Answers to the below questions posed by Dr. Kenneth Pettine, MD. Also watch the videos posted by Dr. Ash, Dr. Cohn, and Ada Wells, PT:
The most basic answer to this question is the fact we have an upright stance. We are the only animals on earth who walk upright on two limbs. A close second to us might be considered the kangaroo, which supports a large proportion of its weight on its large tail. Gorillas and chimpanzees actually spend the vast majority of their time on four limbs.
Because of our upright stance, a curvature is forced to occur in the spine producing a lordosis, or curvature, which is convex to the front and concave to the back. This results in an extensive amount of compressive force on the lower five lumbar discs. The end result is the fact the only thing more common than back pain is sin. The discs wear out causing bulging and herniations, which produce back pain and/or radiating leg pain. In addition, the facet joints, or stabilizing joints, located posterior in the spine become arthritic. Facet arthritis is a very common cause of back pain.
Disc injuries cause back pain because of the intense enervation of the outer portion of the discs. When the discs become injured or degenerated, these nerves are stimulated producing intense pain signals to be sent to the brain.
There is no specific definition for the term herniated disc, bulging or protruded disc. Scientific studies indicate that individual spine specialists utilize these terms interchangeably. More helpful definitions are the terms contained or non-contained disc herniation. A non-contained disc herniation indicates a disc has herniated material that is no longer connected to the main portion of the disc. A contained disc is a disc herniation that still has connections to the main disc. These definitions are very helpful in terms of the surgical treatment and prognosis of someone who has a disc herniation.
The answer is a resounding yes. Studies have shown that 50% of people over the age of 50 have bulging discs at multiple levels in their spine, but never report any symptoms other than the occasional backache following strenuous exercise.
The answer is extremely varied. I have heard of patients who sneezed wrong, picked up a pencil, or did some trivial physical activity resulting in a herniated disc with intense radiating leg pain. A normal disc does not herniate like this, but many of us have discs that are not normal and, thus, are susceptible to trivial injury that can result in catastrophic symptoms. The main symptom of a herniated disc is radiating pain into the buttocks and leg. If this pain continues down the knee into the foot, this is indicative of a more serious herniation.
Typically, a herniated disc causes radiating leg symptoms. Generally, this is what people refer to as sciatica or radiculopathy.
The American Academy of Orthopedic Surgery strongly recommends six weeks of non-operative treatment for a herniated disc since 90% of herniated discs get better in this time frame. A patient who continues to have symptoms of intense leg pain after six weeks of onset carries a poorer prognosis. Non-operative treatments include chiropractic, physical therapy, massage therapy, rolfing, acupuncture, nonsteroidal anti-inflammatory medications, steroids, pain medications, and muscle relaxers.
I absolutely hate this term since people who have this do not have a disease. I believe this is a gross misnomer of a typically normal aging process. With age, discs typically become dried out or desiccated, and this can be diagnosed with an MRI scan.
Unfortunately, when a disc is observed on an MRI scan to be dried out it is often characterized as being degenerated, and a patient with several discs is diagnosed as having degenerative disc disease. Again, I must emphasize this is absolutely not a disease. It is not contagious or transferable.
The fact that people who have dried out discs have symptoms of back pain is secondary to the processes we have already discussed. This includes the fact the outer portion of the disc is heavily enervated and a patient who has a disc not functioning normally often has an instability of that portion of the spine, which results in symptoms of chronic back pain.
This is a very difficult term to diagnose objectively under any circumstances or with any specific radiographic studies. Articles have been published in the literature with definitions of lumbar instability. Most patients who suffer from chronic back symptoms also suffer from chronic muscle spasm, which prevents their spine from moving enough to diagnose instability. I believe lumbar instability exists when a patient has a disc that is not functioning and results in an abnormal amount of motion diagnosed by the fact the patient has chronic pain. I believe patients who have chronic back pain by definition have lumbar instability.
Spinal stenosis means there is less room for the spinal cord and exiting nerve roots, typically resulting in radiating leg pain. The two major causes of radiating leg pain would be either a herniated disc or lumbar stenosis. Stenosis is typically found in the elderly population. I like to use the analogy of an oak tree whose roots have grown into a three-inch sewer pipe. There are places where the pipe is no longer three inches in diameter and the toilet is not functioning properly. The areas where the roots have decreased the diameter of the pipe are stenosis. This exact event occurs in the spine secondary to arthritic buildup of bone and/or ligaments and soft tissues around the spinal cord and exiting nerve roots.
The treatment for spinal stenosis involves exercises, including stretching the quadriceps, psoas and hamstring muscles to put less stress on the spine to help increase the motion in that portion of the spine. Typically, patients who have spinal stenosis are elderly and very stiff. Medically, anti-inflammatory medications and/or steroid injections can be helpful. Ultimately, similar to the roots growing in a sewer pipe, the definitive treatment would be a nerve decompression, or roto-rooter, surgery to remove abnormal bone and soft tissue build up around the nerves.
