy performed at our outpatient surgical center.  This is a 40 year old active duty serviceman with a large herniated nucleus pulposus at the L5.S1 level on the right side.  This sequence of pictures documents the steps that we follow as we move from the pre-anesthetic phase of the operation, through induction of anesthesia, positioning and prepping and draping, and then through the actual operation itself.  Finally, we close the skin with an absorbable suture, apply a layer of dermabond which seals the skin, and then take the patient back to the post-anesthetic care unit so that he can go home on the same day as the operation.

The surgical incision is sewn up with an absorbable suture and then steri-strips are placed perpendicular to the incision.  On top of the steri-strips I use a transparent dressing called “Tegaderm”.  This dressing sticks to the skin very well and it should be left on until the 1st post-operative visit.  Underneath the Tegaderm dressing the steri-strips are left in place until they fall off by themselves, which usually takes another 5 days or so.

Continue reading »]]> This gallery of photographs represents the step by step sequence through an anterior cervical discectomy and fusion.  In this case, this is a young south pacific island male with severe central stenosis at C5/6 and C6/7 with cervical myelopathy.  First the endotracheal tube is placed by the anesthesiologist, next the anterior aspect of the neck is marked, prepped and draped.  The actual anterior cervical discectomy and fusion procedure takes about an hour and a half to two hours for a 2 level case.  When the case is finished, the incision is closed with an absorbable suture and covered with a thin film of dermabond which seals the skin.  A single steri-strip is place across the incision and the patient is allowed to shower and bathe normally the first day after surgery.

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The operation of the century: total hip replacement.  Learmonth ID, Young C, Rorabeck C.  Lancet. 2007 Oct 27;370(9597):1508-19.

Department of Orthopaedics, Bristol Royal Infirmary, Bristol BS2 8HW, UK.

In the 1960s, total hip replacement revolutionised management of elderly patients crippled with arthritis, with very good long-term results. Today, young patients present for hip-replacement surgery hoping to restore their quality of life, which typically includes physically demanding activities. Advances in bioengineering technology have driven development of hip prostheses. Both cemented and uncemented hips can provide durable fixation. Better materials and design have allowed use of large-bore bearings, which provide an increased range of motion with enhanced stability and very low wear. Minimally invasive surgery limits soft-tissue damage and facilitates accelerated discharge and rehabilitation. Short-term objectives must not compromise long-term performance. Computer-assisted surgery will contribute to reproducible and accurate placement of implants. Universal economic constraints in healthcare services dictate that further developments in total hip replacement will be governed by their cost-effectiveness.

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Option #1:  If you are planning on traveling for a surgical consultation and wish to contact me in advance by email, you may contact me directly at sohrab.gollogly@gmail.com. 

Option #2: You can reach my direct office line by calling 831 298 0080.  If you leave a detailed message, my assistant or I will call you back — typically within 24 hours.

I perform inpatient surgical procedures at Community Hospital of the Monterey Peninsula which is located near the highway 68 gate to Pebble Beach at 23625 Holman Highway, in Monterey, California.  I perform outpatient surgical procedures at Monterey Peninsula Surgical Center, which is located in Building B at 2 Upper Ragsdale, Monterey, California

Continue reading »]]> Minimally Invasive Direct Anterior Total Hip Arthroplasty

In a recent article published in the venerable journal The Lancet, total hip arthroplasty was described as the “Operation of the Century“.  This article describes how beginning in the 1960′s total hip replacement completely changed the quality of life of patients with disabling arthritis.  Prior to the development of this operation, every year millions of people suffered from the disabling pain of severe arthritis of the hip which limited their ability to walk comfortably without pain or a limp.  Since the 1960s, the typical patient who receives a total hip replacement expects near complete restoration of their quality of life and they also expect to be able to continue with physically demanding activities such as hiking, skiing, and tennis.   Many advances in the metallurgy, bearing surfaces, and bioengineering have resulted in increased longevity of the replaced joints.  Newer surgical approaches, such as the direct anterior approach, which I perform, can result in shorter hospital stays, faster recoveries, and less costs to the patient in terms of time away from work and family.  The ability to achieve equal leg lengths, reproducible implant positioning, and high levels of patient satisfaction has increased.  Here are a series of pictures of a physician who had severe bilateral hip arthritis who underwent direct anterior minimally invasive total hip replacements and was able to return to skiing within 6 months.  An amazing result considering that this operation was not even invented 50 years ago.

This is an operation that I particular enjoy doing and I have published an entire site devoted to the subject of direct anterior total hip arthroplasty.  Click here for www.anteriorhipreview.com

Continue reading »]]> I perform spine and hip surgery and I see patients in consultation in my office in Monterey, California.  I have written this guide so that you will know in more in advance about my practice philosophy.  I am a direct and open communicator and I strive to educate patients as completely as possible.  I use the medical literature as a guide towards treatment decisions — what we refer to as evidence based medical practice — but please understand that I do have my own biases and opinions.  I am presenting those biases and opinions here so that you may decide in advance if we are likely to form a constructive doctor-patient relationship.

If we examine the causes of disability in the United States of America, we find that arthritis and back and neck pain is identified as a cause of disability in 30% of the population and this is more than all of the other major causes of disability in the US combined.  These are copies of slides from one of my talks on common causes of back pain…click on the thumbnail image to enlarge the slide.

When someone with back or neck pain is referred to a spine clinic, reasonable guidelines suggest that 100% of those patients need to be educated about their condition, 80% would probably benefit from physical therapy, 20 to 30% may need some sort of a minor medical intervention such as an injection, and less than 10% of patients should require operative intervention.  In my practice, it is quite common to see a patient who has had a 1 to 2 month history of low back pain with an MRI scan of the lumbar spine that is described as showing disk bulging and degenerative changes.  This patient is often taking narcotics on a daily basis and states that he or she has tried physical therapy a few times and “failed”.  They are now seeking answers and further care.  Often, this patient is obese, sedentary, and from the perspective of someone who lives in coastal california, leads a relatively unhealthy lifestyle.  This type of patient is often unhappy with the results of their consultation with me because they have unrealistic expectations about how medical science can help them.  Let us examine each of these elements so that we can understand why….

The four things that everyone with back pain should know:

1. The MRI scan is normally abnormal
2. Narcotic pain medications are not a great idea for open-ended diagnoses
3. PT involves more work than you think
4. Lifestyle choices have a huge effect on back pain