FIGHTING BACK AGAINST BACK PAIN
Many of us battle back pain at some point in our lives, and for most it retreats with time. When it doesn’t, Georgia spine centers are here to help.
Charles “Kelly” Hodges began his battle with back pain in his mid-30s. The pain, which started in his lower back and hip, wasn’t too bad at first, he says, but as it worsened it interfered with his job as an interior master craftsman at Gulfstream, his favorite activities and his ability to enjoy time with his wife and two young sons.
“I was in pain all the time,” he says.
That’s when he decided to find out the source of his pain, which turned out to be a herniated, or ruptured, disc – one of the donut-shaped structures situated between the vertebrae – pressing on his sciatic nerve. He fought the pain with all of the tools available to him – oral pain relievers, epidural injections of steroids and nerve-blocking drugs, traction and chiropractic care. Nothing gave him much relief or hope until he met James Lindley, M.D., a neurosurgeon at the Neurological Institute of Savannah and Center for Spine, who told him about a procedure using an experimental device called the Triumph® Lumbar Disc.
On Oct. 27, 2010, Hodges became the first person in the United States to undergo the procedure, in which his herniated disc was removed through a small incision in the spine and the Triumph disc was inserted in its place.
Today, at age 40, Hodges says he is “back to normal.” He coaches his sons’ soccer teams and does pretty much all the things he used to do – working out, going to the gym and even wakeboarding.
“It’s almost like I forgot I even had back surgery,” he says. “Sometimes I have to look in the mirror at my scar to remember.”
From replacing damaged discs to placing supportive hardware with CT-guided technology, Georgia spine centers offer increasingly high-tech – and, in many cases, minimally invasive – treatment options for back pain, a problem that affects as many as 80 percent of us at one point or another.
Fortunately, for the vast majority of back pain cases such measures are never needed, says Oluseun Olufade, M.D., a specialist in physical medicine and rehabilitation and interventional pain medicine at the Emory Orthopaedics and Spine Center in Johns Creek. Even when surgery is needed, it’s often a treatment of last resort after more conservative measures have failed to provide adequate relief from back pain or associated symptoms.
Most back pain resolves, particularly in the absence of a significant traumatic episode, says Ralph “Buck” Cavalier, M.D., an orthopaedic surgeon at Summit Sports Medicine & Orthopaedic Surgery, a strategic affiliate of Southeast Georgia Health System. But when back pain is severe or doesn’t improve after a few weeks, it’s a good idea to see your doctor, he says.
If your pain is accompanied by other symptoms such as a high fever, tingling or numbness down a leg or loss of balance or bladder or bowel function – either retention or incontinence – it is time to see a doctor immediately. Such symptoms could indicate an infection, a tumor or compression of the spinal cord or nerves where they exit the spinal column. The treatment would depend on the cause of the pain and how it is affecting your life.
Common Causes, Simple Solutions
In most cases, however, back pain is the result of simple strain of the soft tissues – a consequence of working too hard in the yard or sitting hour upon hour at your desk. Often the treatment is relatively simple as well.
“For [low back] strain, most of the time, I tell people to rest a day or two at most, start an anti-inflammatory for one or two weeks straight, put ice on it and heat on it and slowly get back to their activities while avoiding activities that aggravate it,” says Wayne Kelley, M.D., an orthopaedic surgeon at OrthoGeorgia in Macon. “Most of the time it gets better by six to eight weeks, if not sooner.”
When pain doesn’t resolve in that timeframe, he prescribes a muscle relaxer to ease muscle spasms, steroids for inflammation and physical therapy (see “What is PT?” sidebar on page 33) to promote flexibility and strengthen core muscles to support the spine.
Another common cause of back pain is degeneration or herniation of the discs of the low back – the condition for which Hodges received a disc replacement. “As we get older, these discs change in their makeup or become dehydrated as a course of the natural aging process and are likely more susceptible to injury, and they cause back pain,” says Dr. Cavalier. “This can lead to reflective muscle spasms [in] the muscles of the low back, which further increases discomfort.”
Disc problems are treated similarly conservatively, at least initially. When noninvasive measures like physical therapy or back braces fail to relieve pain from herniated discs, doctors often inject a steroid and local anesthetic into the disc space to fight both pain and inflammation.
For Dr. Lindley, who replaced Hodges’ disc, the most common back problems he sees as a neurosurgeon include fractures and spinal deformities such as degenerative scoliosis (side to side curvature of the spine caused by degeneration of the facet joints between the vertebrae) and kyphosis (an exaggerated forward curvature of the spine, often caused by age-related fractures of the vertebrae) as well as those that result in compression of the spinal cord within the spinal column or compression or irritation of the nerves as they exit the spine between the vertebrae.