Pain is a subjective complaint. The only person who experiences the pain is the individual patient. I believe any doctor whose recommendation to the patient is to live with the pain is not providing appropriate medical advice. There are multitudes of treatments for back pain, all of which have a history of helping certain people. I don’t believe any one treatment helps everybody, including surgery.
In general, the best treatments for back pain include an active exercise program strengthening the abdominal and back muscles and stretching. This can be accomplished with physical therapy, Med-X programs, and Pilates. Other treatments for chronic back pain certainly worth exploring include chiropractic, magnets, acupuncture, rolfing, traction devices, back braces, lumbar supports at work, home and in the automobile, and special lumbar support pillows for sleep. Heat and ice are excellent treatments with few side effects, being careful not to burn your skin.
The only specific indications for spine surgery include the occasional patient who has a neurologic deficit and is becoming paralyzed because of nerve pressure and a patient who develops such severe pressure on his or her spine that they lose control of their bowel and bladder. Other indications would include someone who has an infection in their spine or cancer that requires removal of the affected area in order to cure the disease. The only other indication for spine surgery is pain relief. As stated, pain is a subjective complaint only experienced by the patient. Any surgery performed is an elective procedure done after the patient decides non-operative treatments have failed and their pain is such that surgery is the only alternative to living with their pain.
A laminectomy specifically means removal of the entire lamina, which is a portion of the spine allowing access to the spinal cord and/or nerve roots. A more accurate term would be a laminotomy, which involves partial removal of the bone. This is the procedure most typically performed for a disc herniation. Rarely is the entire removal of the lamina, or laminectomy, performed.
In general, the surgical treatment for a disc herniation with primarily radiating pain is a partial removal of a disc through a laminotomy. Surgical treatment typically for chronic incapacitating back pain is a fusion. In general, removing a portion of the disc provides very little relief of back pain. The decision as to the appropriate surgical approach to a particular patient’s problem requires careful evaluation by a spine specialist. There are numerous ways to perform a spinal fusion and each of these techniques has advantages and disadvantages, which need to be carefully understood by the patient undergoing the procedure.
Ninety-five percent of all the bending, in terms of being able to touch your hands to the ground or your toes, involves your hip joints, not your spine. Thus, patients undergoing a one or two-level fusion typically have no loss of ability to touch their toes. If more than two levels of the spine are fused, there is some permanent loss of motion, but, again, more than 95% of all the flexion occurs at the hip joints, not the spine. Stretching the muscles about the pelvis and hips cannot be over emphasized.
Historically, spinal fusion has been performed with a bone graft without implants. However, the fusion rate with this technique is notoriously low, in the 50% range. The clinical result of spinal fusion without implants is also not very good. In addition, patients treated in this manner are often immobilized with prolonged bracing and/or bed rest for weeks or months.
Modern techniques utilizing pedicle screw fixation with plates or rods in combination with devices replacing the disc have resulted in fusion rates of well more than 95% and associated increases in clinical results to around 70%. Thus, the use of implants is not necessary, but certainly an advantage in terms of rapid rehabilitation to the patient and better clinical results with higher fusion rates.
All of the spinal implants manufactured or marketed by American companies are of extremely high quality. The difference between various implants is more important to the individual surgeon in terms of his familiarity with their particular surgical techniques rather than specifically providing the patient with specific advantages. The use of titanium rather than stainless steel does have certain advantages in terms of better imaging with MRI scanning. It is certainly reasonable for a patient to ask the surgeon the rationale of using a particular implant for their surgery.
This is certainly possible, if the surgical technique of inserting the implants is not performed appropriately. In addition, it is possible, even with appropriate surgical techniques, that fusion devices can lead to premature breakdown of the spine above and below that is not fused.
The biggest risk is a lack of pain relief. A recently published extensive review of the literate indicates spinal fusion has an associated satisfactory relief of pain in the 70% range – meaning 30% of patients who undergo a spinal fusion do not receive adequate pain relief. This would be by far the biggest risk. A disc herniation operation performed on the appropriate patient has more than 95% chance of success in terms of alleviating severe buttock and leg pain. The other risks of surgery are extremely rare, including infection and nerve injury.
In general, bracing is not required after a disc operation or a fusion operation performed with implants, however, each surgeon has their own protocol and some may advise bracing to remind the patient to avoid certain activities following surgery.
It would be unusual that any surgery would be performed without prior authorization of an insurance company and, certainly, it is important the patient understand the responsibility of the patient verses the insurance company for payment. In general, most insurance companies cover back surgery.
A herniated disc operation performed to relieve severe radiating leg pain typically has relief of leg pain in a matter of hours or days. Often it may take months to recover the sensation or motor deficits of a herniated disc and sometimes this never happens. Most surgeons would ask the patient to refrain from extensive lifting, twisting, bending and stooping for 4-6 weeks following a disc operation, at which point normal activities can be started again. A fusion operation often takes 6-9 months for bone fusion, 4-6 weeks with implants. Each surgeon has their own protocol for physical activities following surgery.
Less invasive back surgeries include lasers and percutaneous procedures. All of these techniques are somewhat controversial. The criticisms leveled against proponents of these procedures are the patient would have improved anyway had the procedure not been performed. They are typically performed on patients with a contained disc herniation whose main compliant is buttocks and leg pain. These non-invasive procedures would not be a substitute for a spinal fusion in the patient with incapacitating back pain. Surgeons who perform these procedures have reported results similar to open procedures, but not in the patient with a non-contained disc herniation.
The use of physical therapy following surgery is certainly individualized to the patient and surgeon. In general, patients should avoid extensive lifting, twisting, bending and stooping for 4-6 weeks following any spine surgery.
It is common for patients to require narcotic pain medications following surgery. In fact, most patients prior to surgery are on these medications because of their intensive pain. Other non-narcotic medications that are sometimes helpful include Tylenol, aspirin, and Advil-type products called nonsteroidal anti-inflammatory medication. It is important patients understand that nonsteroidal anti-inflammatory medications and aspirin do cause an increase in bleeding and should be avoided prior to any surgical procedure. Tylenol does not have this side effect. The use of narcotics in the peri-operative period is not associated with problems of addiction. The major side effect is constipation, which typically occurs with all narcotic medications. Generally, the use of these medications is reserved for a period of weeks and can be individualized to minimize side effects such as nausea or stomach upset.
Half the people undergoing a fusion operation are men. This specific concern is from the anterior approach through the abdomen to expose the spine. In a small percentage of males, this results in retrograde ejaculation. This complication occurs in less than 1% of patients and does not mean the man cannot have an erection and orgasm, it just means he does not have the normal amount of semen and may be sterile. In young men about to undergo an anterior approach to the spine, it may be advisable to donate sperm in case this rare side effect would occur.
Again, the biggest risk of a fusion operation is the lack of adequate pain relief. In addition, fusion surgery may result in the premature breakdown, or wearing out, of the spine above and below the fusion.
Every surgeon has his or her own protocol. In general, a patient would see the surgeon approximately two weeks after surgery for suture removal and then at that point, six weeks, three months, six months, and a year.
A particular spine surgeon should have the ability to perform either anterior or posterior spinal surgery. Any surgeon who is incapable of either approach should be questioned as to why. Each approach has advantages and disadvantages. If the patient requires a nerve decompression for a diagnosis of a herniated disc or stenosis, this needs to be accomplished through a posterior approach. At that point, the surgeon would perform the nerve decompression and then proceed with a posterior approach for the spinal fusion. The anterior approach has the advantage of less muscle dissection with generally less blood loss and postoperative pain. The disadvantage is its inability to provide access to the nerves for a nerve decompression. Each patient’s individual pathology should be evaluated and then the appropriate surgical approach utilized.
The risks from the anterior approach to the spine include retrograde ejaculation, as discussed, and possible damage to blood vessels in the area. The other complication is an ileus, where intestines do not work properly after surgery. This typically lasts for a few days.
The risks from going from the back are disruption of the muscles around the spine, which results in higher blood loss and more pain following the surgery. In addition, muscles moved aside to allow exposure may permanently be damaged, resulting in a loss of a normal muscle function.
A bone graft is the part of the fusion operation that results in a permanent fusion or use of bone to connect mobile segments of the spine in a permanent fashion. The use of implants or hardware is performed to enhance the bone healing producing a fusion. Bone graft can come from the patient’s iliac wing. In addition, more recent technique includes the use of bone morphogenic protein or BMPs, which may come from the patient’s own blood or bone marrow or from exogenous sources to enhance or stimulate bone healing. In addition, bone graft substitutes have been utilized to avoid the taking of the patient’s own bone, which can result in postoperative pain, sometimes long term.
The incision for taking bone graft from the hip varies from utilizing the same incision the surgeon has utilized for exposure to the spine or a separate incision, which may be a few inches long. The patient should ask his or her surgeon about this.
The alternatives to bone graft from the hip are those mentioned, which include allograft, or bone from another person, bone substitutes, which include various bone substitutes that are not human or animal and bone morphogenic proteins recently developed.
Bone taken from the hip is the patient’s own bone whereas donor bone, or allograft bone, is from another human being. This bone is typically radiated and freeze dried and is quite safe in terms of disease transmission. In addition, this bone is not rejected by the person since your body does not recognize it as a foreign substance. The healing rates are not nearly as good with donor bone as it is with the patient’s own bone. To make up this difference researchers have developed bone morphogenic proteins.
Pain following bone grafting from the hip is quite variable. This can be a serious problem, which has stimulated research into alternative techniques to avoid bone grafting from the hip.
The main complication from harvesting bone from the hip is acute or chronic pain from the bone graft site. In addition, bone that has been harvested from the iliac wing will typically never grow back. This bone is not weight bearing and this in and of itself does not produce any long-term problems.
Pain from a bone graft is specific to the side where the bone is taken from and can typically be differentiated from pain secondary to the spine operation.
Yes. Patients occasionally have chronic permanent pain from the bone graft site.