In addition to herniated discs, Lindley also sees spondylosis, a general term for degenerative diseases of the discs and facet joints; spinal stenosis, a narrowing of the spinal canal, which compresses the spinal cord, resulting in back pain and leg pain and numbness; and spondylolisthesis, a condition in which a vertebra slips out of proper position. All of these are potentially treated with surgery.
When surgery is the best or only remaining option, doctors choose the specific surgery based on a number of factors, including the patient’s problem, other health issues, age and activity level.
In some cases, surgery may be as simple as the removal of the portion of disc that is protruding beyond the vertebrae. The actual technique used to remove the herniated portion of disc should be based on the experience and comfort of the surgeon, says Dr. Lindley. His personal preference, he says, is a minimally invasive microdiscectomy, a procedure in which a small tube is placed from the skin surface to the spine after dilating a path through the back muscle. This usually not only helps alleviate low back pain, but also the leg pain that can sometimes accompany it.
“The microscope is used now to visualize the spine through the tube,” says Dr. Lindley. “The disc herniation is removed with microscopic instruments while the nerve is protected. A small dressing is placed and the patient is discharged within several hours of surgery, frequently with relief of the leg pain.”
In other cases surgeons often use a more extensive procedure referred to as decompression and stabilization. Decompression refers to the removal of anything within the spine – such as a herniated disc or bony overgrowth – that is compressing the spinal cord or nerves, says Jenna Wright, neurosurgery clinical navigator – a liaison between the surgeons and nurses – at the Redmond NeuroSpine Center in Rome. Stabilization refers to spinal fusion, a procedure in which two or more vertebrae are permanently joined into a single unit using bone grafts and/or hardware.
In some centers, including Redmond, fusion itself can be a minimally invasive procedure, with a CT scan guiding the physician in the placement of screws to attach the involved bones percutaneously, or by way of a needle puncture through the skin of the back.
When removing discs and performing a fusion, many surgeons are using a relatively new procedure called XLIF (eXtreme Lateral Interbody Fusion) in which the surgeon accesses the space between the vertebrae through an incision in the side. This allows the surgeon access to multiple disc levels, says Dr. Kelley. Screws can then be placed percutaneously.
While fusion is often effective at relieving pain and stabilizing the spine, it prohibits movement between the vertebrae that are fused, and there is evidence that fusing two vertebrae shifts the stress to adjacent areas, increasing the risk of problems in those structures down the line, says Dr. Lindley. For that reason Dr. Lindley and other neurosurgeons prefer surgeries such as disc replacement that preserve spine movement and do not predispose patients for additional surgical procedures.
On the Horizon
Minimally invasive disc replacement is just one of several treatments for back problems on the horizon, researchers say. One of the hottest areas of back pain treatment is in the use of stem cells to treat disc problems. Stem cells are master cells that have the capacity to differentiate and grow into any of the body’s 200-plus cell types.
“The whole idea when you have degenerative disc disease is you lose the protein and you lose some of the water content of the discs,” says Dr. Olufade. “When you lose that, the disc actually gets shorter, and that is why when we get older sometimes we lose height.” The theory, he says, is that injecting stem cells into the discs can help regenerate some of the materials we lose as we age.
The stem cells used for disc regeneration come from donor placentas or one’s own bone marrow, which is drawn through a large needle inserted into the hip. The doctor then injects the stem cells through a needle placed into the disc space in an outpatient procedure.
One downside of stem cell therapy for degenerative discs is that it is not reimbursed by insurance, so patients wanting to try it must be willing and able to pay out of pocket. The other downside is doctors don’t yet know how well – or even if – it works.
“There have been some early indications that it helps,” says Dr. Lindley. “It is one of those new techniques that we don’t know a whole lot about, but there is real potential there.”
Other advances include techniques that will make back surgery even less invasive and allow patients to maintain spinal mobility such as the ACADIATM facet replacement system, a two-part implant designed to replace and mimic the facet joints, which allow for flexibility of the spine. The ACADIA system is currently being evaluated by the FDA to determine if it is safe and effective for lumbar spinal stenosis. Memorial University Medical Center in Savannah is the only hospital in Georgia where the surgery is available.
The trend toward less invasive surgery is one Dr. Lindley and other surgeons hope and expect to see continue. “Minimally invasive is big time, because it preserves the normal anatomy,” says Dr. Lindley. “When we do big back surgeries we expose a lot, and many times you have to expose a lot if you are treating severe scoliosis or kyphosis. That’s just the way it is – you need to take advantage of anything you can mechanically by exposure. On the other hand,” he says, “if you can get away with a smaller, more spine-friendly surgery, you are actually disrupting less of the spine so you are making it less likely the patients will need surgery at other levels [of the spine] in the future.”
All over Georgia, people are finding relief from back pain through less invasive procedures than those that were available just a few years ago. Just ask Kelly Hodges – if you can catch up with him.